Oral Frostbite Injury Highlights Dangers of Recreational Nitrous Oxide Use

A case of oral frostbite injury in a 23-year-old man published in the New England Journal of Medicine highlighted the dangers of recreational use of nitrous oxide, also known as whippets or laughing gas.

The patient sought medical help after a 2-day period of painful swallowing and hoarseness following inhalation of nitrous oxide from a hand-held canister, noted authors Michael Patrizio, MD, and Meredith Hayden, MD, of the University of Virginia in Charlottesville.

An examination revealed redness, swelling, and damage to the mucosa on the soft palate, uvula, and posterior oropharynx, as well as a small area of ulceration and swelling on the right vocal fold. The patient was prescribed over-the-counter analgesics, viscous lidocaine, and topical triamcinolone paste.

“We saw [the patient] twice here in our clinic,” Patrizio told MedPage Today, “and then he was seen once in the ear, nose, and throat specialty clinic, and he never returned for follow-up in either of those locations.”

Nitrous oxide is stored in canisters as a liquid and is very cold upon being released. It is legal and easily accessible for purchase in small canisters sold online and in stores, and it now comes in flavored varieties. It is used as a propellant in aerosol cans such as those that store whipped cream, and it’s used as an anesthetic in dental and medical practices.

Nitrous oxide affects the same receptors that regulate mood, particularly anxiety, said Patrizio, as well as some opioid receptors. Other than pain-relieving and anxiety-lifting effects, the substance can “also lead to some of the psychogenic effects like hallucinations,” he explained.

According to Sawali Sudarshan, MD, an emergency physician and professor at the George Washington University School of Medicine in Washington, D.C., people in the 19th century turned to nitrous oxide for what they considered transcendental spiritual experiences. But now, she told MedPage Today, it’s become “an easily available way to dissociate from the stress that they’re having, and we’ve been seeing a lot of stress in society.”

Frostbite cases from nitrous oxide use, which can also cause scarring and blisters to legs and hands from burns caused by handling the canister, are still relatively rare, with around 100 cases seen nationwide in emergency departments each year, according to Sudarshan.

Data from the National Survey on Drug Use and Health showed that there were 12,640,000 nitrous oxide users in 2019, a number that rose to 12,891,000 in 2020, which is about a 2% increase. Sudarshan noted that use of drugs of all kinds further increased during the COVID-19 pandemic.

With recreational use of nitrous oxide on the rise, the FDA issued an alert advising consumers not to inhale such products.

Long-term effects from nitrous oxide use include vitamin B12 deficiency, which can cause neurological symptoms such as confusion, dissociation, numbness and tingling, and gait imbalance.

Even though some states have banned recreational use of nitrous oxide, Patrizio said more public health efforts need to be made to “limit the accessibility of this product, similar to the way that Juul and vape pens have been regulated in recent years.”