Nasal foreign body and button-battery injury — structured clinical encounter

Candidate brief

You are the paediatric registrar in the emergency department. A two-year-old boy is brought in after a button battery went missing from a remote control. He is well and afebrile, but on anterior rhinoscopy a shiny metallic disc is wedged firmly against the right side of the nasal septum. He ate 30 minutes ago, with no bleeding disorder and no prior removal attempts. [3]

Task

Justify the emergency-removal decision and the fact that fasting status does not delay it, explain the mechanism of septal injury, perform or describe the direct-vision removal with the appropriate instrument, and outline the second-battery check and ENT referral after removal. Be prepared to teach the family household battery-safety advice. A second child — a four-year-old with a unilateral foul-smelling blood-stained discharge and a smooth round bead — will then be introduced for contrast. [5]

Discussion anchors

• Emergency decision: a button battery in the nose is a time-critical emergency removed immediately under direct vision without waiting for fasting, because alkaline liquefactive necrosis begins within one to two hours; theatre and ENT for the uncooperative or embedded case, with topical decongestant and anaesthesia beforehand. [3] [5]
• Mechanism: electrolysis at the negative pole generates hydroxide ions, the tissue turns alkaline and undergoes liquefactive necrosis, compounded by thermal injury from the local current and pressure necrosis from tight contact; damage begins within one to two hours and septal injury can develop within hours. [6]
• After removal: re-inspect for a second battery and for septal injury, irrigate the cavity, consider a topical neutralising agent (medical honey or a carbomer gel) as an adjunct that does not substitute for removal, and refer to ENT for burn surveillance of evolving septal perforation, synechiae and stenosis. [7] [3]
• Imaging if uncertain: a plain lateral X-ray distinguishes a battery from a coin by the battery's step-off edge and double-ring (halo) sign; treat an unidentifiable round metallic object as a battery until proven otherwise. [9]
• Contrast case: the four-year-old with a unilateral foul discharge and a smooth bead is a routine case — a nasal foreign body until proven otherwise; remove by positive pressure (the parent's kiss) after topical decongestant, or a right-angle hook behind the bead rather than forceps, and never perform a blind finger sweep, which pushes the object toward the airway. [10] [11]