Clinical scenario: Sudden drooling | Stridor | Halo sign
A 2-year-old boy is brought to the emergency department with sudden drooling, refusal to eat, and repeated vomiting for the past 2 hours. His parents did not witness any ingestion but report that a remote control battery is missing. He is alert, has mild stridor, and is maintaining oxygen saturation.
A chest radiograph shows a round radiopaque foreign body with a double-rim (halo) sign at the level of the upper thoracic esophagus.
What is the most appropriate next step in management?
A. Observe for spontaneous passage
B. Give a carbonated drink
C. Endoscopic removal immediately
D. Repeat radiograph after 12 hours
E. Start proton pump inhibitor therapy
Correct answer & Explanation:
Correct Answer: C. Endoscopic removal immediately
Explanation
An esophageal button battery is a true pediatric emergency. Tissue injury begins within 2 hours due to the generation of hydroxide ions at the battery’s negative pole, causing liquefactive necrosis. Delayed removal can result in:
- Tracheoesophageal fistula
- Aortoesophageal fistula
- Esophageal perforation
- Massive fatal hemorrhage
The child should undergo immediate endoscopic removal.
Why the other options are incorrect
- A. Observe: Unsafe because esophageal batteries require emergency removal.
- B. Carbonated drink: Has no proven benefit.
- D. Repeat radiograph: Delays definitive treatment.
- E. Proton pump inhibitor: Does not prevent ongoing caustic injury.
High-Yield Pearl
The double-rim (halo) sign on an X-ray distinguishes a button battery from a coin and mandates emergency endoscopic removal.
