Postmortem Computed Tomography Findings of Upper Airway Obstruction by Food

Abstract: This study is a retrospective analysis of 14 cases with food bolus upper airway obstruction as the defined cause of death where both postmortem computed tomography and autopsy were performed. Three groups were defined by the images i.e., Type 1: foreign body situated between the oral cavity and oropharynx, while the epiglottis sits in normal position, Type 2: foreign body situated in the oropharynx just above the epiglottis pushing it posteriorly and obstructing the airway, and Type 3: foreign body obstructing the laryngeal inlet while pushing the epiglottis anteriorly. At the time of autopsy, foreign bodies were detected by pathologists, occasionally in a different position, presumably being dislodged in the act of organ removal especially for the “Type 1” pattern. CT imaging provides accurate interrogation of upper airway bolus obstruction prior to autopsy.     

Acute Fatal Upper Airway Obstruction from an Occult Cavernous Hemangioma of the Larynx

A 42-year-old previously well man collapsed while holding his throat. Resuscitation was unsuccessful, and at autopsy, the most significant findings were limited to the larynx, pharynx, and anterior mediastinum where there were multinodular dark blue tumors. Within the larynx, the lower border of the tumor was well demarcated, not extending beyond the vocal cords. A separate large polypoidal tumor mass was attached to the right aryepiglottic fold by a thin fibrous stalk. Histologic examination revealed numerous large, thin-walled cavernous-type vascular spaces typical of a multifocal cavernous hemangioma. Death was due to asphyxiation from obstruction of the upper airways by a cavernous hemangioma of the larynx. Adult laryngeal hemangiomas are rare and are usually supraglottic. This case demonstrates that pedunculated laryngeal cavernous hemangiomas may remain occult until the initiation of an obstructive episode with sudden collapse and death. In such instances, the diagnosis must rely upon an autopsy examination.     

Lethal Laryngopyocele

A 44‐year‐old man collapsed after complaining of difficulty breathing. Layer dissection of the neck at autopsy revealed a large mixed internal and external laryngopyocele occluding the upper airway. It contained 30 mls of yellow‐gray pus. Mechanisms of death in laryngoceles involve obstruction of the opening into the larynx resulting in accumulation of mucus or air within the sac causing airway occlusion. Once infection supervenes, deaths in laryngopyocoeles result either from accumulated pus causing airway occlusion from a mass effect (as in the current case) or the discharge of pus into the airway causing death from aspiration. Sudden death in laryngopyoceles is a very rare event that requires careful dissection at autopsy to demonstrate the characteristics of the underlying lesion and the possible mechanism of death. Laryngopyocele should be considered in the differential diagnosis of natural conditions causing acute, potentially lethal, upper airway obstruction.     

Elevator-Related Deaths

Elevators are mechanical transportation devices used to move vertically between different levels of a building. When first developed, elevators lacked the safety features. When safety mechanisms were developed, elevators became a common feature of multistory buildings. Despite their well-regarded safety record, elevators are not without the potential for danger of injury or death. Persons at-risk for elevator-related death include maintenance and construction workers, other employees, and those who are prone to risky behavior. Deaths may be related to asphyxia, blunt force, avulsion injuries, and various forms of environmental trauma. In this review, we report on 48 elevator-related deaths that occurred in nine different medicolegal death investigation jurisdictions within the United States over an approximately 30-year period. The data represents a cross-section of the different types of elevator-related deaths that may be encountered. The review also presents an overview of preventive strategies for the purpose of avoiding future elevator-related fatalities.     

Sudden Death by Spontaneous Epiglottic Hematoma Secondary to High Blood Levels of Warfarin

A 67‐year‐old man was found dead, at his home. On external examination, we found a voluminous purplish black ecchymosis of the anterior neck area. On internal examination, we found a voluminous epiglottis hematoma completely obstructing the upper airway. It was associated with other sites of intra‐abdominal hemorrhage. Toxicological studies revealed the presence of warfarin at a concentration of 8.4 mg/L in peripheral blood, which supposes an INR well above 4.5. To conclude, we supposed death was due to asphyxia secondary to a spontaneous epiglottic hematoma caused by a high blood concentration of warfarin. Hemorrhage in the epiglottis is very rare. To our knowledge, our patient is the only case of “sudden death” reported with spontaneous epiglottic hematoma due to high blood concentration of warfarin. In forensic practice, an anterior neck ecchymosis, without trauma, may suggest hemorrhage into soft airway tissues. Pathology findings make it possible to exclude exogenous trauma.     

Sudden death from saccular laryngeal cyst

Laryngeal cysts are benign, uncommon lesions of the larynx that have been reported on rare occasions to cause sudden death in infants and adults by acute airways obstruction. In this report, we document the sudden death of a 36-year-old woman from a previously undiagnosed, asymptomatic laryngeal saccular cyst that presented with acute, and consequent fatal, airway obstruction. Difficulty during intubation, both in theater and in emergency settings, is a frequent presenting problem. This can have significant medicolegal implications in determining possible negligence. The diagnosis, classification, and management of such cysts, and their importance to both the forensic pathologist and clinicians are discussed.     

Firearm Deaths by Law Enforcement

Abstract:  The use of deadly force during law enforcement is a matter that compels public scrutiny. There were 42 gunshot deaths caused by police over a 4-year period in New York City. The decedents' average age was 31 years and ranged from 17 to 64 years. There were 41 males and one female; and 26 Black, nine Hispanic, and seven White decedents. Ethanol and/or drugs of abuse were detected in 78% (31/40) of the decedents. The vast majority of shootings occurred with the police responding to a crime and 90% of the decedents were armed (26 handguns, six knives, one axe, one metal pipe, and one toy gun). Vehicles were used as weapons in two incidents. A total of 177 bullets struck the 42 decedents. Fourteen decedents sustained single gunshot wounds (GSWs), and the remainder had multiple GSWs ranging from 2 to 21. In the majority of the cases in this study, the number of GSWs of the body was three or fewer. Thirteen decedents had at least one GSW of the back or buttocks, accounting for 25 of the total 177 wounds, and four of the 13 had GSWs of only the back. With the exception of the upper extremities, GSWs of all locations were more likely to penetrate than perforate. Although these deaths may be high profile, the certification is typically straightforward and the cause (i.e., GSW) and manner of death (homicide) are readily apparent. Although police shootings in which the decedent was unarmed and/or sustained numerous GSWs are widely reported by the lay press, these types of shootings were not typical in our study.     

Petechial Hemorrhages and Ethanol in Deaths from Intoxication

Petechiae in conjunctivae and in the palpebrae/skin of the eyelids are of particular interest for the forensic pathologist, because of their association with pressure on the neck. They have been described in the eyelids of intoxicated persons both in case reports and in text books of forensic pathology. We studied 590 deaths caused by intoxication, and 75 had petechiae either in the conjunctivae, the eyelids, or in both locations. We examined the influence of drugs and ethanol on the location of the petechial hemorrhages in these deaths. Deaths with ethanol in blood and in urine/vitreous humor more often had petechiae in both locations than those without. This association was statistically significant, independent of body position and livor mortis. No association between the location of petechiae, medicinal drugs, or narcotics was found. These results suggest that ethanol may contribute to the development of petechial hemorrhages in deaths from intoxication.     

Deaths in Unlicensed Alcohol Rehabilitation Facilities,

Non‐English‐speaking people do not always seek medical care through established institutions. This paper reports a series of deaths in unlicensed alcohol rehabilitation facilities serving Spanish‐speaking men. These facilities are informal groups of alcohol abusing men who live together. New members receive various treatments, including administration of ethanol or isopropanol, restraint, and seclusion. We reviewed 42 deaths in unlicensed alcohol rehabilitation facilities in Los Angeles County during the years 2003–2014. Data gathered included age, length of time spent in the facility, blood alcohol and drugs at autopsy, and cause and manner of death. Causes of death included acute alcohol poisoning, alcohol withdrawal, and a variety of other causes. Three cases were considered homicides from restraint asphyxia. The Department of Medical Examiner‐Coroner has worked with the police, district attorney, and State Department of Health Services to try to prevent additional deaths in unlicensed alcohol rehabilitation facilities. Nevertheless, prevention has been difficult.     

Retrospective Analysis of Hanging Deaths in Ontario

Hanging deaths from investigation standpoint are rarely problematic. Unusual circumstances can on occasion raise suspicion of foul play. Associated neck injuries are reported in the literature with variable frequency (from 0% to 76.8%). This study retrospectively analyzed 755 hanging deaths in Ontario (Canada) to evaluate the demographic features and circumstances of hanging fatalities, and the frequency of hanging‐related neck injuries. A number of cases showed unusual/special circumstances (e.g., complex, double suicides, restraints). Among 632 cases with complete autopsies, hyoid and larynx fractures were present in 46 cases (7.3%) with the most common being isolated hyoid fractures. The incidence of cricoid fractures was 0.5% and cervical spine injuries, 1.1%. A higher incidence of neck injuries occurred among males, long drop hangings, and in cases with complete suspension. There was a tendency for the number of fractures to increase with increasing age and weight of the deceased.     

Unusual Elevator-Related Deaths: A Report of Two Cases

We present two cases of elevator-related deaths that occurred in two different elevators, and deaths were caused by a similar, but unusual, mechanism. An elevator is a platform or compartment housed in a shaft for raising and lowering people or things to different levels. Elevator-related deaths and injuries are rarely reported in the literature. In most of these cases, cause of death was attributed to falls. It seems that most of the elevator accidents may be attributed to factors related to device maintenance inadequacies or even to device malfunctioning. In our cases, both elevator cars were not equipped with full-length inner doors, thus allowing both accidents to occur. Since 2014, the European Union adopted a relative directive, which imposes the need to equip all elevators with such full-length doors. The enforcement of the above-mentioned EU Directive is crucial, in order to prevent similar accidents in the future.     

Contributory and Incidental Blood Concentrations in Deaths Involving Citalopram

All cases presenting to the New South Wales Department of Forensic Medicine between January 1, 2001 and December 31, 2010 in which citalopram was detected were retrieved. A total of 348 cases were identified. Citalopram contributed to death in 21.0%, and was incidental in 79.0%. Cases in which citalopram was contributory to death had significantly higher blood citalopram concentrations than incidental cases (0.50 mg/L vs. 0.30 mg/L). Citalopram concentrations varied significantly by contributory status: sole citalopram toxicity (median = 1.30 mg/L), citalopram/other drug toxicity (0.50 mg/L), and incidental cases (0.30 mg/L). Citalopram concentrations also varied by suicide status, with the highest concentration found in suicides where citalopram contributed to death (0.70 mg/L) compared with 0.50 mg/L for nonsuicide cases where citalopram contributed to death. In almost all contributory cases (69/73), other psychoactive substances were also detected, most commonly benzodiazepines (47.9%), alcohol (45.2%), and opioids (40.1%).     

Disrobing associated with epileptic seizures and forensic implications

Little is known about the clinical aspects and medico-legal consequences of disrobing in the context of epileptic seizures. Seizure-related disrobing may occur either as an ictal automatism or during the postictal period. Some patients may experience a seizure while already in the unclothed state, engage in ictal wandering, and thereby appear in public in the nude. Two cases involving disrobing associated with seizures captured via video-monitored electroencephalography are offered. An additional case reveals the legal consequences endured by one patient who experienced a nocturnal seizure and began wandering in an unclothed state. Collectively, these cases illustrate the medical reality of seizure-related disrobing and the related adverse effects on patients' quality of life. Disrobing associated with epileptic seizures carries the potential for serious legal consequences if not properly identified as an ictal phenomenon.     

Trichobezoar in Vagina: Assessment for Child Sexual Abuse and Diagnostic Result of Forensic Science

Vaginal discharge and bleeding in children require a through and thoughtful evaluation to diagnose the underlying problem including infections, sexual abuse, and vaginal foreign bodies. We report a 6‐year‐old girl presenting with bloody vaginal discharge, carefully evaluated for sexual abuse, and finally diagnosed as a vaginal foreign body after vaginoscopy. A rolling hair ball was extracted from the vagina and was diagnosed as trichobezoar pathologically without any endo–ecto‐mesodermal residual tissue. The hair ball was genetically detected and diagnosed to belong herself by containing no foreign structure. Child sexual abuse was ruled out by forensic interview at CAC and report of forensic science that reported genetic structure belonging to the child. Medicolegal assessment helped in final diagnosis to exclude child sexual abuse.     

Trends in Officer‐involved Firearm Deaths in Oklahoma from 2000 to 2015

The purpose of this study was to collect data and disseminate trends in officer‐involved firearm deaths in Oklahoma from 2000 to 2015. The Oklahoma Office of the Chief Medical Examiner (OCME) database was searched for civilian decedents with gunshot wounds inflicted by law enforcement officers and officer decedents with gunshot wounds inflicted by civilians. Five decedents were law enforcement officers, while 274 decedents were civilians. The number of civilian decedents throughout the study followed a quadratic trend. Civilian decedents were most commonly males (95%) between the ages of 20 and 39 (64%), had one or two gunshot wounds (46%), and had an increasing number of gunshot wounds over time. Postmortem toxicology testing most commonly detected ethanol, methamphetamine, cocaine, and PCP. Efforts toward increased tracking by various agencies and more scientific studies like this are needed to facilitate future analysis of trends in officer‐involved firearm deaths.     

Laryngeal Choking on Food and Acute Ethanol Intoxication in Adults—An Autopsy Study*

Abstract: The retrospective autopsy study included 98 adults who died because of laryngeal choking on a bolus of food: 67 men and 31 women (χ² = 6.843, p < 0.01), average age 58.61 ± 15.87 years (range 26–92 years). Most of the subjects had poor dentition (χ² = 34.327, p < 0.01). Twenty individuals died in medical institutions, and 78 were nonhospitalized individuals. More than a third of the nonhospitalized individuals were under the influence of ethanol at the moment of death: average blood concentration 8.3 g/dL (SD = 11.0), ranged from 5.0 to 36.0. Nonhospitalized persons were at the moment of event more often under influence of ethanol than the subjects in control group (χ² = 38.874, p < 0.01), and at the same time significantly more intoxicated (z = −7.126, p < 0.01). Our study pointed out that poor dentition and impairment of the swallowing reflex, as a consequence of ethanol intoxication in individuals without mental disorders, were the most important risk factors for bolus death.     

Is Differentiation of Frequently Encountered Foreign Bodies in Corpses Possible by Hounsfield Density Measurement?

Abstract:  The radiological determination of foreign objects in corpses can be difficult if they are fragmented or deformed. With multislice computed tomography, radiodensities—referred to as Hounsfield units (HU)—can be measured. We examined the possibility of differentiating 21 frequently occurring foreign bodies, such as metals, rocks, and different manmade materials by virtue of their HU values. Gold, steel, and brass showed mean HU values of 30671–30710 (upper measurable limit), mean HU values for steel, silver, copper, and limestone were 20346, 16949, 14033, and 2765, respectively. The group consisting of objects, such as aluminum, tarmac, car front-window glass, and other rocks, displayed mean HU values of 2329–2131 HU. The mean HU value of bottle glass and car side-window glass was 2088, whereas windowpane glass was 493. HU value determination may therefore help in preautopsy differentiation between case-relevant and irrelevant foreign bodies and thus be useful for autopsy planning and extraction of the objects in question.     

Correcting the Count: Improving Vital Statistics Data Regarding Deaths Related to Obesity

Obesity can involve any organ system and compromise the overall health of an individual, including premature death. Despite the increased risk of death associated with being obese, obesity itself is infrequently indicated on the death certificate. We performed an audit of our records to identify how often “obesity” was listed on the death certificate to determine how our practices affected national mortality data collection regarding obesity‐related mortality. During the span of nearly 25 years, 0.2% of deaths were attributed to or contributed by obesity. Over the course of 5 years, 96% of selected natural deaths were likely underreported as being associated with obesity. We present an algorithm for certifiers to use to determine whether obesity should be listed on the death certificate and guidelines for certifying cases in which this is appropriate. Use of this algorithm will improve vital statistics concerning the role of obesity in causing or contributing to death.     

n‐Ethyl Pentylone‐Related Deaths in Alabama

n‐Ethyl pentylone (NEP) is a chemical substance derived from cathinone. Synthetic cathinones are an evolving group of drugs with stimulating, mind‐altering effects sometimes referred to as novel or new psychoactive substances (NPS). There is scarce information in the medical literature regarding forensic cases in which NEP is detected in toxicological testing. We present four fatalities involving NEP from Alabama in 2017. Deaths were attributed to NEP toxicity in two cases (peripheral blood concentrations of 0.121 and 0.953 mg/L) and injuries caused by gunshot wounds in two cases (peripheral blood concentrations of 0.045 and 0.031 mg/L). One case involving NEP described an individual who exhibited classic CNS‐stimulant induced erratic behavior before being found dead. These cases enhance the forensic literature regarding specific NPS like NEP and provide contextual reference for professionals considering the significance of NEP in toxicological interpretation.