Death due to choking caused by swallowing Sushi Rolls

The term Setsubun originally referred to the four days marking the change from one season to the other, but today only the first day of spring according to the lunar calendar is referred to by that time. Setsubun falls on February 3. On Setsubun evening, many households enjoy a bean-throwing ceremony.

Setsubun properly refers to the day before the coming of any of the four seasons. So, this is actually spring Setsubun. Setsubun dinner is simple, sushi rolls. The proper way to eat this dinner is to face a certain direction, and eat the entire sushi roll without stopping. We experienced an autopsy case of a death due to swallowing down sushi rolls. The deceased was a 54-year-old man who was found dead in the restroom. An autopsy revealed congestive changes of organs. We report here an autopsy case.

Introduction

The term Setsubun originally referred to the four days marking the change from one season to the other, but today only the first day of spring according to the lunar calendar is referred to by that time. Setsubun falls on February 3. On Setsubun evening, many households enjoy a bean-throwing ceremony.

People fill a wooden measure with roasted soybeans and throw them in and around their houses. This ceremony is performed to bring in good fortune and drive away evil spirits. It is customary for people to pick up and eat the same number of beans as their own age. Tradition states that you have to eat the sushi roll uncut, in one continuous go as cutting will shorten your luck.

Eating the whole long roll will bring you long-lasting, continuous luck! You must also eat the sushi roll in the lucky direction of the year. For 2016, the lucky direction is South-South-East.

The initiation of swallowing has been thought to depend on separate thresholds for food particle size and for particle lubrication [1]. The moment of swallowing, defined here as the number of chewing cycles until swallowing, will depend on the volume of the food and on the characteristics of the food, like water, fat percentage and hardness [2-5].

The moment of swallowing has been shown to be rather constant within a subject for one type of food, whereas large variations in the number of chewing cycles until swallowing were observed between subjects [4,6,7]. Hard and dry products require more chewing cycles and longer time in the mouth until swallowing for sufficient breakdown to take place and for enough saliva to be added to form a coherent bolus safe for swallowing [8].

Case Report

A 54 years old man was found lying with vomit in the restroom. He was cardiopulmonary arrest on arrival to the emergency department. A forensic autopsy was performed about 12h after his death. The deceased was 161cm tall and weighed 72.0kg. Postmortem rigidity was present at the jaw and upper limbs. Moderately purplish-red post-mortem hypostasis was evident on the dorsal aspect of his body and severe congestion was seen in his face and neck (Figure 1). The heart weighed 380g and contained large amounts of dark-red liquid blood in the heart. The left and right lungs weighed 510g and 610g respectively. Both lungs were edematous (Figure 2). A bolus of food consisting of rice, seaweed and vegetables was plugged in the laryngeal orifice and similar food contents were present in the esophagus (Figures 3,4). Almost all organs were congestive. We verified his death attributed to swallowing down sushi rolls.

Figure 1: Strongly congestion was showed in his face and neck.

Figure 2: Both lungs were edematous.

Figure 3: A lot of rice, seaweed and vegetables were contained. (Pharyngolarynx).

Figure 4: A lot of rice, seaweed and vegetables were contained. (Esophagus).

Discussion

Among accidental deaths in Japan, choking ranks as the number one cause with more than 4000 cases a year [9]. Approximately, half of the elderly population experience reduced activities of daily living (ADL) and/or swallowing function, and approximately one-fifth have some type of disorder that affects daily living [10]. When a liquid is swallowed all at once, a bolus is formed in the oral cavity, and a swallowing reflex is triggered before the bolus reaches the pharynx. However, when eating solids, the bolus mixes with saliva during chewing and is actively delivered to the oropharynx by the tongue, followed by swallowing [11-14]. Since the main cause of aspiration is a delayed swallowing reflex, triggering the swallowing reflex early may present a method to prevent aspiration and choking [15]. On February 3rd, people in Japan celebrate Setsubun, the coming of spring. Special sushi rolls are eaten while facing the auspicious direction for that year. After dinner, roasted soy beans are thrown out the front door of the house to cast out demons, disease and bad fortune, and welcome spring and a new year of good fortune. Basically, fortune rolls are just big fat sushi rolls eaten at this special time of year. They are a combination of special ingredients, put in rice, wrapped in seaweed. Fortune rolls are usually fatter than standard rolled sushi. Mochi is a traditional Japanese food and an important festive feature during the New Year’s holiday. Choking due to Mochi were reported especially among the elderly [16,17]. We showed a first choking case accompanied with the Japanese traditional event, Setsubun.

We thank the Shiga University of Medical Science and Osaka Medical Examiner Office for supporting to publish this case report.

1. Hutchings JB, Lillford PJ (1988) The perception of food texture-the philosophy of the breakdown path. J Texture Studies 19: 103-115. Link: https://goo.gl/f3H84L
2. Lucas PW, Luke DA (1984) Optimum mouthful for food comminution in human mastication. Arch Oral Biol 29: 205-210. Link: https://goo.gl/QTJvxC
3. Gaviao MB, Engelen L, van der Bilt A (2004) Chewing behavior and salivary secretion. Eur J Oral Sci 112: 19-24. Link: https://goo.gl/Cu3oNC
4. Fontijn-Tekamp FA, Slagter MP, van der Bilt A, Van’t Hof MA, Kalk W, et al. (2004) Swallowing thresholds of mandibular implant-retained overdentures with variable portion sized. Clin Oral Impl Res 15: 375-380. Link: https://goo.gl/QBFeQE
5. Anderson DJ, Hector MP, Linden RWA (1985) The possible relation between mastication and parotid secretion in the rabbit. J Physiol 364: 19-29. Link: https://goo.gl/pN4x5D
6. Lucas PW, Luke DA (1986) Is food particle size a criterion for the initiation of swallowing? J Oral Rehabil 13: 127-136. Link: https://goo.gl/Bs6cVo
7. Van der Bilt A, Olthoff LW, Bosman F, Oosterhaven SP (1993) The effect of missing postcanine teeth on chewing performance in man. Arch Oral Biol 38: 423-429. Link: https://goo.gl/u7jjZx
8. Lina Engelen, Anneke Fontijn-Tekamp, Andries van der Bilt (2005) The influence of product and oral characteristics on swallowing. Archives of Oral Biology 50: 739-746. Link: https://goo.gl/fqHcs8
9. (2011) Ministry of Health, Labour and Welfare: Inhalation and ingestion of other objects causing obstruction of respiratory tract. In Ministry of Health, Labour and Welfare, Vital statistics of Japan; 2011.
10. Cabinet Office (2008) Situation of ageing. In Cabinet Office, Annual Report on the Aging Society; 2008. Japanese.
11. Palmer JB (1998) Bolus aggregation in the oropharynx does not depend on gravity. Arch. Phys. Med. Rehabil.1998; 79: 691-6. Link: https://goo.gl/eNRQCQ  
12. Palmer JB (2000) Mechanism of food transport during mastication and swallowing. JJDR 2000; 4: 3-9.
13. Matsuo K, Saitoh E, Takeda S, Baba M, Fujii W, et al. (2002) Effects of gravity and chewing on bolus position at swallow onset. JJDR2002; 6: 65-72.
14. Takeda S, Saitoh E, Matsuo K, Baba M, Fujii W, et al. (2002) Influence of Chewing on Food Transport and Swallowing. Jpn J Rehabil Med 39: 322-330. Link: https://goo.gl/ykMqb8
15. Dua KS, Ren J (1997) Coordination of deglutitive glottal function and pharyngeal bolus transit during normal eating. Gastroenterology 1997; 112: 73-83. Link: https://goo.gl/oXxhX1
16. Sanpei R, Tohara H, Fujita S, Yanagimachi M (2014) Video-endoscopic comparison of swallowing waxy rice mochi and waxy wheat mocha: improvement of a traditional Japanese food that presents a choking hazard. Bioscience, Biotechnology, and Biochemistry 2014; 78: 472-7. Link: https://goo.gl/CkqWVz
17. Mukai M (2008) Food-choking accidents. In Ministry of Health, Labour and Welfare, Report on the Current Prevalence Patterns and Causes of Food-Choking Accidents; 2008.