Challenges in Examination of Drowning Victims with Cervical Injuries Grace A

Challenges in Examination of Drowning Victims with Cervical Injuries
Grace A. Rojas
Wayne State University
According to the World Health Organization, drowning is defined as the “process of experiencing respiratory impairment from submersion/immersion in liquid” (World Health Organization, 2018). Upon recovery of human remains in water, the cause of death is not always obvious, and autopsy findings in drowning deaths are nonspecific (Byard, 2015). The diagnosis of drowning is one of exclusion because of the lack of pathognomonic findings and, if the event is not witnessed, the exact circumstances and manner of death may never be determined. Amanda Fisher-Hubbard, MD endorsed this opinion in her lecture on the investigation of bodies in water at the Advances in Forensic Medicine and Pathology Conference. She described the key findings that one must look for when examining a body recovered from the water, but that these can be hardly developed or totally lacking, especially after the onset of putrefaction. This literature review will concentrate on a more specific aspect of this topic, namely the assessment of cervical injuries in drowning victims. The presence of cervical injuries in a body recovered from the water complicates the diagnosis of drowning even further. The goal of this paper is to analyze previous case reports regarding the source of drowning-related neck trauma and to inform the pathologists’ assistant (PA) on what types of findings may be present in the cervical region of a drowning victim who has died by accident, homicide, suicide, or natural death. This topic is important in forensic practice because it helps the examiner to establish an accurate manner of death in its drowning victims. A PA must be well informed of what to look out for as they perform an autopsy on a drowning victim, as these cases may be encountered while working in the Medical Examiner’s office.
While autopsy findings in drowning deaths are nonspecific, interpretation of cervical injuries in these cases pose an even greater challenge. Current literature on the subject share the viewpoint that using cervical trauma as a determination of cause and manner of death in these situations is controversial. The rulings made in these cases are heavily dependent on the circumstances surrounding death, such as eyewitness accounts. Drowning is determined by exclusion of other causes of death with more specific findings, such as ligature marks in strangulation cases and contusions in blunt trauma (Zuka & Ohshima, 2013). According to the current literature, there are three major mechanisms that can cause cervical injuries in bodies found in water: traumatic impact, injury inflicted before immersion in water, and the violent struggle that occurs with the act alone of drowning. When performing an autopsy on such individuals, the examiner has the difficult job of attempting to differentiate between and rule out such potential causes based on findings and situational context.
Alexander and Jentzen (2011) describe a case report in which a man was found dead at the bottom of a hotel pool. During the autopsy, at the mouth and nose, there was a “foam cone.” There were marked conjunctival and scleral hemorrhages. The right ventricle of the heart was dilated, and the thyroid gland was found to be congested. In the neck dissection, hemorrhage was seen in the anterior and posterior neck. After no foul play was found, the cause of death was confirmed as drowning by accident. The authors attribute these findings to an elevated central venous pressure that occurs in response to coughing, gagging, vomiting, and forceful abdominal contractions involved in the response to drowning. The authors explain that the elevated pressure causes right heart dilation, and it travels through the valveless veins of the neck into the cephalic region, resulting in congestion of the thyroid gland and the rupture of capillaries leading to the hemorrhage seen in the conjunctivae. The authors emphasize that because the hemorrhaging was confined to its fascial surface, there was no traumatic injury to the neck and hemorrhaging as such should not be interpreted as evidence of homicide (Alexander & Jentzen, 2011).
In contrast, two studies examine cervical injuries that can be attributed to the impact of a fall or diving accident. Voland, Vilarino, Grabherr, Lobrinus, and Palmiere (2015) describe a case in which a corpse of a woman was found floating on the surface of a 1.4-meter-deep lake. She was found to have C5-C6 fractures, an epidural hematoma involving the cervical region, and hemorrhages in the cervical paraspinal muscles. She also had water in her mouth and bruises on her face. When considering the low level of the spinal cord injury and the presence of water in her mouth, death was determined to be caused by spine fracture, spinal cord contusion, and subsequent drowning. Diving at such a depth is frequently associated with these findings. The bruises in the frontal region were also consistent with a diver’s head striking the bottom of a surface (Voland et al., 2015). Similarly, Zuka and Ohshima (2013) examined 64 autopsy cases where the cause of death was drowning with cervical injuries after victims fell from a low height. In these cases, there was a pattern of cervical muscle hemorrhage, hyoid bone and thyroid cartilage involvement in addition to vertebral fracture. The authors presented four case studies in detail. These injuries were attributed to a special set of circumstances where the imposition of the weight of the body on the head caused cervical hyperextension. That these injuries could be sustained from such a short height illustrates the nature of water as both a hard, flat object and as a soft and ungraspable substance that victims cannot use to brace themselves. The resistance of the water is greatest at areas of large surface area like the head and trunk. As a result, the body undergoes flexure upon impact resulting in cervical soft tissue hemorrhage, contusions, and hyoid bone fractures. In all four cases, it was purported that the victims’ injuries may have prevented their moving in water, resulting in drowning (Zuka & Ohshima, 2013).
Boussaid et al. (2018) reported a case in which a woman was found dead in a well of water. Autopsy showed bruises in the neck muscles and a bruise associated with a fracture of the hyoid bone. The lesions found suggested homicidal strangulation. However, given there were witnesses that saw her intentionally jump into the well, her death was ruled a suicide by drowning. The authors attributed her cervical injuries to mechanical asphyxia, drowning-related elevated central venous pressure, and impact of fall. The fracture of the hyoid bone is a result of the impact of the fall itself and the contact with the water surface. This study shows the importance of considering the context and circumstances surrounding death. Without such witnesses in this case, the woman’s death would have been attributed to homicidal strangulation (Boussaid et al., 2018).
Finally, Akhlaghi et al. (2013) looked at causes of death accompanying soft tissue neck hemorrhage. Reviewing 86 cases including instances of strangulation, neck trauma, cardiovascular disorders and drowning, the authors compared location of hemorrhage in different compartments of the neck. They found that while hemorrhage is most commonly seen in asphyxia cases, it can also be found in cases with no history of neck trauma, such as drowning. In both instances, hemorrhage was most commonly found in the anterior and lateral compartments of the neck. While the authors specifically pointed out the challenges that neck hemorrhage can pose in suspected drowning cases, they note that hemorrhages in head down prone position can be a result of lividity formation but can also occur due to violent neck movements that occur during drowning. While some drowning cases demonstrated lividity in the posterior aspect of the neck, there was still a presence of intramuscular and submucosal hemorrhage in the anterior and lateral compartments of the neck (Akhlaghi, 2013).
While the current literature available with regards to cervical injuries in drowning includes a wide range of scenarios and focuses, all papers emphasize the complexity of neck injuries in these cases. Overall, the studies available support the position put forth by Fisher-Hubbard. Specifically, multiple papers point out the importance of not attributing hemorrhage in the neck to solely compression or trauma. Boussaid et al. and Alexander and Jentzen point out that elevated central venous pressure can result in hemorrhage. In most cases, other signs of trauma such as ligature marks and blunt trauma are ruled out and drowning is ruled based on exclusion. In addition, witness reports and circumstances surrounding the death are crucial as the case study in Boussaid et al. demonstrates. Zuka and Ohshima’s study seem to represent the strongest research in the field as they looked at 64 autopsy cases that specifically studied drownings, while many of the other available papers focused on one single case study. Their research seems the most complete and, because of their larger sample size, the trends that they established seem to be more credible.
While the available literature related to cervical injuries in drowning seems to be in agreement, many of the articles were based off small samples, usually relying on one case study to emphasize their conclusions. With such a small pool of cases, it is possible that such findings are an anomaly and may not be representative of a trend or as strong of a trend if more studies are included. Also, with such small samples sizes, it is a possibility that authors fit their findings to the points they are intending to make instead of letting the research highlight such findings. In this way, the weakest part of the current research base is the lack of studies available. There are many studies on neck injuries due to asphyxia and other trauma, but the data on injuries in drowning is less extensive. It follows that with more review, such cases could become clearer. Specifically, larger scale studies need to be performed. Akhlaghi et al. had the biggest sample size with 86 cases, but the cause of death included more than drowning. A study including data from multiple hospitals or medical examiner offices and specifically focusing on drowning cases could provide more insight into neck injuries and further solidify the current findings available.
References
Akhlaghi M, Okazi A, Ghorbani M, Taghaddosi-Nejad F, Mazinani R, Mehdizadeh F,
Sanjari K. (2013). Causes of death accompanying by soft tissue neck hemorrhage.

International Journal of Medical Toxicology and Forensic Medicine, 3(1), 10-19.

Alexander, R.T., & Jentzen, J.M. (2011). Neck and scleral hemorrhage in drowning. Journal of
Forensic Sciences, 56(2), 522-525.

Boussaid, M., Mesrati, M.A., Mahjoub, Y., Salem, N.H., Zakhama, A., Chadly, A.,…Aissaoui,
A. (2018). Cervical injuries in drowning cases: A case report and a review of literature.
The American Journal of Forensic Medicine and Pathology, 39(1), 27-29.

Byard, R.W. (2015). Immersion deaths and drowning: Issues arising in the investigation of
bodies recovered from water. The American Journal of Forensic Medicine and
Pathology, 37(11), 323-325.
Voland, C., Vilarino, R., Grabherr, S., Lobrinus, J.A., & Palmiere, C. (2015). Fatal cervical spine
injury from diving accident. The American Journal of Forensic Medicine and Pathology,
36(3), 216-218.

World Health Organization. (2018). Drowning. Retrieved from
http://www.who.int/news-room/fact-sheets/detail/drowning
Zuka, M., & Ohshima, T. (2013). Tracheal injury added to cervical bone destruction due to the
impact of hitting the water surface: Four immersed adult bodies. Forensic Science
International, 228(1), 62-66.