Asphyxiating death due to basal lingual cyst (thyroglossal duct cyst) in two-month-old infant is potentially aggravated after central catheterization with forced positional changes

There are various causes of possible upper airway obstruction in infants. Particularly, large cysts on the base of tongue may cause severe airway obstruction by a mass effect on the hypopharynx and by displacing the epiglottis. Of these basal lingual cysts, thyroglossal duct cyst is rare but occasionally its remnants can be found at the base of the tongue. Although they are pathologically benign, basal lingual cysts may result in death by asphyxia. There are a few reported cases of asphyxia caused by basal lingual cyst. All died suddenly in the bed or cot while sleeping without any significant symptoms and signs. The authors experienced a unique case of death due to airway obstruction by basal lingual cyst (thyroglossal duct cyst), confirmed by postmortem examination, probably aggravated after central catheterization in 2-month-old infant who had open heart surgery for atrial and ventricular septal defect and report with a literature review.     

Positional Asphyxia in Opioid-Related Deaths: Is It Being Overlooked?

The contribution of positional asphyxia in opioid-related deaths is currently unknown. Diagnostic criteria for positional asphyxia include finding the decedent in a position that does not allow for adequate respiration and an inability to extricate themselves from the position due to various conditions. Our primary objective was to assess whether positional asphyxia and the resulting airway compromise were a contributing factor to death due to the toxic effects of opioids. We evaluated 225 deaths where the death scene investigation contained adequate information to evaluate for positional asphyxia and performed a Pearson chi-square test to determine if the proportion of deaths found in an airway compromising position was higher when opioid(s) caused the death. The proportion of decedents found in a potential airway compromising position was greater when the death was related to opioid use (p < 0.0001). Further, narrowing the dataset to decedents who were definitely in an airway compromising position [Yes (24.49%) vs. No (11.02%)] showed a statistically significant association between positional asphyxia and deaths related to opioid use (p = 0.0021). Carefully documenting the position in which the decedent was initially found may be a significant factor in accurate reporting and in harm reduction efforts to decrease the opioid mortality rate.     

Airway obstruction by laryngeal masses in sudden and homicidal deaths

We present two cases of autopsy detection of laryngeal masses with medico-legal implications. The first is a 56-year-old man who died suddenly of asphyxia due to upper airway obstruction caused by a large glosso-epiglottic retention cyst and glottic oedema. Hypothesis of medical liability was raised, due to delayed tracheotomy as the result of repeated failed attempts at oral intubation by various physicians. Difficult oral intubation due to the presence of a laryngeal mass in an asphyxiating subject requires rapid tracheotomy. The second case deals with a 43-year-old woman who died of asphyxia due to airway obstruction, as a result of injury of a cavernous laryngeal haemangioma after homicidal manual strangulation, with severe haemorrhagic infiltration of the surrounding soft tissues. Damage to laryngeal/hypopharyngeal masses should be considered as a possible sign of manual strangulation, as well as neck skin bruises/abrasions and laryngeal haemorrhages.     

Infant death scene investigation and the assessment of potential risk factors for asphyxia: a review of 209 sudden unexpected infant deaths

At the Wayne County Medical Examiner Office (WCMEO) in Detroit, Michigan, from 2001 to 2004, thorough scene investigations were performed on 209 sudden and unexpected infant deaths, ages 3 days to 12 months. The 209 cases were reviewed to assess the position of the infant at the time of discovery and identify potential risk factors for asphyxia including bed sharing, witnessed overlay, wedging, strangulation, prone position, obstruction of the nose and mouth, coverage of the head by bedding and sleeping on a couch. Overall, one or more potential risk factors were identified in 178 of 209 cases (85.2%). The increasing awareness of infant positions at death has led to a dramatic reduction in the diagnosis of sudden infant death syndrome at the WCMEO. This study suggests that asphyxia plays a greater role in many sudden infant deaths than has been historically attributed to it.     

Death in a fold-away bed

The term "death in abnormal body position" refers to deaths caused by a position-induced impairment of the vital functions of respiration and circulation. In the described case from the autopsy material of the Berlin Institute of Legal Medicine (CCM), the 82-year-old woman died in a folded up fold-away bed in a fixed head-down position. Death was caused by the combined effect of neck compression, traumatic asphyxia and head-down position.     

Iatrogenic tracheal laceration causing asphyxia

Endotracheal intubation is a simple, rapid, and safe technique that is being used as a standard procedure for airway management. However, airway injury during endotracheal intubation could be a significant source of morbidity or even mortality for patients and a source of liability for physicians as well. We report an unusual case of fatal tracheal occlusion by intraluminal blood clot complicating endotracheal intubation. The patient, a 62-year-old woman, with renovascular hypertension and incipient renal failure was scheduled for renal autotransplantation. The surgery was uneventful but the postoperative course was complicated with a lethal airway obstruction. At autopsy a linear longitudinal tracheal laceration was identified with an intraluminal blood clot obstructing the tracheal lumen. Tracheal laceration as a cause of death is a rare and potentially fatal complication of endotracheal intubation with intratracheal bleeding, clot formation, tracheal occlusion, and subsequent asphyxia.     

Gas dispersal potential of bedding as a cause for sudden infant death

We assessed the gas dispersal potential of bedding articles used by 14 infants diagnosed with sudden unexpected infant death at autopsy. Of these cases, eight exhibited FiCO₂ values greater than 10% within 2.5 min, six of which were found prone and two supine. The results demonstrated that these eight beddings had a high rebreathing potential if they covered the babies’ faces. We did not, however, take into account in our model the large tissue stores of CO₂. As some bicarbonate pools will delay or suppress the increase of FiCO₂, the time–FiCO₂ graphs of this study are not true for living infants. This model, however, demonstrated the potential gas dispersal ability of bedding. The higher the FiCO₂ values, the more dangerous the situation for rebreathing infants. In addition, FiO₂ in the potential space around the model's face can be estimated mathematically using FiCO₂ values. The FiO₂ graph pattern for each bedding item corresponded roughly to the inverse of the FiCO₂ time course. The FiO₂ of the above eight cases decreased by 8.5% within 2.5 min. Recent studies using living infants placed prone to sleep reported that some babies exhibited larger decreases in FiO₂ than increases observed in FiCO₂. While the decrease of FiO₂ in our model is still theoretical, CO₂ accumulation and O₂ deprivation are closely related. If a striking O₂ deficiency occurs in a short period, babies can lose consciousness before an arousal response is evoked and all infants could be influenced by the poor gas dispersal of bedding; the main cause of sudden death in infancy would thus be asphyxia. When the bedding is soft, the potential for trapping CO₂ seems to be high; however, it is impossible to assess it by appearance alone. We sought to provide some objective indices for the assessment of respiratory compromise in relation to bedding using our model. When a baby is found unresponsive with his/her face covered with poor gas dispersal bedding, we should consider the possibility of asphyxia.     

Unexpected death due to intestinal obstruction by a duplication cyst in an infant

An 11-month-old female infant died at home after being diagnosed as having gastroenteritis. Autopsy examination revealed a distended distal ileum filled with a large amount of watery contents, and a 3 cm x 3 cm x 4 cm cyst at the ileocecal part of the cecum that was histologically consistent with a duplication cyst. The cause of death was determined to be acute dehydration due to intestinal obstruction caused by a duplication cyst. This case indicates that intestinal obstruction by a duplication cyst should be recognized as a cause of unexpected death in infants.     

The relationship between bedding and face-down death in infancy: mathematical analysis of a respiratory simulation system using an infant mannequin to assess gas diffusibility in bedding

Rebreathing is a model for the relationship between a prone sleeping position and sudden infant death syndrome. This study used a mechanical simulation model to establish the relationship between types of bedding and rebreathing potential for an infant placed prone (face down) at different postnatal ages. The infant mannequin was connected to a respirator set to deliver physiologically appropriate combinations of tidal volume (V(T)) and respiratory rates (RR) across a range of postnatal ages (0-18 months). Before measurements were made, CO(2) flow was regulated to 5+/-0.1% of end-tidal PCO(2) (EtCO(2)). After the model was placed in a prone position, any increase in the fractional concentration of inspired CO(2) (FiCO(2)) was measured. FiCO(2) increased immediately and rapidly, and reached a maximum value within a few minutes. The maximum FiCO(2) ranged from under 2% to over 10%, depending on the bedding. FiCO(2) was also affected by V(T) and RR. This model is not applicable to actual infants because of the large tissue stores of CO(2) in infants; however, it is useful for evaluation of gas diffusibility of bedding and will simplify the investigation of sleeping environments when a baby is found dead with its face covered by soft bedding. In general, the higher the FiCO(2), the greater the rebreathing potential. Theoretically, considering the paucity of body stores of O(2), changes in FiO(2) would be affected not by changes in FiCO(2), but by CO(2) production and gas movement around the infant's face. The rapid decrease of FiO(2) is approximated at the inverse of the FiCO(2) timecourse, suggesting the significance of not only CO(2) accumulation but also O(2) deprivation in the potential space around the baby's face.     

Sudden death by Lepomis macrochirus (the killer fish)

In this unusual case, death was not caused by either anaphylactoid reaction to fish or by fish poisoning. Death was due to asphyxia caused by a live, whole fish occluding the mouth and upper airway.     

Sudden death due to a laryngeal cyst.

A 68-year-old woman died suddenly at home; her body was found in an armchair in a sitting position. Autopsy revealed a laryngeal cyst of a dilated secretory gland, located above the vocal cords, which obstructed the glottis, causing asphyxia. A review of the literature with forensic implications is given.     

Suffocation death by occlusion of the airways with sand

Eleven cases are reported in which death occurred because of suffocation as a result of occlusion of the respiratory tract by sand (without thoracic compression: 3 cases) or being buried alive (8 cases). Two tables demonstrate the findings and circumstances in the events. Three cases are described in detail. A 22-year-old woman was manhandled by blows and kicks to the head and neck. She became unconscious and her head and neck were covered by a layer of sand so that she suffocated. A 42-year-old man was smothered, while unconscious, in a prone position with his face in the sand, after hard blows to the head by two culprits. A 17-year-old girl finally died by chocking. Previously the culprit had pressed her face into the ground, so that she aspirated particles of soil. The question of vital reactions during aspiration of sand was investigated by microscopic examination of the content of the air passage and by destroying parts of the lungs by sulphuric acid. Minimal aspiration of sand occurred in all cases. Although the postmortal remains were left in the ground, there was no postmortem penetration of sand into the air passage. Histological examinations were carried out to support the diagnosis of violent suffocation. In some cases, there were remarkable findings (mobilization of alveolar cells, hepatocelullar hydropic degeneration), but there were no typical or unanimous findings that pertained to all cases.     

Metal Railing Fences and Accidental Death

Two cases of accidental deaths caused by the sharp ends of fence or gate posts are reported. Case 1: A 47‐year‐old man was found hanging by his ankle in an inverted position on fencing. He had attempted a shortcut to a railway platform by climbing over a metal rail fence. He had slipped and been impaled through his ankle by the sharp end of the fence post, resulting in death from positional asphyxia. Case 2: An 18‐year‐old male slipped while climbing over a gate and died after being impaled on a spear tip finial, which had lacerated his external iliac vein. Death was due to exsanguination. These cases demonstrate two rare examples of accidental deaths from impalement by the ends of sharp fence posts. Mechanisms of death in such circumstances involve suspension with positional asphyxia and vascular injury with exsanguination.     

Pericardial Cyst: Cause of Sudden Cardiac Death?

Cardiovascular disease is the leading cause of sudden death in the world. The etiology of sudden cardiac death involves a wide range of diseases, but seldom pericardial cysts. A pericardial cyst is an uncommon cyst usually located in the middle mediastinum and rarely in the posterior part. They are usually harmless and asymptomatic. Here, we present a case of a 63‐year‐old woman who presented with dyspnea and hoarseness, but died suddenly after a CT scan was attempted. The detailed forensic pathologic and histologic examination revealed a pericardial cyst located in the posterior mediastinum. Toxicology and biochemistry tests, including tryptase, found no competing cause of death.     

Asphyxia by tracheobronchial thrombus

Asphyxia secondary to airway obstruction has numerous underlying causes, both acute and chronic. Causes of chronic airway obstruction, such as neoplasms and tracheal scarring, are often clinically apparent well prior to asphyxia. Causes of acute airway obstruction may not be as obvious to clinicians or investigators. These include infections, anaphylactic reactions, status asthmaticus, inhalational injuries, and aspirations, which may result in acute obstruction and sudden death.We report the deaths of 2 individuals, a 43-year-old female and a 78-year-old female, both with adenocarcinoma. The 43-year-old was hospitalized with a stage III, poorly differentiated infiltrating ductal carcinoma of the breast metastatic to the lymph nodes. She was intubated to treat poor respiratory function and acidosis. A bronchoalveolar lavage was consistent with alveolar hemorrhage; no organisms were identified. Blood and "clot" were in her endotracheal tube, so the endotracheal tube was replaced. She became comatose and life support was withdrawn. At autopsy, a large red-gray thrombus obstructed the trachea and extended into the right bronchus. Microscopically, the entire clot was composed of fibrin, red blood cells, and some mucus. Findings of acute respiratory distress syndrome with hyaline membranes were identified. The cause of death was listed as acute respiratory distress syndrome with tracheobronchial thrombus. Experiencing a decline in mental status, the 78-year-old had metastatic adenocarcinoma of unknown primary. She developed sudden respiratory distress and an airway obstruction was discovered. After failure to relieve the obstruction, she decompensated and died. At autopsy, a large, red-gray thrombus obstructed the distal trachea and both bronchi. Microscopically, the thrombus was composed of fibrin, platelets, and red blood cells. The cause of death was asphyxia secondary to airway obstruction by thrombus. We present these 2 unusual cases of asphyxia and review of the literature focusing on asphyxia and the etiology of airway thrombi.     

Death by overlaying and wedging: a 15-year retrospective study

Overlaying, the accidental death by smothering caused by a larger individual sleeping on top of an infant, is a cause of death that has been documented for centuries. The hazard of death has been reported to be greater in infants less than 5 months of age but may occur in children up to the age of 2 years. When an adult or older child rolls on top of an infant, mechanical asphyxia results. The face may be pressed into the mattress or into the body of the sleeping adult or older child. The infant's air may be expressed, and he or she is unable to cry due to pressure on the thorax and the inability to inhale. Some pathologists and investigators believe that the victims of overlaying have no pertinent physical findings at autopsy and that any injury is indicative of inflicted trauma. Others believe that one may see contusions and abrasions from overlaying in and of itself. Wedging is another form of accidental mechanical asphyxia that may have negative autopsy findings. The prevalence of bruising, contusions, or facial and ocular petechiae is not clear. The author reviewed all pediatric forensic cases referred for autopsy to the Forensic Section of the Medical University of South Carolina/Medical Examiners' Office over the past 15 years, from 1985 to 1999. Of these, all cases of overlaying, cases listed as undetermined sudden infant death syndrome versus overlaying, and wedging were included. The cases were analyzed as to victims' age, sex, race, location/bedding, bed-sharer, and whether the bed-sharer was known to have ingested drugs or alcohol before sleep. Postmortem physical findings were also reviewed, particularly for documentation of contusions, abrasions, or facial or ocular petechiae. By clarifying not only the victim, bed-sharer, and scenario but also the presence or absence of physical findings in cases of overlaying, wedging, and other accidental asphyxia, we can better categorize these cases.     

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.     

Mesh-sided cots — yet another potentially dangerous infant sleeping environment

Two cases of accidental asphyxia involving an 11.5 month old boy and a 3.5 month old boy who each died after being trapped between the elastic mesh side of their cots and the cot mattress are reported. In both cases the original cot mattress had either been replaced or augmented by a less well fitting, thicker mattress. Particular problems that exist with these type of mesh sided cots are the potential for considerable stretching of the side of the cot admitting the relatively larger, poorly supported infant head, with elastic recoil of the mesh holding the head in potentially dangerous positions. To help determine whether accidental asphyxia has occurred, death scene examination in cases of sudden infant death during sleep should include reconstruction of the position of the body in the cot or bed, with careful examination of the structure of the cot/bed.     

Sudden death resulting from epidermoid cyst of the brain

Epidermoid cysts of the brain are rare tumor-like lesions, most often of maldevelopmental origin. They are benign in nature, causing symptoms depending on their localization. Surgical resection leads to excellent results. A case is reported of a 68-year-old-man who died suddenly and unexpectedly. Postmortem examination revealed signs of central dysregulation and a bifrontal epidermoid cyst. To the authors' knowledge, death resulting from epidermoid cyst of the brain has not been reported so far.     

Massive ovarian cyst and sudden death

ABSTRACT: Massive enlargement of an ovarian cyst is an uncommon cause of morbidity and a rare cause of mortality due in large to part to noninvasive imaging techniques that usually permit early detection. When an ovarian cyst reaches giant proportions, it produces abdominal enlargement often with a fluid wave resulting in a condition that mimics ascites, called pseudoascites. Despite their impressive appearances, such cysts often are operable for cure. We describe a case of a middle-aged woman who presented 3 years before her death with symptoms from an undiagnosed giant cyst and given a diagnosis of ascites of undetermined etiology. She subsequently died at home unexpectedly, and at autopsy, she was found to have a massively enlarged but otherwise benign mucinous cystadenoma.