First Bite Syndrome: Presentation of a Patient Status-Post Right Carotid Endarterectomy

Abstract

First bite syndrome (FBS) is a sharp unilateral pain in the vicinity of the angle of the mandible after taking the first bite of a meal that presents typically after surgery in the area of the ipsilateral parapharyngeal space. It is not confirmed what the pathophysiology is that causes this pain, but the proposed mechanism is the iatrogenic damage of sympathetic fibers that extend from the superior cervical ganglion (SCG) to innervate the parotid gland. The presentation of this syndrome has been acknowledged in patients who have undergone head and neck tumor resections, but it has not been documented in the same thorough manner among vascular surgery cases in the parapharyngeal space, possibly because of a higher risk of development in other head and neck surgeries, or to under-reporting of cases. To date, only 5 cases of FBS status post carotid endarterectomy have been documented in the literature. Definitive treatment of FBS has not been established. Some studies have shown improvement with amitriptyline, and carbamazepine as well as botulinum toxin injections. We will present the case of a 75 year old male who developed first bite syndrome after a right carotid endarterectomy with efforts of raising awareness of a potential acute complication of carotid endarterectomy.

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.…”

Botulinum toxin A for the treatment of first bite syndrome—a systematic review

“…This systematic review examines the potential of BTA to treat FBS resulting as a surgical complication. As previously discussed, while some patients develop resolution of symptoms within 1-18 months (5,10,(19)(20)(21)(22)(23)27,52,53), up to 88% of patients continue to experience symptoms (2,5,19,24,(53)(54)(55). Botulinum toxin has had multiple applications in otolaryngology, including dystonia of the larynx (56), laryngeal granulomas (57), laryngeal joint dislocation (58), cricopharyngeal spasm (57), posterior glottic synechiae (59), blepharospasm (60), hemifacial spasm (60), temporomandibular joint disorders (61), and oromandibular dystonia (60).…”