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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., (© 2020 The Authors. Journal of Forensic Sciences published by Wiley Periodicals LLC on behalf of American Academy of Forensic Sciences.)

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.

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.

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., (Copyright © 2019 Elsevier B.V. All rights reserved.)

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., (Copyright © 2018 Elsevier B.V. All rights reserved.)

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.

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.

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., (Copyright © 2018 Elsevier B.V. All rights reserved.)

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)., (Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.)

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.

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.

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.

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., (Copyright © 2013 Elsevier Ltd and Faculty of Forensic and Legal Medicine. All rights reserved.)

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.

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%).

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).

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.

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.

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.

Fractures of the larynx are uncommon injuries that may be associated with maxillofacial trauma. Clinicians treating maxillofacial injuries should be familiar with the signs and symptoms of laryngeal fractures and with proper airway management. A timely evaluation of the larynx, rapid airway intervention, and proper surgical repair are essential for a successful outcome.

Objective: To investigate the repair process following carbon dioxide laser injury to the upper airway mucosa (UAM) during the development of chronic subglottic stenosis (SGS)., Design: Animals were assigned to either sham control (cricothyroidotomy only) or injured (cricothyroidotomy and posterior subglottic laser) groups using various carbon dioxide laser exposures (8, 12, and 16 W) for 4 seconds., Subjects: Twenty-four New Zealand white rabbits., Interventions: The subglottis was approached via cricothyroidotomy. Sham control airways were immediately closed, whereas injured airways were subjected to graded carbon dioxide laser exposures prior to closure. Airways were endoscopically monitored preoperatively, postoperatively, and on postoperative days 7, 14, 28, 42, 56, 70, and 84. Animals were killed at 14 and 84 days. Subglottic tissue was harvested for histologic evaluation (reepithelialization, extracellular matrix, vascularity, and inflammation)., Main Outcome Measures: Endoscopic visualization and histologic analysis., Results: (1) Increases in UAM thickness (up to 5 times the thickness of normal mucosa) were observed but were limited primarily to the lamina propria. The mucosal epithelium regenerated without chronic changes. Focal areas of cartilage repair were encountered acutely after injury and to a greater extent in the chronic phases of repair. (2) Acutely, the thickened lamina propria comprised poorly organized extracellular matrix components and demonstrated increases in blood vessel size and number. (3) Histologic changes present in the acute phase only partially resolved in progression to chronic SGS. Chronic SGS was characterized by thick collagen fiber bundles extending into the remodeled subglottic cartilage., Conclusions: The carbon dioxide laser induces acute changes to lamina propria architecture and vascularity that persist chronically. Elucidating responsible signaling pathways may facilitate the development of therapeutic agents to prevent or reduce the formation of SGS.

This prospective study aimed at examining various injuries to the neck structures in deaths due to constriction of neck. Neck dissection technique, as advocated by Prinsloo and Gordon was undertaken to study the injuries to the thyro-hyoid complex, strap muscles, carotid vessels, etc. Of the 1746 medico-legal autopsies, conducted during the study period, 5% were deaths due asphyxia of which 82% were those of constriction of neck. The 21-30 years age group accounted for the maximum number of cases (57%). Male:female ratio was 2:1. Hanging (69%) outnumbered other asphyxial deaths--ligature and/or manual strangulation, smothering, etc. Injury to the sternocleido-mastoid muscle (54%) was the commonest injury to the neck structures. The hyoid bone was fractured in 21% cases, while the thyroid cartilage was fractured in 17% cases. Complete hanging was noted in 68% of cases while the hanging was atypical in 88%. Fixed knot was found to have been used in 71%. A single loop round the neck was observed in 80% of the cases and it was above the level of thyroid in 58% cases. Most cases of the fracture of the laryngo-hyoid complex were in the 41-60 year age group, 72% and the fracture was on the same side as the knot in 52% cases. Majority used soft daily wear articles of clothing like a sari (32%) or chunni (24%). Asphyxial deaths due to constriction of neck being common in all parts of the world, prospective studies in different setups to examine the profile of neck structure injuries are needed so as to differentiate the suicidal or homicidal nature of such deaths with a greater certainty.

Hanging is a common method of committing suicide and a routine task in medico-legal autopsies. The hanging mark is the most relevant external sign and its characteristics are well known, but, for unknown reasons, there are major differences in reports on internal findings. We retrospectively studied 228 consecutive cases of hanging deaths. A complete standard autopsy was performed for every case. We investigated the association between the characteristics of the hanging mark and the frequency of bone, cartilage, soft tissue, and vascular injuries with the mode of suspension. Most cases (75.3%) presented some kind of bone or cartilage fracture, but these were unrelated to any of the variables studied. Vascular lesions are clearly more infrequent: intimal injuries were found in the carotid artery (9.1%), the jugular vein (2.2%), and ruptures of the carotid adventitial layer (21.7%). These could be partially associated with the use of a hard fixed noose and body weight.

Conclusion: We recommend early surgical exploration and fixation for patients with dislocated or comminuted laryngeal fractures to avoid long-term voice complications. One-third of 33 fracture patients rated their voice after the fracture had healed as fair but altered., Objectives: To examine the indications for and the outcome of surgical management in patients with laryngeal fractures., Patients and Methods: The study was carried out in a tertiary care referral university hospital and was a retrospective study of case series. Thirty-three consecutive patients, aged 14-84 years, presented with various types of laryngeal fractures. Patients were staged according to the type of the fracture and surgical correction was performed when indicated. Voice outcome was documented and patients with subjectively suboptimal result were further evaluated by phoniatric specialist., Results: In all, 32 of 33 laryngeal fracture patients had blunt trauma and the main causative factors were sport injuries (39%) and physical assault (33%). All of the 33 laryngeal fracture patients had a good airway outcome. The subjective voice outcome was good for 20 (61%) and fair for 13 (39%) patients. The mean follow-up time was 39.5 months (range 2-114 months). In phoniatric evaluation most (six of eight) patients with fair voice outcome could not produce high pitched voices because of inability to stretch the vocal folds.

Laryngotracheal trauma, partial laryngectomy and phonosurgery may necessitate reconstruction of the cartilaginous skeleton to ensure the quality of respiration and voice. The present report focuses on initial experience gained with a new resorbable material for plates and tacks that allows chondrosynthesis of the laryngeal skeleton. A comparison of the extrusion forces necessary to pull out the resorbable tacks versus conventional titanium screws and the degree of deformation until failure represent the experimental parameters of reconstruction quality under investigation. The PolyMax system (Synthes, Oberdorf, Switzerland) was used in a human cadaver dissection. Sixteen tacks with a diameter of 1.5 mm and sixteen titanium screws with a diameter of 1 mm were placed into the two wings of the thyroid cartilage. Extrusion forces and the degree of deformation occurring until mechanical failure of the device-body interface were measured for the two types of fixation systems. Results in N and mm were compared using a two-sided Wilcoxon test. Neither variable differed significantly between the two groups. However, within the two groups, the necessary strength to pull the tacks or the screws out of the cartilage varied markedly depending on both the inhomogeneous quality of cartilage and the degree of calcification. The PolyMax system with the tacks is recommended as an effective tool for reconstructing the cartilaginous skeleton of the larynx and the trachea with the inherent advantage of resorption as well as avoidance of a second surgery for material removal.

In the years 1980-2000 a total of 302 cases of suicidal hanging were analysed at the Department of Forensic Medicine, Medical University of Białystok. In 140 cases (46.36%) the knot was situated on the neck. In 131 corpses 206 intravital reactions were revealed. Descending incidence of the reactions was as follows: petechial subcutaneous facial and palpebre hemorrhages (33.5%), hemorrhages of muscules sternocleidomustoideus (18.4%), hemorrhages within ligature furrow (11.6%), vertebral cervical fracture (0.7%). In overall material 71.8% were sober persons presenting intravital reactions of the cervical organs to ligature. During autopsy examination skin sections were excised from ligature furrow, muscules sternocleidomustoideus and the carotid artery and then stained with hematoxilin-eosin, orcein, Fuller staining and alcian blue. The carotid artery sections were examined in scanning electron microscope. Macroscopically revealed intravital reactions were fully confirmable by scanning electron microscopic examination. Furthermore, in cases with negative macroscopic image lesions of the common carotid arteries were detected.

In forensic autopsies, one of the most important and common signs of violence to the neck is hemorrhages of the soft tissues. The Institute of Forensic Medicine in Bern evaluates the usefulness of postmortem multislice computed tomography (MSCT) and magnetic resonance imaging (MRI) of forensic cases prior to autopsy. The aim of this study was to prove the sensitivity of postmortem MSCT and MRI in the detection of hemorrhages of the neck muscles. A full body scan prior to and a detailed scan of the explanted larynx after autopsy were performed. MSCT detected multiple fractures of the larynx. Detailed MRI was able to demonstrate the hemorrhage of the left posterior cricoarytenoid muscle. The minor hemorrhage of the right posterior cricoarytenoid muscle could not be detected with certainty. Although more experience is required, we conclude that combined MRI and MSCT examination is a useful tool for documentation and examination of neck muscle hemorrhages in forensic cases.

Since the phoniatrician H. Bauer described the first case of recurrent laryngeal nerve palsy most likely caused by intubation some 45 years ago, several case reports have been published. However, systematic analyses regarding the frequency of recurrent laryngeal nerve palsies due to intubation are scarce, and none of them has used the proper methods to demonstrate clearly that such a mechanism exists. Currently available data justify the assumption that not every recurrent laryngeal nerve palsy following thyroid surgery is due to the operation itself and that the damage caused by intubation, however, may only account for a minority of these cases. The differential diagnosis of postoperative recurrent laryngeal nerve palsy requires the use of specific tools which go beyond simple laryngoscopy and include stroboscopy as well as intra- and extralaryngeal electromyography. A partial palsy of recurrent laryngeal nerve due to intubation would be associated with severe dysphonia or aphonia, not with dyspnea because of the typical intermediate position of the paralyzed vocal folds with a normal electromyographic function of the cricothyroid muscle. The use of these methods to identify the nature of postoperative recurrent laryngeal nerve palsy is recommended in cases of regular intraoperative neuromonitoring but postoperatively impaired function of the vocal cords.

The diagnostic value of hemorrhages to hyaline cartilages of the larynx (CL), which is a sign of a trauma in the neck, were investigated. The application of term "hemorrhage" in respect to foci of reddish (brownish) coloring of the CL tissue was shown to be not always justifiable. Thus, genuine hemorrhages to the CL tissue are not altogether possible in children and teenagers owing to the original avascularity of their hyaline cartilage tissue; as for women, they are possible only in the dorsal CL sections. The reddish coloring results often from the imbibition of the CL tissue by hemoglobin at the places of contact of the cartilage surface with blood. Such false "hemorrhages" can occur not only in trauma but also in nonviolent death and also as artifacts of sectional examinations. It was established experimentally that 10 to 12 minutes are sufficient for postmortal hemorrhage to set on. The differential diagnosis should be made with due respect to the anatomic-and-physiological peculiarities of the dead and by applying the hyaline method.

We evaluated the efficacy of resorbable reconstruction plates (polylactic acid copolymer) for the open reduction and stabilization of displaced laryngeal fractures. Both MacroPore and Leibinger reconstruction plates were used with equal ease of application in 3 adult male patients. We found the plating system to be especially effective for the reduction of comminuted cricoid fractures. Adequate skeletal stabilization allowed early resumption of phonatory and respiratory function without long-term intraluminal stenting for skeletal support. No complications of hematoma, seroma, or infection were experienced. Resorbable plates appear to be relatively safe and useful for internal fixation of both cartilaginous and ossified parts of the larynx, allowing rapid rehabilitation and return of function.

This case control study was designed to investigate if laryngeal haemorrhages occur in cases of strangulation and whether these lesions are specific to strangulation. In the study 30 larynges from victims of fatal strangulation were examined (7 cases of manual strangulation, 12 cases of ligature strangulation, 11 cases of combined manual and ligature strangulation). The control group comprised 40 cases of death without any neck injuries and another group consisted of 5 cases of death caused by trauma with findings of non-strangulation neck injuries. In all the groups, only four solitary haemorrhages (two cases, one control, one non-strangulation neck injury) were observed that did not occur in the proximity of areas of blood accumulation. The results of our investigation suggest that histological evidence of blood accumulation or of haemorrhages in thyroid cartilage is not a reliable criterion to distinguish between haemorrhagic lesions due to strangulation and other types of blood accumulation or artefacts.

To assess the curative effects of different reduction techniques on the dislocation of cricoarytenoid joint caused by intubation, indirect laryngoscope (IL) and direct laryngoscope (DL) were utilized for the closed reduction of the displaced arytenoid under local anesthesia. 23 patients who underwent the reduction for dislocated arytenoid under IL or DL from January 1991 to June 2001 were reviewed. The data were collected on the duration of the laryngeal injury, times of receiving reduction, side-effects after the treatment and the period for voice to return to normal. The relationship between the duration of the laryngeal lesion and the period of the voice rehabilitation was examined. 13 patients received the reduction under IL and 10 patients under DL. Except the times of the reduction, which showed significant difference, no differences were found between IL group and DL group in the course and the period of voice rehabilitation, as well as sore throat after the manipulation. The patients' voice recovery was positively related to their course of disease in both IL and DL group. It is concluded that the recovery of normal voice is obviously affected by the duration of arytenoid dislocation. The reduction under IL is as effective as under DL in the treatment of arytenoid dislocation. Reduction by DL is better suit the patients with long time course of disease.

Objective: To investigate the fabrication of allogeneic tissue engineered cartilage in predetermined shapes and its ability to repair laryngeal cartilage defects., Methods: Tissue engineering technique was used to make allogeneic tissue engineered cartilage in predetermined shapes, and then some of them were utilized to repair cartilage defects in the rabbit larynges(n = 12). Finally, the chondrogenesis and reparative effect were studied grossly and histologically at various periods., Results: 1. The gross specimens of 4 weeks after implantation revealed the presence of new hyaline cartilage of approximately the same shapes as original predetermined shapes, which had fair elasticity and support ability. Histological evaluation showed the characteristics of cartilage tissue. 2. Laryngeal cartilage defects were well repaired using allogeneic tissue engineered cartilage in different periods after operation. A few chondrocytes were observed between the reparative areas with tissue engineered cartilage and normal cartilage. Abundant matrices were also detected in the reparative and interfacial areas. No inflammatory cells were found., Conclusion: It is possible to regenerate new cartilage in predetermined shapes using tissue engineering technique in allograft animals with immunity. Allogeneic tissue engineered cartilage can be used as reparative material to repair cartilage defect of rabbit larynx.

A critical analysis of the postmortem diagnostic criteria for asphyxia leads to a difficulty that has significant implications for the forensic pathologist. The difficulty is that there are no universally recognized pathognomic signs of asphyxia, but pathologists frequently make this diagnosis based on observations that individually have indeterminate significance but combined together, in the appropriate context, have diagnostic value. This leads to the question: if asphyxia has no recognizable signs at autopsy how are we able to diagnose this entity in the latter circumstances? This problem can be solved by defining the minimally adequate diagnostic criteria for compressive neck injury. These criteria are potentially well-defined but currently lacking, in part, due to incomplete morphological characterization of the injuries that frequently occur in strangulation. The problem is especially challenging because the signs of strangulation form a spectrum of degree from minimal to marked and there is no consensus as to the minimal number and nature of lesions that is required to make the diagnosis of strangulation. In the present review of lesions that are commonly encountered in strangulation, intracartilaginous laryngeal haemorrhages and laryngeal cartilage microfractures are considered to have unrecognized diagnostic value, and these lesions are described in detail. A triad of haemorrhages (subepithelial laryngeal haemorrhage, intralaryngeal muscular haemorrhage, and intracartilaginous laryngeal haemorrhage) is discussed in the context of developing a definition of strangulation based on morphological criteria in the absence of overt mechanical injuries to the neck. Although definitive criteria for cases with minimal findings are still lacking, several lesions have putative diagnostic value.

Homicides due to asphyxia are relatively uncommon. To better understand the presentation of such cases, the files of the Bexar County Medical Examiner's Office were reviewed from January 1, 1985, through December 31, 1998, for all such homicides. A total of 133 cases were found. The largest category was ligature strangulation with 48 deaths (21 male, 27 female). Petechiae were present in the conjunctivae and/or sclerae in 86% of the cases; fractures of the hyoid and/or thyroid cartilage were present in 12.5%. There were a total of 41 deaths from manual strangulation (27 female, 14 male). Petechiae were present in 89% of the cases. In cases of manual strangulation, fractures of the hyoid, thyroid, or cricoid cartilage were found in all the male victims and slightly more than one half of the female victims. Twenty-six cases of suffocation were found; 20 of the victims were < or =2 years of age. Only 1 of these children had petechiae and/or scleral hemorrhage. Five deaths were due to choking. Three of the deaths involved adults who were gagged; 2 deaths involved infants with foreign material pushed into the mouth. Other categories of asphyxia were as follows: 9 deaths due to more than one form of asphyxia; 1 death due to hanging, and 3 deaths due to drowning. Rape was the motive in 66% of the female victims of ligature strangulation and 52% of those due to manual strangulation.

The article presents the analysis of knitted trauma to the hyoid bone and laryngeal cartilages, revealed while searching for fresh fractures of the laryngopharynx skeleton for medico-legal purposes. Neck organocomplexes (n = 440) were completely prepared after fixation in formalin. Old injuries were found in 17.3% of cases, and in 3.2% of cases two elements of the complex were formerly broken. More often there was consolidated trauma to the thyroid (11.4% of cases) and cricoid cartilages (7.3%) and, rarely, to the hyoid bone (1.6%) and cervical part of the trachea (0.2%). These injuries occurred twice as often in men (20.3% of cases) than in women (P < 0.01). Substantiated conclusions are: (1) people of working age are most prone to neck trauma; and (2) from the 1960s the percentage of such traumas in the St. Petersburg region has grown due to urbanization. This article presents data on the localization and morphology of the injuries, as well as a review of symptoms and the course of blunt neck trauma. Despite the difficulties associated with the complete regeneration of injured tissues, forensic pathologists can obtain certain information which police officials may be interested in.

Laryngohyoid fractures are a frequently investigated matter, especially in the forensic literature. On the other hand, there are only very few (old) forensic reports of such fractures in survived cases. However, healed fractures are not seldom found in forensic autopsies: In a personal series of 1160 forensic autopsies (adult persons) a careful dissection of the laryngohyoid complex was done by 1 investigator. Only a macroscopic examination of the cartilages was carried out; radiographs and histological slices were not regularly made. Therefore only a part of existing old fractures is detectable; for example, healed fissures are not visible with this simple method. Furthermore, asymmetries of the thyroid laminae cannot be declared as posttraumatic without additional examination, because this condition is described as possible anatomic anomaly. From that, the injury frequencies presented here only mark the lower threshold of the existence of such findings. Healed fractures of the upper thyroid horns and the major hyoid horns can be easily detected even in a routine examination, if healing resulted in a fixed dislocation or apposition of bone surrounding the former fracture site. In the present series, this was the predominant localization of old fractures: the upper thyroid horns (43 cases), followed by the hyoid cornua (12 cases), a combination of both sites (5) and cricoid fractures (5). Of the total 65 healed fractures (5.6%), 35 were found in the group of 290 chronic alcoholics (12.1%) and only 3.4% in non-alcoholics. In the subgroup of middle-aged alcoholics, the fracture rate increased up to 19%. However, this group did not present a higher rate of fresh laryngohyoid injuries (not related to strangulation) than the other cases. The old fractures probably resulted from minor "daily" injuries (like falls), which are common, especially in chronic alcoholics. The frequency of such findings should be in mind if an apparently fresh fracture, found in an actual autopsy, should be related to the cause of death: there is a real chance, that this fracture occurred prior, and without causal connection to the factors resulting in death. Therefore a histological examination of the age of this finding is necessary. Cricoid fractures are quite uncommon, except in serious external neck trauma. In 1 of our 5 cases, this fracture was caused by repeated cruelty, finally resulting in death.

We report the clinical course of blunt laryngeal trauma in three young patients. All three patients underwent several phoniatric examinations as well as indirect microlaryngoscopy and microstroboscopy. The follow-up period ranged from three to eight months. In the first case, there was isolated haemorrhage of the left vocal fold; in the second, dislocation of the arytenoid cartilage with formation of an adhesion in the area of the anterior commissure; and, in the third, non-dislocated fracture of the thyroid cartilage with development of haematoma in the right hemilarynx and transient vocal fold paralysis. One patient required surgical treatment; however, repositioning of the arytenoid cartilage, attempted seven weeks following the injury, proved unsuccessful. In conclusion, all three patients showed significant limitation of vocal fold vibration many months after trauma which was unrelated to the extent of resulting tissue damage. In all three cases, patients developed secondary posttraumatic functional dysphonia requiring treatment.

Acute blunt laryngeal trauma can be a life-threatening event and often poses a difficult airway management problem. Patients may be unable to supply important anemnestic facts because of aphonia or intubation as a result of their injury. Therefore the immediate recognition and appropriate initial assessment and treatment are vital for a successful outcome. The first step is assuring an appropriate airway, either by careful intubation or temporary tracheotomy. An assessment of potential vascular and oesophageal injuries must be undertaken. The use of computerized tomography (CT) with contrast material is especially useful in identifying and localizing the damage caused by blunt neck injuries. Laryngeal fractures, air in the soft tissues and the extravasation of contrast material in the neck are all helpful in assessing the injuries before surgical intervention. Immediate initial surgery is aimed at stabilizing the cartilaginous framework and repairing the mucosa. We present a case of severe laryngeal injury caused by blunt trauma to the neck; our evaluation, treatment and the outcome.

The article is devoted to the comparative analysis of effectiveness of the most widely used methods for medico-legal examination of the hyoid bone and laryngeal cartilages, i.e. palpation, radiography and complete preparation. A consecutive study of 137 cases of hanging (including 20 cases of roentgenological analysis) showed that the former two methods can reveal less than 60% of injuries (fractures, infarctions, fissures etc.); at the same time, false diagnostics may occur. These methods can be used only as preliminary, guiding ones, and cannot substitute stereomicroscopic investigation of the skeletized hyoid bone and laryngeal cartilages, which made is possible to find injuries in 76.6% of suicidal hangings.

Presents the methodological principles and succession of examination of the basic formations of the larynx in cases with blunt injuries of the neck. Describes variants of anatomic structure of the sublingual bone and laryngeal cartilages influencing the morphology of injuries thereof. Offers differential diagnostic criteria of various mechanisms of fractures of the basic formations and recommendations on medical criminological assessment of laryngeal injuries.

For the first time the author draws valid conclusions about the mechanisms of formation of an injury to the complex of organs of the neck in strangulation asphyxia. Analysis is based on comprehensive investigation of 137 cases of hanging, 30 cases with strangulation with a loop, and 12 with strangulation by hands. Anatomic and topographic correlations of neck structures, peculiarities of external exposure, localization and type of injuries are considered. New data were obtained, which permit a well-based judgement on the level, direction, and multiplicity (sequence) of exposure of the anterior part of the neck.

Effects of ossification processes on the incidence and specific features of injuries to sublingual bone, thyroid and ring-like cartilages were studied by stereomicroscopy of the skeletal preparations of these anatomical formations for the first time. The results of examination of cases with hanging permit us doubt the opinion universally acknowledged in forensic medicine that the possibility of injuries of the sublingual bone and laryngeal cartilages increases with their ossification.

Presents analysis of mortality caused by strangulation by hands, based on files and author's own observations. The principal mechanisms of compression of the neck with parts of human body are singled out: with one or two hands, with one or two forearms, with the arm and forearm, with the knee, shin, or foot. The most incident injuries to soft tissues of the neck, sublingual bone, and laryngotracheal cartilages detected by experts at autopsy and at additional fractological examination of the hyoid laryngotracheal complex are described. A conclusion about the mechanism of formation of injuries of this complex inflicted by compression of the neck by hands is made.

Unlabelled: The aim of this study was to develop and investigate techniques for stabilising and reconstruction of defects in the larynx similar to osteosynthesis., Material and Methods: (1) 400 extrusion forces of sutures and various screws (Howmedica) in thyroid cartilage of fresh cadavers were measured. (2) A new screw specially designed for cartilage was developed. (3) A new technique for stabilising cartilage with a screw nut made out of bone was developed., Results: The extrusion forces correlate with the calcification of the laryngeal skeleton depending on the investigated area of the thyroid cartilage and the type of suture and screws that are used, respectively. Besides the increased extrusion forces the advantages of chondrosynthesis are the possibility of axial stabilisation and of exact bridging of defects with or without implants.