Journal of Clinical Forensic Medicine (2001) 8, 214±217 ß APS/Harcourt Publishers Ltd 2001 doi: 10.1054/jcfm.2001.0524, available online at http://www.idealibrary.com on
SHORT REPORT
Diagnostic issues in unusual asphyxial deaths R. W. Byard,1 D. Williams,2 R. A. James,1 J. D. Gilbert1 1
Forensic Science Centre, Adelaide, South Australia; John Tonge Centre, Brisbane, Queensland, Australia, 2John Tonge Centre, Brisbane, Australia SUMMARY. Upper airway occlusion may be due to a variety of causes and may result from accidents, suicides or homicides. Underlying natural diseases may also predispose to lethal choking episodes. A series of nine cases is reported to illustrate a range of circumstances that resulted in fatal upper airway compromise. These included suicide from upper airway obstruction due to an impacted blanket, and accidental deaths due to inhalation of soil, a rock, and a video cassette sticker. One death resulted from glottic obstruction due to a mucosal cavernous haemangioma, another from an enlarged tonsil, and two deaths were precipitated by underlying organic disease in the form of dementia and insulin-dependent diabetes mellitus. The manner of death was not clear cut in two cases where there was evidence of possible accidental death or suicide. ß APS/Harcourt Publishers Ltd 2001 Journal of Clinical Forensic Medicine (2001) 8, 214±217 or natural disease. Toxicology revealed only therapeutic levels of a variety of standard psychotherapeutic agents including haloperidol, carbamazepine and olanzapine. Death was due to suicide by upper airway obstruction from a blanket.
INTRODUCTION Upper airway obstruction may occur from a variety of different causes, the most common being self-in¯icted hanging in suicides and accidental choking on food in individuals with dementia.1,2 The following series of cases is described to demonstrate a variety of different circumstances that led to death from asphyxia, with an analysis of predisposing factors and discussion of problems that may occur in determining the manner of death.
Case 2 A 58-year-old male was found dead in his prison cell in a kneeling position hanging from a knotted sheet looped over a bookshelf. Towel padding was present around the neck. The body was naked and a body form had been constructed out of blankets and a pillow in the bed (Fig. 1). No suicide note was present and the deceased was not on antidepressant medication. There was no pornographic material or evidence of recent sexual activity. At autopsy there were no facial or conjunctival petechiae. The left superior horn of the thyroid cartilage was fractured. Apart from this, and the ligature mark around the neck, there was no evidence of injury. There was no signi®cant natural disease. Postmortem toxicology was negative. Death was due to hanging.
CASE REPORTS Case 1 A 53-year-old schizophrenic male had been admitted to a psychiatric facility following attempted suicide by drug overdose. He was subsequently found dead with a blanket inserted into his mouth and pharynx. The blanket was removed during attempted resuscitation. At autopsy there was no evidence of signi®cant injury R. W. Byard, R. A. James, J. D. Gilbert, Forensic Science Centre, 21 Divett Place, Adelaide 5000, Australia. D. Williams, James Tonge Centre, Brisbane, Australia
Case 3 A 24-year-old male was found dead under his carport. Inside the house a laundry trough was ®lled with water within which was a hairdryer connected to the mains.
Correspondence to: Professor Roger W. Byard, Tel.: 618 8226 7700; Fax: 618 8226 7777; E-mail:
[email protected] 214
Diagnostic issues in unusual asphyxial deaths A
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Fig. 1 The bed (A) and a body form constructed from blankets and a pillow (B) in Case 2 to enable the deceased to hang himself without interruption from prison officers.
The laundry fuse had blown. A trail of blood spatters extended from the laundry into the hall, and then outside to an area of gravel and scoria (volcanic rock), where it appeared that the deceased had fallen. The trail then led around the side of the house to the body. At autopsy the upper body was covered in blood spatters with a gaping transverse incised wound of the anterior neck (Fig. 2A). The wound had completely severed the trachea below the thyroid cartilage but had not damaged any major neck vessels. A piece of scoria was found at the bifurcation of the trachea completely occluding both main bronchi (Fig. 2B). Death was due to upper airway occlusion from a piece of volcanic rock. Case 4 A seven-year-old boy was found unresponsive in bed. During attempted resuscitation by ambulance of®cers a piece of cellotape with a coloured sticker was found wedged into the glottis completely occluding the upper airway (Fig. 3). At autopsy there was no evidence of injury or signi®cant natural disease. Death was due to upper airway obstruction from the tape.
Fig. 2 A gaping incised wound to the anterior neck in Case 3 with severing of the trachea. Although no major vessels were damaged, considerable spraying of blood had occurred through the selfinflicted tracheostomy wound (A). A piece of volcanic rock (scoria) (arrow) used in garden landscaping embedded at the tracheal bifurcation (B).
Case 5 A 77-year-old male was found dead at his home. At autopsy a 30 30 40 mm faecal mass was found obstructing the glottis. Faecal soiling of the ®ngernails of the right hand was also noted. Neuropathological evaluation revealed multifocal microinfarcts. Death was due to upper airway occlusion in an individual with multi-infarct dementia. Case 6 A 68-year-old male collapsed and was unable to be resuscitated. At autopsy the major ®nding was occlusion of the glottis by a large fold of pharyngeal mucosa
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Journal of Clinical Forensic Medicine
Fig. 3 A piece of Sellotape with a sticker found embedded in the glottis of a seven-year-old boy in Case 4.
measuring 10 20 40 mm. Histologic examination revealed a submucosal cavernous haemangioma. There was no evidence of injury or signi®cant natural disease. Death was due to upper airway obstruction from the haemangioma.
Fig. 4 Impacted soil filling the upper airway of a 12-year-old boy in Case 9 who was involved in a motor vehicle accident.
Case 7 A 19-month-old boy was found dead in his bed. At autopsy the major ®nding was of an enlarged, pedunculated left tonsil measuring 9 9 13 mm which was capable of occluding the glottis. Histological examination revealed reactive lymphoid hyperplasia with an overlying purulent exudate. Death was attributed to upper airway obstruction from an enlarged mobile left tonsil. Case 8 A 52-year-old male was found dead face down in the depths of a grave that he had been excavating. His face was lying in soft soil and at autopsy there was ®lling of his upper airway with soil. His past medical history included insulin-dependent diabetes mellitus with hypoglycaemic episodes. There was no evidence of signi®cant injury or other natural disease. Death was due to upper airway obstruction from inhaled soil, with collapse most likely being precipitated by a hypoglycaemic episode related to exercise.
Case 9 A 12-year-old boy was found dead lying on his back in the sleeping compartment of an overturned semitrailer. The cabin was ®lled with dirt due to the roof of the overturned truck scooping up soil as it travelled down the highway verge after rolling over. At autopsy there was ®lling of the upper airway down to the trachea with soil (Fig. 4), with no evidence of signi®cant injury or natural disease. Death was due to upper airway obstruction from inhaled soil. DISCUSSION While death in many reported cases of choking is accidental, both suicidal and homicidal cases occur. Suicidal smothering or choking is uncommon, particularly when compared to hanging, and most often involves the tying of a plastic bag around the head and neck,3 sometimes as a backup to other methods such as
Diagnostic issues in unusual asphyxial deaths drug overdose. In Case 1 choking occurred in an individual with underlying psychosis who was in institutional care. The relatively unpleasant technique of causing airway obstruction by forcing a blanket into the oropharynx most likely re¯ected the mental status of the deceased as well as the lack of availability of other methods of suicide in a hospital setting. As often occurs in cases of choking on foreign material, the obstructive matter was removed during attempted resuscitation. Determination of the manner of death in Case 2 was complicated by the possibility of accidental death during autoerotic activity. Autoerotic asphyxia refers to masturbation enhanced by self-induced asphyxia, most commonly involving low-suspension hanging.4 Features in favour of autoerotic activity, and therefore of accidental death in this case, included neck padding (possibly to prevent marking or bruising of the neck) and nudity. Features against this diagnosis included the absence of evidence of recent masturbation, pornography and typical `props', although the latter would not necessarily be available in prison. Neck padding and nudity are also occasionally found in suicidal hangings. The body form in the bed did not help in determining the manner of death as it merely indicated that the deceased wanted uninterrupted time on his own. Although there was no history of recent depression and no suicide note was found, it was considered most likely that the manner of death was suicide given the absence of any history, or diagnostic features, of autoerotic asphyxial activity. In Case 3 the deceased had failed in attempting suicide by both electrocution and by cutting his throat. Although death was due to tracheobronchial obstruction by a piece of volcanic rock, it is uncertain that the deceased had deliberately placed this into his trachea. It was considered more likely that the foreign material had been inhaled through the self-induced tracheostomy wound when the deceased had fallen into an area of rock and gravel in his back yard, i.e. that death was accidental, occurring in the course of an attempted suicide. Given that the deceased had been walking around the house after cutting his throat, leaving considerable blood-staining, and had managed to walk some distance from where he had left the knife before collapsing, the initial police interpretation was of homicide. Another factor that several of these cases illustrate is a failure to appreciate potential dangers from certain activities which tend to characterize individuals at the extremes of life. For example, the boy in Case 4 who choked on a sticker (most likely obtained from a video cassette) had been chewing the sticker while going to sleep, unaware of the potential for inhalation and airway obstruction. Elderly individuals may suffer
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from dementia that may also reduce the awareness of dangerous eating practices, as was seen in Case 5. This not infrequently results in fatal choking on food in geriatric institutions.2,5 Upper airway obstruction may also result from organic lesions within the aerodigestive tract, such as the pharyngeal haemangioma in Case 6 and the enlarged tonsil in Case 7. This means that examination of the upper aerodigestive tract at autopsy is necessary at all ages, not only early childhood,6 as such lesions may not produce marked symptoms and signs prior to lethal airway occlusion. Organic disease may also lead to a situation where an individual is put at risk of choking or suffocation. In Case 8, a diabetic grave-digger collapsed from presumed hypoglycaemia and choked on inhaled loose soil, while lying face down in the base of the grave that he was working in. As already noted, dementia may predispose to rapid swallowing of large pieces of semichewed food causing airway blockage in the so called `cafe coronary' syndrome.2,5 All manner of materials, including faeces,2 may be ingested by such individuals as was demonstrated in Case 5. Finally, accidents of all kinds may cause death from asphyxia. Case 9 is unusual in that it represents another case of choking on dirt in an individual who was not buried. The deceased boy did not have lethal injuries from the vehicle accident, but had been trapped within a truck cabin that had ®lled with soil scooped up as the truck moved along the highway verge on its roof. In summary, the reported cases represent a series of deaths due to choking and hanging and illustrate a variety of issues including variability in the circumstances of death, differences in predisposing factors, and problems that may arise in determining the manner of death. ACKNOWLEDGEMENTS We would like to thank Mr Wayne Chivell, the South Australian State Coroner, for permission to publish details of these cases. REFERENCES 1. DiMaio DJ, DiMaio VJM. Asphyxia. In: Forensic Pathology Boca Raton, FL: CRC Press, 1993; 207±251 2. Byard RW. Coprophagic cafe coronary. Am J Forensic Med Pathol 2001; 22: 96±99 3. Jones LS, Wyatt JP, Busuttil A. Plastic bag asphyxia in Southeast Scotland. Am J Forensic Med Pathol 2000; 21: 401±405 4. Byard RW, Eitzen DA, James R. Unusual fatal mechanisms in non-asphyxial autoerotic death. Am J Forensic Med Pathol 2000; 21: 65±68 5. Mittleman E, Wetli CV. The fatal cafe coronary. Foreign body airway obstruction. JAMA 1982; 247: 1285±1288 6. Byard RW, Silver MM. Sudden infant death and posterior lingual inflammation. Oral Surg Oral Med Oral Pathol 1994; 28: 77±82
