Summary Owing to the severity of its corrosive effects, an alkaline hearing-aid battery in the external auditory meatus is an otological emergency. This report emphasizes the particular risk to confused elderly patients and points out that a delay in diagnosis is common. Aetiology, clinical features and treatment are discussed with reference to three recent cases.
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Introduction Hearing loss presents a particular problem to the elderly population. Not only is the diagnosis often delayed but treatment with a hearing aid leads to new difficulties in management [1]. The role of the audiology department, and in some instances private companies, is to provide a proper fitting hearing aid and to give adequate instruction as to its use and to provide appropriate help in the months and years following the initial fitting.
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Ideally a full initial assessment of the capability of each recipient in fitting and adjusting the aid should be made and, if the patient is experiencing difficulties, a relative or friend may be put in charge of the hearing aid. However this is often not the case and elderly patients may be prescribed hearing aids that they do not understand owing to cognitive impairment, or they are unable to fit because of medical problems affecting dexterity. Related to these problems is the potentially serious hazard to those prescribed behind-the-ear or intra-canal hearing aids of impaction of a hearing-aid button battery in the external auditory meatus.
Since their introduction there have been a number of reports outlining the danger of battery ingestion and more recently cases of impaction in the nose and ear have occasionally been documented [2-5], usually involving children. We would like to draw attention to the specific danger to an elderly confused patient that may arise from the prescription and use of a hearing aid. If the battery comes to be lodged in the external auditory meatus (EAM) a severe tissue reaction develops and this is often compounded by a delay in diagnosis. Three such cases have recently presented to our department and are summarized in the Table.
Case Reports Although the actual time when each battery was inserted cannot be certain, patients 1 and 2 were in hospital at least 3
weeks prior to presentation to the ENT department and no aid had been used during this time (Table). It would appear extremely likely, therefore, that the batteries had been in the EAM at least 4 and 3 weeks, respectively, and in the third case the patient had suffered increasing ear symptoms for over 2 weeks prior to the battery being removed.
By the time of diagnosis, all patients had extensive necrosis of the external auditory meatus in addition to a swollen and erythematous pinna. During the weeks following diagnosis a marked granulomatous response was noted.
Discussion Button batteries such as those supplied with hearing aids are considerably more dangerous than most foreign bodies due to the extent and rapidity of their destructive effect. A battery in the ear is now well recognized as an otological emergency.
Button batteries vary in size between 0.5 and 1.5 cm diameter and are capable of delivering 1. 5 V of direct current. If placed in the ear a spontaneous leakage of alkaline electrolyte solution produces a low-voltage direct-current burn causing a tissue reaction within a few hours of impaction. Over a longer period, pressure necrosis potentiates the problem. The effect of a topical steroid/antibiotic solution (as used in case 3) potentiates the electrochemical reaction thus increasing corrosion, and can be illustrated by applying various T drops to the battery. Interestingly, Terra- [Cortry.sup.TM] ointment (which had been used in case 1 prior to the correct diagnosis being made) protects against corrosion presumably by providing an airtight seal. Once leakage is occurring the ultimate mechanism of injury, producing the most severe effects, is an alkaline burn. Alkali penetrates much deeper than acid into soft tissue producing an extensive liquefying necrosis [2].
The major aetiological factors leading to the insertion of foreign bodies in the ear have been shown to be associated irritation in the ear due to otitis externa, chronic middle-ear disease, or wax impaction [6]. However, probably of more importance in the cases of battery insertion is the confused state of the patient with regard to the workings and positioning of the hearing aid. Twenty peT cent of elderly patients over 85 years of age admit to lots of trouble' using their aid [1 ]. Mistakes can easily occur, including mistaking a button battery for an aid (in particular an intra-canal model) and inserting it into the ear.
The clinical picture is generally one of increasing pain and offensive otorrhoea with a worsening confusional state. In the cases mentioned above the delay in diagnosis in each case was approximately 3 weeks and this certainly potentiated the problem. During this period each patient had been assessed on more than one occasion by a medical practitioner (varying from GP to ENT surgeon) and, despite the fact that an ear problem had been focused upon, alternative diagnoses of otitis externa and advanced cholesteatoma were made. For reasons outlined above the use of topical steroid/ antibiotic drops may have made the situation worse whilst a battery was still in place.
o
Introduction Hearing loss presents a particular problem to the elderly population. Not only is the diagnosis often delayed but treatment with a hearing aid leads to new difficulties in management [1]. The role of the audiology department, and in some instances private companies, is to provide a proper fitting hearing aid and to give adequate instruction as to its use and to provide appropriate help in the months and years following the initial fitting.
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Ideally a full initial assessment of the capability of each recipient in fitting and adjusting the aid should be made and, if the patient is experiencing difficulties, a relative or friend may be put in charge of the hearing aid. However this is often not the case and elderly patients may be prescribed hearing aids that they do not understand owing to cognitive impairment, or they are unable to fit because of medical problems affecting dexterity. Related to these problems is the potentially serious hazard to those prescribed behind-the-ear or intra-canal hearing aids of impaction of a hearing-aid button battery in the external auditory meatus.
Since their introduction there have been a number of reports outlining the danger of battery ingestion and more recently cases of impaction in the nose and ear have occasionally been documented [2-5], usually involving children. We would like to draw attention to the specific danger to an elderly confused patient that may arise from the prescription and use of a hearing aid. If the battery comes to be lodged in the external auditory meatus (EAM) a severe tissue reaction develops and this is often compounded by a delay in diagnosis. Three such cases have recently presented to our department and are summarized in the Table.
Case Reports Although the actual time when each battery was inserted cannot be certain, patients 1 and 2 were in hospital at least 3
weeks prior to presentation to the ENT department and no aid had been used during this time (Table). It would appear extremely likely, therefore, that the batteries had been in the EAM at least 4 and 3 weeks, respectively, and in the third case the patient had suffered increasing ear symptoms for over 2 weeks prior to the battery being removed.
By the time of diagnosis, all patients had extensive necrosis of the external auditory meatus in addition to a swollen and erythematous pinna. During the weeks following diagnosis a marked granulomatous response was noted.
Discussion Button batteries such as those supplied with hearing aids are considerably more dangerous than most foreign bodies due to the extent and rapidity of their destructive effect. A battery in the ear is now well recognized as an otological emergency.
Button batteries vary in size between 0.5 and 1.5 cm diameter and are capable of delivering 1. 5 V of direct current. If placed in the ear a spontaneous leakage of alkaline electrolyte solution produces a low-voltage direct-current burn causing a tissue reaction within a few hours of impaction. Over a longer period, pressure necrosis potentiates the problem. The effect of a topical steroid/antibiotic solution (as used in case 3) potentiates the electrochemical reaction thus increasing corrosion, and can be illustrated by applying various T drops to the battery. Interestingly, Terra- [Cortry.sup.TM] ointment (which had been used in case 1 prior to the correct diagnosis being made) protects against corrosion presumably by providing an airtight seal. Once leakage is occurring the ultimate mechanism of injury, producing the most severe effects, is an alkaline burn. Alkali penetrates much deeper than acid into soft tissue producing an extensive liquefying necrosis [2].
The major aetiological factors leading to the insertion of foreign bodies in the ear have been shown to be associated irritation in the ear due to otitis externa, chronic middle-ear disease, or wax impaction [6]. However, probably of more importance in the cases of battery insertion is the confused state of the patient with regard to the workings and positioning of the hearing aid. Twenty peT cent of elderly patients over 85 years of age admit to lots of trouble' using their aid [1 ]. Mistakes can easily occur, including mistaking a button battery for an aid (in particular an intra-canal model) and inserting it into the ear.
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