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PurposeHyolaryngeal excursion (HE) is typically assessed via palpation during clinical swallowing exams (CSE) or visually during videofluoroscopy (VFSS). Minimal evidence exists to support the use of these perceptual methods for judging HE. We investigated whether binary judgment of HE differentiates quantitative measures of hyoid movement, using frame-by-frame VFSS analysis to measure anatomically scaled peak hyoid positions.MethodsMedical records of patients who received a CSE and VFSS within a 24-h period were reviewed. Clinician ratings of HE (‘reduced’ or ‘normal’) were collected from CSE and VFSS reports, along with rater experience. Five ml puree swallows were extracted from each VFSS for randomized, blinded analysis. Peak hyoid position from C4 was captured in anterior, superior, and hypotenuse positions and expressed relative to C2–C4 length. T-test comparisons of hyoid positions between patients judged to have reduced versus normal HE on palpation and VFSS were conducted.ResultsEighty-seven patients (56 male, mean age 61) met criteria. Peak anterior hyoid position was significantly different between patients judged to have reduced (mean = 89.2% C2–C4) and normal (mean = 110.6% C2–C4) HE on palpation (p = 0.001). Further analysis revealed no effect of clinician experience on differentiation of objective measures based on palpation. No differences were found across any objective measures when compared to clinician VFSS ratings.ConclusionsClinicians appeared to be able to differentiate peak anterior hyoid movement but not superior or hypotenuse movement on palpation. On VFSS visualization, no significant differences were found between swallows judged to have reduced versus normal HE in any directional dimension. While perceptual methods may contribute to clinical decision-making, clinicians should remain cautious when making judgments about HE using these methods.

Purpose Obesity is the most important risk factor for obstructive sleep apnea (OSA); however, the exact underlying mechanisms are still not fully understood. The aim of this study was to examine the morphology of upper airways in overweight habitual snorers and in mild OSA patients. Furthermore, the associations between weight loss, parapharyngeal fat pad area and OSA were assessed in a 1-year randomised, controlled follow-up study originally conducted to determine the effects of lifestyle changes with weight reduction as a treatment of OSA. Methods Thirty-six overweight adult patients with mild OSA [apnea–hypopnea index (AHI) 5–15 events/h] and 24 weight-matched habitual snorers (AHI < 5 events/h) were included in the study. All patients underwent nocturnal cardiorespiratory recordings and multislice computed tomography (CT) of parapharyngeal fat pad area, the smallest diameter and area in naso-, oro- and hypopharynx, the smallest diameter and area of the whole pharyngeal airway, the distance from the hyoid bone to the mandibular plane and to cervical tangent as well as the distance between mandibular symphysis and cervical spine. In addition, OSA patients were further randomised to receive either an active 1-year lifestyle intervention with an early weight loss programme or routine lifestyle counselling. After 1 year, the cardiorespiratory recordings and CT scans were repeated. Results The pharyngeal fat pad area was significantly larger, and the distance from the hyoid bone to cervical spine was longer in patients with OSA than in habitual snorers ( p  = 0.002 and p  = 0.018, respectively). The multiple regression analysis showed that besides a large pharyngeal fat pad area and a long distance from the cervical spine to hyoid bone, also a short distance from the mandibular symphysis to cervical tangent increased a risk to OSA. During the 1-year follow-up in OSA patients, the pharyngeal fat pad area and AHI decreased significantly in the intervention group ( p  = 0.003 and p  < 0.001, respectively). Conclusions In the early stages of OSA, the pharyngeal fat pad seems to play an important role in the development of disease in overweight patients. Furthermore, weight reduction by lifestyle intervention-based programme reduces both central obesity and pharyngeal fat pads, resulting in an improvement of OSA.

Forensic examination of the hyoid-larynx complex (HLC) is crucial in diagnosing (inflicted) neck trauma. Clinical Total-Body CT (TBCT) scans of the (non-)calcified HLC lack sensitivity for fracture detection. Micro-computed tomography (micro-CT) is an upcoming imaging modality capable of scanning samples at microscale resolution up to 1 µm. Soft-tissue contrast can be established with iodine staining, known as diffusible iodine-based contrast-enhanced CT (diceCT). We study the additional value of micro- and diceCT in detecting HLC fractures and hemorrhages in forensic cases, compared to standard forensic imaging techniques and findings at autopsy. Fifteen, during forensic autopsy excised, adult HLCs were scanned with micro-CT. Subsequently, the samples were stained with buffered Lugol’s solution (B-Lugol) and scanned with contrast-enhanced micro-CT. The scans were examined on fractures and hemorrhages. Total body CT, optimized clinical CT of the explant and autopsy reports were compared with the micro- and diceCT scans and the results were confirmed using histological examinations. Sixteen potential fractures were identified in the micro-CT scans and with diceCT, nine hyperdensities were detected around potential fractures. Two previously undiscovered vital fractures were found, which were verified by histological examination. This research demonstrated that micro-CT can be a valuable tool to detect fractures of the HLC in forensic neck trauma cases and diceCT enables us to image the injured HLC in detail and indicate possible hemorrhages. With increasingly better stain and scan protocols and more experience gained by forensic radiologists, micro-CT could become invaluable for the examination of HLC trauma. [Display omitted] •Micro- and diceCT provide detailed images of the hyoid larynx complex.•Micro-CT reveals subtle fractures in the hyoid-larynx complex missed by standard CT.•DiceCT imaging can detect hemorrhages, aiding in forensic evaluation of neck trauma.•Two vital fractures, undetected by traditional methods, were confirmed via histology.•Micro-CT and diceCT combined enhance accuracy in forensic neck trauma assessment.

Hanging is defined as a form of asphyxia caused by the suspension of the body with a ligature around the neck, where the constriction is generated by the body’s own weight. The aim of this study is to examine autopsy findings in hanging cases among children, a rare cause of death in this age group, using data collected from a forensic autopsy center. This retrospective study was conducted by reviewing electronic autopsy reports of pediatric cases referred to the Morgue Department between January 1, 2012, and December 31, 2021, for the determination of the cause of death. Demographic data physical characteristics, scene-related findings and autopsy findings were analyzed. A total of 162 pediatric cases Of these, 113 (69.8 %) were male and 49 (30.2 %) were female. The age range of the cases was between 5 and 17 years, with a mean age of 15.66 ± 2.42 years. The Body Mass Index (BMI) ranged between 12.85 % and 52.94 %, with a mean of 22.14 ± 5.48 %. No statistically significant correlation was found between age or BMI and the presence of hyoid bone fracture, thyroid cartilage fracture, sternocleidomastoid (SCM) muscle injury, or infrahyoid muscle injury. When findings were evaluated according to the knot location (typical vs. atypical), no significant relationship was found between the knot position and hyoid bone fracture, thyroid cartilage fracture, infrahyoid muscle or SCM muscle injury. Compared to adult series in literature, the lower frequency of fractures, particularly of the thyroid cartilage, may be attributed to the fact that in pediatric individuals, these structures are less calcified and thus less prone to fracture. This study represents one of the largest autopsy-based analyses focusing solely on pediatric hanging cases. Preventive strategies should include a careful reassessment of environmental safety to mitigate accidental deaths. •Pediatric hanging deaths show fewer neck fractures than in adults.•Most events occurred at home, emphasizing environmental safety.•Soft tissue injuries were infrequent and not linked to age or body size.

Hyoid fractures are uncommon, but when they occur they are commonly the result of strangulation or hanging. Although there is a lack of available quantitative data, there is increasing evidence to suggest that strangulation is a relatively common feature of consensual sex play. This creates difficulty in clinical forensic medicine given the “rough sex” defence has previously been used successfully in cases of fatal intimate partner strangulation. We present a case where consensual and non-consensual strangulation has occurred in a woman who presents with a hyoid fracture. While manual strangulation was thought to be a more likely mechanism than consensual wearing of a sex-collar; ultimately the similar timeframes of the collar-wearing and the non-consensual manual strangulation meant that the accused was not convicted of this particular strangulation offense. This case highlights the importance of further research into consensual strangulation and the incidence of resultant injuries. It also demonstrates the importance of collecting a detailed forensic history and adequately documenting injuries in a contemporaneous matter.

Several articles have described the use of postmortem computed tomography (CT) and postmortem magnetic resonance imaging (MRI) in forensic medicine. Although access to CT scanners and, particularly, access to MRI scanners, is still limited for several institutes, both modalities are being applied with increasing frequency in the forensic setting. Certainly, postmortem imaging can provide crucial information prior to autopsy, and this method has even been considered a replacement to autopsy in selected cases by some forensic institutes. However, the role of postmortem imaging has to be assessed individually according to various injury categories and causes of death. Therefore, this systematic review focuses on the role of postmortem CT and MRI in cases of hanging and ligature and manual strangulation. We assessed the most common and relevant findings on CT and MRI in cases of strangulation and compared the detectability of these findings among CT, MRI and autopsy. According to the available literature, mainly fractures of the hyoid bone or thyroid cartilage were investigated using postmortem CT. Compared to autopsy, CT demonstrated equivalent results concerning the detection of these fractures. A currently described “gas bubble sign” may even facilitate the detection of laryngeal fractures on CT. Regarding the detection of hemorrhages in the soft tissue of the neck, postmortem MRI is more suitable for the detection of this “vital sign” in strangulation. Compared to autopsy, postmortem MRI is almost equally accurate for the detection of hemorrhages in the neck. Another “vital sign”, gas within the soft tissue in hanging, which is hardly detectable by conventional autopsy, can be clearly depicted by CT and MRI. The number of cases of manual and ligature strangulation that were investigated by means of postmortem CT and MRI is much smaller than the number of cases of hanging that were investigated by CT and MRI. Likewise, judicial hanging and the hangman’s fracture on postmortem imaging were described in only a few cases. Based on the results of this systematic review, we discuss the additional value of CT and MRI in fatal strangulation compared to autopsy, and we reflect on where the literature is currently lacking.

Background Obstructive sleep apnea (OSA) is a common disorder characterized by repetitive complete or partial closure of the upper airway during sleep, resulting in sleep fragmentation and oxygen desaturation. Cephalogram is recognized as an effective diagnostic tool for predicting OSA risk in clinical practice. This study aims to assess and analyze the morphological characteristics of the upper airway and hyoid bone position associated with OSA using data from polysomnography studies and two-dimensional cephalometric analysis. Methods The study included lateral cephalograms and polysomnography reports from the records of 105 adult (64 males & 41 females) patients who underwent comprehensive clinical examination. The severity of OSA was evaluated based on the apnea-hypopnea index (AHI) and lowest nocturnal oxygen saturation (LSaO 2 ). The participants were divided into male and female groups to investigate the correlation between cephalometric parameters and OSA severity. Thirteen cephalometric parameters, including eleven linear measurements and two angular measurements, were analyzed. The significance level was set at P -value < 0.05. Results The male group exhibited significantly higher severity of OSA compared to the female group, as indicated by higher AHI and lower LSaO 2 . There was an inverse association between AHI values with width of upper airway as well as distance between hyoid bone position relative to mandibular plane in both male and female groups. Additionally, only the male group showed a correlation between hyoid bone position relative to gonion/third-fourth vertebrae positions with AHI values. 4 out of 7 parameters associated with AHI in male group remained correlated with LSaO 2 , while in females only the distance between hyoid bone and line formed by ptergoid and pterygomaxillary fissure point showed correlation with LSaO 2 . Conclusion Correlation analysis revealed that a narrower upper airway was positively associated with increased AHI, while an inferiorly positioned hyoid bone in relation to mandible was negatively correlated with LSaO 2 . Our findings highlight the importance of several cephalometric parameters in predicting OSA severity based on AHI and LSaO 2 levels; moreover, certain parameters exhibited significant gender-specific associations.

Background Adenotonsillar hypertrophy (ATH) is a major cause of pediatric obstructive sleep apnea (OSA), potentially impacting craniofacial growth and development. Currently, whether children with ATH exhibit distinctive hyoid bone position and upper airway morphology remains uncertain. This research aimed to compare the hyoid bone position and upper airway morphology of children with and without ATH. Methods A total of 199 children aged 6–8 years were recruited for the study, and their pre-treatment lateral cephalograms were obtained. The size of the adenoids and tonsils on the lateral cephalogram was assessed based on Fujioka’s and Baroni’s methods for classification into groups: adenoid hypertrophy only (AHO) group, tonsillar hypertrophy only (THO) group, adenoid and tonsillar hypertrophy (AH + TH) group, and control group (CG). The position of the hyoid bone and upper airway morphology was analyzed using Dolphin Image Software. Results The distance between the hyoid bone and mentum was greater in the THO group compared to the AHO group ( P  = 0.005). Children in the AHO group exhibited a longer soft palate (SPL) compared to the THO group ( P  = 0.014), whereas the THO group displayed a reduced SPL in comparison to healthy controls ( P  = 0.008). The THO group showed a more inferior tongue position compared to children in the AHO group ( P  = 0.004). Subjects in the THO group exhibited significantly wider inferior airway space compared to healthy children ( P  < 0.001). Conclusions Adenotonsillar hypertrophy may be associated with hyoid bone position and upper airway morphology in children seeking for orthodontic treatment. In children with enlarged tonsils, the hyoid bone was positioned farther from the mentum than in those with enlarged adenoids. Conversely, children with enlarged adenoids had a longer soft palate compared to those with enlarged tonsils.

The thyrohyoid complex and cervical spine fracture distribution patterns may reflect the knot position as the force distribution by the noose to different neck regions may vary depending on it. Recently, machine learning models (MLm) were used to classify knot position through these fractures. The contribution of aging on the fracture susceptibility is better demonstrated, but data on body weight (BW) and height (BH) significance on this is more doubtful and MLm did not consider them. A retrospectively obtained autopsy data on sex, age, BW, BH and distribution of greater hyoid bone horn (GHH), superior thyroid cartilage horn (STH), and cervical spine fractures in 368 suicidal hangings were analyzed by standard statistics to determine association of the anthropometrics (age, BW, and BH) with the fracture occurrence, and by machine learning algorithms to determine if body weight and height improved MLm classification of hanging cases with typical and atypical knot positions. In the sample, unilateral GHH fracture was significantly more common in atypical hangings, while isolated STH fractures were more common in typical hangings. Age was a predictor of GHH fractures and BW of STH fractures, but BW poorly correlated with their number. BH was not a predictor of any thyrohyoid fracture. On the ROC curve analysis, the MLm that considered BW and BH did not perform statistically better than MLm that did not consider them. The study indicates that body weight and height are of no detrimental value in assessing the thyrohyoid and cervical spine fracture patterns in suicidal hangings.

Producing tongue pressure (TP) by pushing the tongue against the palate consists of lifting the tongue muscles and elevating the floor of the mouth via suprahyoid muscle contraction. Though studies have shown that tongue-pressure resistance training (TPRT) increases tongue function, none have focused on suprahyoid muscle function enhancements. Our study aimed to verify whether TPRT improves both tongue function and hyoid movement during swallowing. Eighteen patients (mean age: 76.8±6.2 years) with presbyphagia presenting with symptoms such as coughing and choking were enrolled. All patients performed daily living activities independently. None of the participants had diseases causing dysphagia or previous oral or pharyngeal surgery. Participants were instructed to push their tongues against the palate as hard as possible with their mouths closed for 10 seconds, and then resting for 10 seconds. A set consisted of five consecutive exercise and resting periods; two sets per day were performed for a month. TP and the oral diadochokinetic rate (ODKR), measured by repetitions of the syllables /ta/ and /ka/, assessed tongue function. The extent of anterior and superior hyoid movement and parameters related to swallowing, including the penetration aspiration scale (PAS) and the normalized residue ratio scale (NRRS) in the valleculae (NRRSv) and piriform sinus (NRRSp), were evaluated based on videofluoroscopic data. The anterior ( =0.031) and superior hyoid movement ( =0.012), TP ( =0.002), ODKR/ta/ ( =0.034), ODKR/ka/ ( =0.009), and the width of the upper esophageal sphincter ( =0.001) were larger at follow-up than at baseline. NRRSp ( =0.022), PAS ( =0.016), and pharyngeal transit times ( =0.004) were smaller at follow-up than at baseline. TPRT improved tongue strength, dexterity, both anterior and superior hyoid elevation, and swallowing functions. Therefore, TPRT could improve tongue function and suprahyoid muscle function simultaneously and contribute to prevention of sarcopenic dysphagia.