From the Department of Surgery and Paediatric Surgery, Command Hospital (Southern Command) Pune 411 040, Maharashtra; and Department of Otorhinolaryngology, and #Department of Surgery, Army Hospital (Research & Referral), Delhi Cantt, New Delhi 110 010, India.

Received: October 03, 2010;
Initial review: October 07, 2010;
Accepted: October 28, 2010.
 

We describe a case of corrosive tracheo-esophageal fistula following button battery ingestion in a 1-year old nonverbal pediatric patient. The delay in diagnosis was caused by failure to obtain correct history and failure to detect opacity of the battery in the neck at the first visit. The large fistula was successfully treated with division and repair with non absorbable sutures, with interposition of strap muscles between separated trachea and esophagus.

Key words: Button battery, Corrosive ingestion, Ingestion, Tracheo-esophageal fistula.

Tracheo-esophageal fistula following a foreign body impaction in the esophagus is a rare and serious complication. We report consequences of an unrecognized button battery impaction in the esophagus, which resulted in tracheo-esophageal fistula formation and was not diagnosed for more than 18 days due to masquerading of button battery shadow by haziness of associated pneumonia.

One year old child was taken to a private practitioner by the parents for sudden onset of hoarseness of voice. He was treated as a case of acute laryngitis. When symptoms of high grade fever, cough, change in voice and drooling persisted for 10 days, baby was brought to the emergency room of a peripheral hospital. The chest radiograph revealed hazy opacities all over both lung fields with unclear cervical region. A diagnosis of acute laryngotracheobronchitis was made and patient treated accordingly. However, patient was not maintaining saturation and developed cyanosis. He was placed on ventilatory support along with broad spectrum antibiotics and other supportive measures. Patient showed signs of improvement after 48 hours and was extubated after 72 hours. Even after extubation patient did not show expected improvement. He had persistent excessive drooling of saliva with increased cough on swallowing and had episodes of desaturation. On 18th day of illness a fresh chest skiagram showed a hitherto unnoticed round opacity in the neck region (Fig. 1). A possibility of foreign body impacted in the esophagus was considered. Review of old skiagram of chest, the same opacity was now be discerned. The foreign body was extracted with the help of a rigid esophagoscope. It was a button battery of 1.5 cm diameter from a toy electronic harmonium. The symptoms persistently increased even after removal of button battery. Patient was transferred to our centre with a provisional diagnosis of esophageal stricture. Contrast study revealed spill of dye in the lung fields. A diagnosis of acquired tracheo-esophageal fistula secondary to button battery impaction was made. A upper gastrointestinal endoscopy revealed a large wide fistula at the level of thoracic one vertebrae. The endotracheal tube was clearly visible from the esophageal side. In view of wide fistula in a symptomatic child, decision of primary closure of the fistula was taken. The fistula was divided and repaired with non absorbable sutures with interposition of strap muscles between separated trachea and esophagus. He was kept on elective ventilation for 48 hours. Post operative period was uneventful.

Fig. 1 Skiagram chest showing appreciable button battery shadow in the neck region on 18th post-ingestion day.

In our patient, a wide tracheo-esophageal fistula developed due to the presence of impacted foreign body for 20 days. In this child, button battery must have lodged or impacted for tissue damage to occur.　The esophagus is especially susceptible to foreign body retention due to its several anatomic areas of narrowing and weak peristalsis [1,2].　 The tissue damage that result from contact with charged battery is a chemical burn caused by production of sodium hydroxide (cathode) and hydrochloric acid (anode) generated from electric current passing through physiologic electrolyte solution [3]. Failure to recognize or appropriately manage a foreign body in the oesophagus may lead to complications and occasional mortality. Management approaches include endoscopic or open surgical repair. Unfortunately, these procedures can be complicated by high rates of recurrent laryngeal nerve injury, tracheal stenosis, recurrent fistula and significant patient mortality. These fistulae can be managed conservatively by use of esophageal rest to permit closure by secondary intention [4]. However, we did a primary repair of tracheo-esophageal fistula with interposition of strap muscles of neck as we found on upper gastrointestinal endoscopy that the margins of fistula were healthy and the fistula was very wide, which was unlikely to close spontaneously.