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Button (Disc) battery impaction in the esophagus is a time critical presentation with significant associated morbidity and mortality. We present the case of a 15-month old boy with an unwitnessed foreign body ingestion, and who was subsequently found to have two ingested lithium button batteries, which were lodged at the upper esophagus, distal to cricopharyngeus. We discuss the “macaroon sign” of two button batteries lying parallel to one another, with both positive poles facing each other, as this may be an unusual barrier to urgent identification of the impacted foreign body as batteries.0.25% acetic acid was used as a neutralising agent at the time of button battery removal (8 h after ingestion), based on published evidence that this effectively decreases tissue pH and mitigates the severity of the injury in animal models, whilst not increasing ambient tissue temperature as once thought [4]. Our patient had a significantly better clinical outcome than predicted from the severity of the burn at time of button battery removal, suggesting acetic acid used topically is a safe adjunct treatment of impacted ingested button batteries and may reduce the likelihood of serious long term sequelae. Keywords: Button battery, Caustic ingestion, Esophageal injury, Foreign body ingestion, Electrical injury, Acetic acid

Introduction Suprastomal Collapse (SuStCo) is a common complication of prolonged tracheostomy in children. There is a paucity of literature on this subject, especially regarding how to manage significant suprastomal collapse that prevents safe decannulation. Objective Provide a definition, classification system, and recommend management options for significant suprastomal collapse in children with tracheostomy. Methods Members of the International Pediatric Otolaryngology Group (IPOG) who are experts in pediatric airway conditions were surveyed and results were refined using a modified Delphi method. Results Consensus was defined as > 70% agreement on a subject. The experts achieved consensus: • on a standard definition of Suprastomal Collapse • that there is clinical importance between significant and insignificant collapse • that the gold standard diagnostic modality is endoscopic examination under anesthesia • that the severity of collapse is a major determinant in the surgical approach • that surgical intervention is the first line management in combined anterior and lateral Suprastomal Collapse. Conclusion This consensus statement provides recommendations for medical specialists who manage infants and children with tracheostomies with significant Suprastomal Collapse. It provides a classification system to facilitate diagnosis and treatment options for this condition.

Objectives Pediatric tracheostomy is performed in a variety of complex, comorbid patients. Tracheostomy involves a significant burden of care for families and a risk of life-threatening complications. There is little research regarding the ideal location and protocol for safe tracheostomy decannulation. This study aims to determine patient factors that may be predictive of trial of tracheostomy decannulation being able to take place safely outside of the intensive care setting. Methods A 10-year retrospective review of all decannulation trials at our institution is used to assess for patient factors associated with a higher risk of decannulation failure. The timing of failure and the interventions required to secure the patient's airway are reviewed. This data is used to inform recommendations regarding location of tracheostomy decannulation trial and length of inpatient stay, aiming to rationalize the use of resources while maintaining safe tracheostomy decannulation practices. Results One hundred and fifty-eight decannulation events occurred in 131 children over the study period, resulting in 132 successful decannulations (83.5%). Twenty-six failed episodes (16.5%) occurred in 16 patients (12.2%). Ten of these patients were successful on a second decannulation attempt and six had two or more failed decannulation attempts (4.6%). Failed decannulation was higher in patients with upper airway obstruction as the indication for tracheostomy (20.3% failure rate versus 0%). History of prematurity was significantly associated with failure of decannulation. Nine decannulation failures occurred immediately, with a further 9 failures occurring within the first 24 hours. A further 3 failures occurred in hospital and 5 following discharge. No mortality or significant morbidity occurred during any decannulation trial. Conclusions Our study identified a higher rate of decannulation failure in patients with upper airway obstruction, suggesting that decannulation trials for this subgroup should occur in the intensive care unit. Patients with tracheostomy for other indications may be safe to decannulate in a ward setting. Early failures demonstrated more rapid deterioration. Further research is recommended on the utilization of capping trials or polysomnography prior to decannulation to help guide the ideal location and timing for trial decannulation.

Summary Objective To study the outcomes, complications, and indications for pediatric tracheotomies performed at a major tertiary care children's hospital, Starship Children's Hospital in Auckland, New Zealand, over the period 1987–2003. Methods A retrospective review of hospital records from 1987 to 2003 was conducted to assess all pediatric patients who had undergone tracheotomies. Results A total of 122 tracheotomies (119 surgical, 3 percutaneous) were performed on patients less than 16 years of age. Upper airway obstruction (including craniofacial dysmorphism, n = 40, and subglottic stenosis, n = 18) was the most common indication for surgery ( n = 86; 70%) with a lesser number ( n = 36; 30%) requiring tracheotomy for prolonged ventilation. The median age at tracheotomy was 4.5 months in patients with upper airway obstruction and 16 months in those requiring prolonged ventilation. Decannulation was carried out successfully in 92 patients (75%), although 6 (6.5%) subsequently required recannulation. The overall complication rate was 51% ( n = 62). Early postoperative complications occurred in a total of 9 (7.4%) patients, including difficulties with ventilation in intensive care due to inadequate seal or tube position in 5 (4.1%), and accidental decannulation in 3 (2.5%). Late complications included localized granulation in most patients, for which 15 (12.3%) required intervention whilst under a routine planned general anesthetic. Major vascular erosion was not encountered in any patient, although 5 (4.1%) required intervention for minor bleeding associated with granulation tissue. Suprastomal collapse occurred in 13 patients (10.7%); but did not affect their subsequent decannulation, although 2 (1.6%) developed tracheotomy-related subglottic stenosis. Closure of tracheocutaneous fistulas was required in 16 (13.1%) decannulated patients. Only 2 patients (1.6%) died from tracheotomy-related complications, with an overall mortality rate of 14%. Conclusions Pediatric tracheotomies performed at Starship Children's Hospital between 1987 and 2003 were associated with a low incidence of procedure-related mortality and morbidity and successful decannulation in most cases. The majority of procedures were performed to treat upper airway obstruction, most commonly caused by craniofacial dysmorphism or subglottic stenosis.

Frostbite is tissue necrosis secondary to freezing. Expansion of developing ice crystals disrupts intracellular architecture, causing autolysis as the tissue thaws. The condition is usually seen in the exposed parts of the body, particularly fingers, toes, nose and ears. It commonly occurs in mountaineers and polar adventurers, who are both young and medically fit. We present a case that is unusual both in its anatomical location and because of the patient’s age. It was successfully managed with supportive treatment and minimal, late surgical intervention as is required for peripheral frostbite management.