Fatal food bolus airway obstruction: Part one - Forensic investigations and toxicological findings

Food bolus airway obstruction (FBAO), traditionally described as café coronary, is a well-recognized but often underestimated cause of unexpected death in adults. Comprehensive forensic studies integrating circumstantial evidence, autopsy findings, dentition status, and toxicological data remain limited. We conducted a retrospective analysis on cases of fatal FBAO examined at the Institute of Legal Medicine of the University of Modena (Italy) over a 25-year period (1997-2022). For each case, we reviewed demographic characteristics, circumstances of death, clinical history, oral cavity findings, bolus characteristics, and complete toxicological results. The cohort included 11 males and 7 females. Most deaths occurred at home (50%) and were unwitnessed. Comorbidities were present in 16 subjects (88.9%), predominantly neurological or psychiatric disorders. Dentition assessment was available in 11 cases: 9 individuals (81.8%) showed partial or complete edentulism. Meat was the most common obstructing material (85.7%), and multiple boluses were identified in 76.5% of cases. Toxicological analyses were available in 16 subjects, all of whom tested positive for at least one xenobiotic. Ethanol was found in 56.3% (two cases > 3.0 g/L), and psychotropic medications-mainly benzodiazepines and antipsychotics-were detected in 81.3%. Fatal FBAO emerges as a multifactorial event resulting from the convergence of impaired mastication, neurological or psychiatric vulnerability, sedative medications, alcohol consumption, and adverse circumstances. Our results highlight the need for a systematic forensic approach that includes airway inspection, oral cavity evaluation, and comprehensive toxicology. Preventive strategies should prioritize dysphagia recognition, supervision during meals, dental rehabilitation, and careful review of sedative drugs in at-risk populations.