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Recognition and Documentation of Strangulation Crimes A Review

Michael Armstrong Jr, MD1,2,3; Gael B. Strack, Esq4,5
[+] Author Affiliations
1Richmond ENT, Richmond, Virginia
2Department of Otolaryngology, Virginia Commonwealth University, Richmond
3Department of Nursing, Virginia Commonwealth University, Richmond
4Training Institute on Strangulation Prevention, Alliance for HOPE International, San Diego, California
5California Western School of Law, San Diego
JAMA Otolaryngol Head Neck Surg. 2016;142(9):891-897. doi:10.1001/jamaoto.2016.0293.
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Importance  Strangulation accounts for 10% of violent deaths in the United States and 15% to 20% of deaths associated with domestic violence. However, strangulation deaths represent only a small fraction of nonfatal strangulation assaults, which occur with daily frequency in medium to large US cities. Careful evaluation and documentation of strangulation injuries may identify life-threatening medical conditions, and may facilitate prosecution of strangulation crimes.

Observations  The most recent article on strangulation identified in the otolaryngology literature was published in 1989, leaving a generation of head and neck surgeons without current guidance regarding this injury. However, strangulation is a common form of intimate partner violence. Among the 300 cases of strangulation reviewed in San Diego in 1995, most survivors (94%) were women who were strangled by a male member of their own household. Many state laws require evidence of injury to prosecute felony strangulation, but as shown in the review of 300 cases, most survivors (97%) were strangled with the perpetrator’s hands, leaving little to no sign of injury in most cases. Survivors may seek an otolaryngology consultation with complaints of hoarseness, sore throat, respiratory disturbance, or accidental injury to the neck. A thorough head and neck examination may reveal marks on the neck, facial petechiae, and neck swelling. Fiberoptic laryngoscopy is recommended to look for petechiae and swelling in the airway. Chest radiographs may demonstrate postobstructive edema, and computed tomography of the neck may demonstrate vascular injuries. The most sensitive test for subtle strangulation injuries is magnetic imaging of the neck. Careful examination and documentation can provide critical evidence for the prosecution of these crimes.

Conclusions and Relevance  Otolaryngologists should be knowledgeable of the subtle patterns of injury and potentially life-threatening complications of strangulation and should consider domestic violence in women presenting with throat complaints or bruises on the neck.

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Figure 1.
Documentation Chart for Nonfatal Strangulation—History

Adapted with permission from the Training Institute on Strangulation Prevention and California District Attorneys Association.10

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Figure 2.
Documentation Chart for Nonfatal Strangulation—Physical Examination

Adapted with permission from the Training Institute on Strangulation Prevention and California District Attorneys Association.10 PTSD indicates posttraumatic stress disorder.

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