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*†‡§
Abstract: Discovery of bruises in the muscles of the neck and a fracture
of the hyoid bone in a body recovered from water makes the diagnosis and
the determination of the manner of death difficult.
The aims of this work are to report a case of a drowned body with
cervical injuries and to highlight the importance of interpreting these
findings accurately.
A 39-year-old woman was found dead face down in a 6-m deep well with a
3-m water level. She was mentally disturbed and had a history of suicide
attempts. In fact, she had previously attempted to jump into that well in
an attempt to put an end to her life. The autopsy revealed bruises in the
muscles of the neck and a bruise associated with a fracture of the left horn
of the hyoid bone.
The mechanism for the origin of drowning-related neck injuries will
be discussed.
Key Words: forensic science, cause of death, drowning, hemorrhages,
neck muscles
(Am J Forensic Med Pathol 2017;00: 00–00)
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
aimed at determining the cause of death and differentiating be-
tween accidental and criminal deaths, especially when cervical
injuries are found. The key question is whether these injuries oc-
curred before getting in the water or not.1 In fact, hemorrhage
into the neck musculature and fracture of the hyoid bone have
been reported in hanging, strangulation, or other neck compres-
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
The aims of this work are to report a case of a drowned body
with cervical injuries and to highlight the importance of inter-
preting these findings accurately. The mechanism for the origin
of drowning-related neck injuries will be discussed.
CASE REPORT
A 39-year-old woman was found dead face down in a 6-m
deep well with a 3-m water level. She was mentally disturbed
and had a history of suicide attempts. In fact, she had previously
attempted to jump into this well. A legal autopsy was conducted
Manuscript received February 27, 2017; accepted September 11, 2017.
From the *Department of Forensic Medicine, University Hospital Tahar Sfar,
Mahdia; Departments of †Forensic Medicine and ‡Forensic Pathology,
University Hospital Fattouma Bourguiba, Monastir; and §Faculty of
Medicine, University of Monastir, Monastir, Tunisia.
The authors report no conflict of interest.
Reprints: Abir Aissaoui, MD, Faculty of Medicine, University of Monastir,
Mahdia, Tunisia. E-mail: aissaoui_abir@yahoo.fr.
Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.
ISSN: 0195-7910/17/0000–0000
DOI: 10.1097/PAF.0000000000000357
Am J Forensic Med Pathol • Volume 00, Number 00, Month 2017
Copyright © 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
at the Department of Forensic Medicine at Fattouma Bourguiba
University Hospital. The deceased was moderately built and poorly
nourished. The external examination showed a marked facial cya-
nosis with conjunctival and scleral hemorrhages, a “foam cone” at
the mouth and nose, and an immersion wrinkling of the hands and
feet. No injuries were present anywhere on the body, and particu-
larly no abrasions or contusions were found on the anterior or pos-
terior neck. The autopsy showed a bruise of the scalp at the right
frontal level measuring 8  5 cm. The lungs were edematous and
hyperinflated. A frothy fluid filled the airways. The cut surfaces of
the lung exuded foamy hemorrhagic fluid. The heart weighted
360 g. The right ventricle was dilated. A layered anterior neck dis-
section revealed patchy hemorrhage of the left subcutaneous tissues
on the surface of the left sternocleidomastoid and sternohyoid mus-
cles (Fig. 1) associated with a fracture of the left greater horn of the
hyoid bone, which was confirmed by using x-ray. The thyroid gland
was markedly congestive. A posterior neck dissection revealed
focal hemorrhage, up to 1 cm in diameter, on the fascial surfaces
of the muscles of the upper back.
The histological examination of the lungs showed lung em-
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
(Fig. 2). A toxicological screening of the femoral blood did not de-
tect toxic substances or drugs. Avitreous electrolyte screen was nor-
mal. The investigations revealed that there were 2 eyewitnesses who
stated that the victim intentionally jumped in the well. They were 2
strangers that coincidently were walking around this area. The death
was attributed to drowning. The manner of death was suicide.
DISCUSSION
Drowning is defined as death secondary to hypoxemia as
a result of asphyxia while immersed in a liquid, usually water.4
The diagnosis of drowning is still difficult.2 The autopsy findings
are nonspecific, and a careful forensic examination is recommended
in all cases of drowning, especially the examination of the structure
of the neck.1
In the reported case, the victim was found dead face down in
a 6-m deep well. The autopsy revealed bruises in the muscles of
the neck and a bruise on the left horn of the hyoid bone associated
with a fracture of this bone. The lesions found were strongly sugges-
tive of homicidal strangulation. They are known to be symptoms of
asphyxia resulting from constriction of the cervical region.5 How-
ever, in this case, the investigations revealed that there were 2 eyewit-
nesses who stated that the victim intentionally jumped in the well. No
previous relationship or enmity existed between the victim and the
witnesses. They were passing by this area, that day, by coincidence.
Given the absence of defense injuries, the fact that no abra-
sions or contusions were detected on the anterior or posterior neck,
the history of suicide attempt, the investigations and the witnesses'
statements led to conclusion that the victim had committed suicide.
www.amjforensicmedicine.com 1
Boussaid et al
FIGURE 1. Hemorrhage on the left subcutaneous tissues of the
neck muscle.
The homicidal strangulation hypothesis was excluded. The death
was attributed to drowning.
Finding a fracture of the hyoid bone and a hemorrhage of the
neck in a drowned body is controversial and may be misinterpreted.2,3
Alexander and Jentzen6 reported a case of a drowning victim with
conjunctival and bilateral anterior-posterior neck hemorrhages. In this
study, these lesions were explained by the elevated central pressure
communicated to vessels within the anterior and posterior neck,
which occurs in response to drowning-related coughing, gagging,
vomiting, and forceful abdominal and thoracic contractions. Further-
more, Puschel et al7 stated that the hemorrhage within the neck, trunk,
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
hemorrhages of the neck are vital signs, they may also occur after
death.11 Keil et al12 concluded that hemorrhage of the posterior
2 www.amjforensicmedicine.com
Copyright © 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
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
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
height of approximately 15 m found cervical soft tissue bruising
in 5 cases and laryngohyoid fractures in 5 other cases. These le-
sions were explained by the impact of the structures of the neck
with the ground or by the cervical hyperextension or hyperflexion,
or were due to mandible or cervical vertebral column fractures.
In the reported case, the cervical injuries found, namely, the
fracture of the hyoid bone and the hemorrhage of the muscles of
the neck, can be explained by multiple mechanisms that have been
well described in the literature. These lesions can be attributed to
the cervical hyperextension or hyperflexion during the convulsive
phase due to mechanical asphyxia. It can also be explained by
FIGURE 2. Extensive interstitial hemorrhage dissociating the
striated fibers of the neck (Hematoxylin and eosin, original
magnification 100).
© 2017 Wolters Kluwer Health, Inc. All rights reserved.
Am J Forensic Med Pathol • Volume 00, Number 00, Month 2017
drowning-related elevated central venous pressure that is com-
municated to the head through the valveless veins of the neck.
Moreover, the impact of the fall from a high place can cause
such lesions.
REFERENCES
1. Saukko P, Knight B. Knight's Forensic Pathology. 3rd ed. London:
Arnold; 2004.
2. Piette MH, De Letter EA. Drowning: still a difficult autopsy diagnosis.
Forensic Sci Int. 2006;163(1–2):1–9.
3. Zuka M, Ohshima T. Tracheal injury added to cervical bone destruction due
to the impact of hitting the water surface: four immersed adult bodies.
Forensic Sci Int. 2013;228(1–3):e62–e66.
4. Spitz DJ. Investigation of bodies in water. In: Spitz WU, Spitz DJ, eds. Spitz
and Fisher's Medicolegal Investigation of Death. 4th ed. Springfield, IL:
Charles C. Thomas; 2006:846–881.
5. Akhlaghi M, Okazi A. Causes of death accompanying by soft tissue neck
hemorrhage. Int J Med Toxicol Forensic Med. 2013;3(1):10–19.
6. Alexander RT, Jentzen JM. Neck and scleral hemorrhage in drowning.
J Forensic Sci. 2011;56(2):522–525.
© 2017 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Cervical Injuries in Drowning Cases
7. Puschel K, Schulz F, Darrmann I, et al. Macromorphology and histology of
intramuscular hemorrhages in cases of drowning. Int J Legal Med. 1999:
112(2):101–106.
8. Carter N, Ali F, Green MA. Problems in the interpretation of hemorrhage
into neck musculature in cases of drowning. Am J Forensic Med Pathol.
1998;19(3):223–225.
9. Lach H, Puschel K, Schulz F. Intramuscular bleeding in deaths from an
internal cause: forensically significant differential diagnosis between
external trauma and hemorrhages occurring during agony. Arch Kriminol.
2005;216(3–4):97–107.
10. Prinsloo I, Gordon I. Post-mortem dissection artifacts of the neck; their
differentiation from ante-mortem bruises. S Afr Med J. 1951;25(21):358–361.
11. Rajs J, Thiblin I. Histologic appearance of fractured thyroid cartilage and
surrounding tissues. Forensic Sci Int. 2000;114(3):155–166.
12. Keil W, Kondo T, Beer GM. Haemorrhages in the posterior cricoarytenoid
muscles—an unspecific autopsy finding. Forensic Sci Int. 1998;95(3):225–230.
13. de la Grandmaison GL, Krimi S, Durigon M. Frequency of laryngeal and
hyoid bone trauma in nonhomicidal cases who died after a fall from a
height. Am J Forensic Med Pathol. 2006;27(1):85–86.
14. Turk EE, Tsokos M. Pathologic features of fatal falls from height. Am J
Forensic Med Pathol. 2004;25(3):194–199.
www.amjforensicmedicine.com 3