Virtopsy: postmortem imaging of laryngeal foreign bodies.
Abstract: Context.--Death from corpora aliena in the larynx is a well-known entity in forensic pathology. The correct diagnosis of this cause of death is difficult without an autopsy, and misdiagnoses by external examination alone are common.

Objective.--To determine the postmortem usefulness of modern imaging techniques in the diagnosis of foreign bodies in the larynx, multislice computed tomography, magnetic resonance imaging, and postmortem full-body computed tomography-angiography were performed.

Design.--Three decedents with a suspected foreign body in the larynx underwent the 3 different imaging techniques before medicolegal autopsy.

Fatalities from foreign bodies in the larynx are reported frequently in middle-aged and elderly people. (1-4) This age group is rapidly growing in Western society, and the importance of accidental deaths from choking on food might increase. In the United States, choking is the fourth leading cause of death from unintentional injury. (5) Typically, in these types of fatalities, the victim collapses immediately while eating. The diagnosis of bolus death is difficult because the sudden nature and led to the vivid description Cafe-Coronary Syndrome6 because the sudden cause of death is mostly misinterpreted as acute cardiac--or coronary--failure. The cause of death is mainly a food bolus in the larynx. These bolus fatalities are still rare in daily forensic practice. (1-4,7,8)

Risk factors for this cause of death include neurologic and psychiatric diseases, old age, poor dentition, local malformation, local tumors, and intoxication from alcohol and drugs. (1,2,4,9-13) In the early years of medicolegal investigation, it was assumed that death occurred due to asphyxia, but today, it is known that many cases are reflexogenic. (1,4,14) In addition, deaths in scurrile situations are reported in case reports. (15-18)

Results.--Multislice computed tomography has a high diagnostic value in the noninvasive localization of a foreign body and abnormalities in the larynx. The differentiation between neoplasm or soft foreign bodies (eg, food) is possible, but difficult, by unenhanced multislice computed tomography. By magnetic resonance imaging, the discrimination of the soft tissue structures and soft foreign bodies is much easier. In addition to the postmortem multislice computed tomography, the combination with postmortem angiography will increase the diagnostic value.

Conclusions.--Postmortem, cross-sectional imaging methods are highly valuable procedures for the noninvasive detection of corpora aliena in the larynx.

(Arch Pathol Lab Med. 2009;133:806-810)
Article Type: Report
Subject: Foreign bodies (Medical care) (Diagnosis)
Magnetic resonance imaging (Usage)
Radiology (Practice)
Radiology, Medical (Practice)
Laryngeal diseases (Diagnosis)
Authors: Oesterhelweg, Lars
Bolliger, Stephan A.
Thali, Michael J.
Ross, Steffen
Pub Date: 05/01/2009
Publication: Name: Archives of Pathology & Laboratory Medicine Publisher: College of American Pathologists Audience: Academic; Professional Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2009 College of American Pathologists ISSN: 1543-2165
Issue: Date: May, 2009 Source Volume: 133 Source Issue: 5
Topic: Event Code: 200 Management dynamics
Accession Number: 230152005
Full Text: Modern imaging techniques like multislice computed tomography (MSCT) and magnetic resonance imaging (MRI) allow the medical specialist in clinical radiology to localize foreign bodies--even if these are not radiopaque--and to perform virtual bronchoscopies or gastroscopies. (19-21) With the postmortem use of modern imaging techniques, small hemorrhages in the laryngeal muscles are assessable without any dissection,22 but investigation of bolus fatalities by postmortem MSCT or MRI are still unreported.

MATERIALS AND METHODS

Three decedents with a suspected foreign body in the larynx were delivered to the Institute of Forensic Medicine, University of Bern, Switzerland, for medicolegal autopsy. A detailed history of the incidents is given in the case reports below.

Before autopsy in all 3 cases postmortem cross-sectional imaging was executed on a 6-row multislice computed tomography scanner (Emotion 6, Siemens Medical Solutions, Erlangen, Germany). Image reconstruction was carried out in a slice thickness of 1.25 mm with an increment of half the slice thickness and in a soft tissue and a bone-weighted kernel. In the first case, an additional MRI of the neck was performed (GE 1.5T Signa Echospeed Horizon, General Electric Medical Systems, Milwaukee, Wis) in T1 and T2 weighted sequences. In a third case, a postmortem full-body computed tomography-angiography was carried out. For this angiography, access to the arterial and venous system was gained by preparation of the left femoral vessels. Using a pressure-controlled, modified heart-lung machine (HL20, Maquet, Hirrlingen, Germany), the body was perfused anterograde by the arterial system and retrograde by the venous system. As a contrast agent, a 10:1 mixture of PEG (PEG 200, Schaerer and Schlaepfer AG, Rothrist, Switzerland) and Imagopaque 300 (GE Healthcare Diagnostic Imaging, Slough, United Kingdom) was used.

A board-certified radiologist performed the interpretation of the radiologic images, and the autopsies were performed by board-certified forensic pathologists. The responsible department of justice and the ethics committee of the University of Bern approved this study.

[FIGURE 1 OMITTED]

[FIGURE 2 OMITTED]

REPORT OF CASES

Case 1

A 70-year-old man had dinner in a restaurant. While eating a piece of meat, the man collapsed lifelessly. Resuscitation attempts were undertaken but remained unsuccessful. The man was declared dead at the incident scene. The deceased had a history of alcoholism with repeated falls. Furthermore, the man suffered from hypertension and--since a biking accident more than 25 years ago--from a skeletal deformation of the right leg. In addition, he had a history of minor cerebral strokes.

By order of the District Attorney of Bern, an autopsy was performed one day after the incident. Additionally, toxicologic screening, including alcohol, was demanded. One day after the incident, postmortem imaging by MSCT and MRI was carried out.

In the postmortem MSCT, as well as in the MRI scan, a foreign body in the larynx was clearly visible (Figure 1). In addition, the findings of cerebral atrophy and small stroke residues were detected by the imaging procedures. During the autopsy of the throat, a nonmasticated single piece of fried chicken (4.5 X 2 X 2 cm) was found in the larynx in between the epiglottis and the vocal cords. This piece of meat led to a nearly complete obstruction of the larynx (Figure 2). Because of the deep position in the larynx, this food bolus was not visible at external examination of the body.

The toxicologic screening did not show any sign of drug intoxication. However, the blood alcohol concentration was 0.61 g/L.

Case 2

A 90-year-old woman was fed her breakfast in a nursing home. The woman routinely ate 3 dried prunes and some yogurt. While being fed the first prune, the elderly woman choked and coughed, then she collapsed lifeless. The nurse performed the Heimlich maneuver without success. On manual inspection of the mouth, no food was palpable in the oral cavity or upper pharynx. The woman remained lifeless and died without any endotracheal intubation.

The deceased had a long-time history of Parkinson's disease. Autopsy was performed one day after the incident. Before autopsy, a full-body MSCT was obtained. In the postmortem imaging, a foreign body in the larynx was clearly visible (Figure 3). The trachea and the bronchi were free of any foreign material. In addition, the finding of a mild cerebral atrophy was detected by the imaging procedures. During the autopsy, a poorly masticated dried prune with yogurt was found in the larynx. This food bolus caused a complete obstruction of the larynx (Figure 4).

[FIGURE 3 OMITTED]

The toxicologic screening did not show any sign of drug intoxication. The blood alcohol concentration was 0.00 g/L.

Case 3

While having breakfast, a 60-year-old man with known dementia collapsed suddenly. The relatives started resuscitation, but the man was declared dead on arrival of the emergency forces without any further medical procedures. The last week before his death, the man suffered from a persistent coughing.

A medicolegal autopsy was performed one day after the incident. A full-body MSCT, including postmortem computed tomography-angiography, was performed directly before the autopsy. In the imaging, a laryngeal mass, causing a stenosis of the larynx, was visible with enhancement by the contrast agent. Inside the remaining lumen, foreign material was detectable (Figure 5). In addition, the finding of severe cerebral atrophy and clipping of the right medial cerebral artery were shown by the imaging procedures. During the autopsy, a primary laryngeal squamous cell carcinoma involving nearly the entire circumference of the larynx was detected. Soaked white bread was impacted in the remainder of the lumen, and no foreign material extended beneath this level (Figure 6). The diagnosis of Alzheimer's dementia was proven by a board-certified neuropathologist.

The toxicologic screening did not show any sign of drug intoxication, and the blood alcohol concentration was 0.00 g/L.

COMMENT

If we trust the ancient Greek historians, one of the firstknown bolus deaths is described more than 2400 years ago when Sophocles, at the age of 90, died from choking on a grape.23 One of the major problems in bolus fatalities is the differentiation between accidental death by a foreign body in the larynx and a natural death from other causes, for example, sudden cardiac failure. By emergency services, the fatal accident is identified correctly in less than 10% of incidents.24 The major diagnostic problem is the deep position of the bolus in the pharynx--making it often not detectable during the external examination.

[FIGURE 4 OMITTED]

Furthermore, the accusation of maltreatment from a medication overdose or inappropriately prepared food may emerge in hospitalized patients or elderly if they die while eating or getting fed.25,26 Choking or bolus death should be excluded in these cases, but the relatives often refuse an autopsy. By postmortem MSCT and/or MRI, it is possible to exclude or substantiate the accusation of maltreatment without an autopsy.

In some countries, the use of imaging techniques like computed tomography and MRI is becoming a routine procedure before--or even instead of--an autopsy. (27-31) The data survey for a full-body, virtual autopsy is possible within a few minutes by MSCT. The present cases demonstrate the diagnostic value in locating a foreign body and abnormalities in the larynx without any major manipulation that might lead to a movement of the bolus. The differentiation between neoplasm or soft foreign bodies is possible, but difficult, by MSCT alone. By MRI, the discrimination of the soft tissue structures and soft foreign bodies--like fried meat--is much easier. In addition to the postmortem MSCT, the combination of MSCT with postmortem angiography will give more valuable information because of enhancement in neoplastic tissue. (32)

[FIGURE 5 OMITTED]

[FIGURE 6 OMITTED]

CONCLUSION

Postmortem imaging methods like MSCT and MRI are highly valuable procedures for the detection of bolus fatalities. The advantage of these procedures is the noninvasive approach that provides a diagnosis without an autopsy. By the use of MSCT, it is even possible to get the necessary images within a few minutes.

We gratefully acknowledge the support of the Virtopsy Foundation, Bern, Switzerland.

Accepted for publication August 15, 2008.

References

(1.) Althoff H, Dotzauer G. Zur problematik des bolustodes. Z Rechtsmed. 1976; 78:197-213.

(2.) Berzlanovich AM, Fazeny-Dorner B, Waldhoer T, et al. Foreign body asphyxia: a preventable cause of death in the elderly. Am J Prev Med. 2005;28: 65-69.

(3.) Finestone HM, Fisher J, Greene-Finestone LS, et al. Sudden Death in the dysphagic patient--a case of airway obstruction caused by a food bolus: a brief report. Am J Phys Med Rehabil. 1998;77:550-552.

(4.) Wick R, Gilbert JD, Byard RW. Cafe coronary syndrome--fatal choking on food: an autopsy approach. J Clin Forensic Med. 2006;13:135-138.

(5.) National Safety Council. Injury facts. Edition 2005-2006. Itasca, Ill: National Safety Council; 2006.

(6.) Haugen RK. The cafe coronary. Sudden death in restaurants. JAMA. 1963; 186:142-143.

(7.) Mallach HJ, Oehmichen M. Bolustod: reflex oder erstickung? Beitr Gerichtl Med. 1982;40:473-483.

(8.) Thiele KH, Hofmann V. "Bolustodesfalle" im sektionsgut 1981-1 989. Beitr Gerichtl Med. 1991;49:275-279.

(9.) Boczko F. Patients' awareness of symptoms of dysphagia. J Am Med Dir Assoc. 2006;7:587-590.

(10.) Mallach HJ, Roseler P. Uber die rolle der alkoholischen beeinflussung beim bolustod. Beitr Gerichtl Med. 1962;22:219-223.

(11.) Mittleman RE, Wetli CV. The fatal cafe coronary: foreign-body airway obstruction. JAMA. 1982;247:1285-1288.

(12.) Pozorski-Ritter C, Adebahr G. Bolustod bei missbildungen des gehirns. Z Rechtsmed. 1984;93:43-47.

(13.) Samuels R, Chadwick DD. Predictors of asphyxiation risk in adults with intellectual disabilities and dysphagia. JIntellect Disabil Res. 2006;50:362-370.

(14.) Reimann W, Prokop O, Geserick G. Vademecum Gerichtsmedizin. 4th ed. Berlin: Volk und Gesundheit; 1985.

(15.) Enwo ON, Wright M. Sausage asphyxia. Int J Clin Pract. 2001;55:723-724.

(16.) Kalbfleisch HH. Erstickungstod durch ungewohnliche fremdkorper. Dtsch Z Gesamte Gerichtl Med. 1942;36:114-118.

(17.) Pinheiro J, Cordeiro C, Vieira DN. Choking death on a living fish (Dicologoglossa cuneata). Am J Forensic Med Pathol. 2003;24:177-178.

(18.) Schneider V, Rossel U. Uber einen besonderen fall von bolustod. Arch Kriminol. 1988;182:65-74.

(19.) Applegate KE, Dardinger JT, Lieber ML, et al. Spiral CT scanning in the detection of aspiration LEGO foreign bodies. Pediatr Radiol. 2001;31:836-840.

(20.) Berger PE, Kuhn JP, Kuhns LR. Computed tomography and the occult tracheobronchial foreign body. Radiology. 1980;134:133.

(21.) Jones CM, Athanasiou T. Is virtual bronchoscopy an efficient diagnostic tool for the thoracic surgeon. Ann Thorac Surg. 2005;79:365-374.

(22.) Aghayev E, Jackowski C, Sonnenschein M, et al. Virtopsy hemorrhage of the posterior cricoarytenoid muscle by blunt force to the neck in postmortem multislice computed tomography and magnetic resonance imaging. Am J Forensic Med Pathol. 2006;27:25-29.

(23.) Smith W. Dictionary of Greek and Roman Biography and Mythology, Vol 3. Boston: Little Brown & Co; 1867.

(24.) Berzlanovich AM, Muhn M, Sim E, et al. Foreign body asphyxiation--an autopsy study. Am J Med. 1 999;107:351-355.

(25.) Bockholdt B, Ehrlich E, Maxeiner H. Forensic importance of aspiration. Leg Med (Tokyo). 2003;5(suppl):311-314.

(26.) Hunsaker DM, Hunsaker JC III. Therapy-related cafe coronary deaths: two case reports of rare asphyxial deaths in patients under supervised care. Am J Forensic Med Pathol. 2002;23:149-154.

(27.) Dirnhofer R, Jackowski C, Vock P, et al. Virtopsy: minimally invasive, imaging-guided virtual autopsy. Radiographics. 2006;26:1305-1333.

(28.) Mitka M. CT, MRI scan offer new tools for autopsy. JAMA. 2007;298:392-393.

(29.) Poulsen K, Simonsen J. Computed tomography as routine in connection with medico-legal autopsies. Forensic Sci Int. 2007;171:190-197.

(30.) Thali MJ, Yen K, Schweitzer W, et al. Virtopsy, a new imaging horizon in forensic pathology: virtual autopsy by postmortem multislice computed tomography (MSCT) and magnetic resonance imaging (MRI)--a feasibility study. J Forensic Sci. 2003;48:1-18.

(31.) The Virtopsy Project. 2008. Virtopsy. Available at: http://www.virtopsy.com. Accessed March 31st, 2008.

(32.) Ross S, Spendlove D, Bolliger S, et al. Postmortem whole-body CT angiography: evaluation of two contrastmedia solutions. AJR Am J Roentgenol. 2008; 190:1380-1389.

Lars Oesterhelweg, MD; Stephan A. Bolliger, MD; Michael J. Thali, MD; Steffen Ross, MD

From the Center of Forensic Imaging and Virtopsy, Institute of Forensic Medicine, University of Bern, Switzerland. Dr Oesterhelweg is now with the State Institute of Legal Medicine Berlin, Senate Administration for Health, Environment and Customer Protection, Berlin, Germany.

The authors have no relevant financial interest in the products or companies described in this article.

Reprints: Lars Oesterhelweg, MD, State Institute of Legal Medicine Berlin, Senate Administration for Health, Environment and Customer Protection, Turmstrasse 21, D-10559 Berlin, Germany (e-mail: lars.oesterhelweg@germed.berlin.de).
Gale Copyright: Copyright 2009 Gale, Cengage Learning. All rights reserved.