Otorrhagia as an intravital phenomenon in a case of incomplete atypical hanging

Herein, we describe a case of an 81-year-old woman who was found hanged in the kneeling position, at the height of about 1.3 m, with anterior position of the knot. There were two downward directed stripes of dried blood coming out of the left nostril and left ear, while the right ear was filled with a small pool of blood. Since the hanging occurred in the kneeling position with the head "on top," it is likely that the anterior position of the knot, with only (partial) weight of the head pulling the noose, resulted in complete obstruction of the venous flow, but only partial obstruction of the arterial flow, probably including both carotid and vertebral arteries. The venous pressure rise was not caused by the position of the head, meaning that it required a "pump," that is, preserved circulation and heart function. The first finding that speaks in favor of this mechanism is the small pool of blood in the right external auditory canal, since its position is completely antigravitational. The second one, even more convincing, is the finding of the so-called trout phenomenon, that is, petechial bleeding on upper and lower eyelids and on the skin between the eyebrows, because this phenomenon requires impaired or obstructed venous return in the presence of continued arterial input. We can conclude that in this case of atypical, incomplete, suicidal hanging, otorrhagia was a vital reaction.