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A 25 yr old girl came to the opd along with his parents with the complaints of pain in the midline of neck and also at jaw and back of neck. On taking history parents reveals that she try to commit suicide one month back ( manual strangulation using shall as ligature material) but some how the saved her life. She is an anxious person and going through academic stress and taking( serta 25mg tablets daily) can you appreciate what will be the reason of her pain

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non-fatal strangulation delayed neck pain evaluation red flags guideline

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nonfatal strangulation AND neck injury

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https://www1.racgp.org.au/ajgp/2022/november/management-of-n…

Quick answer

Her pain could be due to soft-tissue and muscle injury after ligature strangulation, particularly strain/spasm of the anterior neck muscles, sternocleidomastoid, suprahyoid/infrahyoid muscles, and cervical paraspinal muscles. This can cause midline neck pain, posterior neck pain, and referred pain toward the jaw.
Other possibilities that must be considered before attributing it to anxiety include:
  • Laryngeal or hyoid injury: tenderness over the hyoid/larynx, pain on swallowing, voice change, or painful speech.
  • Cervical spine injury: persistent midline tenderness, reduced neck movement, neurological symptoms.
  • Carotid or vertebral vascular injury, including dissection: uncommon at one month, but important if there is severe/new headache, focal weakness/numbness, visual symptoms, dizziness, imbalance, speech difficulty, or transient loss of consciousness.
  • Temporomandibular/masticatory muscle pain from clenching, anxiety, or trauma. Sertraline can occasionally contribute to jaw clenching or bruxism, which may worsen jaw and neck pain.
  • Persistent stress-related muscle tension and somatic amplification. This is possible, but should be a diagnosis of exclusion in this context.
She requires an in-person assessment, ideally urgent ENT/emergency or trauma evaluation if she has any red flag symptom. Red flags include difficulty breathing or swallowing, hoarseness/voice change, neck swelling, stridor, bruising, severe headache, focal neurological signs, visual symptoms, fainting, or marked midline cervical tenderness. Guidance on non-fatal strangulation emphasizes assessment for airway, neurological, and vascular complications rather than assuming a benign injury (RACGP guidance).
At minimum, assess:
  • Full neck, laryngeal, jaw/TMJ and cervical spine examination
  • Voice and swallowing assessment
  • Neurological examination and carotid examination
  • Consider CT neck/cervical spine and CT angiography if concerning findings or neurological/vascular symptoms
  • ENT review/flexible laryngoscopy if dysphonia, odynophagia, dysphagia, or laryngeal tenderness
Most importantly, this was a suicide attempt one month ago. She needs same-day psychiatric risk assessment and a safety plan, with direct questioning about current suicidal thoughts, intent, plan, access to means, and supervision. If she currently has suicidal thoughts, intent, cannot be kept safe, or has escalating distress, take her to emergency services immediately and do not leave her alone.
Do not simply increase or stop sertraline based on jaw pain without the treating psychiatrist/physician reviewing her.Her pain may be related to the strangulation attempt, but it should not be attributed to anxiety alone without a focused examination.
Possible causes one month later include:
  • Soft-tissue and neck-muscle injury/strain from forceful traction and tightening of the ligature. This can cause midline anterior neck pain, posterior neck pain, and pain referred to the jaw.
  • Laryngeal, hyoid, or thyroid-cartilage injury, including a small fracture or bruising. These may produce focal midline tenderness, pain on swallowing, altered voice, or a throat-lump sensation. Attempted strangulation can cause laryngo-hyoid or laryngeal fractures. Cummings Otolaryngology Head and Neck Surgery, external laryngeal trauma section.
  • Cervical spine or facet/ligament strain, particularly if the neck was pulled, twisted, or held in extension, explaining posterior neck and jaw/occipital pain.
  • TMJ and masticatory muscle tension, from clenching during severe distress or persistent anxiety, which can cause jaw pain plus neck pain.
  • Less commonly but important: carotid/vertebral arterial injury or dissection, laryngeal edema/scarring, or neurologic sequelae. These are less likely after a month if she has been stable, but need consideration if symptoms or red flags are present.

She needs urgent emergency assessment today if she has any of the following

  • Difficulty breathing, noisy breathing, throat or neck swelling
  • Hoarseness, voice change, difficulty speaking
  • Pain/difficulty swallowing, choking, drooling, or aspiration
  • Severe or worsening headache, dizziness, fainting, confusion, seizures
  • Weakness, numbness, facial asymmetry, visual changes, imbalance
  • New severe unilateral neck pain, pulsatile neck mass, or carotid bruit
  • Marked midline neck tenderness, deformity, bruising, or fever
A non-fatal-strangulation assessment should include vitals; airway and voice examination; oral cavity/pharynx; palpation of the hyoid/larynx and cervical spine; cranial nerve and neurologic examination; and assessment for carotid injury. Depending on findings, she may require ENT evaluation with flexible laryngoscopy, CT neck/cervical spine, and, if vascular or neurologic features are present, CT angiography of the neck/head. Carotid Doppler alone is not considered adequate to exclude traumatic dissection. The RACGP clinical guidance specifically highlights voice change, neck tenderness/swelling, dysphagia, breathing difficulty, carotid signs, and focal neurologic deficits as warning features.

Psychiatric safety is equally urgent

Because this was a suicide attempt only one month ago and she remains anxious under academic stress, assess current suicidal thoughts, intent, plan, access to ligature/means, supervision, and family safety today. Do not rely only on sertraline 25 mg. She needs prompt review by her treating psychiatrist or mental-health professional for risk assessment, psychotherapy/support planning, and medication review. If she has current suicidal intent or cannot be kept safe, take her to the emergency department immediately or contact local emergency services.
So, the most likely explanation is musculoskeletal and soft-tissue injury with anxiety-related muscle tension, but midline neck and jaw pain after ligature strangulation warrants in-person ENT/emergency assessment to exclude laryngeal-hyoid, cervical, and vascular injury before labeling it psychogenic.
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