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LETTERS TO EDITOR
Year : 2020  |  Volume : 21  |  Issue : 2  |  Page : 165-166
 

Iatrogenic tracheoesophageal fistula after button-battery ingestion


1 Department of Anaesthesiology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
2 Department of Anaesthesiology, S.N. Medical College, Jodhpur, Rajasthan, India

Date of Submission29-Feb-2020
Date of Acceptance12-Mar-2020
Date of Web Publication19-Sep-2020

Correspondence Address:
Dr. Pooja Bihani
Department of Anaesthesiology, S.N. Medical College, Jodhpur - 342 005, Rajasthan
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/TheIAForum.TheIAForum_16_20

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How to cite this article:
Vaishnavi B D, Bihani P, Kumar R, Bhatia P, Sayal R, Jaju R. Iatrogenic tracheoesophageal fistula after button-battery ingestion. Indian Anaesth Forum 2020;21:165-6

How to cite this URL:
Vaishnavi B D, Bihani P, Kumar R, Bhatia P, Sayal R, Jaju R. Iatrogenic tracheoesophageal fistula after button-battery ingestion. Indian Anaesth Forum [serial online] 2020 [cited 2020 Oct 24];21:165-6. Available from: http://www.theiaforum.org/text.asp?2020/21/2/165/295323




Sir,

Spectrum of presentation after button-battery ingestion (BBI) may vary from harmless to devastating injuries or even death.[1],[2] We present the case of a 1-year-old child, posted for diagnostic esophagoscopy after BBI and instrumentation led to increase in the size of a small tracheoesophageal fistula (TEF) that hampered ventilation. The child had a history of BBI 2 months back. As the child was asymptomatic and the X-ray was normal, the BBI was thought to have passed beyond the gastroesophageal junction. The parents were reassured and the child was discharged. Subsequently, the child developed recurrent cough and nonresolving fever, for which he was prescribed antibiotics and bronchodilators. The child did not respond to the treatment but was maintaining saturation on room air, and chest X-ray and computed tomography (CT) of the chest were inconclusive of any pathology. Esophagoscopy was planned suspecting TEF.

After anesthesia induction, the child was intubated with a size 4.0 cuffed tracheal tube. Adequate tidal volume was delivered on pressure control ventilation, with a pressure of 20 mmHg. Just after the insertion of rigid esophagoscope, ventilation became almost impossible. On manual ventilation, there was no chest rise and capnograph trace also disappeared, so immediately, the esophagoscope was removed and ventilation improved thereafter. Then, esophagoscope was reintroduced and we found a large TEF beyond the tip of the endotracheal (ET) tube which allowed even introduction of the esophagoscope and the carina was visible through the esophagoscope. Mucosa surrounding the TEF appeared friable and granulation tissue also led to little bleeding surrounding the TEF at the entry of esophagoscope. The surgeon could not find any foreign body impacted in the esophagus. It was suspected that the insertion of esophagoscope could have led to the conversion of small TEF into a large TEF [Figure 1]. The TEF was later repaired uneventfully.
Figure 1: Esophagoscopic view of large tracheoesophageal fistula

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Iatrogenic TEF can be caused by the ingestion of foreign body and corrosives, prolonged mechanical ventilation with ET tube or tracheostomy tube, prior esophageal surgeries, and indwelling stents. BBI leading to TEF is from direct pressure necrosis as well as release of local electronic current and alkali leakage.[1] Battery impaction may result in erosive esophagitis, TEF, esophageal stricture, spondylodiscitis, vocal cord paralysis due to recurrent laryngeal nerve paralysis, and aorto-esophageal fistula.[2],[3] TEF following the BBI may remain undiagnosed due to nonspecific symptoms such as fever, respiratory distress, poor feeding, and lethargy, therefore delaying the diagnosis and management. Rigid esophagoscope, chest X-ray, and CT of the chest can be helpful in diagnosis, but endoscopic examination remains a gold standard for diagnosis and planning further management. In the present case, the fistula was probably small sized initially, thereby allowing adequate ventilation through bag and mask and immediately after intubation but was iatrogenically converted into a larger TEF during esophagoscopy. The case highlights the importance of careful instrumentation of airway and esophagus after BBI to avoid iatrogenic injuries.

Informed consent

Parents have given consent for possible publication of the case.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that the patient's names and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Marom T, Goldfarb A, Russo E, Roth Y. Battery ingestion in children. Int J Pediatr Otorhinolaryngol 2010;74:849-54.  Back to cited text no. 1
    
2.
Bhosale M, Patil S, Aathwale H. Impacted button battery causing acquired tracheoesophageal fistula in a 2-month-old infant. J Clin Neonatol 2016;5:268-70.  Back to cited text no. 2
  [Full text]  
3.
Ettyreddy AR, Georg MW, Chi DH, Gaines BA, Simons JP. Button battery injuries in the pediatric aerodigestive tract. Ear Nose Throat J 2015;94:486-93.  Back to cited text no. 3
    


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