First-Bite Syndrome: A Rare Complication of Carotid Endarterectomy

Abstract

This report describes the rare complication of first-bite syndrome (FBS) after carotid endarterectomy (CEA). Although FBS is well known in otolaryngologic literature, it is rarely discussed in relation to vascular surgery. FBS is most commonly a postoperative pain syndrome that is thought to be the result of selective parotid gland sympathetic denervation. The resultant facial pain is centered around the parotid region and triggered by initiation of mastication. The pain is severe, but short in duration, and quite specific in pattern.We present a case of FBS after CEA with complex anatomy. The patient developed typical symptoms of ipsilateral parotid, mandibular pain during the postoperative course. Workup excluded other diagnoses. The symptoms were self-limiting but did not resolve completely. Vascular surgeons, who are universally aware of the presentation of Horner's syndrome, should also be aware of this rare complication with similar pathophysiology.

First Bite Syndrome after Carotid Endarterectomy for High Carotid Bifurcation and Extensive Lesions: Two Case Reports and Literature Review

“…Table 1 shows a summary of the present cases and eight previous cases of FBS following CEA. [4][5][6][7][8][9][10][11] Of the 10 reported cases, including our cases, 7 showed a high carotid bifurcation or high cervical lesions as the anatomical difficulty in CEA. During CEA, cross-clamping of the ECA is often placed between the superior thyroid artery and the lingual artery.…”

“…3) To date, only eight case reports on first bite syndrome (FBS) related to CEA have been published, and the pathogenic mechanism of FBS secondary to CEA is currently poorly understood because of its rarity. [4][5][6][7][8][9][10][11] FBS is an interesting condition that is rarely observed after upper cervical surgery. In FBS, a brief and sharp pain develops in the parotid region after the first bite of each meal and improves with each bite.…”

Severe blood pressure elevation following ephedrine administration during carotid endarterectomy under general anesthesia: A CARE-compliant case report

“…Possible complications caused by sympathetic nerve injury during neck surgery include postoperative Horner syndrome [14] and first-bite syndrome [15] ; however, the present case exhibited no symptoms of these conditions. Hence, we believe that there was an ischemic event in the cervical sympathetic trunk during the surgical procedure that drastically reduced sympathetic postganglionic signaling to the heart, but the ischemia did not cause postoperative neuronal palsy sequelae.…”