X-ray examination is used to detect foreign bodies during forensic autopsy of a suspected gunshot wound case. There are several previously described situations in which a projectile is not immediately localized by radiography. In this report, we present a case of a metal bullet lodged near the atlanto-occipital junction, where it was present but not readily apparent on radiograph. Although computed tomography is ideal for detecting such objects, many forensic pathologists must still rely on x-ray only. To our knowledge, the forensics literature does not contain a case where a lead bullet was rendered nearly imperceptible by x-ray examination. We describe 2 concepts of radiation physics-poor x-ray penetration and summation artifact-which can cause a radiopaque object such as a bullet to seem much less so. The difference between best practices in hospital and forensic radiology may explain how this occurred. This case serves to caution the pathologist that forensic radiographs may not completely depict the type or quantity of projectiles present in a gunshot wound case.
The investigation of deaths that are suspected to be related to medical therapy present several challenges for the forensic pathologist. In all such cases, it is important for the pathologist to understand the therapy/procedure that may have played a role in death. As such, review of medical records and possible consultation with various medical specialists before autopsy can provide valuable information to ensure proper evaluation in any given case.Herein, we describe a rare death occurring as a complication of septoplasty, nasal polypectomy, and intranasal endoscopic ethmoidectomy, which are common surgical procedures performed by otolaryngology/head and neck surgeons. An otherwise healthy 58-year-old woman underwent the elective surgical procedures for a deviated nasal septum, multiple nasal polyps, and chronic ethmoid sinusitis. Following surgery, the patient never awoke from general anesthesia, and further evaluation before death revealed a basilar subarachnoid hemorrhage. Autopsy disclosed basilar subarachnoid hemorrhage, a traumatic defect of the right cribiform plate, and associated anterior cerebral artery injury with frontal lobe damage. No vascular anomalies were present. The cause of death was attributed to complications related to nasal surgery, and the manner of death was ruled "accident."Following the presentation of this case, the authors discuss these common nasal surgical procedures, including a summary of their known complications. In addition, the authors address and review the topic of deaths related to medical therapy.
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