The Laryngoscope V C 2016 The American Laryngological, Rhinological and Otological Society, Inc. Basic Mechanism of Button Battery Ingestion Injuries and Novel Mitigation Strategies After Diagnosis and Removal Kris R. Jatana, MD; Keith Rhoades, BS; Scott Milkovich, PhD; Ian N. Jacobs, MD Objectives/Hypothesis: Button battery (BB) injuries continue to be a significant source of morbidity and mortality, and there is a need to confirm the mechanism of injury for development of additional mitigation strategies. Study Design: Cadaveric piglet esophageal model. Methods: Lithium, silver oxide, alkaline, and zinc–air BBs were placed in thawed sections of cadaveric piglet esophagus, bathed in normal saline. Severity of gross visual burn, pH, and temperature were recorded every 30 minutes for 6 hours. In other esophageal tissue specimens, the lithium BB was removed after 24, 36, and 48 hours and the site was irrigated with either 0.25% or 3% acetic acid. Separately, ReaLemon V R juice, orange juice, Coke V R , Dasani V R water, Pepsi V R , and saline were infused over a vertically suspended esophagus with a CR2032 lithium battery every 5 minutes for 2 hours while tissue tem- perature and pH were measured. Results: A gradual rise in tissue pH and minimal change in temperature was noted for all BBs. ReaLemon V R and orange juice applied every 5 minutes were most effective at neutralization of tissue pH with minimal change in tissue temperature. After BB removal (24, 36, 48 hours), irrigation of esophageal tissue specimens with 50–150 mL 0.25% acetic acid neutralized the highly alkaline tissue pH. Conclusions: BB appear to cause an isothermic hydrolysis reaction resulting in an alkaline caustic injury. Potential new mitigation strategies include application of neutralizing weakly acidic solutions that may reduce esophageal injury progression. Key Words: Button battery, foreign body, pediatric injury, battery injury, prevention. Level of Evidence: NA Laryngoscope, 00:000–000, 2016 INTRODUCTION Button battery (BB) ingestion injuries have been a known hazard to children for >30 years, but in the past decade, there has been a sharp rise in the incidence of severe injuries and death. 1 Given more consumer elec- tronics available on the market, there are numerous BB- containing products in every home. Too many otherwise healthy children have suffered serious injury or death from BBs. The BB problem is global and creates the “perfect storm” for severe esophageal injury: 1) ubiqui- tous in every home; 2) too easily removed from electronic devices; 3) large enough to get stuck in esophagus; 4) electrolyte-rich esophageal environment facilitates BB current/injury; 5) if unwitnessed, children may be ini- tially asymptomatic or have nonspecific symptoms mak- ing it difficult to make a diagnosis; and 6) rapid injury that occurs. Of children <6 years of age who ingested a 20-mm-diameter lithium BB, 12.6% experienced a major effect such as a perforation, tracheoesophageal fistula, fistulization into major vessels, esophageal strictures, vocal cord paralysis, or spondylodiscitis. 1 The National Battery Ingestion Hotline was created in 1982 to help gather case data, create triage algo- rithms, and identify methods of reducing this hazard. This hotline is available 24/7 and provides the public as well as health care providers with guidance when a battery-related injury is suspected. Updated statistics are available at www.poison.org/battery. On March 1, 1983, the U.S. Consumer Product Safety Commission issued a warning on BBs. The National Poison Data Sys- tem captures data from all U.S. poison control centers and has demonstrated a near seven-fold increase in BB injury severity between 2003 and 2010. Although 20-mm lithium BBs account for a majority of the severe injuries, it is known that smaller 1.5-V non-lithium BBs also have caused severe esophageal injuries and are large From the Department of Otolaryngology–Head and Neck Surgery, Nationwide Children’s Hospital and Wexner Medical Center at Ohio State University, Columbus, Ohio, U.S.A. (K.R.J.); Intertek Product Intel- ligence Group, Oak Brook, Illinois, U.S.A. (K.R., S.M.); Division of Otolar- yngology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, U.S.A. (I.N.J.); and Department of Otorhinolaryngology– Head and Neck Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A. (I.N.J.). Editor’s Note: This Manuscript was accepted for publication September 9, 2016. Presented at the American Broncho-Esophagological Association Meeting, Chicago, Illinois, U.S.A., May 18–19, 2016. This study was awarded the 2016 Seymour Cohen Award in Pedi- atric Laryngology and Broncho-Esophagology. K.R.J. serves as a medical consultant and provides expert witness testimony. K.R.J. and I.N.J. serve in leadership positions on the national Button Battery Task Force, affiliated with the American Academy of Pediatrics and American Broncho-Esophagological Association. The authors have no other funding, financial relationships, or con- flicts of interest to disclose. Send correspondence to Kris R. Jatana, MD, Pediatric Otolaryn- gology, Nationwide Children’s Hospital, 555 South 18th Street, Suite 2A, Columbus, OH 43205. E-mail: Kris.Jatana@nationwidechildrens.org DOI: 10.1002/lary.26362 Laryngoscope 00: Month 2016 Jatana et al.: Button Battery Ingestion Injuries 1