A Possible Mechanism of Laryngohyoid Fractures in Hanging: A Preliminary Observation.

ABSTRACT: Fractures of the hyoid bone, particularly the greater horns, and thyroid cartilage (superior horns) are known to be associated with hanging deaths. Depending on the literature, the frequency of these fractures varies from 0% to 83%. The mechanism underlying these fractures is believed to be direct compression or indirect traction from the ligature. The relationship of these structures with the cervical spine cannot be visualized with traditional internal examination, due to obstruction by surrounding soft tissue. Postmortem computed tomography scan offers an unobscured view of the relationship of the laryngohyoid structures with the cervical spine.We aim to illustrate the phenomenon of displacement of the laryngohyoid structures associated with fractures of the horns. In our case reports, the laryngohyoid structures were displaced, not only superiorly and posteriorly, but also in 2 of the cases, by tilting, when the suspension point was at the posterior or posterolateral aspect of the neck. This displacement had caused the greater horns of the hyoid bone and superior horns of the thyroid cartilage to be approximated against the cervical spine, particularly the transverse processes. We believe that, in these circumstances, the fractures were caused by pressure of the horns of the laryngohyoid structures against the cervical spine.

Laryngeal function-preserving of frontolateral vertical partial laryngectomy (FLVPL) for selected T4a glottic cancer with thyroid cartilage invasion adherence to the anterior commissure: an innovative attempt.

OBJECTIVE: To evaluate the feasibility and efficacy in selected T4a glottic cancer (thyroid cartilage invasion adherence to the anterior commissure) treated with frontolateral vertical partial laryngectomy (FLVPL) and laryngeal framework reconstruction using titanium mesh. METHODS: Six patients with the limited T4a glottic cancer with thyroid cartilage destruction adherence to the anterior commissure, underwent FLVPL from 2009 to 2016 in Sun Yat-Sen University Cancer Center. All patients were followed up postoperatively. RESULTS: All patients comprised radical tumor resection and favorable functional outcomes, and no aspiration and laryngeal stenosis were observed. According to postoperative pathology, four patients should go through postsurgical radiotherapy with a mean dose of 66 Gy. But one of them refused to undergo postoperative radiotherapy, who observed local recurrence in postcricoid area underwent total laryngectomy (TL) and ipsilateral selected neck dissection in post-surgery two year. During follow-up period, all patients were still alive, and five patients without local recurrence and distant metastases. CONCLUSION: FLVPL and laryngeal framework reconstruction using titanium mesh is one viable surgical procedure to obtain adequate oncologic and functional outcomes.

Is thyroid excision mandatory with laryngectomy in carcinoma larynx?

BACKGROUND: Advanced stage operable cancers of larynx are treated with total laryngectomy including thyroid resection in most of the cases, which may expose patient to hypothyroidism and hypoparathyroidism. The requirement of thyroidectomy during Total Laryngectomy is controversial. METHODS: A cross sectional observational study was set out to review preoperative clinical and radiological assessment; intraoperative and histopathological findings; and follow-up data to predict thyroid gland invasion in the setting of squamous cell carcinoma of the Larynx. RESULTS: 11 (16%) out of 69 patients had thyroid gland involvement on histopathological examination with mean age 63 years. Out of these 11 cases, 8 (72%) underwent primary total laryngectomy. 90% patients with thyroid gland involvement were male. 9 cases with thyroid gland involvement were staged as T4a preoperatively. CONCLUSION: Invasion of thyroid gland by laryngeal cancer is uncommon. Unnecessary hemithyroidectomies lead to hypothyroidism and hypoparathyroidism. The study points out the clear indications of thyroid excision in patients undergoing total laryngectomy. We can suggest that total thyroidectomy should be done with total laryngectomy in cases which have gross clinical, radiological or intraoperative thyroid gland involvement, subglottic extension and thyroid cartilage invasion. This can save the patients from the brunt of unnecessary morbid hypothyroidism and hypoparathyroidism.

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.

Current role of computed tomography imaging in the evaluation of cartilage invasion by laryngeal carcinoma.

OBJECTIVES: To evaluate thyroid, arytenoid, and cricoid cartilage invasion on computed tomography (CT) imaging in patients undergoing total laryngectomy for both primary and recurrent laryngeal carcinoma. Secondary endpoint was to compare laryngeal cartilage invasion between primary and recurrent tumours. METHODS: Pre-treatment CT of 40 patients who had undergone total laryngectomy was retrospectively evaluated and compared with histology. Focal erosions of thyroid cartilage were accounted for neoplastic invasion of the inner cortex. Full-thickness thyroid cartilage invasion was defined as a tumour-like tissue replacing thyroid cartilage or extended in extra-laryngeal soft tissues. Sclerosis and erosion of arytenoid and cricoid cartilages were assessed as signs of neoplastic invasion. RESULTS: CT erosion showed perfect agreement for thyroid inner cortex and cricoid cartilage invasion and almost perfect agreement (87%) for arytenoid cartilage invasion. For tumours in contact with thyroid cartilages, the absence of CT erosion underestimated inner cortex infiltration. CT showed perfect agreement in predicting full-thickness thyroid cartilage invasion only in the case of extra-laryngeal neoplastic extension. Arytenoid sclerosis showed poor correlation with neoplastic invasion. For primary tumours, CT demonstrated good (inner cortex 75%; full-thickness 85%), substantial (67.5%), and perfect (100%) accuracy in thyroid, arytenoid, and cricoid cartilage invasion, respectively. No CT differences were observed between primary and recurrent laryngeal tumours. CONCLUSION: Tumour-like tissue extension in the extra-laryngeal soft tissues was accurate in predicting thyroid cartilage full-thickness invasion. Erosions of arytenoid, cricoid, and thyroid cartilages' inner cortex on CT were highly indicative of neoplastic infiltration. No CT difference in cartilage infiltration between primary and recurrent tumours was observed.

Complex fracture patterns in hanging associated with a fall from height.

In some rare cases of hanging, the so-called 'hangman's fracture' is observed. This occurs when a fall from height is associated with hanging, e.g. capital executions. We describe the case of an 81-year-old man who committed suicide by jumping off a bridge, with a rope wrapped around his neck. The combination of hanging and falling caused a series of bone fractures to the cervical spine and the hyoid bone, leading to dislocation of the vertebral column and multiple bone fragments, producing peculiar patterns. Computed tomography also identified a transverse full-thickness fracture of the dens, which is a rare event. This case highlights specific injuries associated with the combination of hanging and falling, and underlines the importance of a multidisciplinary approach in terms of radiological examination and complete autopsy.

The added value of postmortem magnetic resonance imaging in cases of hanging compared to postmortem computed tomography and autopsy.

The purpose of this study was to evaluate the added value of postmortem magnetic resonance imaging (MRI) compared to postmortem computed tomography (CT) and autopsy in cases of fatal hanging. In addition, the study analyzed the strengths of each examination method regarding typical injuries in these cases. We investigated a cohort of 25 decedents who underwent CT, MRI and autopsy. Two radiologists assessed all MR images of the head and neck as well as the corresponding CT images. The results were compared to autopsy findings by retrospectively analyzing the autopsy reports. Postmortem MRI revealed intramuscular hemorrhages in a large number of cases, however, autopsy did not confirm all of the detected hemorrhages. CT and autopsy detected fractures in several cases, whereas MRI showed a fracture in just one single case. Other previously described vital signs and relevant findings, such as fracture-related gas bubbles, soft tissue emphysema or pneumomediastinum, were observed in only a few individual cases. MRI provided added diagnostic value in the detection of soft tissue injuries and lymph node swelling in fatal hangings. As an adjunct to autopsy, postmortem MRI may reveal additional hemorrhages, which might be missed at autopsy. Since standard MRI demonstrated low sensitivity for the detection of fractures, an additional imaging modality or autopsy is required to overcome this limitation.

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.

Morphological Evaluation of Thyroid Cartilage Invasion in Early Glottic Tumors Involving the Anterior Commissure.

INTRODUCTION: The anterior commissure is an area of glottic cancer infiltration, even in early stages. OBJECTIVE: To evaluate the invasion by tumors into the anterior commissure cartilage in surgical specimens of frontolateral laryngectomy. METHODS: Forty-eight patients who had undergone frontolateral laryngectomy for T1b/T2 squamous cell carcinoma were included. Epidemiological and clinical aspects as well as morphological histopathological analysis were evaluated. RESULTS: Of the 48 patients, 42 (87.5%) had T1b lesions and 6 (12.5%) had T2. Thirty-four cases (70.8%) showed healthy tissue between the tumor and the thyroid cartilage, 10 cases (20.8%) had a tumor in close proximity to the cartilage, and in 4 cases (8.3%) there was cartilage invasion. There was no major risk of adverse outcome in the groups with infiltration or tumor adjacent to the cartilage. Level of differentiation, mitotic index, nuclear irregularity, and the presence of nucleolus and tumor necrosis were not related to cartilage invasion. CONCLUSION: The infiltration of thyroid cartilage occurred in 8.3% of tumors and did not change the outcome in patients submitted to frontolateral laryngectomy. The morphological characteristics did not present any statistical significance.

[The forensic medical characteristic of the age based on the results of the comprehensive examination of the thyroid cartilage]. / Sudebno-meditsinskaia kharakteristika vozrasta po kompleksnomu issledovaniiu shchitovidnogo khriashcha.

The objective of the present study was the development of the diagnostic model for determining the human age based on the results of the comprehensive examination of the 230 thyroid cartilages (TC) obtained from the corpses of men and women of different age. TC were examined with the use of the anthropometric, X-ray, and histological methods. The anthropometric investigations confirmed the gender-related differences in the structure of human TC. Various characteristics of TC were shown to correlate with the age but these relationships were rather weak even if formally significant. The X-ray studies of TC have revealed the significant correlation of the relative amount of the bone tissue on the images with the age (r=0.8). Of the 27 parameters subjected to the morphometric evaluation, the following ones were shown to significantly correlates with the age: percentage of the bony (r=0,82) and cartilaginous (r=-0.8) tissue areas, average density of the adipose (r=0.76) and reticular (r=0.7) tissues, the maximum length of trabeculae (r=0.67), the width of the mature cartilage zone (r=0.54), the cortical plate thickness (r=0.5), and the mean number of immature chondrocytes in the field of vision (r=0.5). The comprehensive investigation into the structure of the human thyroid cartilage provided a basis for the development of the method for determining the human age with the use of the linear regression equations. It is concluded that the proposed method can be employed as an additional diagnostic tool for determining the human age for the purposes of forensic medical expertise and personality identification.

Laryngohyoid Fractures in Fatal Nonhomicidal Falls From a Height.

In cases of fall from a height, the presence of laryngohyoid fracture or bleeding at autopsy constitutes a suspicion of strangulation before trauma in these types of cases. This study has aimed to investigate the incidence of laryngohyoid fractures in nonhomicidal fall from height cases, and their relationship with age, sex, height of fall, body mass index, and other injuries.A total of 170 cases proven to be nonhomicidal falls from height with certain witnesses and evidences in 4683 autopsy cases in 2013 were included in this study.The mean age of the patients included in the study was 39.96 ± 22.25, and 70.6% of the cases were men. It was found that 118 (69.4%) of the deaths were accidental and 52 (30.6%) were suicidal. Laryngohyoid fracture was determined in 9.4% of the cases. In the multivariate logistic regression analyses, it was found that as the height increased, the incidence of hyoid bone fracture increased, and as the age increased, the incidence of thyroid cartilage fracture increased significantly. Furthermore, in cases with cervical spine fractures, the incidence of hyoid bone fracture, and in cases with clavicle or cervical spine fractures, the incidence of thyroid cartilage fracture were observed to be significantly higher.When there is a suspicion in falls from height with laryngohyoid fractures, the height of fall, the age of case, and the injury in the adjacent bones contribute to the determination of the cause and manner of death.

Strangulation and Its Role in Multiple Causes of Death.

Forensic pathologists have a duty to determine the cause and manner of death and are bound by international guidelines in the completion of the death certificate. Sometimes, there are complex circumstances surrounding a death that cannot be captured in the structure of the death certificate and its requirement of listing only 1 cause of death per line. Cases may have multiple causes of death with comorbid medical conditions or inflicted injuries that equally contribute to the ultimate demise. Compared with other forms of homicide, autopsy evidence of strangulation will often be found with other life-threatening traumatic injuries. The Wayne County Medical Examiner's Office conducted a retrospective study of strangulation cases that came into the office from mid-2007 to the end of 2016. The purpose of the study was to examine patterns of injuries in strangulation cases and identify those with additional traumatic injuries of commensurate extent that required incorporation into the cause of death. A total of 43 strangulation cases were found, of which there were equal numbers of ligature and manual strangulations (19 each) and 5 cases in which the method was not specified, and decedents were divided: 63% female and 37% male. Fourteen of these cases were recognized to have multiple causes of death, where blunt force trauma was the most common additional cause, and the sex distribution weighed heavily toward the female (approximately 79%).

[The age-specific changes in the histological structure of the thyroid cartilage in the men]. / Vozrastnye izmeneniia gistologicheskoi struktury shchitovidnogo khriashcha u lits muzhskogo pola.

The objective of the present study was to elucidate the morphological and morphometric characteristics of the human thyroid cartilage during different periods of life. The thyroid cartilages were harvested from 70 cadavers of the subjects of the masculine gender who had died at the age from 1 to 93 years from the non-violent causes and had neither injuries nor signs of pathological changes in the neck organs. The microscopic studies were carried out using the standard methods for the staining of the preparations with hematoxylin and eosin. The following parameters were evaluated: the area of the cartilaginous and bone tissues, the average area of the cartilaginous and bone tissues in the field of vision, the average width of the cartilaginous plate, the thickness of the cortical plate, the number of trabeculae, the average area and length of the trabeculae, the average, minimal, and maximum area of the trabeculae, the number of the young and mature chondrocytes, the width of the zones of the young and mature cartilage and their ratio, the area of the reticular-fibrous and adipose tissues and their ratio. In addition, we also determined mean values, standard deviations, correlation coefficients, and the significance of differences (p). The following characteristics exhibited the most significant correlation with the age: the average area of the bone (r=0.69) and cartilaginous (r=-0.63) tissues, adipose (r=0.67) and reticular fibrous (r=0.61) tissues, the average length of the trabeculae (r=0.7), the number of young chondrocytes in the field of vision (r=-0.789). It is concluded that the described correlations can be helpful in the practical forensic medical activities as the additional diagnostic criteria for the determination of the human age.

[The possibilities for sex determination based on the specific anatomical features of the human thyroid cartilage]. / Vozmozhnosti ustanovleniia pola po anatomicheskim osobennostiam shchitovidnogo khriashcha cheloveka.

The objective of the present work was to study the specific morphological features in the structure of the human thyroid cartilage obtained from 35 men and 35 women. The analysis and evaluation of 31 characteristics of the thyroid cartilage have demonstrated that its size in the men was bigger than in the women with the exception of the angle between the plates that was of a larger size in the women than in the men and showed the closest correlation with the sex. The majority of other characteristics of the thyroid cartilage measured in the study either strongly or moderately correlated with the sex which makes it possible to use these measurements for the purpose of personality identification during forensic medical expertise.

The incidence of thyroid cartilage invasion through the anterior commissure in clinically early-staged laryngeal cancer.

In this study, the incidence of thyroid cartilage invasion in early-stage laryngeal tumors involving anterior commissure was assessed. Medical charts and pathology reports of 62 patients who underwent supracricoid partial laryngectomy as the primary treatment of early-staged laryngeal squamous cell carcinoma were retrospectively reviewed. Patients were divided into two groups according to the macroscopic examination of the surgical specimen: tumors limited to the glottis with the involvement of anterior commissure (TLG); tumors invading both supraglottis and glottis with the involvement of anterior commissure (TISG). Thirty-seven of the cases were classified as TLG group (59.7 %) and the remaining 25 of them were classified as TISG group (40.3 %). Thyroid cartilage invasion was observed totally in ten patients (16.1 %), as macroscopic invasion in two cases and microinvasion in eight patients. Only two were in the TLG group (cartilage invasion rate of 5.4 %), the remaining eight were in the TISG group (cartilage invasion rate of 32 %). Thyroid cartilage invasion rate of TISG group was significantly higher than that of TLG group (p = 0.011, p < 0.05). Tumors limited to the glottis with AC involvement may be more suitable for endoscopic resection; on the contrary, tumors with vertical extension invading both AC and supraglottis should be evaluated more suspiciously due to high rate of thyroid cartilage invasion, which may still necessitate external laryngectomy techniques.

Thyroid cartilage invasion in laryngeal and hypopharyngeal squamous cell carcinoma treated with total laryngectomy.

The objective of this study is to analyze the accuracy of computed tomography in detecting malignant thyroid cartilage invasion. In a retrospective chart review, 120 patients with carcinoma of the larynx and hypopharynx underwent computed tomography before total laryngectomy. These data were compared with the histological specimens. Multidetector computed tomography (MDCT) scan had a positive predictive value (PPV) of 76 % and a negative predictive value (NPV) of 69 %. The specificity of MDCT was 89 % and sensitivity was 46 %. Comparison between radiologic suspected cartilage invasion and histologic results showed a significant correlation (p < 0.02). We found no significant impact of cartilage invasion concerning survival rates (5-year overall survival p = 0.683; 5-year disease-free survival p = 0.711). Preoperative CT scan is an important instrument in detecting neoplastic cartilage invasion.

Current Analysis of Hangings That Deviates From Recently Published Studies.

The constellation of injuries observed in hangings is a subject receiving frequent review in forensic pathology literature. Whereas recent studies have reported high concordance between hangings and internal findings such as strap muscle hemorrhages and hyoid bone and thyroid cartilage fractures, a 2-part study examining autopsied suicidal hangings over a 9-year period at the Wayne County Medical Examiner's Office produced markedly differing results. Retrospectively and prospectively, external and internal autopsy observations were correlated with factors such as age, sex, body height, body mass index, ligature, and height of suspension. In keeping with well-established forensic textbooks, nearly all cases displayed ligature marks and there was strong association between body position and the presence of petechiae. Diverging from contemporary articles, there was a distinctive paucity of internal injuries in both retrospective and prospective portions. Addressing concerns of confirmation bias, assessments confirmed the consistency in identifying and documenting injuries by the pathologists both retrospectively and prospectively.

Computed tomography appearance of normal nonossified thyroid cartilage: implication for tumor invasion diagnosis.

OBJECTIVE: The objective of this study was to determine the density and homogeneity of the nonossified thyroid cartilage (NOTC) on contrast-enhanced computed tomography (CT) providing preliminary information for future evaluation of cartilage invasion using dual-energy CT. METHODS: One hundred normal-larynx CT scans were evaluated for the density and homogeneity of NOTC. RESULTS: The density of the NOTC was homogeneous in all cases. Nonossified thyroid cartilage had higher mean density than contiguous muscle, but there was overlap. In 47 cases, a lucent area was observed at the junction of the ossified and NOTC but not within the NOTC itself. In 11 cases, ossification was observed in only 1 cortex of the thyroid cartilage. Cartilage at the anterior commissure was not ossified in 7 cases. CONCLUSIONS: Nonossified thyroid cartilage has a homogeneous appearance on contrast-enhanced CT scans, but showed some normal variations that could be mistakenly reported as tumor invasion.

An orthotopic mouse model of laryngeal squamous cell carcinoma.

OBJECTIVE: This study aimed to create a reliable and reproducible orthotopic mouse model of laryngeal malignancy that recapitulates its biologic behavior, local invasiveness, and spread as seen in patients. METHODS: Via direct laryngoscopy, human squamous cell carcinoma line FaDu (ATCC HTB-43) was implanted in the larynx (supraglottis and glottis) in nu/nu mice (n = 31). Animals were monitored with direct laryngoscopy and ultrasound for tumor growth and survival. Specimens of larynxes, neck lymphatics, livers, and lungs were removed for histopathologic evaluation to assess tumor extension, thyroid cartilage invasion, and nodal spread. RESULTS: Thirty-one successful direct laryngoscopies were performed. Supraglottic and glottic tumor uptake was 100% and 25%, respectively. Median survival for the animals with supraglottic tumors was 35 days. Histopathologic evaluation revealed pre-epiglottic extension, paraglottic extension, thyroid cartilage invasion, and lymph node metastasis. CONCLUSION: We describe the first orthotopic model for laryngeal cancer. Our model faithfully recapitulates the phenotype and malignant behavior that reproduces its natural biologic behavior as seen in laryngeal cancer patients. This model offers an opportunity to identify and specifically target therapy for larynx squamous cell carcinoma.

Dyspnea, Dysphonia, and Cough: Varied Presentations of Tracheobronchopathia Osteochondroplastica.

OBJECTIVES: Tracheobronchopathia osteochondroplastica (TPO) is an uncommon, benign disease consisting of submucosal, osteocartilaginous nodules that project into the tracheal lumen. Far less commonly, these nodules can occur outside the tracheal cartilage. This case series discusses the wide range of symptoms and treatments of the disease. METHODS: Three patients presented to the laryngology clinic with 3 varied presentations of TPO, including dyspnea, dysphonia, and cough. These patients were evaluated, subsequently diagnosed with TPO, and treated accordingly. RESULTS: Two of the 3 patients presented with extratracheal lesions presenting in the cricoid and thyroid cartilages. The patient presenting with symptoms of dysphonia was found to have bilateral TPO exclusively within the thyroid cartilage, which has never been reported previously. After undergoing a partial thyroid cartilage resection removing the bulk of the lesion, the patient's symptoms drastically improved. CONCLUSION: While TPO may be a rare diagnosis in the general otolaryngologist practice, symptoms frequently bring patients into the otolaryngologist's clinic, and an awareness of the disease can help minimize unnecessary interventions and allow the surgeon to appropriately counsel patients.