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.

Postmortem Magnetic Resonance Imaging and Postmortem Computed Tomography in Ligature and Manual Strangulation.

PURPOSE: The aim of this study was to evaluate magnetic resonance imaging (MRI) findings in cases of fatal manual or ligature strangulation. Verification of strangulation by computed tomography (CT), MRI, and at autopsy as well as its detectability in each modality was assessed. METHODS: We retrospectively analyzed 6 manual and ligature strangulation cases between 2013 and 2019 who all underwent a whole-body CT, head and neck MRI, and an autopsy. Two radiologists examined head and neck imaging data and compared the data to autopsy findings. RESULTS: Magnetic resonance imaging showed a high efficiency in verifying intramuscular hemorrhages, which were confirmed in autopsy. Moreover, in one case without a visible strangulation mark, soft tissue injuries associated with strangulation were detected. Fractures, especially thyroid cartilage fractures, were successfully diagnosed by CT. CONCLUSIONS: As MRI showed a successful detection of soft tissue lesions in relation to strangulation, it can serve as an alternative method or provide additional value to an autopsy. Intramuscular hemorrhages are a common finding in manual and ligature strangulation, providing a useful sign of applied pressure on the neck. However, to evaluate fractures, an additional CT or autopsy is recommended.

Management of Laryngotracheal trauma: A review of current trends and future Directions.

Laryngotracheal trauma is rare but can pose serious threats to one's life. Presenting symptoms vary according to the severity of injury. Immediate Airway control is first step in the management, intubation should be considered by a senior member of the trauma team if the injury is minor while tracheostomy should be reserved for more severe injuries. Evaluation by a fibre-optic laryngoscopy and CT scan should be done whenever possible. Reconstruction is done according to the site involved using suture, titanium miniplates and stents. Tissue engineering has added a new horizon in this management but up till now complete laryngotracheal regeneration is very far-fetched, but tissue regeneration at individual sites have shown some positive results. More work needs to be done in this less explored field including laryngeal transplantation.

Differentiation of homicidal or suicidal strangulation.

Hanging can be suicidal, accidental, or homicidal, and these backgrounds must be discriminated by police and forensic pathologists. We herein report a case involving a 33-year-old man who was found dead on the floor behind the entrance door of an apartment house. The man's brother declared that he had found him hanging in the gap between the stairs on the top floor. When his brother tried to cut him down, the victim fell three floors down through the gap between the stairs. Autopsy was performed to confirm suicidal hanging and a postmortem fall into the narrow gap. In this case, however, a homicide was suspected, and the version of events told by the victim's brother was initially doubted. Homicidal hanging may be uncommon, but intensive scene investigation and thorough autopsy are necessary in hanging cases to rule out homicide.

Multidetector CT of Laryngeal Injuries: Principles of Injury Recognition.

Blunt laryngeal trauma is associated with high morbidity and mortality. However, owing to their relatively rare occurrence, laryngeal injuries may be missed or underdiagnosed. Even subtle abnormalities at multidetector CT may correspond to significant functional abnormalities. It is important to understand normal CT laryngeal anatomy and develop a systematic review of the cervical soft tissues and laryngeal skeleton in patients who undergo screening CT cervical spine or other neck examinations in the setting of trauma, such as CT angiography. Multidetector CT findings of the normal larynx are reviewed, and blunt laryngeal injuries including soft-tissue edema, hematoma, mucosal lacerations, cartilage fracture, cricoarytenoid dislocation, and vocal fold paralysis are presented. The radiologist plays an important role in diagnosis and may be the first to identify laryngeal injuries that are not evident at physical examination. This article reviews normal laryngeal anatomy, presents various blunt laryngeal injuries at multidetector CT with case examples, discusses the role of multidetector CT in acute management, and describes pitfalls of diagnosis. ©RSNA, 2019.

Relevant findings on postmortem CT and postmortem MRI in hanging, ligature strangulation and manual strangulation and their additional value compared to autopsy - a systematic review.

Several articles have described the use of postmortem computed tomography (CT) and postmortem magnetic resonance imaging (MRI) in forensic medicine. Although access to CT scanners and, particularly, access to MRI scanners, is still limited for several institutes, both modalities are being applied with increasing frequency in the forensic setting. Certainly, postmortem imaging can provide crucial information prior to autopsy, and this method has even been considered a replacement to autopsy in selected cases by some forensic institutes. However, the role of postmortem imaging has to be assessed individually according to various injury categories and causes of death. Therefore, this systematic review focuses on the role of postmortem CT and MRI in cases of hanging and ligature and manual strangulation. We assessed the most common and relevant findings on CT and MRI in cases of strangulation and compared the detectability of these findings among CT, MRI and autopsy. According to the available literature, mainly fractures of the hyoid bone or thyroid cartilage were investigated using postmortem CT. Compared to autopsy, CT demonstrated equivalent results concerning the detection of these fractures. A currently described "gas bubble sign" may even facilitate the detection of laryngeal fractures on CT. Regarding the detection of hemorrhages in the soft tissue of the neck, postmortem MRI is more suitable for the detection of this "vital sign" in strangulation. Compared to autopsy, postmortem MRI is almost equally accurate for the detection of hemorrhages in the neck. Another "vital sign", gas within the soft tissue in hanging, which is hardly detectable by conventional autopsy, can be clearly depicted by CT and MRI. The number of cases of manual and ligature strangulation that were investigated by means of postmortem CT and MRI is much smaller than the number of cases of hanging that were investigated by CT and MRI. Likewise, judicial hanging and the hangman's fracture on postmortem imaging were described in only a few cases. Based on the results of this systematic review, we discuss the additional value of CT and MRI in fatal strangulation compared to autopsy, and we reflect on where the literature is currently lacking.

Laryngeal fractures treated with titanium mesh fixation.

The larynx plays a vital role in respiration, swallowing, and vocal function. Thus, laryngeal fractures that are not appropriately managed may lead to permanent dyspnea, dysphagia, and voice disorders. In cases of laryngeal fractures, surgical repair by internal fixation has been performed with materials such as thread, steel wire, and titanium miniplates. However, thyroid and cricoid cartilage have a complicated morphology, and ossification at each site in the cartilage is not uniform; thus, in some cases it is difficult to perform internal fixation with conventional methods. In this case report, we describe two patients who underwent successful fixation of fractures in their laryngeal cartilage after trauma by using titanium mesh with thread and screws. Since optimal reduction and fixation of fractured laryngeal cartilage cannot be performed with conventional methods in patients with unossified cartilage, titanium mesh may be considered a safe and reliable alternative.

Laryngohyoid fractures in suicidal hanging: A prospective autopsy study with an updated review and critical appraisal.

Laryngohyoid fractures in hanging victims are one of the most studied and paradoxically contradictory topics in forensic pathology. According to literary sources, the incidence of laryngohyoid fractures in hanging varies significantly, from 0% to 100%. To verify the diagnostic significance of these injuries in hanging, we prospectively and consecutively analyzed the occurrence of laryngohyoid fractures in a group of 178 suicidal hanging victims (M/F=150/28, aged 14-94years, mean age=50, complete suspension=111 cases, partial suspension=67 cases) in relation to selected variables (age, sex, weight, the completeness of body suspension, and ligature knot location). Altogether, we identified the following types of laryngohyoid fractures in 129 of 178 cases (72.5%): isolated fracture(s) to the thyroid cartilage in 60 cases (33.7%), combined thyrohyoid fractures in 41 cases (23.0%), isolated fracture(s) to the hyoid bone in 28 cases (15.7%), and no fractures to the cricoid cartilage or the cervical vertebrae. The highest frequency of laryngohyoid fractures was found in lateral hangings (right lateral: 26/34, 76.5%; left lateral: 31/37, 83.8%), whereas the lowest rate was found in anterior hangings (4/11, 36.4%). In lateral hangings, fractures more often occurred contralaterally to the suspension point. Statistical analysis revealed significant associations of the occurrence of laryngohyoid fractures with the age of the victim (p=0.028), with the position of the ligature knot on the neck (p=0.019) and with the age-corrected weight of the victim (p=0.026). In addition, we performed a systematic updated review and critical appraisal of relevant literary sources to report the incidence, fracture patterns, and contributing variables of laryngohyoid injuries in hanging. Both the results of our study and the provided literary synthesis show that if evaluated properly, laryngohyoid fractures in hanging may diagnostically offer far more than just evidence that injury to the neck occurred and may also present research opportunities regarding several issues that should be further analyzed and explained.

Trauma to the hyoid bone and laryngeal cartilages in hanging: review of forensic research series since 1856.

Since 1856 lots of forensic reports, concerning trauma to the hyoid bone and laryngeal cartilages in hanging, have been published. Differences in percentage of injured neck complexes ranged from 0 to 83.3%. Simple arguments suggest that the reason for discrepancy is difference in scientific approach (retro- or prospective) and use of various research methods. Comparative analysis of widely used techniques shows considerable variety in their effectiveness. Plain radiography and palpatory method have fairly low sensitivity (33-60% for different elements of the neck complex) with relatively high specificity (89-98.5%). Reported sensitivity of postmortem CT in identification of different lesions (including fractures) in trauma victims for the head/neck region is higher than 53% in different series with possible false-positive findings. In clinical setting the whole-body CT (pan-scanning) in blunt trauma patients showed sensitivity for head and neck injuries at the level of 84.6%, and specificity - 98.9% (Stengel et al., 2012 [68]). Only complete preparation allows to identify all the damages to the laryngopharynx framework, to avoid false diagnostics and ascertain the exact location, morphology, mechanism and intravital nature of the neck trauma. Currently complete preparation can be regarded as the method of "gold standard". Use of this method shows the frequency of discovered injuries in hanging to be about 70% of cases. In practical use, one should consider radiological techniques and palpation as preliminary and orienting methods (rather excluding, than revealing anterior neck trauma).

[Complex fracture of the larynx caused by a horse kick]. / Komplexe Larynxverletzung durch Pferdetrittverletzung.

Every blunt laryngeal trauma requires examination by an ENT physician and may necessitate observation for a number of hours. The literature shows a heterogeneous picture regarding airway management (tracheotomy vs. intubation). Extremely violence forces such as horse kicks require a tracheotomy, as demonstrated by case studies. In such cases, a high level of responsibility lies with the emergency physician providing the initial treatment. We present the case of a 37-year-old horse trainer, who suffered a horse kick to the larynx with a complex laryngeal fracture. Intubation of the patient by the emergency physician would most probably have led to incorrect placement of the tube or complete displacement of larynx and trachea. In addition to securing a vital airway by tracheotomy, a timely reconstruction of the airways, where necessary by employing the temporary insertion of a tracheal stent, is the treatment of choice. The latter therapy should be applied within the first 6 hours following the accident.

Cervical spine injuries in suicidal hanging without a long-drop--patterns and possible underlying mechanisms of injury: an autopsy study.

OBJECTIVES: The incidence of cervical spine injuries in suicidal hangings with a short-drop has been reported to be extremely low or non-existent. The aim of this study was to determine the frequency and pattern of cervical spine injuries in suicidal hanging. METHODS: A retrospective autopsy study was performed and short-drop suicidal hanging cases with documented cervical spine injuries were identified. This group was further analyzed with regard to the gender and age of the deceased, the position of the ligature knot, the presence of hyoid-laryngeal fractures, and the level of cervical spine injury. RESULTS: Cervical spine injuries were present in 25 of the 766 cases, with an average age of 71.9 ± 10.7 years (range 39-88 years). In 16 of these 25 cases, the ligature knot was in the anterior position. The most common pattern of cervical spine injury included partial or complete disruption of the anterior longitudinal ligament and widening of the lower cervical spine disk spaces, associated with absence of hyoid-laryngeal fractures. CONCLUSIONS: Cervical spine injuries are not commonly found in short-drop suicidal hanging, occurring in only 3.3 % of all observed cases. Cervical spine injury may be occurring in 80 % of subjects aged 66.5 years and above. The most common pattern of cervical spine injury included anterior longitudinal ligament disruption of the lower cervical spine, disk space widening, and no vertebral body displacement. These injuries were mainly associated with an anterior knot position, and may be a consequence of loop pressure to the posterior neck and cervical spine hyperextension.

Laryngeal anomalies: Pitfalls in adult forensic autopsies.

OBJECTIVE: This is the first paper to group together most of adult laryngeal anomalies or malformations which may be misinterpreted by the forensic pathologist and taken for a proof of violence. MATERIAL AND METHODS: A review of the literature, to list the main pitfalls, to explain their nature and their origins. RESULTS: We found two main categories, the congenital defects and the acquired anomalies. CONCLUSIONS: The laryngeal region is complex. The pathologist must keep in mind anatomical variations or malformations, but also sequelae of old injuries and iatrogenic lesions. The survey, the patient's clinical history, the findings of the whole autopsy and, if necessary, histology may help to interpret a laryngeal anomaly.

Multidisciplinary approach to fatal dog attacks: a forensic case study.

Dog-bite-related injuries and fatalities are increasing in incidence and represent an important public health concern, as dogs are more and more becoming an integral part of human social life. We report the case of a 27-year-old woman who was found dead in her home. Her body was discovered lying face down in a large pool of partially desiccated blood with signs of having been dragged. Site examination revealed the presence of severe injuries on the face, neck and head, which were then traced back to the dog she owned. Death was attributed to exsanguinations due to a neck blood vessel's laceration with fracture of the fifth cervical vertebra. This was uncommon because the dog bites injured the vertebral artery only without any lacerations of the carotid artery. Confirming that the injuries are dog-bite related was based on a multidisciplinary approach including histological findings, odontological examination of bite marks and DNA analysis.

Causes of laryngeal cartilage and hyoid bone fractures found at postmortem.

The principal aims of this retrospective study were to assess the prevalence and causes of laryngo-hyoid fractures found in coroners' adult postmortem examinations over a five-year period. In 78 of 1930 cases (4%), there was a fracture of the larynx (thyroid or cricoid cartilage) or hyoid bone. The thyroid cartilage alone was fractured in 38 cases; the hyoid bone alone was fractured in 19 cases; the larynx and hyoid bone were both fractured in 21 cases, including one which involved the cricoid cartilage. There was no evidence of surface injury to the neck in 14.1% of cases. The majority (44/78; 56.4%) involved classical manual or ligature 'pressure to the neck', i.e. hanging (32) or strangulation (12) but a significant minority (35.9%) involved other circumstances: road/rail traffic collision (12; 15.4%); falls (6; 7.7%); assaults involving blunt force trauma to the head and neck (4; 5.1%); incised wounds (3; 3.8%); gunshot wounds (2; 2.6%); and explosion (1; 1.3%). The circumstances of death and cause of fracture(s) were 'unascertained' in four cases (5.1%). Postmortem artefact accounted for two cases (2.6%).

Laryngohyoid and cervical vertebra lesions after a fall from a low height.

The aim of this study was to determine the frequency and nature of cervical trauma in the case of low-height falls (up to 2.50 m). A retrospective study was carried out on 114 autopsy cases that died after low-height falls. For each case, age, sex, manner and cause of death, estimated height of fall, ground type, type of primary impact, type of laryngeal and hyoid bone trauma, presence of associated local trauma in the neck and cephalic region, and toxicological data were reported. Fractures of the hyoid bone and/or of the laryngeal cartilages were present in 2.5% of the cases (n = 3). Cervical soft tissue bruising was found in 13% of the cases (n = 15). About 6% of the cases (n = 7) showed blunt cervical vertebral column trauma, including 3 cases with ruptured intervertebral disk. Interpretation and mechanisms of these lesions are discussed.

Traumatic airway management in Operation Iraqi Freedom.

OBJECTIVES: To examine the role of head and neck surgeons in traumatic airway management in Operation Iraqi Freedom and to understand the lessons learned in traumatic airway management to include a simple airway triage classification that will guide surgical management. STUDY DESIGN: Case series with chart review. SETTING: Air Force Theater Hospital at Balad Air Base, Iraq. SUBJECTS AND METHODS: The traumatic airway experience of 6 otolaryngologists/head and neck surgeons deployed over a 30-month period in Iraq was retrospectively reviewed. RESULTS: One hundred and ninety-six patients presented with airway compromise necessitating either intubation or placement of a surgical airway over the 30-month timeframe. Penetrating face trauma (46%) and penetrating neck trauma (31%) were the most common mechanisms of injury necessitating airway control. The traumatic airways performed include 183 tracheotomies, 3 cricothyroidotomies, 9 complicated intubations, and 1 stoma placement. Red or emergent airways were performed in 10% of patients, yellow or delayed airways in 58% of patients, and green or elective airways in 32% of patients. Lastly, surgical repair of the laryngotracheal complex was performed in 25 patients with 16 thyroid cartilage repairs, 4 cricoid repairs, and 8 tracheal repairs. CONCLUSIONS: The role of the deployed otolaryngologist in traumatic airway management was crucial. Potentially lifesaving airways (red/yellow airways) were placed in 68% of the patients. The authors' recommended treatment classification should optimize future traumatic airway management by stratifying traumatic airways into red (airway less than 5 minutes), yellow (airway less than 12 hours), or green categories (airway greater than 12 hours).

Severe laryngeal fracture treated by supracricoid laryngectomy.

OBJECTIVE: To report a rare case of severe laryngeal fracture treated by supracricoid laryngectomy. Previously, a few cases of major laryngeal trauma treated by reconstructive laryngectomy have been briefly described. This paper aims to comprehensively document a rare case of severe laryngeal fracture for which this difficult treatment choice represented an acceptable option. METHODS: A 33-year-old woman sustained very serious blunt laryngeal trauma. The complexity of the laryngeal injuries led us to opt for supracricoid laryngectomy, rather than to attempt laryngeal repair. RESULTS: The post-operative course was normal. The patient's post-operative voice was breathy but functional. No airway stenoses occurred. CONCLUSION: For severe laryngeal fractures, reparative procedures and stenting constitute the standard treatment. However, in selected and especially critical cases, a primary partial or reconstructive laryngectomy is justifiable.

Study of endolaryngeal structures by videolaryngoscopy after hanging: a new approach to understanding the physiopathogenesis.

PURPOSE: To evaluate laryngoscopic findings in hanging cases and to compare them with magnetic resonance imaging (MRI) and forensic autopsy results. MATERIALS AND METHODS: Postmortem nasolaryngofibroscopy and MRI of five people who died from hanging were performed. Three people who died from other causes than hanging were also examined with a flexible laryngofibroscope. The results were compared with injuries discovered during forensic autopsy. RESULTS: In all five hanging cases, laryngofibroscopic investigation showed a vocal fold position in complete adduction confirmed by MRI. This position did not seem to be influenced by the intensity of the forces applied to neck or postmortem delay and cadaveric phenomena. The vocal cords of the three non-hanging deceased were found in the intermediate position. These findings could suggest that pressure applied to the cervical nervous and cartilaginous structures or their elongation during hanging could lead to closure of the glottis with vocal cord adduction maintained after death. CONCLUSION: Laryngofibroscopic examination in hanging cases could be very useful in confirming the vital character of the hanging and understanding asphyxial phenomena in incomplete suspension without laryngeal crush.

[Laryngeal fractures due to blunt trauma]. / Larynxfrakturer opstået ved stump vold.

INTRODUCTION: Laryngeal fractures due to blunt trauma are rare. Consensus on diagnosis and treatment is therefore needed. MATERIALS AND METHODS: A retrospective search of patient records in the period 2000-2007. Data were obtained on sex, age, time from trauma to first medical visit, time from trauma to operation, result of laryngeal computertomography, pre- and postoperative videostroboscopy, pre- and postoperative evaluation of voice quality, method of operation and status at last follow-up. RESULTS: Seven patients, six males aged 24-54 and one female aged 24. All had moderate to severe laryngeal trauma, and all except one needed surgical intervention. Three had the fracture stabilized with titanium net/miniplates. The postoperative voice was evaluated as good/acceptable in four patients, one had a recurrent nerve palsy and was lost to follow-up; one is still undergoing voice therapy. CONCLUSION: Patients must be examined for hoarseness, laryngeal pain, aphonia, asymmetry, bleeding and subcutaneous emphysema located in or around the larynx. Based on a computertomography, dislocated fractures should be operated (preferably within 48 hours). It is necessary to obtain stable fractures. The use of titanium nets or miniplates is recommended.