At what level of the esophagus is a coin lodged at the C4 to C7 level in a 3-year-old male?

Coin in the Esophagus at C4 to C7 Level in a 3-Year-Old Male

A coin lodged at the C4 to C7 level in a 3-year-old male is located in the upper thoracic esophagus, specifically at the level of the cricopharyngeus muscle and aortic arch. 1

Anatomical Considerations

• Foreign body impaction in children commonly occurs at the level of the hypopharynx or upper thoracic esophagus due to anatomical narrowing at the cricopharyngeus muscle and aortic arch 1
• The C4-C7 vertebral level corresponds to the upper esophageal sphincter and the beginning of the thoracic esophagus, an area where coins frequently become lodged 1
• Children are particularly vulnerable to foreign body impaction due to their smaller esophageal diameter compared to adults 1

Clinical Implications and Management

• Coins lodged at the C4-C7 level require urgent flexible endoscopy (within 24 hours) if there is no complete obstruction 1
• If the coin is causing complete esophageal obstruction, emergent endoscopy (within 2-6 hours) is recommended to prevent complications such as aspiration and perforation 1
• The location at the upper esophageal sphincter/upper thoracic esophagus may influence the choice of removal technique:
  • Flexible endoscopy is the first-line approach for most esophageal foreign bodies 1
  • Rigid endoscopy should be considered for foreign bodies in the upper esophagus (the "Achilles' heel" of flexible endoscopy) 1
  • In some cases, direct laryngoscopy with Magill forceps may be effective for coins lodged at this level 2

Radiographic Considerations

• Coins in the esophagus are typically oriented in the coronal plane (appearing en face on frontal radiographs), but may occasionally present in the sagittal plane 3
• Biplanar radiography (AP and lateral views) is essential to confirm the location and orientation of the coin 4
• At the C4-C7 level, the coin may be visualized at the level of the aortic arch on chest radiographs 3

Risk Factors and Epidemiology

• Children aged 3 years or younger account for more than three-fourths (77.1%) of choking episodes 1
• Coins are the most common non-food foreign bodies ingested by children 1
• The size of the coin correlates with the risk of impaction - coins with diameters between 23.45 and 26.00 mm are most commonly retained in the esophagus 5

Potential Complications

• Prolonged retention of coins in the esophagus can lead to pressure necrosis, perforation, and mediastinitis 1
• The smaller diameter of a child's airway means that even small changes in the cross-section can lead to dramatic changes in airway resistance and air flow 1
• Aspiration is a risk if the coin dislodges and enters the airway 1

Management Algorithm

1. Confirm coin location with biplanar radiography (AP and lateral views) 1
2. Assess for signs of complete obstruction (inability to swallow saliva, drooling, respiratory distress) 1
3. If complete obstruction: emergent endoscopy within 2-6 hours 1
4. If no complete obstruction: urgent endoscopy within 24 hours 1
5. Consider the most appropriate removal technique based on the exact location:
   • Upper esophageal (cricopharyngeal) location: rigid endoscopy or direct laryngoscopy with Magill forceps may be preferred 1, 2
   • Mid-thoracic location: flexible endoscopy is typically preferred 1

Remember that a coin at the C4-C7 level requires prompt intervention as it is located at a critical anatomical narrowing where complications are more likely to develop if left untreated 1.