Journal of Pediatric Surgery Case Reports 36 (2018) 36–39

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Journal of Pediatric Surgery Case Reports

journal homepage: www.elsevier.com/locate/epsc

Double button battery ingestion – The “macaroon” sign T

a,∗ b b c a
Emma Littlehales , Eric Levi , Nikki Mills , Russell Metcalfe , James Hamill
a
Department of Paediatric Surgery, Starship Child Health, Auckland, New Zealand
b
Department of Paediatric Otorhinolaryngology, Starship Child Health, Auckland, New Zealand
c
Department of Paediatric Radiology, Starship Child Health, Auckland, New Zealand

ARTICLE INFO ABSTRACT

Keywords: Button (Disc) battery impaction in the esophagus is a time critical presentation with significant associated
Button battery morbidity and mortality. We present the case of a 15-month old boy with an unwitnessed foreign body ingestion,
Caustic ingestion and who was subsequently found to have two ingested lithium button batteries, which were lodged at the upper
Esophageal injury esophagus, distal to cricopharyngeus. We discuss the “macaroon sign” of two button batteries lying parallel to
Foreign body ingestion
one another, with both positive poles facing each other, as this may be an unusual barrier to urgent identification
Electrical injury
of the impacted foreign body as batteries.
Acetic acid
0.25% acetic acid was used as a neutralising agent at the time of button battery removal (8 h after ingestion),
based on published evidence that this effectively decreases tissue pH and mitigates the severity of the injury in
animal models, whilst not increasing ambient tissue temperature as once thought [4]. Our patient had a sig-
nificantly better clinical outcome than predicted from the severity of the burn at time of button battery removal,
suggesting acetic acid used topically is a safe adjunct treatment of impacted ingested button batteries and may
reduce the likelihood of serious long term sequelae.

1. Case
A 15 month old boy presented to the Children's Emergency
Department with a history of possible unwitnessed foreign body in-
gestion. His parents gave a history of a sudden choking episode at ap-
proximately 2pm that afternoon while the child was on his own. He was
found to be distressed and coughing, was administered first aid by his
parent in the form of back blows, causing him to vomit. He then pro-
ceeded to have several further episodes of vomiting when given food
and drink throughout the afternoon, and was noted to be drooling at
times.
On presentation to the Children's Emergency Department, 7 h fol-
lowing ingestion, he was drooling but had no airway compromise. Neck
radiographs demonstrated a foreign body in the esophagus, although
the diagnosis of button (disc) battery was not immediately recognized
because of the atypical profile of the foreign body on the lateral film
(Figs. 1 and 2).
The child was then taken immediately to the operating theatre,
intubated, and with a rigid esophagoscope and optical grasping forceps,
the surgeon removed two button batteries from the upper esophagus
just beyond cricopharyngeus. The esophagus was further examined and
severe circumferential erosion of the upper esophageal mucosa with
marked mucosal oedema above and below the area of necrosis (Fig. 3).
There was no obvious esphageal perforation. The foreign bodies were
both 20 mm lithium/manganese dioxide 3 V button batteries found
with the positive poles facing each other [3] (Fig. 4). The estimated
time from ingestion to removal was 8 h. A rigid bronchoscopy was then
performed to assess the airway, showing erythematous trachealis
muscle in the upper third of the trachea but no erosion. Once the pa-
tient was re-intubated again with a cuffed endotracheal tube, a rigid
esophagoscope with a suction channel was passed into the upper eso-
phagus. The esophagus was lavaged with 100 mls of 0.25% acetic acid
via the suction channel. At completion of the procedure a nasogastric
feeding tube was gently passed into the stomach under endoscopic vi-
sion.
The child made an uneventful recovery. He was made nil by mouth
for a week and was given a course of post operative antibiotics for post
operative fevers. There was no clinical evidence of esophageal per-
foration. A contrast study on day 7 post ingestion demonstrated con-
trast passing freely through the esophagus and into the stomach with no
esophageal leak or stenosis identified (Fig. 5). He was commenced on
full oral diet, which he tolerated well, and was discharged at day 9 post
injury. On review at 6 weeks post injury, he was tolerating a soft diet
well, but was having some mild dysphagia with solids, and will be
further assessed with an oral contrast study at 3 months post injury.

∗
Corresponding author. Department of Paediatric Surgery, Starship Children's Hospital, 2 Park Rd, Grafton, Auckland 1023, New Zealand.
E-mail address: elittlehales@doctors.org.uk (E. Littlehales).

https://doi.org/10.1016/j.epsc.2018.06.013
Received 8 June 2018; Received in revised form 21 June 2018; Accepted 23 June 2018
Available online 28 June 2018
2213-5766/ © 2018 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/BY-NC-ND/4.0/).
E. Littlehales et al.
Fig. 1. AP view of a neck and chest, demonstrating an impacted button battery
lodged at the cervical thoracic junction at the level of medial clavicles.
2. Discussion
This case highlights several key points in the diagnosis and man-
agement of button battery ingestion. Foreign body ingestion is rela-
tively common [2,3] and 70–80% of cases of foreign body in the upper
GI tract are seen in children under 15, of which the highest incidence is
seen in children between 1 and 3. The most common site of impaction
in children is the upper esophageal sphincter [1,2,7]. Significant com-
plications can arise when a button battery becomes impacted in the
esophagus, however those that pass through the GI tract without be-
coming impacted usually do so without incident [1]. Those that do
become lodged become a time critical emergency, as complications can
occur in as little as 2 h. Potentially fatal complications (including tra-
cheo-esophageal and aorto-esophageal fistula) have been reported and
can present in a delayed fashion, up to 18 days post removal [5]. The
most common long term complication is esophageal stenosis created
from the circumferential luminal injury, often requiring serial dilata-
tions and in severe cases excision of the scarred segment of esophagus.
Other less common but severe complications include recurrent lar-
yngeal nerve injuries, salivary leak into the neck and mediastinitis. For
these reasons, emergent endoscopic removal is the recommended
treatment of an impacted button battery [1,3,5,7], and early identifi-
cation of these patients is paramount.
The characteristic X ray imaging of a button battery in the upper
esophagus is of a well defined densely radio-opaque cylindrical object
with a double ring in an AP view, and a bilaminar appearance in a
lateral view. This is important to differentiate them from a coin, which
has a more uniform structure and only a single ring [2,3]. In this case,
the double ring can be easily seen on the AP (Fig. 1), but the char-
acteristic lateral appearance is not present, due to the presence of two
batteries lying next to each other (Fig. 2). This unusual appearance led
to some initial uncertainty as to the nature of the foreign body that had
been ingested. In addition, the importance of the lateral view high-
lighting two foreign bodies is noted, as it is possible to miss a second
object after the first had been removed, especially in the context of
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Journal of Pediatric Surgery Case Reports 36 (2018) 36–39
Fig. 2. Lateral view of neck and thoracic inlet, demonstrating the “macaroon
sign” of two parallel button batteries.
oedema or bleeding which can make the esophagoscopy technically
difficult. In addition, the lateral is key in localising the foreign body to
the esophagus, distinguishing it from inhaled foreign bodies located in
the trachea. It also help to assess tracheal narrowing from inflamma-
tion, and to assess for the bilaminar “step off” sign in the case of a
battery, which may be easier to identify than the double ring sign seen
on the AP.
The key mechanism of injury in the esophagus is due to electrical
injury. Mucosal contact on both sides of a battery create a flow of
electrical current, causing generation of sodium hydroxide in tissues
and leading to local hydrolysis and liquefactive tissue injury with a
significant increase in pH of the surrounding tissue [3–6]. It is also
thought that the alkalotic liquefactive injury continues to occur hours
after the battery has been removed [6]. In this case, as can be seen in
the lateral view, the two positive poles are touching each other, with
the two negative poles being in contact with the esophageal mucosa,
leading to an image with the macaroon shape described, with a wider
middle section, a small line of separation between the two batteries,
and a smaller diameter at the outside edge (Fig. 2).
The largest study into button battery ingestion found that the most
important predictors of significant complications include battery dia-
meter of > 20 mm, age < 4 years and ingestion of > 1 battery, all
present in this case [5]. 12.6% of all patients under 6 who ingest a
button battery of > 20 mm diameter will experience a serious compli-
cation. It was also noted that clinicians missed the diagnosis of button
battery ingestion in 27% of cases, and 92% of fatal presentations were
unwitnessed, most in non-verbal children. It has also been found that
outcomes are worsening, likely due to the increasing use of the 20 mm
lithium ion batteries in modern households [5,7].
A novel aspect of this case has been the use of acetic acid to lavage
the esophagus post removal of the batteries to mitigate the severity of
the burn. A recent paper by Jatana et al. [4] has looked into the me-
chanism and treatment of the esophageal injury left following the re-
moval of a button battery. A concern with using neutralising agents has
been a suggestion that this may raise the tissue temperature of the area
and cause a thermal injury in the reaction. Using animal models, no
significant change in temperature of esophageal tissue was seen with
E. Littlehales et al. Journal of Pediatric Surgery Case Reports 36 (2018) 36–39

Fig. 3. Rigid oesophagoscopy following removal of both button batteries demonstrating circumferential esophageal burns, pre and post irrigation with acetic acid.
Still image from video.

Fig. 4. The batteries retrieved from the patient. Corrosion can be seen on the
surface of both, along with the identifying marks.

instillation of 0.25% acetic acid, and the pH of tissues was seen to de-
Fig. 5. Contrast study at day 7 post ingestion, showing no contrast leakage or
crease from a highly alkaline 11–12, down to a more neutral pH of 6, as
stenosis.
well as reducing visible eschar.
The most important factor in treating esophageal button batteries is
time to diagnosis and extraction. The injury free window in which a Patient consent
button battery can be removed with no minimal complications is < 2 h
[5,6], and increasing severity is seen with increasing time of contact Formal written consent was obtained from the child's parents to
[3,5]. In an animal model, perforation was seen in every case of a publish this case report, including consent for publication of all imaging
battery being in place for over 12 h [6]. This case demonstrates the studies and intraoperative photographs and videos.
importance of a high index of suspicion for unwitnessed ingested for-
eign bodies in a young child who presents with choking and vomiting.
The associated imaging should help guide treating physicians towards a Declarations of interest
correct diagnosis. An important adjunct treatment method with 0.25%
acetic acid lavage to neutralise the mucosal alkalotic injury has been None.
demonstrated in this case to be safe and potentially effective in redu-
cing local and long term complications. This has significant implica-
tions for treatment of ingested, inhaled or nasal impacted button bat- Funding
teries.
No funding or grant support.

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E. Littlehales et al. Journal of Pediatric Surgery Case Reports 36 (2018) 36–39

Authorship References

All authors attest that they meet the current ICMJE criteria for [1] Munoz JC. Foreign body ingestion. BMJ Best Practice 2017.
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Conflict of interest [3] Sinclair K, Hill ID. Button and cylindrical battery ingestion: clinical features, diag-
nosis and initial management UpToDate 2017.
[4] Jatana KR, Rhoades K, Milkovich S, Jacobs IN. Basic mechanism of button battery
The following authors have no financial disclosures: EL, EL, NM, ingestion injuries and novel mitigation strategies after diagnosis and removal.
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[5] Litovitz T, Whitaker N, Clark L, White NC, Marsolek M. Emerging battery-ingestion
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Appendix A. Supplementary data [6] Völker J, Völker C, Schendzielorz P, Schraven SP, Radeloff A, Mlynski R, Hagen R,
Rak K. Pathophysiology of esophageal impairment due to button battery ingestion.
Int J Pediatr Otorhinolaryngol 2017;100:77–85.
Supplementary data related to this article can be found at http://dx. [7] Litovitz T, Whitaker N, Clark L. Preventing battery ingestions: an analysis of 8648
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