Endoscopic findings in 56 patients who ingested hair relaxer.
Ahsan S, Haupert M. Absence of Esophageal Injury in Pediatric Patients After Hair Relaxer Ingestion. Arch Otolaryngol Head Neck Surg. 1999;125(9):953-955. doi:10.1001/archotol.125.9.953
Copyright 1999 American Medical Association. All Rights Reserved. Applicable FARS/DFARS Restrictions Apply to Government Use.1999
To review the initial signs, symptoms, and endoscopic findings in children admitted to the hospital for ingestion of caustic hair relaxer.
Retrospective medical chart review of all children admitted to the hospital with a diagnosis of caustic ingestion from January 1, 1992, to June 30, 1997. Demographics, admission signs and symptoms, and operative findings were recorded from the medical records.
An urban tertiary care children's hospital.
Fifty-nine children (<3 years old) admitted to the hospital for ingestion of hair relaxers.
Two hundred nine patients were evaluated for possible caustic ingestion. Only 163 medical charts were available for review. Of these, 59 (36.2%) ingested hair relaxers. Initial signs and symptoms ranged from none to drooling and vomiting and second-degree oral cavity burns. Fifty-six patients (95%) underwent endoscopy, which revealed normal esophageal mucosa in 53 of them, mild erythema of the distal esophagus in 2, and mild esophagitis in 1.
In our experience, hair relaxer ingestion makes up a significant proportion of all children admitted to the hospital for caustic ingestion. No significant esophageal injury was associated with hair relaxer ingestion, suggesting that endoscopy may not be necessary in these patients. Alternative management is suggested. We believe that patients who ingest hair relaxer should be admitted to the hospital for observation if parents are thought to be unreliable, and should undergo endoscopy if they cannot tolerate oral intake. Asymptomatic patients may be cared for as outpatients if they demonstrate adequate oral intake.
MODERN management of caustic ingestion began with the introduction by Chevalier Jackson of the esophagoscope. His lobbying efforts were instrumental in the passing of the Federal Caustic Act in 1929, which provided for the labeling of poisons in caustic products. This was followed by the Federal Hazardous Substance Labeling Act in 1960, which was in response to widely available lye, and the Safe Packaging Act in 1970 after the introduction of liquid lye. Even with these legislations, caustic ingestion remained a significant public health problem.1- 4
Approximately 5000 to 26,000 cases of accidental caustic ingestion occur in the United States every year, mostly in children. The distribution is bimodal, with the second group consisting of older patients first encountered after suicide attempts. Incidentally, it is suspected that only 10% of such cases are brought to medical attention.2- 4
There are 2 main categories of caustic products: acids and alkalis. Ingestion of acids leads to coagulative necrosis with eschar formation preventing further tissue penetration. Ingestion of acids also causes less esophageal damage secondary both to the protection afforded by the slightly alkaline pH of the esophagus and to the resistance of the squamous epithelium to acids. The most vulnerable region is the antrum of the stomach. Alkalis are responsible for more severe caustic ingestion sequelae. They penetrate the esophageal wall by liquefactive necrosis, usually in areas of anatomic narrowing (eg, the cricopharyngeus, aortic arch, left mainstem bronchus, and diaphragmatic hiatus).1,3,5
The degree of injury is associated with the type of caustic agent ingested and the concentration and time of contact with tissue. The pH and amount of substance ingested also play a significant role. Results of experimental studies in rabbits indicate that the depth of injury varies with the concentration of lye. Even short exposure to substances with a pH of 12.5 or greater can result in significant injury. Also, exposure to liquid caustics is thought to cause more significant injury than exposure to powders or tablets secondary to specific gravity and the greater surface area affected. Exposure to solids causes severe pain, and solids are often trapped in oral or pharyngeal mucosal surfaces, limiting extension into the esophagus.1,5,6 In addition, Hoffman et al7 conclude that the titratable acid/alkaline reserve of a caustic agent correlates better than pH with esophageal injury.
Commonly ingested substances include bleaches, drain cleaners, disc batteries, toilet bowl cleaners, and detergents.6 Recently, reports of hair relaxer ingestion among children have increased.2,8 Hair relaxer is an alkaline product with a pH of 12 or greater that is used to straighten curly hair. It functions by denaturing structural proteins found in hair. Hair relaxers have a pleasant odor and are packaged attractively, making them likely candidates for accidental ingestion by children. The relaxer is usually calcium or lithium hydroxide combined with guanidine carbonate to form guanidine hydroxide with a pH of 12.5 to 13, which has the potential to cause significant esophageal damage.8 However, results of recent studies indicate that burns are limited to the oral cavity or face, with no significant esophageal burns. Most patients have drooling (73%-81%) or swollen lips or oral cavity burns (33%). No patients had unstable vital signs, stridor, or chest or abdominal complaints.2,8 However, many authors9,10 point out that there is no association between signs and symptoms and esophageal injury. Therefore, there has been an impetus to perform endoscopy on all patients with caustic ingestion.
Our current treatment for patients first seen with caustic ingestion is hospital admission and direct laryngoscopy with rigid esophagoscopy. The objectives of this study were to review the Children's Hospital of Michigan, Detroit, experience with treating hair relaxer as a caustic ingestant, to determine the incidence of ingestion and identify any significant injuries, and to determine whether rigid esophagoscopy is indicated in all pediatric patients seen for accidental hair relaxer ingestion. Intraoperative inspection of the airway and esophagus is a relatively safe procedure but is costly, potentially traumatic to the child and parents, and can lead to unnecessary hospital stays. Incidentally, Stannard11 reported 14 cases of perforation in 571 endoscopies when using a rigid endoscope.
This was a retrospective medical chart review of all patients evaluated for caustic ingestion at Children's Hospital of Michigan during a 5½-year period. Demographics, admission signs and symptoms, and operative findings were recorded from the medical records. Hospital course was also reviewed. Injuries were classified as first-degree (erythema, edema, superficial desquamation), second-degree (shallow ulceration, sloughing of mucosa), or third-degree (transmural injury, periesophageal extension) burns.
Between January 1, 1992, and June 30, 1997, 209 patients were evaluated for possible caustic ingestion. Of these, 163 medical charts were available for review. Fifty-nine (36.2%) of the patients were initially seen after ingestion of hair relaxers (Table 1). Essential demographic data are presented in Table 2.
Initial signs and symptoms ranged from none (11 patients) to second-degree oral cavity burns (2 patients). Most patients presented with first-degree lip burns (33 patients), drooling (28 patients), or first-degree oral cavity burns (15 patients) (Table 3). No patient had respiratory, chest, or abdominal complaints.
Fifty-six of 59 patients underwent endoscopy. Two patients were admitted to the hospital for observation only and were discharged within 23 hours. One patient underwent a barium swallow test, with normal results. Endoscopic findings are shown in Figure 1. Fifty-three of 56 patients had no esophageal findings, 2 had mild erythema, and 1 had mild esophagitis. No significant esophageal injury was found in our population. All patients tolerated sufficient oral intake and were discharged within 23 hours. The average operative and hospitalization cost was approximately $4300.
There have been many reports4,8 of hair relaxer ingestion in the pediatric population. Cox and Eisenbeis8 reported hair relaxers to be the most common caustic product ingested by children, composing 42.6% of all cases seen for evaluation at their institution. Gorman et al12 reported 28 cases of hair product ingestion, and Stenson and Gruber2 reported 11 cases of hair relaxer ingestion. We found 36.2% of cases of caustic ingestion to be related to ingestion of hair relaxers. Our series represents, to our knowledge, the largest reported in the English-language literature.
Our findings are consistent with others2,4,8 in that no significant esophageal injuries were associated with hair relaxer ingestion. Cox and Eisenbeis8 described 26 patients, with 24 (92%) undergoing endoscopy. Only 2 patients had first-degree esophageal burns. Of 7 patients who underwent endoscopy in the study by Gorman et al,12 none had any significant esophageal findings. Likewise, no patients in the study by Forsen and Muntz4 had severe burns of the upper aerodigestive tract after hair relaxer ingestion. Three of 10 patients who underwent rigid esophagoscopy had only mild erythema or edema of the aerodigestive tract. In addition, results of studies2 of caustic cosmetic product ingestion reveal that children who ingest hair products have burns limited to the face, oral cavity, or oropharynx.
In agreement with others,8 we believe that hair relaxers have less potency than indicated by their pH. The lack of significant injury found in our study possibly relates to the low titratable alkaline reserve (as described by Hoffman et al7), the small quantities ingested, and its semisolid nature, which can cause severe oral pain—thereby limiting the quantity ingested.
Because of a lack of significant injury found in our study and others, accidental hair relaxer ingestion should not be treated with the standard protocol of hospitalization and endoscopy. Articles13- 16 in the literature address conservative management of ingestion of potentially caustic products. For example, household bleach ingestion has been managed conservatively without serious sequelae. Hawkins et al14 reviewed 214 cases of caustic ingestion and found that all serious problems resulted from ingestion of lye or acid. They concurred with Yarrington15 that sodium hypochlorite household bleach does not cause significant esophageal injury and in accordance, performed endoscopy only in patients ingesting household bleach if they had dysphagia or suspected that another agent was ingested. Range et al16 suggested that observation and symptomatic treatment is recommended when bleach is ingested. Landau and Saunders17 also found no serious consequence and recommended symptomatic treatment for those who ingest bleach.
In conclusion, hair relaxer ingestion in the pediatric population should not be treated like ingestion of other potential caustic products. Its low titratable acid/alkaline reserve and lack of significant esophageal injury indicate that, in accidental ingestion, its potential to cause damage is minimal. Hair relaxer is a common caustic ingestant among children in an urban setting. Health care dollars can be saved and children would not undergo unnecessary procedures if alternate management were sought. Asymptomatic patients can be followed up as outpatients if parents are believed to be reliable. We recommend that all symptomatic children who accidentally ingest hair relaxer be admitted to the hospital for observation and subsequently undergo endoscopy if they cannot tolerate oral intake. Of course, any patient with unstable vital signs or who complains of or displays signs of chest or abdominal pain or discomfort should have appropriate radiological workup and surgical exploration if indicated.
Accepted for publication February 1, 1999.
Presented as a poster at a meeting of the American Society of Pediatric Otolaryngology, Palm Beach, Fla, May 12-13, 1998.
Corresponding author: Syed Ahsan, MD, 4941 Heather Dr, #105, Dearborn, MI 48126 (e-mail: firstname.lastname@example.org).