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CASE REPORT

Cervical Injuries in Drowning Cases


A Case Report and a Review of Literature
Maroua Boussaid, MD,*†‡§ Mohamed Amin Mesrati, MD,*†‡§ Yosra Mahjoub, MD,*†‡§
Nidhal Haj Salem, MD,†‡§ Abdelfateh Zakhama, MD,‡§ Ali Chadly, MD,†‡§
Adnen Moussa, MD,‡§ and Abir Aissaoui, MD*†‡§

at the Department of Forensic Medicine at Fattouma Bourguiba


Abstract: Discovery of bruises in the muscles of the neck and a fracture University Hospital. The deceased was moderately built and poorly
of the hyoid bone in a body recovered from water makes the diagnosis and nourished. The external examination showed a marked facial cya-
the determination of the manner of death difficult. nosis with conjunctival and scleral hemorrhages, a “foam cone” at
The aims of this work are to report a case of a drowned body with the mouth and nose, and an immersion wrinkling of the hands and
cervical injuries and to highlight the importance of interpreting these feet. No injuries were present anywhere on the body, and particu-
findings accurately. larly no abrasions or contusions were found on the anterior or pos-
A 39-year-old woman was found dead face down in a 6-m deep well with a terior neck. The autopsy showed a bruise of the scalp at the right
3-m water level. She was mentally disturbed and had a history of suicide frontal level measuring 8  5 cm. The lungs were edematous and
attempts. In fact, she had previously attempted to jump into that well in hyperinflated. A frothy fluid filled the airways. The cut surfaces of
an attempt to put an end to her life. The autopsy revealed bruises in the the lung exuded foamy hemorrhagic fluid. The heart weighted
muscles of the neck and a bruise associated with a fracture of the left horn 360 g. The right ventricle was dilated. A layered anterior neck dis-
of the hyoid bone. section revealed patchy hemorrhage of the left subcutaneous tissues
The mechanism for the origin of drowning-related neck injuries will on the surface of the left sternocleidomastoid and sternohyoid mus-
be discussed. cles (Fig. 1) associated with a fracture of the left greater horn of the
Key Words: forensic science, cause of death, drowning, hemorrhages, hyoid bone, which was confirmed by using x-ray. The thyroid gland
neck muscles was markedly congestive. A posterior neck dissection revealed
focal hemorrhage, up to 1 cm in diameter, on the fascial surfaces
(Am J Forensic Med Pathol 2017;00: 00–00)
of the muscles of the upper back.
The histological examination of the lungs showed lung em-
I nvestigations of bodies retrieved from water make up a large part
of our medicolegal practice. Drowning is a difficult diagnosis.
Autopsy findings in these cases are nonspecific.1 A necropsy is
physema and edema aquosum (intra-alveolar edema and dilatation
of the alveolar spaces with secondary compression of the septal
capillaries) and hemorrhagic reactions in the muscles of the neck
aimed at determining the cause of death and differentiating be-
(Fig. 2). A toxicological screening of the femoral blood did not de-
tween accidental and criminal deaths, especially when cervical
tect toxic substances or drugs. Avitreous electrolyte screen was nor-
injuries are found. The key question is whether these injuries oc-
mal. The investigations revealed that there were 2 eyewitnesses who
curred before getting in the water or not.1 In fact, hemorrhage
stated that the victim intentionally jumped in the well. They were 2
into the neck musculature and fracture of the hyoid bone have
strangers that coincidently were walking around this area. The death
been reported in hanging, strangulation, or other neck compres-
was attributed to drowning. The manner of death was suicide.
sions, but finding such lesions in corpses recovered from water
is controversial, especially when there are no injuries on the ex-
ternal examination of the neck.2,3 DISCUSSION
The aims of this work are to report a case of a drowned body
Drowning is defined as death secondary to hypoxemia as
with cervical injuries and to highlight the importance of inter-
a result of asphyxia while immersed in a liquid, usually water.4
preting these findings accurately. The mechanism for the origin
The diagnosis of drowning is still difficult.2 The autopsy findings
of drowning-related neck injuries will be discussed.
are nonspecific, and a careful forensic examination is recommended
in all cases of drowning, especially the examination of the structure
CASE REPORT of the neck.1
A 39-year-old woman was found dead face down in a 6-m In the reported case, the victim was found dead face down in
deep well with a 3-m water level. She was mentally disturbed a 6-m deep well. The autopsy revealed bruises in the muscles of
and had a history of suicide attempts. In fact, she had previously the neck and a bruise on the left horn of the hyoid bone associated
attempted to jump into this well. A legal autopsy was conducted with a fracture of this bone. The lesions found were strongly sugges-
tive of homicidal strangulation. They are known to be symptoms of
Manuscript received February 27, 2017; accepted September 11, 2017. asphyxia resulting from constriction of the cervical region.5 How-
From the *Department of Forensic Medicine, University Hospital Tahar Sfar, ever, in this case, the investigations revealed that there were 2 eyewit-
Mahdia; Departments of †Forensic Medicine and ‡Forensic Pathology,
University Hospital Fattouma Bourguiba, Monastir; and §Faculty of
nesses who stated that the victim intentionally jumped in the well. No
Medicine, University of Monastir, Monastir, Tunisia. previous relationship or enmity existed between the victim and the
The authors report no conflict of interest. witnesses. They were passing by this area, that day, by coincidence.
Reprints: Abir Aissaoui, MD, Faculty of Medicine, University of Monastir, Given the absence of defense injuries, the fact that no abra-
Mahdia, Tunisia. E-mail: aissaoui_abir@yahoo.fr.
Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.
sions or contusions were detected on the anterior or posterior neck,
ISSN: 0195-7910/17/0000–0000 the history of suicide attempt, the investigations and the witnesses'
DOI: 10.1097/PAF.0000000000000357 statements led to conclusion that the victim had committed suicide.

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Boussaid et al Am J Forensic Med Pathol • Volume 00, Number 00, Month 2017

cricoarytenoid muscles is unspecific for any particular cause of


death, by reviewing 2060 autopsies.
In the reported case, a fracture of the hyoid bone was found.
This injury can be explained by the impact of the fall itself and
the contact with the water surface, which can cause a flexure
of the neck.3
A critical determinant for the injuries of the neck such as
fracture of the hyoid bone is the height of the fall until the water
surface. Some authors stated that the neck injuries like muscle
bleeding and fracture of the hyoid bone can be observed only if
the fall occurs from a height of more than 10 m.13 In the case re-
ported here, the height of the fall was approximately 6 m. The fall
from a relatively low height, like 1 to 2 m, causing a severe injury
in the neck, was explained by Zuka and Ohshima3 by the rotation
of the body, which transmits the force directly into the face and the
neck. In this study, the authors3 stated that the water surface has 2
properties, of being hard as flat object and at the same time of be-
ing soft and ungraspable substance. This water surface exerts, at
the moment of impact, a greater resistance against relatively broad
areas like the head, face, and trunk than against the extremities that
have a small area. Thus, the water surface is considered as a hard
surface, like the ground, which can exert some force against the
whole body. This total resistance would promote flexure, so it
can cause directly or indirectly cervical soft tissue bruises, with
FIGURE 1. Hemorrhage on the left subcutaneous tissues of the
neck muscle.
or without fracture of the hyoid bone. Another study conducted
by Turk and Tsokos14 focused on laryngohyoid fractures second-
ary to trauma and injuries due to falls from heights. This retrospec-
tive study of 93 autopsies of victims who died after a fall from a
The homicidal strangulation hypothesis was excluded. The death height of approximately 15 m found cervical soft tissue bruising
was attributed to drowning. in 5 cases and laryngohyoid fractures in 5 other cases. These le-
Finding a fracture of the hyoid bone and a hemorrhage of the sions were explained by the impact of the structures of the neck
neck in a drowned body is controversial and may be misinterpreted.2,3 with the ground or by the cervical hyperextension or hyperflexion,
Alexander and Jentzen6 reported a case of a drowning victim with or were due to mandible or cervical vertebral column fractures.
conjunctival and bilateral anterior-posterior neck hemorrhages. In this In the reported case, the cervical injuries found, namely, the
study, these lesions were explained by the elevated central pressure fracture of the hyoid bone and the hemorrhage of the muscles of
communicated to vessels within the anterior and posterior neck, the neck, can be explained by multiple mechanisms that have been
which occurs in response to drowning-related coughing, gagging, well described in the literature. These lesions can be attributed to
vomiting, and forceful abdominal and thoracic contractions. Further- the cervical hyperextension or hyperflexion during the convulsive
more, Puschel et al7 stated that the hemorrhage within the neck, trunk, phase due to mechanical asphyxia. It can also be explained by
and upper extremities found in 20 cases among 39 drowning victims
was attributed to the agonal convulsion and the hypercontraction of
the affected muscle groups. Carter et al8 conducted a study on a total
of 99 drowning-deaths, of which 8 cases were selected and in which
hemorrhage was found to occur within the neck musculature. This
hemorrhage can be explained by the violent neck movements during
the process of drowning. Another study carried out by Lach et al9
showed that bleeding into the muscles of the neck were due to internal
causes and could be attributed to intensified breathing with dyspnea
leading to ruptures of the accessory respiratory muscles, and these
lesions are associated with death by drowning. Furthermore, a ret-
rospective review of 86 cases of neck hemorrhage found drowning
to be the cause of death in only 2 cases with intramuscular and sub-
mucosal hemorrhage in anterior and lateral compartments of the
neck, but no subcutaneous bleeding was detected. These lesions
can be explained by the cervical hyperextension or hyperflexion
due to the convulsion caused by the mechanical asphyxia.5
However, the interpretation of these neck hemorrhages was
described by Prinsloo and Gordon10 as an artifactual extravasation
of blood due to a postmortem hemorrhage. Thus, a dissection and
inspection of the structures of the neck in situ are recommended in
all forensic autopsies. The hemorrhage in the retropharyngeal soft
tissue of the neck is a common postmortem artifact, which should
not be interpreted in isolation as evidence of trauma.5 Although FIGURE 2. Extensive interstitial hemorrhage dissociating the
hemorrhages of the neck are vital signs, they may also occur after striated fibers of the neck (Hematoxylin and eosin, original
death.11 Keil et al12 concluded that hemorrhage of the posterior magnification 100).

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Am J Forensic Med Pathol • Volume 00, Number 00, Month 2017 Cervical Injuries in Drowning Cases

drowning-related elevated central venous pressure that is com- 7. Puschel K, Schulz F, Darrmann I, et al. Macromorphology and histology of
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Moreover, the impact of the fall from a high place can cause 112(2):101–106.
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into neck musculature in cases of drowning. Am J Forensic Med Pathol.
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