E-Cigarette Safety? A Case of Combustion Causing Severe Intraoral

Trauma Joseph R. Jacob, MD1; Richard H. Wiggins, MD2; Loren G. Longenecker, MD2; Richard K. Gurgel, MD1

1University of Utah, Division of Otolaryngology; 2University of Utah, Department of Radiology

INTRODUCTION

Electronic nicotine delivery system (ENDS) also known as

electronic cigarettes (or e-cigarettes), have recently become popularized

despite a lack of research on their safety.(1) E-cigarettes are so-called

because of their physical resemblance to the standard tobacco cigarette

and their electronic vapor generating mechanism. In 2004, Ruyan, a

Beijing-based company patented and launched the first of these

devices.(2) Many other manufactures have since made similar devices.

All of these devices contain a mouthpiece, a micro-electrical circuit, a

vaporizer, and a rechargeable lithium ion battery. A solution containing

nicotine is contained in replaceable cartridges or used to fill a reservoir

in some models. When the user draws air through the e-cigarette the

micro-electrical circuit activates an electrical coil to heat and vaporize a

small amount of the nicotine solution, creating a visible cloud of mist

that the user inhales.(3) A case was reported in the lay press of a 57 year

old man whose e-cigarette exploded in his mouth, knocking out his front

teeth and injuring his tongue and soft palate.(4) The exact cause of the

explosion is still unclear, but may have been caused by explosion from

the lithium battery power source.(5) In this report, we describe an

additional case of an e-cigarette exploding, causing significant oral

trauma, leading to an emergent tracheotomy and prolonged

hospitalization.

Daily wound care and bacitracin twice daily was provided for

partial thickness burns to the nose, nares, mouth and cheeks with no

operative management. Patient tolerated tracheostomy capping and was

decannulated six days after the tracheotomy was placed. The following

day the patient was discharged home at baseline oxygen requirements.

CONCLUSIONS

While rare, serious injury can occur from exploding e-cigarettes,

causing significant oral-facial trauma. As we understand the risks of these

devices, we will be better prepared to handle these difficult cases.

REFERENCES •U.S. Food and Drug Administration (2013, April 25). News and Events: Electronic Cigarettes (e-Cigarettes). Retrieved from

http://www.fda.gov/newsevents/publichealthfocus/ucm172906.htm

•Bullen C, Williman J, et al. Study protocol for a randomized controlled trial of electronic cigarettes versus nicotine patch for smoking cessation. BMC Public Health

2013, 13:210

•Trtchounian A, Talbot P. Electronic nicotine delivery system: is there a need for regulation? Tob Control 2011, 20:47-52

•CBS News (2012, February 16). Electronic cigarette explodes in man’s mouth, causes serious injuries. Retrieved from http://www.cbsnews.com/8301-504763_162-

57379260-10391704/electronic-cigarette-explodes-in-mans-mouth-causes-serious-injuries/

•CSP Daily News (2012, February 20). UPDATE: Was Exploding E-Cigarette a “Mod”? Retrieved from http://www.cspnet.com/news/tobacco/articles/update-was-

exploding-e-cigarette-mod

•Regan AK, Promoff G, et al. Electronic nicotine delivery system: adult use and awareness of the “e-cigarette” in the USA. Tob Control 2011, 050044 Published Online

First: 27 October 2011

CASE REPORT

A 50 year old male with history of hypertension and COPD on

home oxygen, was brought to the emergency room after his electronic

cigarette exploded in his face. At the time of the explosion he and his

wife were swapping out flavored nicotine liquids. He was not using his

oxygen at the time. He was using a Prodigy V3 e-cigarette from Pure

Smoker which has 2 lithium batteries stacked on top of each other. The

device was reportedly being used as directed without modification.

After the explosion, the patient was coughing up carbonaceous

sputum as well as blood. A trauma I was called and initial assessment by

trauma team was pertinent for second degree burns to face, fractured

maxillary number 7 and 8 teeth, oral mucosa ulcerations and burns,

edematous palate and erythematous conjunctiva. The patient was then

sent to CT scanner for facial bones CT. CT showed a large soft palate

hematoma containing tooth shrapnel, soft tissue emphysema, and

narrowing of the oropharyngeal airway. (Fig 1)

Upon ENT evaluation, the patient was in respiratory distress with

active bleeding from the mouth precluding evaluation of the palate.

Patient was emergently taken to the OR for fiberoptic intubation and

exam under anesthesia. There was active arterial hemorrhaging from a

soft palate laceration approximately 3cm in size. (Figure 2 and 3)

Laryngoscopy then revealed normal larynx, epiglottis, AE folds, vocal

cords and subglottis. Fractured tooth 7 was extracted. Due to

oropharyngeal edema, a tracheostomy was performed and the patient

was then transferred to the SICU.

DISCUSSION

A government survey concluded that in 2010 2.7% of American

adults had tried vapor smoking.(6) There are approximately 2.5 million

people currently using electronic cigarettes and the number is estimated

to continue growing despite a lack of research on their safety.(4) The

FDA has reported that the safety of e-cigarettes has not been fully

studied.(1) There is a paucity of case reports of other similar injuries in

the medical literature. Although the investigation is still not concluded

in the first event, it does not appear that the incident involved an off-the-

shelf e-cigarette device but rather a custom made modified e-cigarette

that used stacked batteries. These devices are put together by the

consumer and usually are modified to produce a heavy nicotine burst

typically achieved by using lithium batteries lager that those found in

off-the-shelf products. Stacking batteries is a common practice and is

felt to be a risk for battery malfunction. Cheap, unprotected lithium ion

batteries also have the possibility of overcharging and have been known

to explode. An electrical fire inside the device may produce a buildup of

hydrogen gas resulting in an explosion.(5) The manufacturer, V2 Cigs,

have reported that every action against possible electronic issues has

been taken for non-modified off-the shelf devices. There have been

safeguards integrated into the batteries such as automatic shutoff and

smart chargers that prevent overcharging.

In our current case the device was reported to be an off-the-shelf

device without modification but the batteries being used were

aftermarket batteries. No formal investigation has been performed to

delineate an exact cause of the explosion.

Figure 1: Sagittal CT showing large soft palate hematoma containing tooth

shrapnel, soft tissue emphysema, and narrowing of the oropharyngeal airway

Figure 2: Soft palate laceration

Figure 3: Magnified view of soft palate laceration