Diagnostic value of external and internal neck findings in fatal strangulation: a scoping review of the forensic pathology literature.

This scoping review maps the forensic-pathology literature on the diagnostic value of external and internal neck findings in fatal manual and ligature strangulation, and on findings used to differentiate strangulation from hanging and homicidal from suicidal manner of death. A scoping review was conducted in accordance with Joanna Briggs Institute methodology [1] and reported following PRISMA-ScR [2]. PubMed/MEDLINE and Europe PMC were searched in April 2026; title/abstract and full-text screening were performed by a single reviewer with supervisor consultation. Findings were reported using three pre-specified inference categories: confirmed, contested, and hypothesis-generating. Sixteen studies reporting on approximately 1,500 cases across eight world regions met eligibility criteria. Manual strangulation produced a higher laryngohyoid fracture burden than ligature strangulation across nationwide series. Two findings from the Berlin institute cohort of Maxeiner and Bockholdt - laryngeal muscle hemorrhage and fractures of more than one thyroid superior horn - reached 0% prevalence in suicidal ligature strangulation, providing a high-specificity indicator panel for homicidal manner that remains single-cohort and awaiting replication. Apparent variation in petechiae prevalence across studies was attributable to ascertainment methodology rather than biological difference. The two included Chinese provincial series reported hyoid fractures more frequently than thyroid cartilage fractures, at ratios of approximately 3:1 and 4:1, which reverses the thyroid-predominant pattern of the Western and Nordic series. This two-paper, single-country observation is reported as hypothesis-generating rather than as an established regional difference. The classic claim of intracartilaginous laryngeal hemorrhage as a strangulation-specific marker emerged as contested and unsupported by contemporary controlled evidence. The synthesis supports a high-specificity indicator panel for homicidal manner in ligature strangulation and clarifies the petechiae prevalence variation as an ascertainment artifact. It identifies three research priorities. The first is replication of the two markers reaching 0% prevalence in suicidal ligature strangulation reported by Maxeiner and Bockholdt, outside the Berlin institute cohort in which they were established and against the findings set out in Table 4. The second is post-mortem CT testing of the regional anomaly, and the third is contemporary testing of the cervical lymph node hemorrhage observation.