Button batteries in the ear, nose and throat: a novel survey of knowledge of UK advanced nurse practitioners

Foreign body impaction is a common emergency presentation, particularly among the paediatric population (McConnell, 2013; Kodituwakku et al, 2017). In most cases, ingested foreign bodies traverse spontaneously through the gastrointestinal tract without sequelae (Rodríguez et al, 2012). However, impaction in the upper aerodigestive tract or aural cavity has the potential to cause significant morbidity (Rodríguez et al, 2012).

Button batteries (BBs) are among the most hazardous of foreign bodies and may cause severe harm within 2 hours of placement in the ear, nose or throat (ENT)(NHS England, 2014). A rising incidence has been observed because of an increase in household electronic devices and toys using these batteries (Kodituwakku et al, 2017). According to data collected by the National Capital Poison Center (2021) in the US, the incidence of BB ingestion has risen sharply over the past two decades, with 3467 cases reported in 2019; the exact incidence of BB ingestion in the UK is unknown (Healthcare Safety Investigation Branch, 2019).

The complications of BB ingestion can be catastrophic. Serious complications include oesophageal injuries (perforation, fistulisation and stenosis), vocal cord paralysis, mediastinitis and aspiration pneumonia among others, all of which have the potential to cause major morbidity and death (NHS England, 2014).

In 2014, NHS England released a nationwide patient safety alert following five incidents of serious morbidity, including one death, because of delays in the recognition, assessment and management of BB ingestion in children (NHS England, 2014). Institutions were instructed to identify delays in assessing BB ingestion and implement local protocols to facilitate prompt recognition and escalation (NHS England, 2014).

The NHS faces mounting pressures year on year because of a growing and ageing population with higher demands and expectations (Reynolds and Mortimore, 2018). This was intensified recently by the disastrous and ongoing impact of the COVID-19 pandemic (Suleman et al, 2021). Roles and responsibilities within the multidisciplinary team outside the traditional ‘doctor’ and ‘nurse’ roles have developed rapidly in the face of persistent challenges to the healthcare system.

Advanced nurse practitioners (ANPs) play a pivotal role in the initial assessment and management of patients in a wide array of acute, inpatient and community care settings (Reynolds and Mortimore, 2018). They are expected to possess a high level of clinical knowledge and be able to autonomously apply critical thinking to complex and challenging circumstances (Reynolds and Mortimore, 2018). As the ANP role continues to develop and expand throughout the UK healthcare system, it is increasingly likely that these nurses will encounter patients presenting with BBs in the ENT.

BB impaction is a time-critical event with potentially life-threatening consequences; however, it is not always recognised as a medical emergency by healthcare staff (NHS England, 2014). A sound understanding of risk stratification and the variable nature of BB presentation among ANPs is therefore imperative to minimise patient harm. This will facilitate prompt recognition and referral to otolaryngology for immediate retrieval.

A quantitative analysis of ANP knowledge in this area would determine current levels of understanding and competence, as well as potential educational requirements. At present, there are no other published studies in the literature assessing ANP knowledge of BB recognition and management.

The present study sought to assess knowledge of ANPs in the UK with respect to the assessment and management of BBs within the ENT. The authors hypothesised that knowledge deficits would be identified, highlighting areas in ANP training where further education on BB impaction was required.

Method

To assess existing levels of ENT knowledge among ANPs in the UK, a survey based on multiple-choice questions titled ANP Survey on Button Batteries in ENT was developed by ENT specialists, focusing on key elements of BB triage.

It was recognised that ANPs working across the UK would have variable training and exposure to BB ingestion based on their specialty, level of experience and geographical location. An online survey was selected as the means of data acquisition to allow for widespread and rapid data collection that would be representative of knowledge across the ANP workforce in the UK. Multiple-choice questions were used to facilitate wide coverage of the topic and allow for objective and efficient scoring.

Knowledge assessment was based on radiological investigation of BB ingestion, mechanism of injury, symptomatology and presentation and timing of retrieval (Table 1). Eight knowledge-based multiple-choice questions were included. The maximum attainable knowledge score was 21, based solely on correct responses to the eight knowledge-based multiple-choice questions (Table 1, questions 4–11). One point was awarded for each correct answer provided (with some questions having more than one correct response, in which case respondents were asked to select all answers they thought were correct). Answers to the remaining five questions (Table 2, questions 1–3, 12, 13) included in the survey were not scored but used for correlating knowledge scores with seniority, specialty and ENT experience, as well as determining respondents' perception of local BB protocols and the need for further education.

The survey was disseminated nationally to ANPs over a 2-week capture period between 27 February and 13 March 2021. It was developed using Google Forms and distributed using an online link which was shared via social media platforms, deanery emailing lists and the Royal College of Nursing (RCN). The use of an online survey allowed for widespread and rapid dissemination. Responses were collated electronically and exported to an Excel spreadsheet for analysis.

Results

A total of 255 responses were received from primary and secondary care centres across the UK. Incomplete responses and specialties unlikely to be involved in BB assessment—namely obstetrics and gynaecology, palliative care and ophthalmology—were excluded. Therefore, 242 responses were included in final analysis.

Responses were analysed according to specialty, banding and previous ENT experience (Tables 1–3). The majority of responses were from primary care/community settings (50.8%; n=123) and emergency/acute medicine settings (26.9%; n=65) (Table 1). The remainder of respondents were in medicine (10.3%; n=25), surgery (8.7%; n=21), paediatrics (2.5%; n=6) and ENT (0.8%; n=2). The majority of respondents were in band 7 (39.7%; n=96), followed by band 8 (36.4%; n=88), band 6 (21.5%; n=52) and band 5 (2.5%; n=6). Most respondents had no prior ENT experience (85.1%; n=206).

A limited cohort of respondents correctly identified the ‘halo’ and ‘step-off’ signs on lateral view radiographs as discriminating features of ingested BBs (36.0%; n=87 and 14.5%; n=35 respectively), with almost half (45.5%; n=110) uncertain. Fifty-six percent of respondents (n=136) correctly identified caustic injury and pressure necrosis (45.5%; n=110) as mechanisms of injury. Electrolyte extravasation and local mercury toxicity as possible mechanisms were cited by only 22.3% (n=54) and 21.1%, (n=51) of respondents respectively. More than one in four respondents were uncertain (28.1%; n=68).

Over one-third of respondents (38.8%; n=94) correctly identified the onset of mucosal injury from BBs was within 2 hours, with fewer than one-third uncertain (31.0%; n=75). Regarding urgency of intervention, 29.3% (n=71) correctly identified the need for immediate retrieval (CEPOD category 1/emergency). The majority opted for urgent removal within hours (42.1%; n=102), while 24.4% (n=59) were uncertain.

With regards to symptoms following ingestion, haemoptysis and drooling were correctly identified by 59.9% (n=145) and 50.0% (n=121) of respondents respectively. Haemodynamic instability was correctly identified by 37.2%, while torticollis was selected by only a small minority (13.2%%; n=32). The majority of respondents correctly identified unilateral nasal discharge (56.2%; n=136) and nasal crusting/bleeding (55.0%; n=132) as early signs of nasal BBs, with 32.6% (n=79) uncertain. Concerning possible aural complications, hearing loss (59.5%; n=144) and tympanic membrane perforation (56.6%%; n=137) were correctly identified by the majority. Approximately one in four also correctly included facial nerve palsy (24.4%; n=59) and temporal bone osteomyelitis (28.5%; n=69) in the list of potential complications.

Regarding investigations on presentation, most respondents opted for anteroposterior and lateral chest radiographs (70.7%; n=171), with fewer than half including abdominal radiographs (46.7%; n=113) and soft tissue neck radiography (33.5%; n=81). Some respondents incorrectly considered CT imaging of the neck and thorax as an initial investigation (11.2%; n=27) and 22.7% (n=55) were uncertain regarding the most appropriate initial imaging modality.

Regarding awareness of local trust policies relating to BBs in the ENT, a minority (14.5%; n=35) were aware of them, more than half were uncertain (59.3%%; n=143), with the remainder indicating an absence of protocols (26.1%; n=63).

Almost all respondents advocated for additional training relating to BBs lodged in the upper aerodigestive tract (97.0%; n=234).

The overall mean score was 8.5/21 (40.5%). Comparative analysis indicated that ENT experience and seniority correlated positively with overall knowledge. Band 8 ANPs (n=88) attained a mean score of 9.9/21 (47.1%) compared to band 5 (n=6) who scored a mean of 6/21 (28.6%), band 6 (n=52; 7/21; 33.3%) and band 7 (n=96; 8.2/21; 39.0%). Respondents with ENT experience (n=36) achieved an average score of 11/21 (52.4%) compared to 8.1/21 (38.6%) of those without (n=206). The highest mean scores were attained by ANPs working within ENT (n=2; 16/21; 76.2%), followed by those working in paediatric (n=6; 11.3/21; 53.8%) and emergency care (n=48.6%; 10.2/21; 48.6%) settings. Surgery (n=21) and community-based (n=123) respondents achieved similar mean scores of 8.3/21 (39.5%) and 7.8/21 (37.1%) respectively. Respondents working in medical specialties attained a mean score of 6.3/21 (30.0%).

Discussion

Clinical assessment of BBs in ENT poses a significant clinical challenge because of a lack of clinical exposure and the wide spectrum of presentation (NHS England, 2014). Complications of BBs can be catastrophic and, although BB ingestion is rare, the incidence is rising (Kramer et al, 2015).

A study performed in the Netherlands described 16 cases of serious complications between 2008 and 2016 among 0–18-year-olds, including tracheoesophageal fistula, mediastinitis and mortality (Krom et al, 2018). Additionally, in a cohort of >8600 BB ingestions, serious complications were identified in 73 patients (0.8%) and mortality in 13 (0.15%) (Kramer et al, 2015).

In the UK, NHS England released a national patient safety alert in 2014 highlighting the risk of death and serious harm from delayed recognition and treatment of BBs following five serious incidents (NHS England, 2014). A review of incidence reports suggested that healthcare staff did not recognise BB ingestion as a medical emergency (NHS England, 2014), which would perhaps correlate with delays in retrieval and thus long-term morbidity.

While BB foreign bodies are most prevalent among the paediatric population, vulnerable adults and patients attempting self-harm may also be involved (NHS England, 2014). BBs in the ENT may present in a wide variety of clinical settings because of the non-specific and, at times, insidious onset of symptoms.

ANPs work within a wide array of both primary and secondary care settings and, as such, are likely to play a fundamental role in the initial assessment and management of BBs in the ENT (King et al, 2017). The demands of the wider healthcare community will no doubt continue to evolve as patient demographics change, and the expectations of an already strained healthcare service continue to rise, delineating the increasing need for ANPs within the multidisciplinary emergency care team.

The survey highlighted areas of knowledge deficiency, particularly surrounding BB recognition, appropriate initial investigations and urgency of intervention. Although seniority and ENT experience correlated with higher overall mean knowledge scores (Figure 1), the survey identified deficits in knowledge among even experienced ANPs working within high-exposure specialties, such as ENT, accident and emergency and paediatrics.

BBs can cause serious injury within 2 hours of ingestion (NHS England, 2014), further highlighting the importance of the ANP role in the prompt recognition and escalation of such patients. Oesophageal impaction is the highest risk site for injury with the potential for significant morbidity (Kramer et al, 2015). Ingested BBs may lead to non-specific symptoms of cough, vomiting, fever, drooling and/or dysphagia (Kodituwakku et al, 2017). Latter signs and symptoms of oesophageal impaction may include haemodynamic instability and haemoptysis, which indicate severe complications. Consequently, immediate BB removal is paramount. A minority of participants in the survey were aware of how soon BB injury could ensue and the need for immediate retr ieval (38.8%; n=94 and 29.3%; n=71 respectively).

While not immediately life threatening, BB foreign bodies in the aural and nasal cavities for prolonged periods may lead to significant morbidity if not removed (Bakshi, 2019; Premachandra and McRae, 1990). Aural BBs may initially present with otorrhoea and severe otalgia (Premachandra and McRae, 1990), with necrosis potentially leading to temporal bone osteomyelitis and tympanic membrane perforation (Premachandra and McRae, 1990). More severe consequences include progressive injury to the ossicles and facial nerve injury (Kavanagh and Litovitz, 1986).

Nasal impaction may present with unilateral nasal discharge, which may be foul smelling and/or bloodstained (Bakshi, 2019). BBs in the nasal cavity can be easily missed depending on their position and the presence of significant oedema and discharge obscuring a direct view (Bakshi, 2019). Any nasal foreign body with a delayed presentation, impaired visualisation or with a high index of suspicion of a BB necessitates further investigation (Bakshi, 2019). Initial diagnostic modalities may include the deployment of a metal detector or a radiograph of the post-nasal space. Serious complications of nasal BBs include septal perforation, with subsequent nasal deformity (Kavanagh and Litovitz, 1986; Bakshi, 2019), as well as the involvement of critical nearby structures including the orbit and brain. Thus, prompt referral to otolaryngology for BB retrieval is of paramount importance.

Regarding knowledge of local protocols, only 35 (14.5%) of respondents were aware of specific ENT BB protocols within their trust. As recently identified by Houston et al (2021), significant discrepancies exist between local NHS trust guidelines around BB assessment. Of the 29 guidelines reviewed, fewer than half included symptoms of BB foreign bodies, and only 14% included guidance on BBs in the ears or nose (Houston et al, 2021). Furthermore, only one-third recommended a combination of chest, abdominal and lateral soft tissue neck radiographs as part of the initial investigation (Houston et al, 2021).

Plain radiographs of the neck, chest and abdomen are crucial in identifying the location of BBs, while also differentiating them from less hazardous foreign bodies such as coins (McConnell, 2013). The shape of BBs means they show specific signs on radiography. The inner positive terminal is encircled by an outer negative terminal, resulting in the ‘halo sign’ (or ‘double-ring’ sign) on anteroposterior views (Bolton et al, 2018). The ‘step-off’ sign, on account of the bevelled edge, can be observed on lateral neck radiographs (Bolton et al, 2018). Computerised tomography (CT) and magnetic resonance imaging may be performed if the duration of button battery retention is prolonged and/or uncertain because of the likelihood of fistulisation into critical nearby structures including major vessels within the neck and thorax. Cross-sectional imaging also plays a crucial role following retrieval where delayed complications are suspected (Bolton et al, 2018) as well as in long-term follow-up.

While most participants correctly identified the need for chest radiographs as a part of initial assessment (70.8%; n=172), fewer recognised the need for soft tissue neck and abdominal radiographs (33.3%; n=81 and 46.5%; n=113 respectively). The authors identify that there is therefore a significant need for substantive and standardised guidance on BB imaging.

The clinical guideline for retained BBs developed by Houston et al (2021) provides a succinct means of assessing a suspected or known BB in the ear, nose, throat or gastrointestinal tract (Figure 2). This has been peer reviewed and published as a recognised clinical guideline by the British Association of Otorhinolaryngology and Head and Neck Surgery. It is intended for use by all frontline health professionals, including ANPs, to facilitate immediate recognition and onward referral to appropriate specialties.

The authors strongly advocate its use in informing practice, developing local BB protocols and as a basis for future training initiatives. The sparsity of otolaryngology within pre- and postregistration nursing curricula, combined with limited exposure and the self-directed learning aspect of individual modules, provides a theoretical explanation behind potential knowledge deficits among the studied cohort.

This study has unequivocally highlighted the urgent need for further education to aid ANPs in the prompt recognition, management and escalation of impacted BBs within the ENT, with 97.0% (n=234) of our surveyed cohort advocating for this.

The RCN (2017) national curriculum and competency emergency nursing framework (level 2) lists an understanding of the pathophysiology and clinical presentation of ‘ENT foreign body’ as a required knowledge competency but does not specifically refer to BBs. Although there is a dearth of literature relating to the delivery of ENT education within current undergraduate or postgraduate nursing curricula, there are a number of avenues through which education surrounding BBs in ENT may be optimised, in addition to public safety announcements and household education on BBs. Simulation-based education is evolving and becoming more prevalent within the medical profession (Motola et al, 2013) and has been shown to improve competencies specifically relating to ENT emergencies (Smith et al, 2015; Nguyen et al, 2019).

Furthermore, specific online modules could provide an accessible and convenient means through which education on BB assessment and management could be widely and effectively disseminated (Wu, 2018). Integration of core modules on ENT foreign bodies, with a focus on BBs, within ANP training and education may also address learning needs and improve knowledge competencies.

Limitations

There were several limitations of this study, the most significant being the use of a non-validated questionnaire without empirical standardisation of minimum competency scores. A lack of even distribution across specialties, banding and prior ENT experience will inevitably contribute to the skewing of results.

It is also recognised that previous ENT experience is subjective and was not clarified further in the survey question.

Participants were asked to specify whether they were aware of their employing organisations having locally implemented BB protocols. However, given that the survey did not determine respondents' individual trusts, this could not be independently ratified. Failure to incorporate the geographical location of respondents, again, may contribute to bias, with potential variation in exposure to paediatric emergencies (tertiary units) and educational heterogeneity in locally implemented courses.

Further studies using validated questionnaires and incorporating standard-setting studies to address the above limitations would be key focus points for future research.

Ethical considerations

Participation in the survey used to acquire data for this study was voluntary. The survey questions were preceded by a brief paragraph informing participants that the survey findings would be used to address future ANP training needs on the subject. By completing and submitting the survey, participants provided their informed consent without coercion.

No personally identifiable information of any kind was collected, thus maintaining complete confidentiality and anonymity of participants.

No patient data were collected or used in any aspect of this research. NHS Research Ethics Committee review was not required in accordance with the online decision tool.

Conclusion

The ANP role is integral to the emergency care multidisciplinary team, with increasing responsibility for initial patient assessment and escalation to specialty clinicians for definitive management.

BB impaction within the ENT poses a significant diagnostic and management conundrum because of the rarity of presentation and critical need for further education highlighted by our surveyed cohort.

Scope exists for consolidation of knowledge regarding this potentially catastrophic condition through the implementation of standardised protocols, virtual resources, mentorship and simulation platforms within postgraduate advanced practice training programmes.

Key Points

• Button battery impaction in the ear, nose or throat can cause significant morbidity within 2 hours of impaction
• As the advanced nurse practitioner role develops, it is likely that this group of nurses will play a central role in the initial assessment and management of patients with button batteries in the ear, nose and throat
• This study has identified deficiencies in knowledge regarding recognition and assessment of button battery foreign bodies and practitioner advocacy for further education and training on this
• Standardised protocols and educational interventions, including within preregistration training, may help to improve knowledge and minimise delays in button battery retrieval

CPD reflective questions

• Do you feel confident in the recognition, assessment and prompt onward referral of button battery impaction?
• Does your trust have a protocol for the assessment and management of button batteries in the ear, nose and throat?
• How can education best be delivered to address knowledge deficits surrounding button battery recognition and assessment?