10.14639/0392-100X-N2083
Objectives. In this study, the damage caused by button batteries (BB) trapped in the ear canal (EC) and strategies to reduce this damage before their removal were investigated in vitro. Methods. After four EC models prepared from freshly frozen cadaveric bovine ears were thawed, 3 V lithium BBs were placed in the channels. After a three-hour period of preliminary damage, nothing was applied to the first EC model, the second EC model underwent saline administration, the third EC model underwent boric acid administration, and the fourth EC model underwent the administration of 3% acetic acid. The voltage, tissue temperature, and pH of the BBs were measured. The BBs were removed at the end of the 24th hour, and the EC models were examined by a pathologist. Results. The greatest decrease in pH was detected in the fourth EC model in which acetic acid was administered. The depth of necrosis was 854 μm in the first EC model, 1858 μm in the second EC model, and 639 μm in the third EC model at the end of the 24th hour. No necrosis was detected in the fourth EC model. Conclusions. Lithium BBs can cause alkaline tissue damage in a short time in cadaveric EC models. pH neutralisation strategies appear to be experimentally successful under in vitro conditions.
text/xml
1827-675X
2083
en
Ayşe Çeçen
http://creativecommons.org/licenses/by-nc-nd/4.0
ACTA Otorhinolaryngologica Italica
mitigation strategy
Mechanism of ear canal button battery injury and strategies for mitigation of damage
Text.Serial.Journal
https://www.actaitalica.it/
43
Otology
2023-04-26
2022-03-22
2023-04-27
2023-04-27
149-154
1
Ayşe Çeçen
2023/04/26
10.14639/0392-100X-N2083
149
University of Health Sciences Turkey- Samsun Health Practices and Research Center, Department of Otorhinolaryngology
1827-675X
mitigation strategy
en
154
Mechanism of ear canal button battery injury and strategies for mitigation of damage
https://www.actaitalica.it/article/download/2083/966
43
ACTA OTORHINOLARYNGOLOGICA ITALICA 2023;43:149-154; doi: 10.14639/0392-100X-N2083




Otology


Mechanism of ear canal button battery injury
and strategies for mitigation of damage
Meccanismo di lesione della batteria a bottone del condotto uditivo e sperimentazione
di strategie di riduzione del danno
Gökhan Akgül1, Mehmet Eser Sancaktar2, Doğukan Özdemir 3, Mehmet Dursun Mehel1, Nesrettin Fatih Turgut1,
Ayşe Çeçen3
1
 University of Health Sciences Turkey, Samsun Health Practices and Research Center, Department of Otorhinolaryngology, Samsun,
Turkey; 2 Ankara Training and Research Hospital, Department of Otorhinolaryngology, Ankara, Turkey; 3 Samsun University, Faculty of
Medicine, Department of Otorhinolaryngology, Samsun, Turkey


SUMMARY
Objectives. In this study, the damage caused by button batteries (BB) trapped in the ear
canal (EC) and strategies to reduce this damage before their removal were investigated
in vitro.
Methods. After four EC models prepared from freshly frozen cadaveric bovine ears were
thawed, 3 V lithium BBs were placed in the channels. After a three-hour period of prelimi-
nary damage, nothing was applied to the first EC model, the second EC model underwent
saline administration, the third EC model underwent boric acid administration, and the
fourth EC model underwent the administration of 3% acetic acid. The voltage, tissue tem-
perature, and pH of the BBs were measured. The BBs were removed at the end of the 24th
hour, and the EC models were examined by a pathologist.
Results. The greatest decrease in pH was detected in the fourth EC model in which acetic
acid was administered. The depth of necrosis was 854 µm in the first EC model, 1858 µm
in the second EC model, and 639 µm in the third EC model at the end of the 24th hour. No            Received: March 1, 2022
necrosis was detected in the fourth EC model.                                                       Accepted: August 2, 2022
Conclusions. Lithium BBs can cause alkaline tissue damage in a short time in cadaveric
EC models. pH neutralisation strategies appear to be experimentally successful under in             Correspondence
vitro conditions.                                                                                   Gökhan Akgül
                                                                                                    University of Health Sciences Turkey, Samsun He-
KEY WORDS: Button battery, alkali necrosis, aural foreign bodies, mitigation strategy               alth Practices and Research Center, Department of
                                                                                                    Otorhinolaryngology, Kadıköy Mah. Park Sok. No:
RIASSUNTO                                                                                           199, PB: 55090, İlkadım, Samsun, Turkey
                                                                                                    Tel. +90 362 3111500. Fax +90 362 2778865
Obiettivi. In questo studio, sono stati studiati in vitro i danni causati dalle batterie a botto-
                                                                                                    E-mail: g.akgul-57@hotmail.com
ne (BB) intrappolate nel condotto uditivo (EC) e le strategie per ridurre questo danno nel
periodo di tempo intercorrente fino alla loro rimozione.
Metodi. Dopo che 4 modelli EC preparati da orecchi di cadavere bovino appena conge-                   How to cite this article: Akgül G, Sancak-
                                                                                                      tar ME, Özdemir D, et al. Mechanism of
lati sono stati scongelati, sono stati collocati BB al litio da 3 V nel canale. Dopo 3 ore di
                                                                                                      ear canal button battery injury and strate-
danno preliminare, non è stato applicato nulla al 1° modello EC, il 2° modello EC è stato             gies for mitigation of damage. Acta Otorhi-
sottoposto a somministrazione di soluzione salina, il 3° modello EC è stato sottoposto a              nolaryngol Ital 2023;43:149-154. https://doi.
somministrazione di acido borico, il 4° modello EC è stato sottoposto ad acido acetico al             org/10.14639/0392-100X-N2083
3%. Sono stati misurati il ​​voltaggio, le temperature dei tessuti e il pH dei BB. I modelli EC
sono stati esaminati da un patologo.                                                                © Società Italiana di Otorinolaringoiatria
Risultati. La maggiore diminuzione del pH è stata rilevata nel 4° modello EC in cui è stato         e Chirurgia Cervico-Facciale
somministrato acido acetico. Mentre la maggiore profondità di necrosi è stata osservata nel
2° modello EC, non è stata osservata necrosi nel 4° modello EC.                                                    OPEN ACCESS

Conclusioni. Le BB al litio possono causare danni ai tessuti alcalini in breve tempo nei            This is an open access article distributed in accordance with
modelli EC da cadavere. Le strategie di neutralizzazione del pH sembrano avere successo             the CC-BY-NC-ND (Creative Commons Attribution-Non-
                                                                                                    Commercial-NoDerivatives 4.0 International) license. The
sperimentalmente in condizioni in vitro.                                                            article can be used by giving appropriate credit and mentio-
                                                                                                    ning the license, but only for non-commercial purposes and
PAROLE CHIAVE: batteria a bottone, necrosi alcalina, corpi estranei uditivi, strategia di           only in the original version. For further information: https://
mitigazione                                                                                         creativecommons.org/licenses/by-nc-nd/4.0/deed.en




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G. Akgül et al.




Introduction                                                     2-cm-long segments that were approximately 1 cm in in-
                                                                 ternal diameter in the form of a ring after being thawed at
Ear canal (EC) foreign bodies occur quite frequently, es-
                                                                 room temperature (22°C) to preserve the integrity of the
pecially in the paediatric age group 1. Although EC foreign
                                                                 annular canal and skin. A 3 V lithium BB (CR927, positive
bodies, including button batteries (BBs), do not pose a seri-
                                                                 electrode manganese dioxide, negative electrode lithium,
ous problem, it is known that they can present in the form
                                                                 diameter 9.5 mm, thickness 2.7 mm) was placed inside
of ear discharge, otalgia, bleeding, tinnitus, dizziness, or
facial paralysis 2. The size of BBs has decreased as the size    each EC model with the negative pole in contact with the
of small devices such as household appliances, toys, watch-      skin (Fig. 1). All EC models were humidified externally
es and hearing aids has decreased. These high-energy BBs         with 1 puff of saline spray (pH 6.8) every 3 h for 24 h.
might easily attract children’s attention with their bright
colours and can become stuck in the EC 3.                        Ensuring the reaction of BBs in five EC models:
In current in vitro studies, it is suggested that battery dam-   preliminary damage induction
age occurs due to the production of harmful free radicals,       One drop of saline solution every 30 minutes was admin-
which cause a rapid increase in pH as a result of denatured      istered into the channels of the EC models for 3 h, and
organic material undergoing electro-caustic reaction and         the area where the BB and EC came into contact was kept
hydrolysis of water in the medium 4. These effects are more      moist. The pH of the tissue, the voltage of the battery and
pronounced in liquid media. For this reason, it is important     the temperature of the environment were measured at the
to keep BBs dry in the EC and remove them quickly 5. The         end of the process, and visual changes were photographed
moisture of ECs, presence of cerumen and administration          (Fig. 1). One of the models was examined single-blind by
of therapeutic dams while the BB is still inside or bleeding     a pathologist at the end of the third hour, and the other four
during the intervention are among the reasons for increased      models were left for the next procedure.
tissue damage caused by oxidation of BBs 5,6. Many meth-
ods have been tested in animal experiments to reduce BB          Strategies used to reduce the damage caused by the BBs
damage in the upper aero-digestive system, reporting suc-        The following processes were administered to the four EC
cessful results 7.                                               models in which the BBs reacted at the end of 3 hours:
Mucosal damage by BBs begins within 1-2 hours 7, and             1. the outer part of the EC model was moistened with 1
25.7% of EC foreign bodies present to the emergency de-             puff/h of saline spray, and nothing was applied inside
partment after more than 24 hours 8. As the removal of BBs          the canal;
from ECs is often delayed, the degree of damage and the          2. a saline solution (pH: 6.8) was administered in the EC
potential risk of ossicular erosion, facial nerve damage,           model in the form of 1 drop/h over the area with which
hearing loss and formation of vestibular labyrinthitis in-          the BB was in contact (control group);
crease 5,6,9.                                                    3. one drop/h of alcohol boric (pH 4; 3% boric acid, 70%
A limited number of case reports on damage and compli-              alcohol) was administered to the EC model over the area
cations caused by BBs in the EC exist in the literature.            with which the BB was in contact;
The main complications reported in these studies were            4. a solution with 3% acetic acid (pH 2) was administered
tympanic membrane perforation, ossicular damage, skin               in the EC model at a rate of 1 drop/h over the area with
necrosis, malignant external otitis, prolonged otalgia and          which the BB was in contact.
otorrhagia 9-12.
                                                                 The BBs were removed from the EC models with forceps,
The damage mechanisms of lithium BBs in the EC and
                                                                 and their voltages were measured with a digital voltmeter
treatment strategies to reduce this damage are explored in
                                                                 after 3, 6, 12 and 24 hours (UNI-T UT 33D Digital Auto
our in vitro animal model.
                                                                 Range Multimeter, Dongguan City, China). The tissue pH
                                                                 values were determined with litmus paper (Merck KGaA,
Materials and methods                                            Darmstadt, Germany), and the tissue temperature was
The study was conducted in the stages at the Samsun Train-       measured and recorded with a digital infrared thermometer
ing and Research Hospital Pathology Laboratory within the        (Bosch PTD 1, Malaysia). The BBs were then returned to
Health Sciences University.                                      their places in the EC models. At the end of each time period,
                                                                 visual damage was photographed (Fig. 2). All EC models
Preparation of the EC models                                     were examined after the BBs were removed single-blindly
EC models obtained from freshly frozen cadaveric cat-            by a pathologist who observed the depth of necrosis, and all
tle heads of similar sizes were prepared in approximately        models were photographed at the end of 24 hours.



150
                                                                                                      Can the damage caused by button batteries be prevented?




Figure 1. Placement of a 3 V lithium BB in the EC and reaction steps of BB by applying saline (h, hour).



                                                                                  Results
                                                                                  Preliminary damage, BB voltage, tissue pH,
                                                                                  and temperature changes
                                                                                  Gas bubbles and brown discoluration around the BB started
                                                                                  to appear in the first 1.5 hour. The visual changes at 0, 1, 2
                                                                                  and 3 hours were photographed (Fig. 1). After 3 hours, the
                                                                                  pH value of all four models was 13, and their temperature
                                                                                  was 22°C. The voltage values were measured as 2.65 V in
                                                                                  the first model, 2.60 V in the second, 2.58 V in the third,
                                                                                  and 2.63 V in the fourth. No necrosis was detected in the
                                                                                  model sent to pathology at the end of the third hour.

                                                                                  Evaluation of the strategies used to reduce the damage
                                                                                  After 24 hours, the following results were obtained:
                                                                                  1. in EC model (only BB): pH 11, voltage 1.3 V, tempera-
                                                                                     ture 22.5°C, depth of necrosis 1.612 mm;
                                                                                  2. in EC model (BB + saline): pH 10, voltage 1.2 V, tem-
                                                                                     perature 23°C, depth of necrosis 1.858 mm;
                                                                                  3. in EC model (BB + boric acid): pH 7, voltage 1.4 V,
                                                                                     temperature 23°C, depth of necrosis 723 mm;
                                                                                  4. in EC model (BB + acetic acid): pH 4, voltage 1.6 V,
                                                                                     temperature 23.5°C, no necrosis was detected.
                                                                                  No significant visual differences were observed between the
                                                                                  EC models after 3, 6, 12 and 24 hours (Fig. 2). The pH, tem-
                                                                                  perature, and voltage values at these time points are shown in
                                                                                  Figure 3. In the model in which acetic acid was applied, the
                                                                                  pH completely lost its alkalinity in the initial hours, and the
                                                                                  environment was acidic. No necrosis was observed in this
                                                                                  model. The ambient pH was neutralised after 12 hours in the
                                                                                  model to which boric acid was administered, and the tissue
                                                                                  necrosis depth was less than it was in the first and second
                                                                                  models, in which the ambient pH was observed to be highly
                                                                                  alkaline for 24 hours, and the depth of necrosis was greater.
                                                                                  Pathological images are shown in Figure 4. No significant
                                                                                  differences were detected between the models in terms of
Figure 2. Images of changes at 6, 12, and 24 h. (A) Lithium BB, (B) Lithium       ambient temperature after 24 hours. Although the BBs lost
BB + saline, (C): Lithium BB + boric acid, (D) Lithium BB+ acetic acid.           their voltage to a large extent after 24 hours in all models,



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G. Akgül et al.




                                                                                 it was observed that the voltage loss was similar in all the
                                                                                 models.

                                                                                 Discussion
                                                                                 An estimated 65,788 paediatric patients presented to
                                                                                 emergency departments in the US with battery exposure
                                                                                 in the 20-year period between 1990 and 2009 13. An esti-
                                                                                 mated 3,748 of these patients were admitted with BBs in
                                                                                 the external auditory canal 13. Additionally, 0.20 of every
                                                                                 100,000 children admitted to the emergency department
                                                                                 annually are admitted because of BBs in the EC 13. As BBs
                                                                                 are smooth and have a shiny appearance, they can be quite
                                                                                 attractive and interesting to younger children when they are
                                                                                 accessible 10. BB foreign bodies can have fatal results, es-
                                                                                 pecially if they are swallowed 10.
                                                                                 Successful removal of EC foreign bodies depends on many
                                                                                 factors, including initial evaluation, patient cooperation, ob-
                                                                                 taining full vision of the foreign body, type of foreign body,
                                                                                 co-existing otitis externa, previous failed removal attempts
                                                                                 and availability of adequate equipment 10. Most patients are
                                                                                 initially evaluated in the emergency department. If there is
                                                                                 difficulty in removal, it should not be pursued, and an ENT
                                                                                 specialist should be consulted. Although common sequelae
                                                                                 of foreign bodies in the EC are bleeding, infection, tym-
                                                                                 panic membrane perforation and canal wall laceration, BBs
                                                                                 can also cause permanent damage to surrounding tissues
                                                                                 because of the release of harmful chemicals, leading to ne-
                                                                                 crosis, permanent hearing loss and stenosis in the EC 3,6.
                                                                                 The most commonly used BB types are alkaline, silver
                                                                                 oxide, zinc-air and lithium. Among these, lithium BBs are
Figure 3. (A) pH, (B) voltage, (C) temperature, change of ambient data of        faced most frequently as foreign bodies 11,12,14. Tissue dam-
BB over time.                                                                    age by BBs occurs according to three mechanisms 9.




Figure 4. Pathological images after 24 hours. (A) Lithium BB, (B) Lithium BB + saline, (C) Lithium BB + boric acid, (D) Lithium BB + acetic acid. Depth of ne-
crosis A: 1612 µm, B: 1858 µm, C: 723 µm, D: no necrosis. (×40 magnification; H&E paint; Olympus light microscope shot using DP2 program, Olympus Corp.
Shinjuku, Tokyo, Japan).



152
                                                                                    Can the damage caused by button batteries be prevented?




The first is a thermal electro-caustic reaction that coagu-         they reported that administering these substances earlier in
lates and denatures the organic material; the second is a           the critical process until the removal of the button battery had
hydrolysis reaction releasing harmful free radicals as the          the potential to reduce damage and accelerate healing. In our
end product 4; and finally, the third mechanism is pressure         study, we found that administering 0.25% acetic acid and al-
necrosis associated with BB, an effect increased by a pro-          cohol boric solution to the cadaveric in vitro external EC re-
longed presence of the battery 9,14.                                sulted in less damage.
The time taken to visit a physician for BB foreign bodies           In a multi-institutional study in which patients admitted
admitted with complications ranges from 24 hours to four            with BB foreign bodies in the aero-digestive system were
months in case reports 3,5,10,11. Diagnosis may be delayed          examined as a retrospective case series, batteries were de-
until symptoms appear, especially in young children and             tected in the external auditory canal in 4 of 81 paediatric
when there are no witnesses. Even in witnessed cases, the           patients11. The foreign body was found to be bilateral in
urgent removal of BBs may be delayed during transport to            one patient. Two of the patients were asymptomatic, and
specialist centres because some healthcare centres do not           the other two were admitted with otalgia, headache, ear
have personnel trained in foreign body removal 7. This de-          discharge and hearing loss. In one of the patients, the ero-
lay may be more common in rural areas 7.                            sive lesion of the external auditory canal continued for six
Many substances that lower the ambient pH have been used            weeks after the removal of the battery. Huang et al. 12 re-
in the past to reduce the damage of alkali liquefactive tissue      ported six foreign body cases in the ear canal in their series
necrosis. It has been observed that less mucosal damage oc-         that included 116 paediatric BB foreign bodies. Although
curs in the lower gastrointestinal system, such as the stomach,     five patients were asymptomatic, they detected tympanic
which was attributed to the acidic pH of that environment 1.        membrane perforation and ossicular chain damage as com-
Jatana et al. 15 defined two important periods: before and after    plications in one patient.
removal of BBs. They measured tissue damage in cadaveric            Many ear drops are available for the treatment of infectious
oesophageal models using acidic solutions, such as lemon            diseases of the EC, such as otitis externa and otomycosis,
juice, orange juice, cola and 0.25% acetic acid, before the BB      which reduce the pH of the environment. Acetic acid and
was removed. This study found that tissue damage was less se-       alcohol boric solution are used successfully in such diseas-
vere in visual and pathological terms than in the saline control    es 19,20. We applied these acidic solutions, which can be used
group. The authors also reported that alkaline necrosis began       safely in humans, for pH neutralisation in our animal study.
within a short time and that acidic beverages easily available at   In previous animal experiments, it was determined that the
home could be given in the early stages. Tissue necrosis may        most damaging type of battery was lithium and the least dam-
continue after the removal of BBs, so it may be necessary to        aging was zinc-air, and it was reported that the most com-
take precautions against this 16. It was found that the depth of    mon type of BB foreign body in the EC was lithium 13,15,17.
necrosis was less severe in the pathological evaluation of the      Based on these reports, we decided to carry out this study
oesophageal area, which was washed with 0.25% acetic acid           with lithium BBs. As the mucosa of the upper aero-diges-
after the batteries were removed in another animal study. After     tive system is naturally moist, BBs discharge more easily
this study, the authors successfully applied this method in six     and quickly in this area, causing damage. The EC is drier
paediatric patients and recommended the application of this         than the upper aero-digestive system mucosa because of its
treatment protocol after the removal of BBs 16. Sancaktar et        different anatomical-histological structure, which seems to
al. 17,18 tried similar treatment strategies in cadaveric septum    slow the BB’s discharge and delay the related damage. BBs
models before and after battery removal, neutralising the BB        in the EC are generally detected earlier and removed without
with lemon juice, apple vinegar, tea, cola, tap water and saline    causing serious complications. In a country such as ours, in
while the BB was inside the model. They reported that the best      which the population of children is high and there are many
pH neutralisation was achieved with lemon juice (pH 2.5) and        refugee children in the countryside, it is even more impor-
apple vinegar (pH 3). They also found that the tissue necro-        tant, as it is difficult and takes more time to reach healthcare
sis depth was lower with lemon juice and apple vinegar. They        centres and specialists. We could not find any studies in the
administered 0.25% acetic acid after the battery was removed        reviewed literature investigating the effects of delayed BBs
in a cadaveric septum model and found that the damage was           in the EC or testing solutions to reduce damage. In our in
reduced compared to the control group 17,18. Rachel et al. 7        vitro model, BBs were reacted, and treatment strategies were
found that honey and Carafate® showed significant protective        tried afterward. Although the solutions used in our study had
effects in in vitro and in vivo animal experiments. They also       also been used safely in infectious or inflammatory diseases
found that these two substances neutralised the increased pH        of the EC, which represents a positive overlapping outcome,
and resulted in less tissue damage. As a result of their study,     these results cannot be considered a recommendation. These



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experimental results must be confirmed with prospective             6
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                                                                         ditory canal foreign bodies in children and adolescents. Ear Nose Throat J
randomised in vivo, clinical human studies.                              2020;99:648-645. https://doi.org/10.1177/0145561319893164
The limitations of this study were the use of a single sample       7
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for each modelling and the use of only one type of battery. The          injury in the head and neck. Laryngoscope 2014;124:2257-2261. https://
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measurements. The possible effects of this on the measured          8
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the ambient pH provides only changes in the superficial part.            https://doi.org/10.1016/j.ijporl.2020.110431
Furthermore, ischaemia due to compression necrosis, which is        9
                                                                         Premachandra DJ, McRae D. Severe tissue destruction in the ear caused
one of the damaging mechanisms of cells, and actual wound                by alkaline button batteries. Postgrad Med J 1990;66:52-53. https://doi.
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healing were not seen because this was a cadaveric study.           10
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                                                                         A consumer product analysis of aural foreign bodies. Laryngoscope
Conclusions                                                              2015;125:709-714. https://doi.org/10.1002/lary.24935
                                                                    11
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Visual damage was seen after 1.5 hour of exposure to lithium             rigations as a novel mitigation strategy for button battery injury. Laryngo-
BBs in our in vitro bovine model. In experimental terms, the             scope 2019;129:49-57. https://doi.org/10.1002/lary.27312
alkali damage caused by BBs can be decreased by providing
                                                                    12
                                                                         Karimnejad K, Nelson EJ, Rohde RL, et al. External auditory canal for-
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or acetic acid. More prospective randomised studies are re-         13
                                                                         Bhisitkul DM, Dunham M. An unsuspected alkaline battery foreign body
quired to validate this strategy before it is tested on humans.          presenting as malignant otitis externa. Pediatr Emerg Care 1992;8:141-
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Conflict of interest statement                                           dren: hazards, management, and recommendations. Biomed Res Int
The authors declare no conflict of interest.                             2013;2013:846091. https://doi.org/10.1155/2013/846091
                                                                    15
                                                                         Shaffer AD, Jacobs IN, Derkay CS, et al. Management and outcomes
Funding                                                                  of button batteries in the aerodigestive tract: a multi-institutional study.
                                                                         Laryngoscope 2021;131:e298-e306. https://doi.org/10.1002/lary.28568
This research did not receive any specific grant from funding       16
                                                                         Huang T, Li WQ, Xia ZF, et al. Characteristics and outcome of impacted
agencies in the public, commercial, or not-for-profit sectors.           button batteries among young children less than 7 years of age in China:
                                                                         a retrospective analysis of 116 cases. World J Pediatr 2018;14:570-575.
Author contributions                                                     https://doi.org/10.1007/s12519-018-0188-9
All authors participated on the planning and conception of          17
                                                                         Sharpe SJ, Rochette LM, Smith GA. Pediatric battery-related emer-
                                                                         gency department visits in the United States, 1990-2009. Pediatrics
the study and the analytical strategy; GA, MES and DY                    2012;129:1111-1117. https://doi.org/10.1542/peds.2011-0012
performed the data analyses and wrote the manuscript. In            18
                                                                         Litovitz T, Whitaker N, Clark L. Preventing battery ingestions: an analysis
addition, MDM, NFT, AC contributed to the photographing                  of 8648 cases. Pediatrics 2010;125:1178-1183. https://doi.org/10.1542/
of visual data. All authors have assisted in data manage-                peds.2009-3038
ment, analyses and critical review of the manuscript.
                                                                    19
                                                                         Jatana KR, Rhoades K, Milkovich S, et al. Basic mechanism of but-
                                                                         ton battery ingestion injuries and novel mitigation strategies after di-
                                                                         agnosis and removal. Laryngoscope 2017;127:1276-1282. https://doi.
Ethical consideration                                                    org/10.1002/lary.26362
The ethical aspect of this study was approved by the OMU            20
                                                                         Jatana KR, Barron CL, Jacobs IN. Initial clinical application of tissue pH
Animal Experiments Local Ethics Committee (HADTEK).                      neutralization after esophageal button battery removal in children. Laryn-
                                                                         goscope 2019;129:1772-1776. https://doi.org/10.1002/lary.27904
(68489742-604.01.03-E.18528, date: 23.10.2020).                     21
                                                                         Sancaktar ME, Bayraktar C, Bakırtaş M. Injury mechanism of button bat-
The research was conducted ethically, with all study proce-              teries in the nasal cavity and possible mitigation strategies during impaction.
dures being performed in accordance with the requirements                Laryngoscope 2020;130:2487-2493. https://doi.org/10.1002/lary.28913
of the World Medical Association’s Declaration of Helsin-           22
                                                                         Sancaktar ME, Bakırtaş M. A potential post-removal pH neutrali-
                                                                         zation strategy to mitigate nasal button battery injuries. Int J Pedi-
ki. Written informed consent was obtained from each par-                 atr Otorhinolaryngol 2020;133:110011. https://doi.org/10.1016/j.
ticipant/patient for study participation and data publication.           ijporl.2020.110011
                                                                    23
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