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This observation reports a pediatric case of spontaneous resolution of tracheoesophageal fistula caused by button battery ingestion. Button battery ingestion in children is a common problem, and it can cause clinically significant morbidity and mortality. Complications including tracheoesophageal fistula are rare but serious if the battery is not removed early. Our purpose is to emphasize the importance of the conservative management prior to surgical intervention to allow possible spontaneous closure.
Report of a Case
An 18-month-old girl, with a history of accidental button battery ingestion removed after 48 hours endoscopically, presented to an emergency department with dysphagia for solids, violent coughing bouts, tachypnea, and drooling.
The physical examination showed that her weight was 10.5 kg (in the 25th percentile) and that her temperature was 39°C. Chest auscultation revealed bronchial rales in both lung fields. The endoscopic assessment (esophagoscopy and tracheoscopy) and a computerized axial tomography (CT) scan of the chest with 3-D reconstruction (Figure 1) showed a large tracheoesophageal fistula (TEF)(15 mm in diameter) at the D1 level.
A gastrostomy feeding tube was then placed under endoscopic guidance. The patient was scheduled for repair of the TEF with an esophageal stent endoscopically 3 weeks later but a resolution of the TEF was found without need for any therapy.
At a 1-year follow-up, she remained asymptomatic, on a regular diet, and an esophagram (Figure 2) showed no evidence of stricture or residual TEF.
Button battery ingestion can cause significant morbidity and mortality, especially when the button is stuck in the esophagus. Owing to different mechanisms, it may cause local damage and necrosis.1 The generation of the external electrolytic current can hydrolyze tissue fluids and produce hydroxide at the battery's negative pole. Batteries must be removed urgently to limit such potential complications as perforation, TEF, esophageal strictures, vocal cord paralysis, spondylodiscitis, and hemorrhagic complications.2 The TEF is detected in most cases during esophagoscopy and CT scan. If a fistula is seen, the child should not be fed, and intravenous antibiotics should be initiated in case there is a suspicion of mediastinitis.
Various treatment modalities have been described for acquired TEF and there is no consensus.3 Conservative treatment with esophageal stents can be tried if there is no severe sepsis, pneumothorax, or a pneumomediastinum.
Only a few cases of spontaneous closure of the TEF have been reported, although the rate may be higher and just not reported.4,5 Conservative treatment has usually been tried for foreign bodies which have passed the esophagus. For our patient, it took 3 weeks for fistula to heal and close.
We believe that this acquired TEF was caused by button battery ingestion. If the esophagus is allowed to rest for 4 to 10 weeks, it has a chance of healing, which can prevent multistage operation procedures. Education of parents about the potential dangers of button battery ingestion is critical.
Corresponding Author: Yasmine Houas, MD, Department of Pediatric Surgery “A”, Children Hospital Tunis, Tunis El Manar University, 15 Ibn Rachic St, 1064 Hammam Chatt Ben Arous, Tunisia (firstname.lastname@example.org).
Published Online: May 19, 2016. doi:10.1001/jamaoto.2016.1006.
Conflict of Interest Disclosures: None reported.
Houas Y, Sahli S, Fitouri F, Ben Salah M, Hamzaoui M. Spontaneous Resolution of a Tracheoesophageal Fistula Caused by Button Battery Ingestion. JAMA Otolaryngol Head Neck Surg. 2016;142(6):609–610. doi:10.1001/jamaoto.2016.1006
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