Manual strangulation: When the laryngeal “colossus” gives way. A case report and literature review

Introduction

Isolated fractures of the cricoid cartilage are rare. They are caused by violent trauma such as road traffic accidents, sports’ accidents and also assaults.

Observation: We report the case of a 39-year-old male who presented a displaced bifocal posterior fracture of the cricoid cartilage with a retropharyngeal haematoma responsible for the narrowing of the subglottic airway of around 70% following manual strangulation. He was intubated by nasofibroscopy then surgery was attempted to reduce one of the posterior fragments coupled with tracheotomy, with no success. The tracheostomy was kept in place for a total of three months and the subject was kept hospitalised for two months, due to recurring pulmonary abscesses requiring antibiotic treatment and drainage. On the last follow-up consultation, over one year after the trauma, persisted vocal weakness, exertional stridor, asymmetric positioning of the right arytenoid and laryngeal stenosis of around 15%.

Discussion

We found 57 cases of cricoid fractures in the literature review. The primary manifestations of such fractures are dyspnoea, dysphonia and pain. The treatment most often consists in securing the airway by tracheostomy or intubation, however surgery can prove necessary. The main complication is laryngeal canal stenosis by granulomatous scar reaction. From a medico-legal point of view, cricoid fractures are considered by some authors as a potential indicator of homicide given the great force required to achieve this type of fracture, or at the very least, should raise suspicion of third party involvement. In the case of forensic autopsies, a meticulous examination is required given the fact that this cartilage is well sheathed inside the various surrounding structures. In forensic expertise, the potential complications and sequelae of these fractures should be taken into account.

Conclusion

Fractures of the cricoid cartilage are important for both clinician and forensic physician to be aware of, because of potential complications and sequelae, and because this type of trauma should raise suspicion of third-party involvement.