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Iatrogenic fractures of the hyoid bone and the thyroid cartilage. A case report
41
Forensic Science International, 17 (1981) 41 - 43 @ Elsevier Sequoia S.A., Lausanne - Printed in the Netherlands
IATROGENIC CARTILAGE.
FRACTURES OF THE HYOID BONE AND THE THYROID A CASE REPORT
MARKIL GREGERSEN Institute
of Forensic
and ANNIE VESTERBY
Medicine,
(Received June 25,198O;
University
of Aarhus,
8000
Aarhus
C (Denmark)
accepted August 25,198O)
Summary A case of fracture of the hyoid bone and the thyroid cartilage is reported as a corn-, plication to resuscitation. This gave rise to many forensic as well as police investigations and stresses the importance of detailed information at medicolegal autopsies as regards the resuscitation carried out.
Introduction During recent years a large number of complications after attempted resuscitation have been described. Most frequently reported are fractures of the costa and the sternum [ 11. Most of the reported complications seem to be a consequence of the external heart massage rather than a consequence of the simultaneous artificial ventilation. Valtonen and Hakola [2] , however, reported one case of rupture of the stomach following mouth-tomouth resuscitation. The following case history deals with a case of fracture of the hyoid bone and the thyroid cartilage as a complicating factor to resuscitation or laryngoscopy. This autopsy finding gave rise to forensic as well as police investigations.
Case history A 53-year-old male was found unconscious on a pavement, lying on his right side with his face towards the ground and bleeding from nose and mouth. The case of the fall wasnot immediately apparent. According to available data, two years before his death the patient had been admitted to the department of neurology because of suddenly occurring fits of dizziness. The examinations performed during his hospitalization were normal, and it was concluded that his was a case of insufficiency of the vertebral and basilar arteries. The patient lived alone and in recent years had consumed an excessive amount of alcohol plus a heavy daily use of drugs. The patient was now taken to the hospital casualty ward in an ambulance. During transportation two first-aidmen from the ambulance staff
42
attempted resuscitation, using heart massage and artificial ventilation with an oxygen mask. On arrival at the hospital the patient was found to be comatose without respiration and with poor heart action; consequently, the first receiving medical team performed oral intubation followed by treatment in a respirator. A short time after admission violent bleeding occurred from the patient’s nose and mouth, and consequently the following steps were taken in the following order: insertion of a ventricle tube, examination with laryngoscope, plugging of the nose and pharynx region, plus under general anaesthesia reposition of a wedged fracture of the nose. No further manipulative surgery in the face and neck regions was performed, and later it was stated by all doctors involved that the interventions performed by them passed without difficulty and without suspicion that a fracture would occur. The patient died about 22 hours after admission. The medicolegal autopsy revealed a sturdy and overweight male with several fresh excoriations and suggillations on the face, with underlying fracture of nose and cranium base and small excoriations on the knees. No defence or fightlike lesions were found. A small blue mark was demonstrated on the front of the neck with underlying haemorrhage in the soft parts and haemorrhage around the fractures of the hyoid bone (cornu majus sin.) and the thyroid cartilage (cornu superior dxt.). There were no petechial bleedings in the conjunctiva. Furthermore, fractures of the costae and gauze tampons in the nose-pharynx region were demonstrated. In addition, there was steatosis hepatis and complicating bronchopneumonia. Histologic examination of the organs revealed cerebral edema, chronic alcoholic encephalopathy and a slight chronic pyelonephritis.
Discussion In most cases fractures of the hyoid bone and the thyroid cartilage result from throttling. or strangulation. The fractures occur by compression from side to side of the hyoid bone or the thyroid cartilage. Such isolated fractures will, however, in most cases not occur in connection with blunt force (fall or blow against the neck), but rather in connection with total contusion of the larynx (edge-of-hand blow) and other located force against the neck. In the case referred to here it seems most likely that the fractures were produced by pressure or grasp around the neck, even if no sign of strangling in the form of petechial bleeding was demonstrated. Supplementary investigations, interrogations and reconstructions rendered it possible that the patient’s cerebral affection (in connection with the influence of alcohol?) was the cause of the fall and that the demonstrated fractures of the hyoid bone and the thyroid cartilage had most likely occurred during the subsequent transportation, resuscitation or the diagnostic and/or therapeutic interventions. Suspicion may arise regarding the damage in connection with the laryngoscopy. Minor haemorrhages have previously been
43
described in the mucosa of the larynx at intubation [3], but fracture of the larynx in connection with intubation has apparently not previously received attention. We consider it most probable that the fractures occurred during resuscitation, as the blue mark on the neck with underlying haemorrhage bears every indication of a grasp. The usual procedure for resuscitation prescribes that the head is stretched backwards with a firm grasp under the chin, followed by injection of air mouth-to-mouth or mouth-to-nose with application of an oxygen mask. During this procedure the possibility exists of exerting pressure on the neck with resulting compression of the hyoid bone and the larynx. This case, which must be considered as a not previously recognised complication after attempted resuscitation, illustrates that in the case of fracture of the larynx skeleton and/or the hyoid bone (with or without simultaneous petechial bleeding) another cause other than throttling or strangulation must be taken into account. As also stressed by Voigt [4] , it is imperative that at medicolegal autopsies and inquests detailed information be gathered regarding the method of resuscitation carried out. References 1 F. Paaske, J. P. Hart Hansen, G. Koudahl and J. O?um, Complications of closed-chest cardiac massage in a forensic autopsy material. Dan. Med. Bull., 15 (8) (1968) 225 23C. 2 E. J. Valtonen and N. Hakola, Rupture of the normal stomach during mouth-to-mouth resuscitation. Acta Chit-. Stand., 127 (1964) 427 - 431. 3 G. E. Voigt, Petechial bleedings in the larynx. Forensic Sci., 3 (1974) 256 - 257. 4 J. Voigt, Genoplivning og retslaegelige unders#gelser. Ugeskr. Lcrzg., 140 (13) (1979) 726.
Forensic Science International, 17 (1981) 41 - 43 @ Elsevier Sequoia S.A., Lausanne - Printed in the Netherlands
IATROGENIC CARTILAGE.
FRACTURES OF THE HYOID BONE AND THE THYROID A CASE REPORT
MARKIL GREGERSEN Institute
of Forensic
and ANNIE VESTERBY
Medicine,
(Received June 25,198O;
University
of Aarhus,
8000
Aarhus
C (Denmark)
accepted August 25,198O)
Summary A case of fracture of the hyoid bone and the thyroid cartilage is reported as a corn-, plication to resuscitation. This gave rise to many forensic as well as police investigations and stresses the importance of detailed information at medicolegal autopsies as regards the resuscitation carried out.
Introduction During recent years a large number of complications after attempted resuscitation have been described. Most frequently reported are fractures of the costa and the sternum [ 11. Most of the reported complications seem to be a consequence of the external heart massage rather than a consequence of the simultaneous artificial ventilation. Valtonen and Hakola [2] , however, reported one case of rupture of the stomach following mouth-tomouth resuscitation. The following case history deals with a case of fracture of the hyoid bone and the thyroid cartilage as a complicating factor to resuscitation or laryngoscopy. This autopsy finding gave rise to forensic as well as police investigations.
Case history A 53-year-old male was found unconscious on a pavement, lying on his right side with his face towards the ground and bleeding from nose and mouth. The case of the fall wasnot immediately apparent. According to available data, two years before his death the patient had been admitted to the department of neurology because of suddenly occurring fits of dizziness. The examinations performed during his hospitalization were normal, and it was concluded that his was a case of insufficiency of the vertebral and basilar arteries. The patient lived alone and in recent years had consumed an excessive amount of alcohol plus a heavy daily use of drugs. The patient was now taken to the hospital casualty ward in an ambulance. During transportation two first-aidmen from the ambulance staff
42
attempted resuscitation, using heart massage and artificial ventilation with an oxygen mask. On arrival at the hospital the patient was found to be comatose without respiration and with poor heart action; consequently, the first receiving medical team performed oral intubation followed by treatment in a respirator. A short time after admission violent bleeding occurred from the patient’s nose and mouth, and consequently the following steps were taken in the following order: insertion of a ventricle tube, examination with laryngoscope, plugging of the nose and pharynx region, plus under general anaesthesia reposition of a wedged fracture of the nose. No further manipulative surgery in the face and neck regions was performed, and later it was stated by all doctors involved that the interventions performed by them passed without difficulty and without suspicion that a fracture would occur. The patient died about 22 hours after admission. The medicolegal autopsy revealed a sturdy and overweight male with several fresh excoriations and suggillations on the face, with underlying fracture of nose and cranium base and small excoriations on the knees. No defence or fightlike lesions were found. A small blue mark was demonstrated on the front of the neck with underlying haemorrhage in the soft parts and haemorrhage around the fractures of the hyoid bone (cornu majus sin.) and the thyroid cartilage (cornu superior dxt.). There were no petechial bleedings in the conjunctiva. Furthermore, fractures of the costae and gauze tampons in the nose-pharynx region were demonstrated. In addition, there was steatosis hepatis and complicating bronchopneumonia. Histologic examination of the organs revealed cerebral edema, chronic alcoholic encephalopathy and a slight chronic pyelonephritis.
Discussion In most cases fractures of the hyoid bone and the thyroid cartilage result from throttling. or strangulation. The fractures occur by compression from side to side of the hyoid bone or the thyroid cartilage. Such isolated fractures will, however, in most cases not occur in connection with blunt force (fall or blow against the neck), but rather in connection with total contusion of the larynx (edge-of-hand blow) and other located force against the neck. In the case referred to here it seems most likely that the fractures were produced by pressure or grasp around the neck, even if no sign of strangling in the form of petechial bleeding was demonstrated. Supplementary investigations, interrogations and reconstructions rendered it possible that the patient’s cerebral affection (in connection with the influence of alcohol?) was the cause of the fall and that the demonstrated fractures of the hyoid bone and the thyroid cartilage had most likely occurred during the subsequent transportation, resuscitation or the diagnostic and/or therapeutic interventions. Suspicion may arise regarding the damage in connection with the laryngoscopy. Minor haemorrhages have previously been
43
described in the mucosa of the larynx at intubation [3], but fracture of the larynx in connection with intubation has apparently not previously received attention. We consider it most probable that the fractures occurred during resuscitation, as the blue mark on the neck with underlying haemorrhage bears every indication of a grasp. The usual procedure for resuscitation prescribes that the head is stretched backwards with a firm grasp under the chin, followed by injection of air mouth-to-mouth or mouth-to-nose with application of an oxygen mask. During this procedure the possibility exists of exerting pressure on the neck with resulting compression of the hyoid bone and the larynx. This case, which must be considered as a not previously recognised complication after attempted resuscitation, illustrates that in the case of fracture of the larynx skeleton and/or the hyoid bone (with or without simultaneous petechial bleeding) another cause other than throttling or strangulation must be taken into account. As also stressed by Voigt [4] , it is imperative that at medicolegal autopsies and inquests detailed information be gathered regarding the method of resuscitation carried out. References 1 F. Paaske, J. P. Hart Hansen, G. Koudahl and J. O?um, Complications of closed-chest cardiac massage in a forensic autopsy material. Dan. Med. Bull., 15 (8) (1968) 225 23C. 2 E. J. Valtonen and N. Hakola, Rupture of the normal stomach during mouth-to-mouth resuscitation. Acta Chit-. Stand., 127 (1964) 427 - 431. 3 G. E. Voigt, Petechial bleedings in the larynx. Forensic Sci., 3 (1974) 256 - 257. 4 J. Voigt, Genoplivning og retslaegelige unders#gelser. Ugeskr. Lcrzg., 140 (13) (1979) 726.