Presentation
Patient brought to emergency department by his parents after reporting inserting something into his nose.
Patient Data
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Lateral and frontal radiograph reveals a single circular radio-opaque density within the right nasal cavity at the nasal aperture. The frontal radiograph reveals a stepped appearance and a Halo/Double density is visible on the lateral plane highly suggestive of a button battery.
The patient was noted to have been playing with a bike light an hour prior to informing his parents that he had put something up his nose. X-rays were arranged by the emergency department.
An attempt to remove the foreign body was unsuccessful by the emergency team and prompt referral was made to the Ear, Nose and Throat team. Unfortunately, the patient was too distressed to allow another attempt at removal in the emergency department and proceeded to theater.
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The patient proceeds to theater some 4-5 hours of inserting the battery. An LR44 alkaline battery was removed from the right nasal cavity just posterior to the internal nasal valve. The battery showed significant signs of hydrolysis.
Extensive but apparent superficial burns were visualized in the nasal cavity limited to the septum, lateral nasal wall (mainly inferior turbinate) and floor. The nasopharynx was unaffected. The nasal cavity was irrigated and topical antibiotic ointment applied.
Case Discussion
Ingested, inhaled or inserted button batteries require a high index of suspicion and prompt medical attention. A range of different button batteries are available including alkaline, lithium, manganese, mercury, silver and zinc. Batteries contain an anode, cathode and electrolyte soaked spacer 1.
A number of mechanisms by which batteries cause injury have been proposed including; leakage of battery contents, local pressure/ischemic necrosis, local current and alkaline fluid generation through contact with moist mucosa (nasal or gastrointestinal) resulting in caustic and electrical burns in the surrounding tissue 2.
Button batteries can cause damage within hours of ingestion/insertion and require prompt identification and referral for removal. Delayed battery removal from the nose can result in mucosal ulceration, epistaxis, septal perforation, saddle deformities, chondritis, atrophic rhinitis, alar collapse, and nasal/choanal stenosis 3. Delayed battery removal from the digestive tract can cause catastrophic complication including perforation, tracheal-esophageal fistula or oesophago-aortic fistula 4.
Radiologically it is important to identify button battery compared to other radiopaque foreign bodies such as a coin. Frontal radiographs will typically demonstrate a halo/double density sign alerting the presence of a button battery. Where clinical doubt exists an orthogonal lateral radiograph should be obtained which usually reveals a stepped profile 2. Given the plane of the button battery in this case the frontal view revealed the stepped profile and the lateral the halo/double density sign.
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