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 Table of Contents  
CASE REPORT
Year : 2016  |  Volume : 3  |  Issue : 3  |  Page : 119-122

Acquired tracheo-esophageal fistula from disc battery in a child: A case report and review of literature


Department of Surgery, Cardiothoracic Surgery Unit, Usmanu Danfodiyo University Teaching Hospital, Usmanu Danfodiyo University, Sokoto, Nigeria

Date of Submission21-Mar-2016
Date of Acceptance09-Aug-2016
Date of Web Publication2-Nov-2016

Correspondence Address:
Umar Abubakar
Department of Surgery, Cardiothoracic Surgery Unit, Usmanu Danfodiyo University Teaching Hospital, Usmanu Danfodiyo University, Sokoto
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2394-2010.193183

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  Abstract 

Disc battery ingestion has increased drastically due to the fact that most household devices use these batteries. Children have access to these devices either as their toys which they play with or as devices that are used on daily basis such as remote control and watches. Children place things in their mouth, using it as a means of exploring their environment. It is common for these batteries to get impacted in the esophagus and if not removed immediately will cause liquifactive necrosis leading to perforation into the trachea which is closely related to the esophagus. We report a case of disc battery ingestion that presented to us with a tracheo-esophageal fistula. We also reviewed literature related to this pathology.

Keywords: Disc battery, ingestion, tracheo-esophageal fistula


How to cite this article:
Abubakar U, Ismail S, Ukwuani SI. Acquired tracheo-esophageal fistula from disc battery in a child: A case report and review of literature. J Health Res Rev 2016;3:119-22

How to cite this URL:
Abubakar U, Ismail S, Ukwuani SI. Acquired tracheo-esophageal fistula from disc battery in a child: A case report and review of literature. J Health Res Rev [serial online] 2016 [cited 2021 Dec 4];3:119-22. Available from: https://www.jhrr.org/text.asp?2016/3/3/119/193183


  Introduction Top


Devices with disc battery have become very common worldwide.[1] Children place things in their mouth, using it as a means of exploring their environment, and consequently, ingestion of these foreign objects is common in early childhood. This is said to be common in toddlers.[2] An esophageal foreign body may lodge in any of the narrowed parts of the esophagus. If a battery gets impacted, it may penetrate the esophageal wall and cause a tracheo-esophageal fistula.[3] We report a case of disc battery ingestion in a child who presented to us with a tracheo-esophageal fistula from a disc battery he ingested.


  Case Report Top


A 20-month-old male child was referred to us with 7-month history of choking during feeding. This was associated with episodes of cough and vomiting. He also had a history of recurrent respiratory tract infections warranting several hospital admissions. There was a history of significant weight loss since the onset of symptoms. There was a preceding history of ingestion of a button cell-type battery about 7 months ago, which was removed via esophagoscopy after about 30 h, and the procedure was said to have been difficult and traumatic. Symptoms were noticed a day after this procedure.

Esophagogram revealed a tract connecting the trachea and cervical esophagus at the level of the C5/C6. There was no proximal or distal narrowing, and lung fields were clear [Figure 1].
Figure 1: Barium swallow

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He had a repair of tracheo-esophageal fistula through a lateral neck incision. The fistulous tract was mobilized and transected [Figure 2] and [Figure 3]. Tracheal and esophageal ends were closed in two layers, and a muscle flap was placed between them.
Figure 2: Exposed tracheo-esophageal fistula

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Figure 3: Divided fistulous tract

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The patient recovered well and was discharged on the 6th postoperative day. Postrepair esophagogram did not reveal any fistulous connection between the trachea and esophagus.


  Discussion Top


Disc battery is a small single-cell battery shaped as a squat cylinder typically 5–25 mm in diameter and 1–6 mm high – like a button on a garment, hence the name. Button cells are used to power small portable electronic devices such as wrist watches, pocket calculators, artificial cardiac pacemakers, implantable cardiac defibrillators, and hearing aids. Thinner variants are usually called coin cells.

The disc or button batteries are small, disc-shaped power units commonly used in digital watches, hearing aids, calculators, cameras, blood glucose meters, some toys, and other electronic instruments. They contain corrosive and toxic chemicals that can lyse or digest soft tissues leading to perforation. These include mercury, zinc, silver, nickel, cadmium, manganese, and lithium.[1],[3],[4],[5]

Disc battery ingestion is seen in toddlers. There is no sex predilection, but in older age group, boys are said to be more commonly affected.[6],[7]

Thoracic inlet has been reported to be the narrowest point and the most common site of foreign body impaction.[3] Our patient had the disc impacted at the thoracic inlet. The size of the battery plays a great role in impaction. Batteries that are > 20 mm are associated with a high risk of impaction.[8] The mean duration of impaction was reported to be about 5 h,[1] but our patient had the battery impacted for about 30 h. This time is enough for fistulation between the trachea and esophagus to occur.

The chemicals in these batteries can leak and lead to inflammatory reaction that will set the stage for perforation and fistula formation. There are different mechanisms by which these batteries cause damage. It can be caused by any of the following: Alkaline electrolyte leakage from the battery, “de novo” alkali production from external current, heavy metal toxicity, direct flow of current causing low-voltage burn, and pressure necrosis. Perforation occurs within hours of exposure to the battery substances.[9],[10] Our patient had the battery impacted for about 30 h before it was removed. There was enough contact time between the disc battery and mucosa which led to the development of the fistula.

Most button battery ingestions go unnoticed as such the diagnosis can be missed. They may present in emergency department with dysphagia, refusal to eat, drooling of saliva, choking, coughing, stridor, vomiting, gagging, regurgitation, and cyanosis. Distal esophageal foreign body produces nonspecific symptoms such as fever, irritability, lethargy, poor appetite, and dehydration. Many children with esophageal foreign body may be asymptomatic.[11],[12],[13] Our patient presented with the features of recurrent respiratory tract infection despite various forms of treatments.

Neck X-ray (antero-posterior and lateral view) – this is readily available, cheap, and has a high accuracy in diagnosing radiopaque objects. This will aid in identifying the location of the battery.[14],[15] In patients who have already developed the fistula after removal, chest X-ray may only show the features of respiratory tract infection, which can be misleading to the managing physician.

Chest X-ray can localize radiopaque objects lodged in the intrathoracic esophagus. If a fistula has developed, chest X-ray will demonstrate the effects of repeated respiratory tract infection.

Abdominal X-ray may localize intra-abdominal segment of the esophagus. This segment is short about 3–4 cm. This film can also localize any foreign body that has passed to the stomach and bowel.

Barium swallow will demonstrate the site, width, length, and direction of the fistula.[16],[17] It may also demonstrate contrast in the tracheobronchial tree and lung fields.

Endoscopy is the best diagnostic modality as it enables visualization of the fistula if it is wide enough. Mucosal folds may cause small fistulae to be missed.

Flexible and rigid bronchoscopy is employed to identify the fistula. Broncho-alveolar larvage can be instituted at the same time to clear the respiratory tract.[16],[18],[19]

Toxicology studies is required for the determination of blood and urine levels of toxic substances.[20],[21],[22],[23]

Treatment

Patients who perforate at the time of retrieval should be made to observe the following:

  1. Nil by mouth and intravenous fluid
  2. Broad spectrum antibiotics
  3. Appropriate analgesics
  4. Use of steroids is controversial
  5. Contrast esophagogram before the child is allowed to eat. This should be repeated in 3–6 weeks to evaluate the presence of a stricture.


Nonoperative treatment tracheo-esophageal fistula – spontaneous closure has been reported in some of these patients.[24]

Endoscopic cauterization with sodium hydroxide, endoscopic excision, and closure with fibrin glue have all been reported.[25] Esophageal stenting has also been reported, especially in patients who are not fit for the surgery.[26],[27]

Surgical treatment – the principles of repair of tracheo-esophageal fistula are:

  1. Treat pre-existing pulmonary infections
  2. Separate closure of the fistulous tracts on the tracheal and esophageal ends
  3. Interposition of viable muscle flap between the tracheal and esophageal suture lines.


General anesthesia is the preferred anesthesia of choice in these patients. A cuffed endotracheal tube is far beyond the fistula. This has been reported to prevent anesthetic gas loss in the stomach.[28] A nasogastric tube should be inserted and regularly aspirated to prevent gastric distension with anesthetic gases. This tube will also serve as a mark to identify the esophagus intraoperatively.[29]

Proximal tracheo-esophageal access is via a low cervical incision, the fistula is divided and closed in two layers after which, it is butressed with skeletal muscle flap from the neck or intercostal muscles.[30]

Intrathoracic tracheo-esophageal fistula access here is via a right posterolateral thoracotomy with the head end of the bed elevated to prevent the reflux of gastric content into the trachea. The fistula is isolated, divided, and repaired. The repair is reinforced with mediastinal pleura.[31]

The goal is early extubation so as to avoid prolonged ventilation as this may compromise the suture line. Various postoperative analgesics have been used.[32]


  Conclusion Top


Disc battery ingestion can cause acquired tracheo-esophageal injury. It results from damage caused by the leakage of chemical constituent of the disc. If patients present within 2 h of ingestion, the chances of perforation are less and these group of patients can be managed nonoperatively. Once they present with a fistula, surgical repair offers the best outcome.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

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Khaleghnejad Tabari A, Mirshemirani A, Rouzrokh M, Seyyedi J, Khaleghnejad Tabari N, Razavi S, et al. Tracheoesophageal fistula following disc battery ingestion and foreign body impaction. Caspian J Intern Med 2011;2:336-9.  Back to cited text no. 3
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    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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