Niger J Paediatr 2019; 46 (3):148 – 151
Disk battery ingestion mimicking
acute tonsillitis in a Nigerian child:
A case report
Accepted: 17th September 2019
examination findings supporting a
dence of disk battery ingestion in
diagnosis of acute tonsillitis was
children. This is due to their in-
misleading, causing regrettable
Aigbe IC, Omo-Okhuasuyi G
creased use in electronic devices
delays in the diagnosis and man-
Nwaneri DU, Osarogiagbon WO
(including toys) commonly found
agement of this child, who subse-
Department of Child Health,
the home setting. Children be-
quently developed a tracheoe-
University of Benin Teaching
low the age of 6 years are mostly
hospital, Benin City, Edo State,
affected with peak incidence in
high index of suspicion by clini-
the ages of 1 to 3 years. Although
cians is needed especially in the
most disk batteries when ingested
non verbal child for early identifi-
pass through the gastro intestinal
cation and to prevent complica-
Olufemi P, Okugbo SU
tract harmlessly, they may be
tions. Increased awareness by par-
lodged in the oesophagus causing
ents and other care givers of the
University of Benin Teaching
hidden dangers of these innocuous
hospital, Benin City, Edo State,
within 4-6 hours of impaction due
-looking batteries in homes and
their corrosive nature. Impac-
legislation directing the need for
tion of foreign bodies may present
child safety locks on disk battery
with specific symptoms, non spe-
compartments of electronic gadg-
cific symptoms or may be asymp-
ets and toys will help in reducing
tomatic. We present an 11 month
the incidence of battery ingestion
old child in whom an ingested
cases in children.
disc battery had been lodged in
the oesophagus for 6 days prior to
Key words: Disk,
retrieval by rigid endoscopy. The
tion, mimic, Acute tonsillitis
presence of a clinical history and
may likely lodge at one of three areas of esophageal
Foreign body ingestion is common in children and oc-
(cricopharyngeus), the aortic arch and the level of the
curs mostly between the ages of 6months to 3 years.
lower oesophageal sphincter. The oesophageal impac-
Worldwide, coins are the most commonly ingested for-
tion of a disk battery is considered a surgical emergency
eign bodies. But with technological advancement, there
due to its rapidly corrosive nature (it can cause mucosal
has been an increase in the use of disk batteries to power
injury in as little as 1 hour of contact time) and must be
children’s toys, watches, calculators and remote control
Oesophageal perforation and
gadgets, with children accidentally ingesting disk batter-
tracheoesophageal fistula are common complications
These batteries may easily be removed from the
following long term impaction of disc battery
gadgets and considering the propensity of children be-
low the age of 4 years to put objects indiscriminately in
their mouths, their incomplete dentition and immature
Following oesophageal impaction of a foreign body,
30% of children may be asymptomatic.
swallowing coordination, these objects are easily swal-
ingestion occurs in a child yet to attain
may present with an initial bout of choking, gagging and
speech and in the absence of a witness to report the inci-
coughing which may be followed by excessive saliva-
dent, this may pose a diagnostic challenge to an unsus-
tion, dysphagia, refusal of feeds, vomiting, pain in the
pecting clinician due to varying clinical presentations.
neck, throat or sternal notch regions. Respiratory symp-
Most foreign bodies in the oesophagus move down the
toms such as stridor, wheezing, cyanosis or dyspnea
gastrointestinal tract and are passed out unhindered via
may be encountered if the foreign body impinges on the
for those trapped in the esophagus, they
larynx or the membranous posterior tracheal wall.
Cervical swelling, erythema or crepitations point to per-
grade fever (37.8 C). He weighed 10kg (100% of ex-
foration of the oropharynx or proximal oesophagus. Di-
pected for age and sex). His tonsils were enlarged (grade
agnosis have been initially missed by health providers in
III) and hyperaemic, with absence of exudates. There
about half of fatal cases due to no initial history of in-
was no excessive salivation. He was not dyspnoeic but
gestion and nonspecific presenting symptoms such as
had a respiratory rate of 62cycles per minute. His breath
vomiting, fever, lethargy, poor appetite, irritability,
sounds were vesicular and had widespread transmitted
wheezing, cough, and/or dehydration.
sounds. All other systems were normal. A diagnosis of
acute tonsillitis was made and he was placed on suspen-
Acute tonsillitis is inflammation of the pharyngeal ton-
sion cefuroxime and syrup ibuprofen on an outpatient
sils. It is a common infection in children, mostly be-
basis. However, two days later, he was brought to the
tween the ages of 3 to 7years. Viruses are mostly impli-
children’s emergency room with persistence of the vom-
as the cause but Group A Beta-haemolytic
iting, fever, refusal of feeds and worsening of the cough
(although the noisy breathing had ceased). On examina-
tion, he was acutely ill looking, febrile (38.4 C), not
Symptoms include fever, vomiting, sore throat, drooling
saliva, dysphagia, odynophagia, foul breath and poor
pale, not dehydrated and saturating at 96% in room air.
appetite. These symptoms are similar to some of those
was tachypnoeic (respiratory rate 68cycles per min-
that may be present in foreign body ingestion. Signs
ute), not dyspnoeic with vesicular breath sounds. All
include dry tongue, erythematous enlarged tonsils,
other systems were normal. He was then admitted with a
tonsillar or pharyngeal exudates, palatine petechiae and
diagnosis of Acute tonsillitis with persistent vomiting
tender cervical lymph nodes. Airway obstruction may
commenced on intravenous cefuroxime and gen-
manifest as mouth breathing, snoring, sleep disordered
ticin, and also placed on intravenous fluids. However,
breathing and sleep apnea.
after two days on admission, he had become pale, lethar-
Tonsillitis is a clinical diagnosis. Throat cultures are
gic and dyspnoeic with wide spread coarse crepitations.
done to detect bacterial causes. Viral cultures are often
Oxygen saturation remained 96% in room air. Chest
unavailable and are generally too expensive and slow to
radiography (anteroposterior and lateral views) done at
this point revealed a roundish opaque material in the
distal cervical oesophagus compressing the trachea.
Treatment of acute tonsillitis is largely supportive and
(Figures 1 and 2)
focuses on ensuring adequate hydration and caloric in-
take, also, controlling pain and fever. GABHS or other
Fig 1: A
bacterial infection requires antibiotic treatment.
showing a roundish opaque object in the oesophagus.
plain anteroposterior radiograph of the neck, chest and
abdomen, along with lateral views of the neck and chest
are paramount in evaluating a child with a history of
foreign body ingestion. The flat surface of a disc battery
the oesophagus is seen on the anteroposterior view
and the edge on the lateral view.
Treatment of oesophageal foreign body is by rigid oe-
sophagoscopy and removal of the foreign body, with an
endotracheal tube protecting the airway.
this article, we present a case of disc battery ingestion
an 11 month old infant who presented with features of
A.E, an 11 month old male (2nd of a set of twins) pre-
sented at the Outpatient Clinic of University of Benin
Fig 2: A
Teaching Hospital, Benin city, Edo State with a three
day history of sudden onset of persistent vomiting while
play, refusal to feed, fever and a two day history of
cough, intermittent noisy breathing and restlessness. He
had no previous history of admission. The twins are the
only children in a monogamous setting and the index
patient was under the supervision of a 10 year old rela-
tive when the symptoms started. Mother is a 35 year old
stay-at-home mum with secondary level of education
and his father, a 47 year old spare parts dealer with sec-
ondary level of education. The socioeconomic class of
the family as determined using the method described by
Oyedeji was III.
examination, he was acutely ill looking with a low
His packed cell volume was 19% for which he received
reported cases of disk battery ingestion in the United
States of America . But from 1985-2009,
blood transfusion (sedimented red blood cells). He also
had hypokalemia (2.5mmol/L) which was corrected. He
battery ingestions were
reported to the United States
National Poison Data
System and 13 (0.02%) of these
subsequently intubated and rigid oesophagoscopy
cases were fatal.
Although there is no National registry
was performed to remove the foreign body. Surgical
findings revealed inflammed and friable oesophageal
for cases of battery
ingestion in Nigerian children, cases
mucosa at the level of the thoracic inlet about 20cm
of disk battery
ingestion have been reported from Nige-
from the incisors.
Examination of the foreign body revealed a disk battery
The case presented is an 11month old child, which is in
25mm in diameter with signs of corrosion (Figures 3
keeping with previous reports in which the usual age
and 4). Post operatively, intravenous ceftriaxone and
group in which ingestion commonly occurs is 6months
metronidazole were administered. Nil per os was main-
Being a male toddler also agrees with the findings of
Okhaku et al
Fig 3 and 4. Anterior
2013 that male children are more af-
disk battery retrieved.
fected than females. This is probably due to the more
active and exploratory nature of boys in comparison to
their female counterparts, making them more prone to
foreign body ingestion. Inadequate child supervision
has also been linked to unintentional injuries including
foreign body ingestion. Some studies have shown that
supervision of young children by older children as
shown in the case presented is associated with an in-
creased risk of unintentional injury.
worldwide have consistently shown that children from
low socioeconomic class are associated with a higher
incidence of childhood accidental injuries and morbid-
However, in the case presented this may not
have played a role as the child was from a middle socio-
The size of ingested foreign bodies can determine the
Four hours post op, he developed stridulous breathing
likelihood of impaction. An ingested disk battery of
with drooling of saliva. A three day course of intramus-
20mm and above in diameter is associated with a high
risk of oesophageal impaction.
cular dexamethasone at 0.15mg/kg/dose 8hourly was
The battery ingested
administered. Symptoms resolved within 24 hours. Na-
our patient was 25mm in size.
sogastric tube feeding was commenced four days post
The thoracic inlet has been reported to be the narrowest
operatively and this was well tolerated.
point and the most common site of foreign body impac-
tion, as was the case in the patient presented.
However, seven days post operation, a trial of oral wa-
ter intake elicited a bout of severe coughing and vomit-
Unwitnessed cases in non-verbal children can easily be
ing. He developed respiratory distress with wide spread
mis-diagnosed causing delays as was the case in the
coarse crepitations a few minutes after the trial. A tra-
The non specific symptoms of vom-
cheo-oesophageal fistula with aspiration was suspected.
iting, fever and refusal of feeds also contributed to the
However, a barium swallow contrast study done re-
delay in diagnosis. These symptoms can be present in
vealed no stricture or defect suggestive of a tracheo-
many common childhood illnesses such as malaria and
oesophageal fistula or oesophageal perforation. Oral
acute tonsillitis. The presence of inflamed tonsils further
feeds were recommenced by the fifth week post-
lent credence to the diagnosis of acute tonsillitis further
operation. Due to the persistent cough, fever, and wors-
reducing the index of suspicion for a foreign body. Disk
ening of difficulty with breathing, barium swallow con-
battery ingestion being missed due to a diagnosis of
acute tonsillitis has previously been reported. It is pos-
trast study was repeated and it showed a tracheo-
esophageal fistula. Nil per Os was recommenced and a
sible that the lesion in the tonsils may have been due to
the recurrent vomiting or possibly the presence of the
gastrostomy tube for feeding was placed. The child is
presently being worked up for definitive management.
battery irritating the pharynx.
delay in diagnosis may lead to prolonged lodgement
the battery in the oesophagus, thereby increasing the
risk of complications associated with disk battery inges-
tion ranging from minor oesophageal burns, which can
The incidence of disk battery ingestion in the paediatric
lead to oesophageal strictures to trachea-oesophageal
fistula, and even aorto-oesophageal fistula.
age group is on the rise, due to its use by the growing
number of portable electronic devices. This has been
Following removal of the disk battery, his parents on
noted by various researchers.
Prior to 1983, there were
hindsight recalled that he often played with a remote
control, powered by a lithium disk battery which had
immense danger to children in our modern day setting.
become missing from its battery compartment in the
Preventing battery ingestion and limiting the dangers
remote, prior to the onset of their child’s symptoms. The
inherent in their ingestion can be achieved by multiple
battery compartment had an extremely poor child tamper
interventions. An important intervention is ensuring that
proof measure (clip lock) which is an important risk
children do not have access to them. In homes, parents
factor with battery ingestion in children.
caregivers must be educated on the dangers disk
batteries pose to children and must keep them far out of
The use of plain radiograph in determining the location
their reach and disposed off safely. Children’s playtime
and the type of foreign body in the digestive tract proved
should always be supervised by a grown up. Once inges-
invaluable in making an accurate diagnosis in this case.
tion of a disk battery has occurred or is suspected, care-
The findings of other researchers have attested to this.
givers must ensure that the child is taken to the emer-
the retrieval of an oesophageal foreign body, the pro-
gency room immediately.
cedure commonly employed is the use of rigid oe-
sophgoscopy, which was used in the removal of the for-
Clinicians must have a high index of suspicion, be able
body in this patient.
Oesophagoscopy may be
make a prompt diagnosis and ensure quick retrieval of
associated with iatrogenic dental injury, laryngeal injury
the battery to prevent the devastating complications
with voice change, oesophageal perforation with bleed-
from the corrosive agents in the battery. Clinicians
ing, aortic rupture which may lead to aortoesophageal
should also consider possible foreign body ingestion in
Oesophageal perforation may cause medi-
non verbal children whose response to standard manage-
astinitis and fulminant sepsis, which may lead to death.
ment of acute tonsillitis is suboptimal. The government
can play a major role in preventing the potential hazards
The patient unfortunately developed a tracheoesophag-
battery ingestion by ensuring that manufacturers
eal fistula, a common complication with prolonged
make packaging of new batteries more secure and all
lodgement of an ingested disc battery.
battery packs to be labelled boldly with the warning
away from children”. Also, the government can
ensure that manufacturers of electrical devices make
their disk battery compartments child proof by requiring
tool to open the compartment. A National registry for
cases of foreign body ingestion should also be encour-
With the widespread use of disc batteries and its easy
aged to formulate better management strategies and thus
availability in homes, they no doubt pose a source of
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