Intra-cartilaginous laryngeal haemorrhages and strangulation

A previously unrecognized laryngeal injury in young female victims of manual strangulation is described. Twelve larynges that were retrospectively and prospectively collected at the Office of the Chief Coroner for Ontario (1982–1997) were used for this study. In all instances, the larynges were from cases of strangulation (mean age 27±10 years, range 20–46) with classical postmortem findings of asphyxia and either manual or combined manual and ligature strangulation. None of the larynges had fractures of the lamina of the thyroid cartilage, superior cornua, or cricoid cartilages. However, in 9 of the 12 cases (75%), sagittal sections revealed multifocal acute haemorrhages into the base of the superior cornua of the thyroid cartilage at the point of origin from the laminae. The presence of acute intra-cartilaginous haemorrhage into the larynx likely represents the disruption of small blood vessels due to elastic deformation of the flexible larynx during strangulation. The recognition of this form of laryngeal injuries broadens the pathological findings in cases of asphyxia associated with pressure on the neck.     

Correlation of circumstances with pathological findings in asphyxial deaths by hanging: a prospective study of 61 cases from Seattle, WA

Correlation of the circumstances of death with the pathologic findings in this prospective study of deaths by hanging affords insight pertaining to certain of the pathophysiologic mechanisms involved in fatalities of this type. The presence of conjunctival and facial/periorbital petechial hemorrhages correlates with increasing levels of body support below the point of ligature suspension. Hyoid bone and/or thyroid cartilage fractures (found in 26% of cases) are most frequently identified in those persons found completely suspended and in victims in the older age ranges. No hyoid bone/thyroid cartilage fractures, internal soft tissue injury, or petechiae were present in 13 (21%) of the study cases.     

Asphyxia Homicides in Finland, 1983–2012

Finland has one of the highest homicide rates in Western Europe, and almost every tenth homicide is caused by asphyxiation. Reliable statistics, a strict legislation, and an exceptionally high medico-legal autopsy rate formed a base for a nationwide analysis of asphyxia homicides (n = 383) during 30 years. The cases were identified through multiple records, and all the forensic pathology case files were studied in detail. In more than one out of five cases, there were indications of staging, and the homicide was revealed first at autopsy in close to one in ten cases. The vast majority of the homicides took place in private locations and involved persons known to each other. Every third victim was an intimate partner, and every tenth a child. Almost half of the victims died from manual strangulation, one in three from ligature strangulation. Smothering, choking, neck compression with a firm object, and thoracic compression were more rare methods. Drownings were excluded from this study material. Of all the victims, 7% had no observable external injuries. Petechiae were recorded in approximately in 61%, laryngohyoid fractures in 47%, and vocal cord hemorrhages in 16% of the cases. Every tenth female victim had genital injuries. Toxicological analyses were performed in close to all of the cases, and almost three out of four victims tested positive for blood alcohol. The various aspects of the demographics and autopsy findings covered in this study contribute reliable and accurate data to further strengthen the spectrum of observable medico-legal characteristics of asphyxia homicides.     

2633例机械性窒息法医尸检资料回顾性研究

本文根据湖北省部分地区1957～1986年间尸检记录,收集并分析了2633例机械性窒息死的出现率、案情性质、城市与乡村的差别等问题,为法医学实践提供了可供参考的资料。     

Homicidal and suicidal ligature strangulation--a comparison of the post-mortem findings

Suicides by ligature strangulation are rare events. In Berlin (3.5 million inhabitants; ca. 500 suicides per year) approximately one case per year occurs. Here, we present the main findings of 19 cases investigated between 1978 and 1998, compared to 47 cases of homicidal ligature strangulation. Two of the 19 suicidal victims had single fractures of the upper thyroid horns and one victim a fracture of a lower thyroid horn; other types of laryngohyoid injuries were not observed. In the homicidal series, the laryngohyoid structures were unaffected in 26 cases (12 of these victims were children or adolescents), single thyroid horn fractures were present in three cases and more significant injuries in 18 cases. Macroscopic bleedings of the laryngeal muscles were found in 12 victims of the homicidal group and in none of the suicidal. Bleedings in the neck muscles seldom occurred in suicides. According to these findings, the laryngohyoid injuries can be helpful in the differentiation of suicide from homicide, if more than a single thyroid horn fracture or a laryngeal soft tissue trauma is present.     

Hyoid fracture and strangulation.

Observation of hyoid fracture in skeletonized remains offers potentially valuable information on the history of the skeleton or evidence of foul play, or both. Perimortem hyoid fracture frequently indicates manual strangulation, although ligature strangulation, hanging, and other forms of trauma to the neck cannot be ruled out without additional evidence. Such fractures are rare in children and infants, since the hyoid components are not fully ossified and are more flexible than in adults. Both antemortem and postmortem origins of the fractures must also be considered.     

Asphyxial homicide in two Scandinavian capitals

In the Oslo and Copenhagen capital areas, 94 asphyxial homicides were committed in the 10-year period 1985-1994, accounting for 22% of all homicides in that period. Sixty-nine (73%) of the asphyxia victims were female. The most common method of asphyxiation was manual strangulation. Seventeen (18%) of the victims were below the age of 10, accounting for 59% of all homicides in that age group. Whereas 38% of the female victims were killed by their spouse, this was the case for only one male victim. The motive was not known in a great proportion of cases. Fifty-seven percent of the victims had been subjected to additional violence, and in this respect there was no difference between the sexes. In 12 of the cases the offender was female; in 9 such cases the victim was her offspring. More than half of the victims had no blood alcohol. When disregarding the victims less than 10 years of age, 33% of the male and 49% of the female victims had no blood alcohol. The crime scene was the victim's domicile among 72% of female and 52% of male victims. Forty-two percent of the female and 11% of the male victims above the age of 10 years were married or cohabitant.     

Thyreoglobulin and violent asphyxia

The concentration of thyreoglobulin (tg) was determined for death caused by hanging, strangulation by ligature, and throttling. Cases of sudden death (traumatic aortic rupture, penetrating wounds of the heart) were used for comparison. The mean values in cases of hanging (149.9±202.3 ng/ml), strangulation by ligature (193.1±173.3), manual strangulation (561.6±173.9) are distinguishable from violent acute deaths (23.3±27.6) and living healthy individuals (17.3±16.1). By means of statistical comparisons, significant differences were found between throttling and strangulation by ligature and between throttling and hanging (adjusted P<0.001). In connection with examination of the bodies high tg values can be regarded as a vital reaction in obstructive asphyxia.     

Patho-anatomic findings in neck structures in asphyxiation due to hanging: a survey of 80 cases

By examining 80 consecutive cases of death due to hanging, fractures of the thyroid cartilage or the hyoid bone or both, were noted in 45%. Fracture of the cricoid cartilage did not occur. No fracture occurred below the age of 25, and the frequency was slightly increasing with increasing age. There was a preponderance of fractures in males. The highest incidence of fractures was noted in typical hangings, while incomplete hanging to a very great extent was combined with congestion to the face, especially if the location of the ligature was atypical. Typical hanging in general did not produce congestion. The lividity in the declivous areas became fixed at the earliest after 5-6 h suspension time, while after 12 h almost all the cases demonstrated fixed lividity in the distal parts, especially in the legs. There is slight indication that the frequency of fractures increases with the length of suspension time.     

Artifactual injuries of the larynx produced by resuscitative intubation

Over a period of 9 months we examined a series of 50 deaths due to natural and unnatural causes in which there had been endotracheal intubation and chest compression during resuscitation at the scene or in the emergency department shortly before death. In 37 of 50 cases (74%) there were airway injuries directly resulting from the intubation procedure which we documented using a standardized protocol and photography. Specific airway injuries, ranging from petechiae to contusions, included oral injury (28%), posterior pharyngeal injury (16%), epiglottic injury (22%), piriform recess injury (12%), laryngeal and tracheal mucosa injury (64%), strap muscle hemorrhage (14%), and cutaneous injury of the neck (4%). In addition, we recorded the presence of facial (6%) and conjunctival petechiae (21%) and attributed these changes to resuscitative chest compression. No cases had associated fractures of the hyoid or thyroid cartilage. Based on our findings, we conclude that resuscitative intubation can cause artifactual injury that may mimic inflicted injuries caused by neck compression, including strangulation and neck holds.     

Instructions for the complete preparation of the larynx

A method of preparing the larynx in forensic cases is described especially when death occurs by strangulation (manually or using some form of ligature). After the usual dissection of the hyoid bone and the upper horns of the thyroid cartilage, the complete larynx is clipped and fixed in formaldehyde overnight. The first part of dissection after that is to cut away the thyroid gland and the remaining muscles in front of the larynx, except for the cricothyroid muscle and the esophagus and hypopharynx from the back of the larynx. The complete thyroid cartilage is dissected out, and then a horizontal cut is made through the cricoid cartilage. Median-sagittal halving of the remaining larynx completes the gross dissection. Arytenoid cartilages are exposed by dissection of the arytenoid muscles and opening the cricoarytenoid joints. Now all parts of the laryngeal skeleton and all articulations are examined, and all muscles and soft tissues are visible and can be clipped for histological examination.     

Histological examination of the temporal bone in medicolegal cases of asphyxia

Histological findings of the temporal bone in 23 autopsy cases of various asphyxial fatalities were studied. The temporal bones of 12 cases who died of tumors including mammary cancer, gastric cancer, myxoma of heart and craniopharyngioma, the bones of 3 cases of heart attack and the bones of 17 cases who died of various poisoning (barbiturate, amphetamine, paraquat and alcohol) were used as controls. In drowning, the primary finding was hemorrhage in the mastoid air cells of the bilateral temporal bones. In cases of strangulation by ligature, hemorrhage and edema of the cochlear duct in the inner ear as well as hemorrhage in the mastoid air cells were demonstrated bilaterally. In contrast, congestion and edema in the mastoid air cells and inner ear were found in cases of manual strangulation but there was no hemorrhage. From these results, the histological examination of the temporal bone is useful as an adjunct procedure for diagnosing the cause of asphyxia. Differentiation between drowning, strangulation by ligature and manual strangulation may be possible by observing hemorrhages or their absence in the mastoid air cells and inner ear.     

Autoerotic asphyxia: part I

Fatal autoerotic asphyxia refers to death during solitary sexual activity with self-induced asphyxiation meant to be brief and reversible. However, an unexpected fatality results from a failure of a release mechanism apparatus. The large majority of victims of autoerotic death are Caucasian males between the second and fourth decade. While autoerotic death may encompass a myriad of other means of achieving sexual gratification, which includes asphyxia by plastic bag or inhalation of noxious chemicals, the most common method is by ligature about the neck. This study presents a 9-year retrospective review of deaths due to autoerotic asphyxia, specifically ligature asphyxia, in Kentucky between 1993 and 2001. Of the sixteen victims, all were Caucasian males between the ages of 14 and 59 years, with a mean age of 38.3 years. Cross-dressing was a feature in 4 cases. A thorough review of the decedent's background, meticulous scene investigation, and complete postmortem examination may shed light on the mechanism and psychosocial predisposition associated with autoerotic asphyxia.     

Congestion bleedings of the face and cardiopulmonary resuscitation--an attempt to evaluate their relationship

OBJECTIVES: Are any other factors besides the factor "cause of death" involved in the development of petechial hemorrhages (PET) of the head? The significance of the cause of death is well known, other factors have been rarely investigated in medical literature. Do they include cardiopulmonary resuscitation (CPR), as has been claimed in several forensic publications? MATERIALS AND METHODS: (a) 473 consecutive autopsy cases (without strangulation) evaluated by one examiner, which were appropriate for this investigation; (b) analysis of 181 cardiac deaths (investigated by all physicians of our institute). RESULTS: Petechiae were found in 13.3% of all cases and were clearly dependent on the cause of death, up to 20% were found in burn victims, intensive-care patients and cardiac fatalities. Petechiae were more frequently observed in the middle age groups (>20%) than in old persons (<10%). The number of PET cases increased with body mass but was lower in extremely obese persons, a greater number of cases with PET was also observed with increasing heart weight. PET were observed in 11% of the deaths without CPR compared to 19% with CPR. This difference was predominantly caused by the subgroup "acute coronary death", especially if victims younger than 60 years were considered, whereas in many other causes of death no difference in the prevalence of PET with or without CPR could be observed. CONCLUSION: Besides the cause of death, other factors (age, body mass and possibly even heart weight) influence the development of petechiae. The hypothesis that CPR alone produces PET is not confirmed by our experience.     

Laryngohyoid fractures after agonal falls: not always a certain sign of strangulation

Haemorrhagic fractures of the thyroid cartilage and hyoid bone are frequently observed in cases of strangulation and often regarded as evidence for an assault against the neck. In contrast, two cases of laryngohyoid fractures after agonal falls in prone position are presented to draw attention to alternative causes of these injuries with special regard to practical medicolegal casework. A 45-year-old man collapsed at a fairground and died after unsuccessful resuscitation. He showed excoriations at his elbows and right knee, a crush injury at the mentum and his mandibular front teeth were knocked out. The upper parts of the chest and the head showed blue discolouration as a marked sign of congestion due to heart failure. The right coronary artery (RCA) was completely obturated by a 5 cm long post-stenotic thrombus with subsequent myocardial infarction of the lateral part of the left ventricle. Both superior horns of the thyroid cartilage were fractured with surrounding haemorrhage, the skin and muscles of the neck uninjured. In the second case, a 63-year-old woman with a mobility handicap had fallen from a 2m high lifting platform and was found in prone position with her wheelchair on her. Resuscitation efforts were not successful. Autopsy showed signs of blunt external force against head, neck, chest and limbs. Examination of the neck revealed haemorrhage of the right sternocleidomastoid muscle, both superior horns of the thyroid cartilage were fractured, as well as the hyoid bone, with slight haemorrhage of the surrounding soft tissue and mucosa. On the same level, the fifth intervertebral disk was ruptured, without any injury of the spinal cord. These cases demonstrate that laryngohyoid fractures should not be overestimated as unequivocal indication of neck compression and may well be caused by falls, even at ground level.     

A Study of Fatal and Nonfatal Hangings

Approximately 50% of all suicides performed worldwide are strangulations. This article presents options for the medicolegal examination of hanging. The pathogenetic mechanisms and clinical pictures of victims are discussed. Examples of the process of diagnosis and expert conclusions are given. This article is intended for physicians and forensic pathologists. The literature focusing on asphyxia by strangulation is reviewed. Data from Vilnius Hospitals and the State Forensic Medicine Service concerning strangulations performed between 2012 and 2014 are analyzed and include the findings of 5650 autopsies (36% asphyxia) and 4 survived victims. The predominant symptoms were neurological, cardiovascular, and respiratory symptoms. After asphyxia, patients should consult by a psychiatrist, ophthalmologist, gastroenterologist, and endocrinologist. A ligature mark was the most observable sign of asphyxia by neck strangulation. Only complications in the poststrangulation period were treated. Mechanical asphyxia must be identified as the main injury in the clinical diagnosis and encoded as ICD‐10.     

Autoerotic asphyxiation in a female

Autoerotic asphyxiation is an unusual but increasingly more frequently occurring phenomenon, with >1000 fatalities in the United States per year. Understanding of this manner of death is likewise increasing, as noted by the growing number of cases reported in the literature. However, this form of accidental death is much less frequently seen in females (male:female ratio >50:1), and there is correspondingly less literature on female victims of autoerotic asphyxiation. The authors present the case of a 31-year-old woman who died of an autoerotic ligature strangulation and review the current literature on the subject. The forensic examiner must be able to discern this syndrome from similar forms of accidental and suicidal death, and from homicidal hanging/strangulation.     

Classification of Asphyxia: The Need for Standardization

Abstract: The classification of asphyxia and the definitions of subtypes are far from being uniform, varying widely from one textbook to another and from one paper to the next. Unfortunately, similar research designs can lead to totally different results depending on the definitions used. Closely comparable cases are called differently by equally competent forensic pathologists. This study highlights the discrepancies between authors and tries to draw mainstream definitions, to propose a unified system of classification. It is proposed to classify asphyxia in forensic context in four main categories: suffocation, strangulation, mechanical asphyxia, and drowning. Suffocation subdivides in smothering, choking, and confined spaces/entrapment/vitiated atmosphere. Strangulation includes three separate forms: ligature strangulation, hanging, and manual strangulation. As for mechanical asphyxia, it encompasses positional asphyxia as well as traumatic asphyxia. The rationales behind this proposed unified model are discussed.     

Analysis of neck injuries in hanging

Retrospective study of suicidal hangings was made on 175 cases (133 male victims, 42 female victims) for a 5-year period. The mean age was 47.33 +/- 17.51 years. The sample was divided in 4 groups according to the position of the ligature knot (anterior, right, left, and posterior hanging). The authors analyzed all visible injuries of soft tissues and bones and cartilage of the neck, and in 150 cases (85.7%), we established that there was at least one injury of these structures (hematoma or fracture for example). The most frequent injury was to sternocleidomastoid muscles. Fracture of throat skeleton was detected in 119 cases (68%). The proportion of fractures increases with age of the deceased. There was no clear correlation between frequency of neck injuries and type of hanging.     

Toxicological findings in victims of traumatic deaths.

The toxicological findings from 6037 analyses of viscera obtained from victims of traumatic death are used to correlate the relative incidence of carbon monoxide, ethyl alcohol, narcotics, hypnotics, analgesics, and tranquilizers-antidepressants in deaths occurring under the following circumstances: fire related, asphyxia by hanging, by use of plastic bags, from physical obstruction of trachae, and by drowning; traumatic injury from impact of moving train, fall from height, and occupational accident; traumatic injury to pedestrian, driver, and passenger from vehicular accidents; and from violent death by shooting, stabbing, strangulation, and beating. The influence of alcohol, narcotic drugs, and tranquilizers on carbon monoxide can be seen in some of these traumatic deaths. Ethanol alone and in combination with other drugs was present in 42.3% and 19.5% of driver and pedestrian victims, respectively, of vehicular accidents in the year 1974. Comparative analysis is presented for the toxicological data obtained on victims of homicide (shooting, stabbing, strangulation, and beating) in New York City and similar data reported for victims of homicide in Detroit. In New York City 45.9% of such victims died while under the influence of alcohol or narcotic drugs, or both, with methadone predominating in the latter category. Tissue concentrations of drugs found in victims of traumatic death are presented. Diphenylhydantoin, diazepam, meperidine, and slow-acting barbiturates were found in normal therapeutic levels. Higher concentrations of amitriptyline, chlorpromazine, propoxyphene, short-acting barbiturates, and methadone were observed. The concentration of methadone in blood and brain (0.13 +/- 0.14 mg/100 ml) and in liver (0.53 +/- 0.42 mg/100 ml) in cases of traumatic death are not different from those observed in deaths classified as due to methadone overdose.