|Year : 2016 | Volume
| Issue : 1 | Page : 52-55
A rare complication due to button battery cell in ear
Sharad Hernot, Samar Pal Singh Yadav, Bhushan Kathuria, Madhuri Kaintura
Department of Otorhinolaryngology, Pt. B.D. Sharma PGIMS, Rohtak, Haryana, India
|Date of Web Publication||16-Feb-2016|
Pocket-AP, 115-A, Pitampura, New Delhi - 110 088
Source of Support: None, Conflict of Interest: None
We report a case of a 7-year-old male child who presented to ENT emergency with 24 h history of excessive pain and blackish otorrhea from right ear after accidentally inserting button battery in the ear while playing. Otoscopic examination revealed a shiny and round foreign body with excessive blackening of the surrounding skin. Chest and abdominal examination and routine investigations were normal. X-ray bilateral mastoid (Schuller's view) was done which revealed a radiopaque double-contoured foreign body in the right ear. It was removed under general anesthesia and was confirmed as a button battery. A few days later, biopsy from granulation tissue and surrounding bone was taken which revealed acute suppurative osteomyelitis on histopathological examination.
Keywords: Button battery cell, Ear, Temporal bone osteomyelitis
|How to cite this article:|
Hernot S, Yadav SP, Kathuria B, Kaintura M. A rare complication due to button battery cell in ear. Indian J Otol 2016;22:52-5
| Introduction|| |
Button batteries usage has increased a lot as almost every electronic device and even toys are now remote-controlled. Furthermore, the trivialization of electronic items has made these button batteries easily accessible to children. There are numerous studies which report lodgment of button battery and its associated complications in the gastrointestinal tract, but there is a dearth of literature regarding temporal bone osteomyelitis as a complication of button battery cell in ear. Moreover to the best of my knowledge, this is the first such case that we are reporting in which chemical leak from button battery cell has led to osteomyelitis of temporal bone in such short duration, with clinical, histopathological and radiological, all three investigation regimes supporting the diagnosis.
| Case Report|| |
A 7-year-old male child presented to ENT emergency with a history of excessive pain and blackish otorrhea from the right ear for 1 day after accidentally pushing button battery in the ear while playing. There was no other significant history. The child was a full-term normal delivery and weighed 27 kg on presentation. His milestones and growth parameters were normal for his age, and overall general examination was unremarkable.
Otoscopic examination revealed a shiny and round foreign body in the deep external auditory meatus with proximal meatal edema and excessive blackening of the surrounding skin. Chest and abdominal examination and routine investigations were normal. X-ray bilateral mastoid (Schuller's view) was done which revealed a radiopaque double-contoured foreign body in the right ear [Figure 1] and [Figure 2].
|Figure 1: X-ray bilateral mastoid (Schuller's view) showing button battery cell in right external auditory canal|
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|Figure 2: Double contour or bilaminar structure of button battery cell as seen on X-ray|
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Patient was admitted and advised to be nil per orally. Under general anesthesia (GA), a corroded button battery was removed [Figure 3], revealing a small ragged posterosuperior tympanic membrane (TM) perforation. Rest of the TM was congested. The battery cell was 8 mm × 8 mm in size, had number SR721SW engraved on it, belonged to Titan Industries, and was made in Japan. The skin surrounding the battery cell was blackened and also the bone appeared corroded. Adequate debridement of the corroded skin and bone was done. The patient did not complain of pain, vertigo, or facial weakness after the effect of GA weared off, but started complaining of decreased hearing on the 1st postoperative day. Pure tone audiometry (PTA) was done which showed mild hearing loss in the right ear and normal hearing in the left ear. The patient was kept on intravenous antibiotic (injection ceftriaxone), painkiller, and antibiotic-steroid ear drops. On the 5th postoperative day, patient started complaining of fever, mild pain, with purulent greenish discharge coming from his right external auditory canal (EAC). High-resolution computerized tomography (HRCT) bilateral temporal bone was advised and a cotton swab was sent for pus culture and sensitivity along with the blood investigations. Otoscopic examination was done which revealed granulation tissue in the deep meatus. Biopsy was taken from granulation tissue and surrounding bone under local anesthesia which revealed host bone infiltration and destruction by a mixed inflammatory infiltrate composed of neutrophils, lymphocytes, and plasma cells suggestive of acute suppurative osteomyelitis on histopathological examination [Figure 4]. HRCT bilateral temporal bone revealed erosion of anterior wall of the right mastoid and scutum, with etiology being infective or inflammatory in nature [Figure 5] and [Figure 6]. Patient was started on intravenous antibiotics – combination of cefoperazone-sulbactum and gentamicin – for Pseudomonas aeruginosa as stated in the pus culture and sensitivity report.
|Figure 4: Photomicrograph showing host bone infiltration and destruction by a mixed inflammatory infiltrate composed of neutrophils, lymphocytes, and plasma cells suggestive of acute suppurative osteomyelitis (H and E, ×40)|
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|Figure 5: High-resolution computerized tomography bilateral temporal bone showing erosion of anterior wall of right mastoid and scutum|
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|Figure 6: High-resolution computerized tomography temporal bone showing bone involvement (magnified view)|
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The patient was discharged after 2 weeks with a dry ear on oral cefuroxime, painkiller, and antibiotic-steroid ear drops. The patient came after 10 days, and the ear was dry and TM perforation was present in the right ear. The patient was asked to come for regular follow-ups to timely assess the healing of the TM and the skin and bone of external auditory meatus, and also to perform sequential PTAs to look for any sensorineural hearing loss.
| Discussion|| |
Button batteries are small shiny things which appear attractive to children, which as a result pose a potential danger to become a foreign body. Button batteries come in different sizes varying from 8 to 23 mm in diameter, and weighing 1–10 g. The larger-sized button batteries pose a risk of being ingested and then cause gastrointestinal complications, whereas small-sized button batteries are more frequently inserted in orifices such as ear and nose. In the ear, the foreign body gets impacted at two areas of the EAC, which are relatively narrower than the rest of the canal, i.e., one at the junction of the cartilaginous part with the bony part, and other at the isthmus of the bony part.,,,
Button batteries contain a metal as anode and a metal oxide as cathode. Commonly used metals (anode) are zinc or lithium, and commonly used metal oxides (cathode) are manganese dioxide and silver oxide. These are immersed in a strong alkali solution, which is commonly 45% potassium hydroxide. A metal can form the bottom body and the positive terminal of the cell whereas the insulated top cap forms the negative terminal.
A button battery (small or large) can cause extensive tissue damage which is explained by four mechanisms. First mechanism is injury by electric burn, caused by a low-voltage direct current passing between anode and cathode via tissues of EAC.
The second mechanism is by direct tissue damage caused by liquefaction necrosis due to leakage of alkaline electrolyte from the battery cell. The factor responsible for the leakage of the solution is the moist environment provided by the exudation of tissue fluids caused by the burn injury as mentioned in the first mechanism. This has been confirmed by in vitro studies that a spontaneous leakage of electrolyte solution occurs when alkaline batteries are exposed to moisture. Liquefaction necrosis results in dissolution of protein and collagen, saponification of lipids, and dehydration of tissue cells causing extensive tissue damage.
The third mechanism involves pressure necrosis which can occur in any type of foreign body impacted in a given area for a prolonged period.
Fourth mechanism is by local toxic effect due to absorption of substances (for example, mercury toxicity has been reported in case of mercury batteries). Button batteries are known to cause tissue destruction probably by a combination of all the four mechanisms.,,,,
Complications caused by the button battery in the ear occur: (1) as a result of its nature (i.e., its size, shape, and contents that form it), (2) the length of time it has been lodged, or (3) as a result of attempts during its removal. Complications caused as a result of nature, and the duration of lodgment of the button battery inside the ear include infection such as otitis externa and local injury such as burns of the EAC skin leading to canal stenosis. Liquefaction necrosis of surrounding tissue can result in malignant otitis externa (MOE), chondritis, facial nerve injury, ossicular erosion, necrosis of medial wall of middle ear leading to sensorineural deafness and damage to the vestibular labyrinth. Complications occurring as a result of attempting to remove the foreign body from the ear include injury to the EAC (e.g., lacerations, canal hematoma, etc.), perforation of the TM, and disruption of the ossicles.,, As is evident from the discussion now, temporal bone's acute suppurative osteomyelitis as a complication due to button battery insertion in the ear is rarely reported in the literature.
Osteomyelitis of the temporal bone is a serious complication. It occurs mostly secondary to MOE, but other predisposing factors such as positive history of otitis externa or otitis media, tuberculosis, malignancy, radiotherapy, bacteremia, a contiguous infectious focus, bone surgery, or direct trauma to the bone, also play a role. The most commonly causative organism for temporal bone osteomyelitis is P. aeruginosa, although other organisms such as Proteus mirabilis, Aspergillus fumigatus, Proteus sp., Klebsiella sp., and staphylococci have also been isolated. Infection is spread to the temporal bone through the fissures of Santorini and the tympanomastoid suture. Most common clinical features of acute osteomyelitis are continuous ear discharge, pain, and granulations in EAC.,
All suspected cases of osteomyelitis should be investigated thoroughly starting with carefully examining the patients for findings, followed by histopathological examination of granulations and surrounding bone, sending cotton swab for pus culture and sensitivity, and HRCT of the temporal bone. Treatment consists of broad spectrum antibiotics with meticulous debridement and cleaning of corroded part of EAC. In acute osteomyelitis, use of topical antimicrobials is controversial because these drops will affect future culture results if there is no response to therapy. Acute osteomyelitis usually responds well to antibiotics. Antibiotics are given as per the following protocol: Aminoglycoside + β lactamase antibiotic + a third-generation cephalosporin (ceftazidime/ceftriaxone/cefoperazone/cefotaxime), or an oral quinolone (ciprofloxacin).
The key to proper management of button battery foreign bodies is rapid diagnosis and its removal. Rapid diagnosis involves standard radiologic workup for a suspected foreign body. They have a distinctive appearance on radiography as they have a bilaminar structure, making them appear as a double ring on Schuller's view or lateral view. As soon as the diagnosis is made, battery should be removed preferably under GA, so that the child is adequately immobilized during the process of foreign body extraction and also postextraction debridement of corroded skin or bone, and aural toileting can be done. Foreign body retrieval is done using appropriate instruments like alligator or micro-cup forceps, wire loop, a curette, or a right-angle hook. Irrigation should not be done as the saline can push the residual alkaline electrolyte toward inner ear via round window through the perforation (if present), and cause sensorineural deafness.
In every case of button battery in the ear, one should look for warning signs such as the onset of deep pain (temporal/parietal/retroorbital/postauricular), intermittent foul-smelling otorrhea, spiking fever, or granulation tissue in EAC. Otolaryngologists should harbor a high index of suspicion as a patient of button battery in ear who complains of the above-mentioned warning signs may have acute suppurative osteomyelitis, which if picked well in time can be dealt with just intravenous antibiotics and conservative debridement.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]