What is the recommended treatment for an esophageal foreign body at the level of C6 (cervical spine 6) that is 3mm and embedded in the tissue?

Management of Esophageal Foreign Body Embedded in Tissue at C6 Level

For an esophageal foreign body at the level of C6 that is 3mm and embedded in tissue, surgical intervention is indicated due to the irretrievable nature of the object and its embedding in the tissue, which increases risk of perforation and complications. 1

Diagnostic Evaluation

• CT scan is essential for accurate assessment of:

  • Exact location and depth of embedding
  • Proximity to vital structures (carotid artery, major vessels)
  • Signs of perforation or mediastinal contamination
  • Relationship to surrounding tissues 1, 2

• Plain radiographs have limited utility with high false-negative rates (up to 85%) for small objects 1

Treatment Approach

Surgical Management

1. Surgical approach is indicated when the foreign body is:

   • Embedded in tissue (as in this case)
   • Irretrievable by endoscopic means
   • Close to vital structures
   • Associated with perforation 1

2. Surgical approach based on location at C6:

   • Left cervicotomy is the preferred approach for upper esophageal foreign bodies 1
   • Minimally invasive techniques should be considered first-line in referral centers 1

3. Surgical procedure:

   • Esophagotomy with foreign body extraction and primary closure 1
   • Adequate drainage to prevent complications 1
   • Consider buttressing repairs with viable tissue to prevent complications 1

Endoscopic Considerations

While surgery is indicated in this case, endoscopic assessment may be valuable:

• Combined approach using flexible endoscopy introduced through a Weerda diverticuloscope may be helpful for visualization 1
• Rigid endoscopy should be considered for foreign bodies in the upper esophagus, which is the "Achilles' heel" of flexible endoscopy 1
• Fluoroscopic guidance enhances safety during intervention for high-risk cases 1

Post-Procedure Management

• Close monitoring for at least 2 hours in recovery 1
• Suspect perforation if patient develops pain, breathlessness, fever, or tachycardia 1
• CT scan with oral contrast if persistent chest pain develops 1
• Clear written instructions with advice on fluids, diet, and medications 1
• Provide contact information for the on-call team should symptoms develop 1

Complications to Monitor

• Mediastinitis
• Paraesophageal abscess
• Pneumomediastinum
• Subcutaneous emphysema
• Tracheoesophageal fistula
• Aortoesophageal fistula (rare but life-threatening) 3

Follow-up

• Evaluate for underlying esophageal disorders, which are found in up to 25% of patients with foreign body impaction 1, 2
• Consider diagnostic endoscopy with biopsies after healing to rule out conditions like eosinophilic esophagitis, strictures, or tumors 2

The management of this case requires a surgical approach due to the embedded nature of the foreign body in the esophageal tissue. Delay in treatment increases risk of complications including perforation, mediastinitis, and damage to surrounding vital structures.