The study by Philteos et al in this issue of JAMA Otolaryngology–Head & Neck Surgery is a systematic review of published cases of airway injury among pediatric patients who ingested button batteries (BBs). Although these types of severe complications associated with BB ingestion have been previously reported, to date this is the largest review focused on airway injuries. Given the direct proximity of the esophagus and the trachea, airway injury is a possible risk in cases of BB ingestion. The authors' review of the literature and data from the National Capital Poison Center (NCPC) database yielded 195 cases total. The mean age at BB ingestion was 17.8 months, and the mean time between ingestion and removal was 5.8 days. The duration of impaction is difficult to precisely determine because many ingestions are unwitnessed and have a delayed diagnosis. Button batteries at least 20 mm in diameter (with lithium chemistry) are more likely to become impacted in the pediatric esophagus, but smaller BBs (including those with nonlithium chemistry) also pose a substantial risk; 11% of the injury cases with known BB diameters in this report involved BBs smaller than 20 mm, with the smallest diameter being 10 mm. Tracheoesophageal fistula (TEF), a life-threatening complication of BB ingestion, was found to be the most common airway injury (79%). Most TEFs required surgical management, and all 14 deaths reported TEF involvement. Other airway complications found included unilateral and bilateral vocal cord paralysis, subglottic stenosis, tracheal stenosis, and tracheomalacia. The use of injury mitigation strategies before or after BB removal was not assessed in this study, which is limited by the known underreporting of these cases to any data source. This review by Philteos et al describes complications from BB ingestion s associated with airway injury, invaluably highlighting a significant source of pediatric morbidity and mortality.
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