Homicide-Suicide: A Homicidal Asphyxiation Misinterpreted as a Gunshot Wound at the Scene

Strangulation is commonly associated with certain findings at autopsy, including petechial hemorrhages in the conjunctiva and oral mucosa, contusions or abrasions of the neck, hemorrhage within the anterior and posterior neck musculature, and fractures of the hyoid bone or thyroid cartilage. We present the case of a 68-year-old woman who was found dead in her bedroom, with her husband being found dead in the garage. Her husband had shot himself, and the woman, who was lying partially on her side, had blood coming from her ear that was facing upward and was, at the scene, also believed to have been shot. Autopsy revealed no gunshot wound, but instead florid petechial hemorrhages of the face and conjunctivae, a few contusions of the left and right sides of the neck, a laceration of the lower lip, oral mucosal petechiae, focal hemorrhage in the soft tissue around the hyoid bone, and focal hemorrhages in the left and right sternohyoid muscle. The tongue had multiple contusions. Her cause of death was certified as homicidal asphyxiation, including probable strangulation. Extensive contusions of the tongue are not routine findings with strangulation but occur in about 25% of cases, especially those involving the elderly, and hemorrhage from the ear is rarely reported. This case illustrates uncommon and rare autopsy findings for strangulation, which under the right circumstances, deceived investigators into thinking that a gunshot wound had occurred.