Laryngeal oedema caused by accidental ingestion of Oil of Wintergreen

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Abstract

Oil of Wintergreen (methyl salicylate) is a common ingredient for liniments, ointments and essential oils used in self-treatment of musculoskeletal pain. Its pleasant smell also encourages its use to flavour confectionery. The toxic potential of this preparation is not always fully appreciated by the general public and physicians. To appreciate the danger of this oil it can be compared to aspirin tablets (325 mg dose): one teaspoon (5 ml) of Oil of Wintergreen is equivalent to approximately 7000 mg of salicylate or 21.7 adult aspirin tablets. Ingestion of as little as 4 ml in a child can be fatal. Prevention of accidental ingestion of methyl salicylate containing products can be achieved by keeping the products out of reach of children, using child resistant bottles, restricting the size of the openings of the bottles, appropriate labeling on products and reducing the salicylate content. Immediate action should be taken to treat a patient with accidental poisoning and hospitalisation is needed for monitoring and treatment. The danger of this product should be fully appreciated by both physicians and the general public. We present a case of Oil of Wintergreen poisoning with development of laryngeal oedema as a complication, general information and management issues will also be discussed.

Introduction

Childhood poisonings are usually associated with the accidental ingestion of household products or prescribed medication that has serious effects when taken by an infant or child [1].

Methyl salicylate (Oil of Wintergreen) is widely available over the counter as a topical ointment or medicated oil for the relief of musculoskeletal aches and pains (Fig. 1). Oil of Wintergreen is also used to flavour confectionery [2].

Salicylate poisoning due to Oil of Wintergreen ingestion is rare. The earliest cases on record are found in the 1832 edition of Beck's Elements of Medical Jurisprudence [3]. The ingestion of 30 ml can be a lethal dose and even as little as 6 ml has been fatal in adults. As little as 4 ml in a child may be a fatal dose [2].

Oil of Wintergreen's concentrated form, liquid consistency and high lipid solubility pose the threat of severe, rapid-onset salicylate poisoning. The toxic potential of topical medications containing methylsalicylate should be fully appreciated by both physicians and the general public.

Section snippets

Case report

An 18 month old girl presented to the accident and emergency department of her local hospital approximately 12 h following accidental ingestion of Oil of Wintergreen. Initially she had been well, but started vomiting a few hours post ingestion. She was irritable, lethargic and tachypnoeic on examination.

The salicylate level on admission was 4.8 mmol/l. Initial blood gas analysis showed a pH of 7.34, PaCO2 of 2.5, O2 of 12 and base deficit of −12.7. Blood chemistry was normal. After advice had

Discussion

Methyl salicylate or Oil of Wintergreen is an important cause of salicylate poisoning in many western countries and has an appreciable morbidity and mortality [4]. This is largely due to the ready availability of a wide range of topical preparations eg. ‘Extra strength arthritis rub’ and medicated oils eg. ‘Hung far oil’ used for self-treatment of musculoskeletal pain and the common cold, respectively [5]. The pleasant smell of Oil of Wintergreen makes it very attractive to children [2].

Conclusion

Methyl salicylate (Oil of Wintergreen) is widely available over the counter as a topical ointment or medicated oil for the relief of musculoskeletal aches and pains. Oil of Wintergreen is also used as a flavourant in confectionery making. Ingestion of as little as 4 ml could be fatal to a child and this should be fully appreciated by both physicians and the general public.

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Presented at British Association of Paediatric Otolaryngologists, Southampton, UK, October 2000.

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