Journal of Forensic Science and Medicine

CASE REPORT
Year
: 2016  |  Volume : 2  |  Issue : 1  |  Page : 57--59

Choking or Epilepsy


Raktim Pratim Tamuli1, Debarshee Chakraborty2, Nayan Kumar Das1, Braja Gopal Das2,  
1 Department of Forensic Medicine and Toxicology, Tezpur Medical College, Tezpur, Assam, India
2 Department of Forensic Medicine and Toxicology, Gauhati Medical College, Guwahati, Assam, India

Correspondence Address:
Raktim Pratim Tamuli
Department of Forensic Medicine and Toxicology, Tezpur Medical College, Bihoguri, Tezpur - 784 010, Assam
India

Abstract

Choking is a form of asphyxia caused by an obstruction within the air passage usually between the pharynx and bifurcation of the trachea. It is commonly associated with alcohol intoxication, neurological injury, or senility. Choking is almost always accidental. Suicidal and homicidal chokings are rare. Here, in the present case, the dead body of a 29-year-old male was brought by the local police to the mortuary of Gauhati Medical College and Hospital, Guwahati for medico-legal autopsy, who as reported, was mysteriously found dead on his bed. After complete and thorough autopsy, the cause of death was opined to be due to asphyxia as a result of antemortem choking, following impaction of the food bolus in the laryngotracheal region. The person had a history of a single episode of seizure (epilepsy) about 1 month back.



How to cite this article:
Tamuli RP, Chakraborty D, Das NK, Das BG. Choking or Epilepsy.J Forensic Sci Med 2016;2:57-59


How to cite this URL:
Tamuli RP, Chakraborty D, Das NK, Das BG. Choking or Epilepsy. J Forensic Sci Med [serial online] 2016 [cited 2022 Aug 12 ];2:57-59
Available from: https://www.jfsmonline.com/text.asp?2016/2/1/57/155549


Full Text

 Introduction



Choking is a form of asphyxia caused by an obstruction within the air passages. Choking is widely discussed in various literatures. [1],[2] It commonly occurs during a meal when the food is accidentally inhaled, especially when the victim is laughing or crying. The vomited matter may be inhaled by a person under the influence of alcohol or an anesthetic agent, during a fit of epilepsy, or while in a state of insensibility from other causes. Infants are more susceptible to choking caused by regurgitation of clotted milk and impaction of solid bodies such as large boluses of food, coins, and other foreign bodies. Choking by ballpoint pen, balloon, chewing gum, live fish, etc., are mentioned in various literatures. [3],[4],[5],[6],[7] Choking by foreign bodies is rarely mentioned in the literatures and the investigation is also not up to the mark.

American playwright Tennessee Williams, Irish writer-cum-painter Christy Brown, American professional baseball player Jimmie Foxx, and the first Chief of the Air Staff of the Indian Air Force Subroto Mukherjee are a few of the renowned persons who died of choking. [8]

During autopsy, choking can be diagnosed by the presence of typical features of asphyxia like petechial hemorrhages, bluish discoloration above the level of obstruction, and congestion, along with the presence of obstruction in the air passage extending from the larynx to bifurcation of the trachea. Absence of other significant findings is also necessary for the diagnosis of choking.

 Case Report



Here, in the present case, the dead body of a 29-year-old male was brought for medico-legal autopsy to the mortuary of Gauhati Medical College and Hospital, Guwahati by the local police. The person was mysteriously found dead in the morning on his bed. The person had a history of a single episode of seizure (epilepsy) about 1 month back, for which he did not consult any physician.

Autopsy findings

A swarthy-complexioned male dead body was found wearing a half pant and a T-shirt on the autopsy table. Numerous food particles were seen all over the face and inside the oral cavity [Figure 1]. The face was found to be livid and postmortem hypostasis was present over the back. Multiple subconjunctival and petechial hemorrhages were noticed.{Figure 1}

On opening the vault of the skull, the brain was found congested and petechial hemorrhages were noticed over the white matter. No organic or traumatic lesions were seen.

After opening the thoracic cavity, the lungs were found congested and hyperinflated. Frothy fluid blood came out of the cut margins of lung. Numerous petechiae were noticed on the surfaces of the lungs and the heart. The heart was otherwise found to be healthy.

On dissection of the larynx and the trachea, a food bolus completely obstructing the lumen was seen in the region of the larynx [Figure 2] and [Figure 3].

In the abdomen, the stomach was found healthy and no objectionable smell was perceived.{Figure 2}{Figure 3}

Histological examination

Histopathological examination of all the major organs did not reveal any significant finding except in the lungs, where we found massive emphysematous areas with rupture of the septa, alternating with peribronchial alveoli plugged by erythrocytes.

Histopathological examination of the brain (part of hippocampus, thalamus, and cerebellum) did not show any abnormality.

Toxicological examination

Blood and other viscera did not reveal the presence of any drug, poison, or alcohol.

 Discussion



Choking can be defined into two types, namely, typical and atypical, depending upon the capacity of the foreign body to occlude the airway completely or partially. [5]

The objects, which are able to adapt and completely obstruct the airway (e.g. meat, chewing gum) generally cause typical choking. Well-defined objects like button and ball may not completely obstruct the airway and can cause atypical choking. In both types, there is a little bit of laryngospasm that contributes to asphyxia.

Saving the lives of these kinds of patients is very difficult as the timing of care intervention must be very quick, because irreversible brain damage or death may occur within 5-10 min of the obstruction. [9],[10],[11],[12]

Evaluation of the lethal events in the present case is not very easy. There was no external injury found on the body, so any physical assault or fall can be ruled out.

Finding of a large food bolus adherent to the larynx, totally obstructing the access to the larynx resolved the doubts about the mechanism of death. Coherent pathological signs (massive pulmonary emphysema, subserous petechiae, etc.) enabled in making the diagnosis of lethal asphyxia by typical choking easier. [13]

There was neither any evidence of epilepsy found in the body including the histopathological examination, nor did the toxicological analysis reveal any drug or poison in the samples. Sudden unexpected death in epilepsy (SUDEP) can also be excluded, since two-thirds of the SUDEP cases show some kind of macroscopic abnormalities in the brain. [14],[15]

 Conclusion



In the end, we can conclude that the person was suffering from epilepsy and was not taking any medicine for the same. On the day of the incident, he had an episode of seizure causing regurgitation of food into his air passage, leading to the blockage of airflow into his lungs, which led to his demise.

This case carries a special message to all those who had even a single episode of seizure, that they should consult a physician at earliest to prevent the occurrence any such tragic fatal accidents. Life of this person could have been saved, had he consulted a doctor just after his first attack of seizure.

References

1Ekberg O, Feinberg M. Clinical and demographic data in 75 patients with near-fatal choking episodes. Dysphagia 1992;7:205-8.
2Dolkas L, Stanley C, Smith AM, Vilke GM. Deaths associated with choking in San Diego county. J Forensic Sci 2007;52:176-9.
3Bhana BD, Gunaselvam JG, Dada MA. Mechanical airway obstruction caused by accidental aspiration of part of a ballpoint pen. Am J Forensic Med Pathol 2000;21:362-5.
4Dias E. An unusual case of foreign body aspiration in an infant. Ann Med Health Sci Res 2012;2:209-10.
5Barbera N, Arcifa V, Valenti V, Spadaro G, Tomasello S, Romano G. Fatal asphyxia by complete laryngeal obstruction due to chewing-gum aspiration in an adult woman. Rom J Leg Med 2012;20:33-6.
6Haftoura E, Pourzitaki C, Logotheti H, Aroni F, Arambatzis P. Preoperative chewing gum and foreign body airway obstruction. J Anesth 2008;22:479-80.
7Pinheiro J, Cordeiro C, Vieira DN. Choking death on a live fish (Dicologoglossa cuneata). Am J Forensic Med Pathol 2003;24:177-8.
8List of Choking Deaths. Available from: http://www.en.wikipedia.org/wiki/Listofchokingdeaths. [Last accessed on 2014 Apr 07].
9Berzlanovich AM, Muhm M, Sim E, Bauer G. Foreign body asphyxiation--an autopsy study. Am J Med 1999;107:351-5.
10Donato L, Weiss L, Bing J, Schwarz E. Tracheobronchial foreign bodies. Arch Pediatr 2000;7(Suppl 1):56-61S.
11Kitay G, Shafer N. Café coronary: Recognition, treatment and prevention. Nurse Pract 1989;14:35-8, 43, 46.
12Eller WC, Haugen RK. Food asphyxiation--restaurant rescue. N Engl J Med 1973;289:81-2.
13Chrcanovic BR, Souza LN. Tracheotomy for a foreign body in the larynx. Oral Maxillofac Surg 2009;13:55-8.
14Shields LB, Hunsaker DM, Hunsaker JC 3 rd , Parker JC Jr. Sudden unexpected death in epilepsy: Neuropathologic findings. Am J Forensic Med Pathol 2002;23:307-14.
15Black M, Graham DI. Sudden unexplained death in adults caused by intracranial pathology. J Clin Pathol 2002;55:44-50.