Teaching Case

The patient was admitted to the hospital with a diagnosis of recurrent chronic sinusitis not responsive to antibiotic treatments. No inhalation of foreign object was reported in the clinical history. First physical examination was performed and did not reveal remarkable alterations.

To evaluate nasal sinuses, Computed Tomography (CT) without intravenous contrast agents was carried out.
CT examination showed a formation of about 1.5cm with smooth margins and rounded shape in the anterior third of nasal septum cartilage, which appeared damaged (Figures 1a, b; 2a, b).
High density values (>3000HU), superior to those obtained by measuring dentine density, was compatible with metallic material and supported the hypothesis of a foreign body.
CT scout was helpful, demonstrating that this body was composed by two concentric discs with different diameters (Figure 3). This morphology was highly suggestive of a button battery.
Further information about the connection between body and cartilage and bone septum was obtained by 3D reconstructions (Figures 4a, 4b).
Surgical operation was proposed, aimed at removing the object and rebuilding the damaged tissue.
The extraction gave confirmation of a button battery. Retrospectively it was possible to assume that the battery had been inhaled by the child and had caused septum necrosis.

Nasal foreign bodies (NFBs) are common in children. In the learning period they have a natural tendency to put things into face orifices. The highest incidence of NFBs is between 2 and 5 years.
The button batteries represent a growing danger: their small size and brilliant appearance make them attractive to children. [1]
The usual route of entry is through nasal cavities with stop at the level of the anterior third of the nasal passages, under the inferior turbinate or between the middle turbinate and nasal septum.
Aetiology of tissue damage appears to be threefold: leakage of the battery contents with direct corrosive damage, direct current effects on the mucosa, and less likely, simple pressure necrosis.
The button batteries contain different materials, alkaline (sodium hydroxide, potassium oxide, mercury, zinc, silver) within a metal capsule. A plastic gasket separates the positive from the negative. The humidity within the nasal cavity will cause corrosion of the capsule with liberation of alkali content, which causes a chemical burn of the surrounding mucosa. [2] In turn, the battery contact with mucosa generates a low voltage between two poles, causing electrical and thermal burns.
NFBs diagnosis is generally performed either after the direct observation of the object/battery insertion into the nose or when the child is brought for evaluation of a unilateral, purulent rhinorrhoea. Moreover, discovery may be incidental when head or sinus X-rays or Computed Tomography (CT) is obtained for a seemingly unrelated problem such as evaluation of sinusitis or orbital cellulitis.
In severe cases button batteries may produce mucosal turbinate and septal ulceration in 3-6 hours. Necrosis of inferior turbinates usually occurred by 24 hours. Inferior meatus ulceration, saddle deformities, chondritis and atrophic rhinitis may ultimately result.
There is some evidence that use of saline or vasoconstrictors may provide electrolytes that increase necrosis from button batteries. Therefore these should not be instilled to facilitate physical examination until X-rays exclude button battery foreign body. CT cost and possible requirement for sedation make it less desirable as screening test, but it is mandatory in cases of doubt.
Emergency department management for button battery removal should include proper sedation and immobilisation of the patient, followed by careful suctioning of any pus and blood.
Dislodgment, debridement, and irrigation may best be accomplished in the operating room under general anaesthesia. Immediate placement of stents for severe necrosis and reconstructive surgery may be necessary. [3]