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V. PHYSICAL EVIDENCE OF TORTURE AND ILL-TREATMENT ISTANBUL PROTOCOL

tests should be conducted by a qualified audiometric (f) Damage to the larynx – thyroid cartilage (voice
technician. The radiographic examination of fractures box) – causing hoarseness and/or hyoid bone (bone at
of the temporal bone or disruption of the ossicular base of neck);
chain requires specialized radiological imaging.
(g) Scratches to neck – from assailant or victim or
(c) Nose both, or from accidental application of a ligature to the
neck (as victim tries to pull away from an assailant’s
408. The nose should be evaluated for alignment, hands or ligature);
crepitation and deviation of the nasal septum. For
simple nasal fractures, standard nasal radiographs (h) Damage to mucosa of the mouth and tongue due
should be sufficient. Radiological techniques should be to direct pressure on teeth internally and swelling of
used to confirm fractures and identify soft tissue injury. the tongue;

(d) Jaw, oropharynx and neck (i) Bleeding from mucosa where the intravenous
pressure has been raised – for example, from the
409. Mandibular fractures or dislocations may result nose and ears;
from beatings. Temporomandibular joint syndrome
is a frequent consequence of beatings, including (j) Additional non-specific features that may rarely
forceful slaps about the lower face and jaw. The be present include frank haemorrhage from orifices
alleged victim should be examined for evidence such as the nose and ear and spontaneous evacuation
of crepitation of the hyoid bone or laryngeal of faeces and urine. These may appear alone or in
cartilage resulting from blows to the neck. Findings combination.
concerning the oropharynx should be noted in
detail, including lesions consistent with burns from 411. It is essential in possible cases of neck compression
electric shock or other trauma. The maxillary labial or strangulation that all areas of the eyes, skin and
frenum may be torn. Gingival haemorrhage and mucosa (including inside the mouth, the eyelids, the
the condition of the gums should also be noted. palate and the uvula, and the skin of the scalp) above
the level of compression are examined with a good
410. Where strangulation by ligature or hand has light to identify any localized areas of petechiae. It is
been attempted, potential findings include: important to identify petechiae at an early stage as they
fade and disappear within 24 hours or so. In cases of
(a) No injury seen; manual strangulation or neck compression petechiae
may be florid and may coalesce to form larger bruises.
(b) Pain or tenderness – at site of application of There may also be difficulty breathing, ptosis or facial
force with no visible injury on swallowing or on nerve palsy. Late complications include aspiration
neck movement; pneumonia, pulmonary oedema and seizures. 420
In many cases in which an asphyxial mechanism is
(c) Reddening (erythema), which may resolve after a applied for only a short time, the findings may be
few hours; completely absent or minor. Such findings may also
be absent in severe compression for longer periods of
(d) Skin bruising, abrasions or swelling at the point of time. In general, the longer and the more powerful
compression – for example, at sites of finger/thumb/ the force applied, the more likely it is that visual
ligature application – this may appear early or later evidence of compressive force will be apparent. 421
and persist for days;
(e) Oral cavity and teeth
(e) Pinpoint bruising (petechiae) above the site of
compression; 412. Examination by a dentist should be considered
a component of periodic health examinations in
detention. This examination is often neglected,
but it is an important component of the physical

420 International Association of Forensic Nurses, Non-Fatal Strangulation Documentation Toolkit (Elkridge, 2016).
421 Jason Payne-James, “Asphyxia: clinical findings”, in Encyclopedia of Forensic and Legal Medicine, 2nd ed., Jason Payne-James and Roger Byard, eds. (Elsevier, 2015).

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