European Radiology

, Volume 26, Issue 4, pp 1186–1190 | Cite as

Distinction between saltwater drowning and freshwater drowning by assessment of sinus fluid on post-mortem computed tomography

  • Yusuke KawasumiEmail author
  • Akihito Usui
  • Yuki Sato
  • Yumi Sato
  • Nami Daigaku
  • Yoshiyuki Hosokai
  • Yoshie Hayashizaki
  • Masato Funayama
  • Tadashi Ishibashi
Forensic Medicine



To evaluate the difference in sinus fluid volume and density between saltwater and freshwater drowning and diagnose saltwater drowning in distinction from freshwater drowning.


Ninety-three drowning cases (22 saltwater and 71 freshwater) were retrospectively investigated; all had undergone post-mortem CT and forensic autopsy. Sinus fluid volume and density were calculated using a 3D-DICOM workstation, and differences were evaluated. Diagnostic performance of these indicators for saltwater drowning was evaluated using a cut-off value calculated by receiver operating characteristic (ROC) analysis.


The median sinus fluid volume was 5.68 mL in cases of saltwater drowning (range 0.08 to 37.55) and 5.46 mL in cases of freshwater drowning (0.02 to 27.68), and the average densities were 47.28 (14.26 to 75.98) HU and 32.56 (−14.38 to 77.43) HU, respectively. While sinus volume did not differ significantly (p = 0.6000), sinus density was significantly higher in saltwater than freshwater drowning cases (p = 0.0002). ROC analysis for diagnosis of saltwater drowning determined the cut-off value as 37.77 HU, with a sensitivity of 77 %, specificity of 72 %, PPV of 46 % and NPV of 91 %.


The average density of sinus fluid in cases of saltwater drowning was significantly higher than in freshwater drowning cases; there was no significant difference in the sinus fluid volume.

Key points

Sinus fluid density of saltwater drowning is significantly higher than freshwater drowning.

Cut-off value was 37.77 HU based on the ROC analysis.

The cut-off value translated to 91 % NPV for diagnosis of saltwater drowning.


Drowning Freshwater Saltwater Paranasal sinuses Computed tomography 



Computed tomography


Multi-detector computed tomography


Digital imaging and communication in medicine


Receiver operating characteristic


Positive predictive value


Negative predictive value



The scientific guarantor of this publication is Prof. Tadashi Ishibashi. The authors of this manuscript declare no relationships with any companies, whose products or services may be related to the subject matter of the article. The authors state that this work has not received any funding. No complex statistical methods were necessary for this paper. Institutional Review Board approval was obtained. Written informed consent was obtained from all subjects (patients) in this study. Methodology: Retrospective, diagnostic or prognostic study, performed at one institution.


  1. 1.
    Dolinak D, Matshes E, Lew E (eds) (2005) Forensic pathology principles and practice. Elsevier, AmsterdamGoogle Scholar
  2. 2.
    Tsokos M (ed) (2005) Forensic pathology reviews volume 3. Humana Press, New YorkGoogle Scholar
  3. 3.
    Saukko P, Knight B (eds) (2004) Knight’s forensic pathology, 3rd edn. Edward Arnold, LondonGoogle Scholar
  4. 4.
    Pollanen MS, Cheung C, Chiasson DA (1997) The diagnostic value of the diatom test for drowning, I. utility: a retrospective analysis of 771 cases of drowning in Ontario, Canada. J Forensic Sci 42:281–285PubMedGoogle Scholar
  5. 5.
    An JL, Ishida Y, Kimura A, Kondo T (2010) Forensic application of intrarenal aquaporin-2 expression for differential diagnosis between freshwater and saltwater drowning. Int J Legal Med 124(2):99–104CrossRefPubMedGoogle Scholar
  6. 6.
    An JL, Ishida Y, Kimura A, Kondo T (2011) Immunohistochemical examination of intracerebral aquaporin-4 expression and its application for differential diagnosis between freshwater and saltwater drowning. Int J Legal Med 125(1):59–65CrossRefPubMedGoogle Scholar
  7. 7.
    Cala AD, Vilain R, Tse R (2013) Elevated postmortem vitreous sodium and chloride levels distinguish saltwater drowning (SWD) deaths from immersion deaths not related to drowning but recovered from saltwater (DNRD). Am J Forensic Med Pathol 34(2):133–138CrossRefPubMedGoogle Scholar
  8. 8.
    Thali MJ, Braun M, Buck U et al (2005) VIRTOPSY-scientific documentation, reconstruction and animation in forensic: individual and real 3D data based geo-metric approach including optical body/object surface and radiological CT/MRI scanning. J Forensic Sci 50:428–442CrossRefPubMedGoogle Scholar
  9. 9.
    Dirnhofer R, Fackowski C, Vock P, Potter K, Thali MJ (2006) VIRTOPSY: minimally invasive, imaging-guided virtual autopsy. Radiographics 26:1305–1333CrossRefPubMedGoogle Scholar
  10. 10.
    Bolliger SA, Thali MJ, Ross S, Buck U, Naether S, Vock P (2008) Virtual autopsy using imaging: bridging radiologic and forensic sciences. a review of the virtopsy and similar projects. Eur Radiol 18:273–282CrossRefPubMedGoogle Scholar
  11. 11.
    Le Blanc-Louvry I, Thureau S, Duval C et al (2013) Post-mortem computed tomography compared to forensic autopsy findings: a French experience. Eur Radiol 23(7):1829–1835CrossRefPubMedGoogle Scholar
  12. 12.
    Christe A, Aghayev E, Jackowski C, Thali MJ, Vock P (2008) Drowning—post-mortem imaging findings by computed tomography. Eur Radiol 18:283–290CrossRefPubMedGoogle Scholar
  13. 13.
    Levy AD, Harcke HT, Getz JM et al (2007) Virtual autopsy: two- and three-dimensional multidetector CT findings in drowning with autopsy comparison. Radiology 243(3):862–868CrossRefPubMedGoogle Scholar
  14. 14.
    Lo Re G, Vernuccio F, Galfano MC et al (2015) Role of virtopsy in the post-mortem diagnosis of drowning. Radiol Med 120(3):304–308CrossRefPubMedGoogle Scholar
  15. 15.
    Ambrosetti MC, Barbiani C, El-Dalati G et al (2013) Virtual autopsy using multislice computed tomography in forensic medical diagnosis of drowning. Radiol Med 118:679–687CrossRefPubMedGoogle Scholar
  16. 16.
    Kawasumi Y, Kawabata T, Sugai Y et al (2013) Diagnosis of drowning using post-mortem computed tomography based on the volume and density of fluid accumulation in the maxillary and sphenoid sinuses. Eur J Radiol 82(10):e562–e566CrossRefPubMedGoogle Scholar
  17. 17.
    Byard RW, Cains G, Tsokos M (2006) Haemolytic staining of the intima of the aortic root-- a useful pathological marker of freshwater drowning? J Clin Forensic Med 13(3):125–128CrossRefPubMedGoogle Scholar
  18. 18.
    Azparren JE, Cubero C, Perucha E, Martinez P, Vallejo G (2007) Comparison between lung weight and blood strontium in bodies found in seawater. Forensic Sci Int 168(2–3):128–132CrossRefPubMedGoogle Scholar
  19. 19.
    Lucci A, Campobasso CP, Cirnelli A, Lorenzini G (2008) A promising microbiological test for the diagnosis of drowning. Forensic Sci Int 182(1–3):20–26CrossRefPubMedGoogle Scholar
  20. 20.
    Maeda H, Zhu BL, Ishikawa T et al (2009) Analysis of postmortem biochemical findings with regard to the lung weight in drowning. Leg Med 11(Suppl 1):S269–S272CrossRefGoogle Scholar
  21. 21.
    Kawasumi Y, Kawabata T, Sugai Y et al (2012) Assessment of the relationship between drowning and fluid accumulation in the paranasal sinuses on post-mortem computed tomography. Eur J Radiol 81(12):3953–3955CrossRefPubMedGoogle Scholar
  22. 22.
    Usumoto Y, Sameshima N, Hikiji W et al (2009) Electrolyte analysis of pleural effusion as an indicator of drowning in seawater and freshwater. J Forensic Leg Med 16:321–324CrossRefPubMedGoogle Scholar

Copyright information

© European Society of Radiology 2015

Authors and Affiliations

  • Yusuke Kawasumi
    • 1
    Email author
  • Akihito Usui
    • 2
  • Yuki Sato
    • 1
  • Yumi Sato
    • 1
  • Nami Daigaku
    • 2
  • Yoshiyuki Hosokai
    • 2
  • Yoshie Hayashizaki
    • 3
  • Masato Funayama
    • 3
  • Tadashi Ishibashi
    • 1
  1. 1.Department of Clinical ImagingTohoku University Graduate School of MedicineSendaiJapan
  2. 2.Department of Diagnostic Image AnalysisTohoku University Graduate School of MedicineSendaiJapan
  3. 3.Department of Forensic MedicineTohoku University Graduate School of MedicineSendaiJapan

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