Traumatic rupture of deep neck structures in hanging: two case reports

Traumatic thyrohyoid membrane rupture with hyolaryngeal separation due to strangulation injury

Background

Cervical injuries due to hanging have a high mortality rate. Survivors may present for care with subtle symptoms that belie potentially life-threatening injuries to vital structures of the neck.

Case report

We report a case of a 39-year-old male admitted to the Intensive Care Unit following attempted self-strangulation. Alert and clinically stable, his primary symptoms were pain and voice changes. His external exam was remarkable only for a cervical ligature mark and subcutaneous emphysema on palpation. CT imaging demonstrated disruption of the infrahyoid strap muscles and displacement of the hyoid and epiglottis superiorly. Subsequent flexible laryngoscopy by the Otolaryngology-Head & Neck Surgery (OTO-HNS) team revealed avulsion of the epiglottis from the thyroid cartilage and disruption of the aryepiglottic folds/false cord mucosa, resulting in an open wound into the soft tissues of the anterior neck. The airway was secured in the operating room via fiberoptic nasotracheal intubation. A tracheostomy was performed. Neck exploration revealed transection of the anterior strap muscles and thyrohyoid membrane. The wound was repaired in layers via a modified thyrohyoidopexy. At one-month follow-up, the patient was successfully decannulated and tolerating a regular diet.

Conclusion

Evaluation and management of head and neck trauma requires a systematic approach and thorough evaluation, as potentially life-threatening injuries can present subtly. Swift establishment of safe airway, when needed, and prompt repair of laryngeal injuries is essential to optimal functional recovery.

Forensic application of aquaporins

Aquaporins (AQPs) are a family of water channel proteins that primarily elicit the basic functions of water transport and osmotic homeostasis. To date, at least 17 mammalian AQPs have been identified, AQP-0 to -12 have been found in higher orders including human, and AQP-13 to -16 have been described in older lineages. Moreover, these proteins have recently been shown to regulate many biological processes through unique activities, such as cell proliferation, migration, apoptosis, and mitochondrial metabolism. Several studies have focused on the involvement of AQPs in cell biology aspect, showing that they are involved in a variety of physiological processes and pathophysiological conditions. Furthermore, in the field of forensic medicine, studies on whether AQPs can be a useful marker for diagnosing various causes of death have been conducted using autopsy samples and animal experiments, which have produced interesting results. Herein, we review certain observations regarding AQPs and discuss their potential to contribute to the future practice of forensic research.

Forensic Application of Epidermal Ubiquitin Expression to Determination of Wound Vitality in Human Compressed Neck Skin

Ubiquitin is a member of the heat shock protein family and is rapidly induced by various types of stimuli, including ischemic and mechanical stress. However, its significance in determining wound vitality of neck compression skin in forensic pathology remains unclear. We immunohistochemically examined the expression of ubiquitin in the neck skin samples to understand its forensic applicability in determining wound vitality. Skin samples were obtained from 53 cases of neck compression (hanging, 42 cases; strangulation, 11 cases) during forensic autopsies. Intact skin from the same individual was used as the control. Ubiquitin expression was detected in 73.9% of keratinocytes in intact skin samples, but only in 21.2% of keratinocytes in the compression regions, with statistical differences between the control and compression groups. This depletion in the case of neck compression may be caused by the impaired conversion of conjugated to free ubiquitin and failure of de novo ubiquitin synthesis. From a forensic pathological perspective, immunohistochemical examination of ubiquitin expression in the skin of the neck can be regarded as a valuable marker for diagnosing traces of antemortem compression.

Neck vascular lesions in hanging cases: A literature review

The aim of this review was to investigate the types and rates of vascular lesions occurring in cases of completed hanging and near-hanging, defined in literature. In the literature to date, 6 specific types of vascular injuries have been defined in cases of death as a result of hanging. These are Amussat's sign, Etienne Martin's sign, Dominguez-Paez sign, Friedberg-Lesser sign, Ziemke-Otto's sign, and Lupascu sign. As a result of this study, it was determined that the most defined finding was the Amussat sign, and it was concluded that the other findings were not sufficiently recognized. Likewise, considering that the proportional differences are due to the differences in the rates of autopsy practice and autopsy protocols between countries, it can be suggested that international joint autopsy protocols should be developed at the meetings in which national professional associations participate.

Forensic application of epidermal AQP3 expression to determination of wound vitality in human compressed neck skin

In forensic practices, it is often difficult to determine wound vitality in compression marks of the neck with naked eyes. AQP1 and AQP3 are the major water channels associated with skin. Thus, we immunohistochemically examined the expression of AQP1 and AQP3 in neck skin samples to discuss their forensic applicability to determination of the wound vitality. Skin samples were obtained from 56 neck compression cases (hanging, 35 cases; strangulation, 21 cases). The intact skin from the same individual was taken as a control. Although AQP1 was immnunostained in dermal capillaries in both the neck compression marks and intact skin samples, there was no significant difference in the magnitude of AQP1 expression between both groups. On the contrary, AQP3-positive signals could be faintly detected in uninjured skin samples, and the positive signals seemed more intense in the keratinocytes in compression regions. Morphometrical analyses revealed that the ratio of AQP3-expressed keratinocytes was significantly enhanced in neck compression regions, compared with control groups. From the viewpoints of forensic pathology, immunohistochemical detection of AQP3 in the neck skin can be considered a valuable marker to diagnose the trace of antemortem compression.