Delayed Recognition of an Intranasal Button Battery in a Child with Autism Spectrum Disorder: A Case Report.

Abstract

Intranasal foreign bodies (IFBs) are common in children, and button battery impactions represent a surgical emergency due to the risk of rapid tissue destruction via electrochemical burns and liquefactive necrosis. Diagnosis is challenging in children with neurodevelopmental disorders, where unreliable clinical histories and difficult physical examination are common. We report a 9-year-old Malay boy with autism spectrum disorder (ASD) and communication limitation who presented with a two-month history of alternating, foul-smelling, greenish nasal discharge. The symptoms developed after an episode of being punched by a classmate, leading to epistaxis. There was no reported foreign body insertion. Initial assessments at the health clinic and the emergency department attributed the rhinosinusitis and the epistaxis to unknown causes respectively. Subsequent otorhinolaryngology (ORL) assessment was initially limited by patient distress and poor tolerance of the examination, showing only inferior turbinate hypertrophy and old blood clots. Persistent symptoms prompted a nasal endoscopy during a subsequent visit, which identified bilateral purulent discharge and a suspicious foreign body. An X-ray confirmed a button battery. The diagnosis was revised to intranasal button battery impaction with suspected septal perforation, and urgent foreign body removal under general anaesthesia was arranged. The child underwent successful removal of the battery, revealing a 5 x 10 mm nasal septal perforation and right inferior turbinate absence with granulation tissue. This case highlights the importance of maintaining a high index of clinical suspicion for IFBs in children presenting with chronic foul-smelling nasal discharge in the absence of witnessed or reported foreign body insertion. In patients with ASD, where communication barriers may mask clinical presentation, clinicians should prioritize definitive imaging or bedside endoscopy to ensure early recognition and prevent complications such as septal perforation.