First bite syndrome: Case report of 3 patients treated with botulinum toxin and review of other treatment modalities

Guidelines for the Use of Botulinum Toxin in Otolaryngology From the Korean Society of Laryngology, Phoniatrics and Logopedics Guideline Task Force

The Korean Society of Laryngology, Phoniatrics and Logopedics created a task force to establish clinical practice guidelines for the use of botulinum toxin (BT) in otolaryngology. We selected 10 disease categories: spasmodic dysphonia, essential vocal tremor, vocal fold granuloma, bilateral vocal fold paralysis, Frey's syndrome, sialocele, sialorrhea, cricopharyngeal dysfunction, chronic sialadenitis, and first bite syndrome. To retrieve all relevant papers, we searched the CORE databases with predefined search strategies, including Medline (PubMed), Embase, the Cochrane Library, and KoreaMed. The committee reported 13 final recommendations with detailed evidence profiles. The guidelines are primarily aimed at all clinicians applying BT to the head and neck area. In addition, the guidelines aim to promote an improved understanding of the safe and effective use of BT by policymakers and counselors, as well as in patients scheduled to receive BT injections.

State of Rehabilitation Research in the Head and Neck Cancer Population: Functional Impact vs. Impairment-Focused Outcomes

PURPOSE OF REVIEW

Management of head and neck cancer (HNC) typically involves a morbid combination of surgery, radiation, and systemic therapy. As the number of HNC survivors grows, there is growing interest in rehabilitation strategies to manage HNC-related comorbidity. In this review, we summarize the current state of HNC rehabilitation research.

RECENT FINDINGS

We have organized our review using the World Health Organization's International Classification of Function (ICF) model of impairment, activity, and participation. Specifically, we describe the current research on rehabilitation strategies to prevent and treat impairments including dysphagia, xerostomia, dysgeusia, dysosmia, odynophagia, trismus, first bite syndrome, dysarthria, dysphonia, lymphedema, shoulder syndrome, cervicalgia, cervical dystonia and dropped head syndrome, deconditioning, and fatigue. We also discuss the broader impact of HNC-related impairment by exploring the state of rehabilitation literature on activity, participation, psychosocial distress, and suicidality in HNC survivors. We demonstrate that research in HNC rehabilitation continues to focus primarily on impairment-driven interventions. There remains a dearth of HNC rehabilitation studies directly examining the impact of rehabilitation interventions on outcomes related to activity and participation. More high-quality interventional studies and reviews are needed to guide prevention and treatment of functional loss in HNC survivors.

First Bite Syndrome: What Neurologists Need to Know

PURPOSE OF REVIEW

Though first bite syndrome is well known in surgical settings, it is not commonly included in the differential for sharp paroxysmal facial pain in the neurology literature. This paper will highlight the clinical features and relevant anatomy of first bite syndrome, with the goal of helping clinicians differentiate this from other similar facial pain disorders.

RECENT FINDINGS

First bite syndrome is severe sharp or cramping pain in the parotid region occurring with the first bite of each meal and improving with subsequent bites. Pathophysiology has been attributed to imbalanced sympathetic/parasympathetic innervation of the parotid gland. This is seen most typically in the post-surgical setting following surgery in the parotid or parapharyngeal region, but neoplastic etiologies have also been reported. It is common for patients to present with concurrent great auricular neuropathy and/or Horner's syndrome. Evidence regarding treatment is limited to case reports/series, however, botulinum toxin injections and neuropathic medicines have been helpful in select cases. It is critical for clinicians to be able to differentiate first bite syndrome from other paroxysmal facial pain. To help with this, we have proposed diagnostic criteria for clinical assessment. Patients often improve gradually over time, but symptomatic treatment with botulinum toxin or neuropathic medicine may be required.

First bite syndrome after parotidectomy: a single-centre experience

The aim of this study was to investigate the prevalence of first bite syndrome (FBS) among post-parotidectomy patients and to analyse the risk factors for its occurrence. The study involved 111 adult patients operated for benign parotid tumours. After surgery, the participants were asked to assess the presence of food-related pain and the nature of the pain. Participants also answered questions on complications after parotidectomy. FBS was found in seven patients (6.3%). Sex (P=0.036) and age (P=0.002) differed significantly between patients with and without FBS. Female patients were found to be at higher risk of FBS, and the lower the patient's age, the more likely FBS was to occur after surgery. Tumour location (P=0.002) and the occurrence of disturbing symptoms before surgery (P=0.009) had a statistically significant effect on the occurrence of FBS. A tendency towards significance for paresis of cranial nerve VII after surgery (P=0.051) was found; this complication was more frequent in the FBS patients. FBS is a rare pain syndrome that can occur after parotidectomy and should be distinguished from postoperative pain. Proper diagnosis and implementation of the appropriate treatment can significantly improve patient quality of life.

Clinical and Pain-Related Characteristics of Idiopathic First Bite Syndrome Induced by Taste in Japanese Patients without Diabetes: A Retrospective Study of Five Cases

Objective

First bite syndrome (FBS) is a condition in which the first bite of each meal causes parotid pain. Etiologies of FBS include prior surgery of the upper cervical region and, rarely, head and neck tumors. Idiopathic FBS rarely presents in patients without a history of surgery or evidence of an underlying tumor. Idiopathic FBS may be categorized into two subtypes: that in patients with diabetes and that in patients without diabetes. Idiopathic FBS in patients without diabetes may be overlooked or misdiagnosed because the condition has been described only in a few case reports. We aimed to identify the clinical and pain-related characteristics of idiopathic FBS in patients without diabetes.

Methods

We retrospectively analyzed the clinical data of five patients without diabetes who were diagnosed with idiopathic FBS in our department between January 2010 and December 2016.

Results

Four of the five patients were female, and the overall median age was 52 years (range: 13–61). All patients immediately experienced parotid pain upon tasting food without chewing. Addition of an acidic solution to the ipsilateral posterior third of the tongue evoked parotid pain. The median degree of pain intensity and interference with eating due to pain was 9 (range: 3–10) and 9 (range: 5–10) on a numerical rating scale of 0–10, respectively. Idiopathic FBS was bilateral in two patients. Two patients had tenderness on mild pressure over the affected parotid region. Two patients presented with ipsilateral idiopathic Horner's syndrome.

Conclusions

Our findings indicate that the characteristics of idiopathic FBS in patients without diabetes are largely consistent with those previously reported in postoperative FBS, supporting the notion that idiopathic FBS is a subtype of FBS. Thus, it is necessary to consider idiopathic FBS during the evaluation of facial pain triggered at the beginning of a meal.

First Bite Syndrome After Parotidectomy: A Case Series and Review of Literature

INTRODUCTION

First bite syndrome (FBS) is a rare but potentially debilitating complication observed after surgery involving the upper cervical region. Patients classically complain of severe facial pain in the ipsilateral parotid region with the first few bites of a meal.

OBJECTIVE

The aim of this study is to shed light on the incidence and potential risk factors of FBS, including a series of cases depicting FBS observed after parotidectomy.

METHODS

Retrospective review of 419 patients who underwent parotidectomy at a single tertiary care facility between December 2016 and June 2020.

RESULTS

With a mean follow-up time of 16.5 months, 8 (2%) patients were documented to have symptoms of FBS after parotid gland surgery. Six of these patients underwent partial parotidectomy by dissection of the deep lobe of the parotid (DLP).

CONCLUSION

Patients undergoing dissection of the DLP are particularly at risk for the development of FBS. All patients should be appropriately counseled during informed consent discussions, especially in high-risk cases.

Primary First Bite Syndrome of the Parotid Gland: Case Report and Literature Review

OBJECTIVE

A case of primary first bite syndrome (FBS), diagnosed in a patient with nonspecific adenocarcinoma of the deep lobe of the parotid gland.

DATA SOURCES

A Medline literature search was conducted on PubMed, using the keywords "first bite syndrome."

REVIEW METHODS

Using primary FBS and existence of a definite etiology as inclusion criteria.

RESULTS

We report on an unusual case of primary FBS, which had no surgical history. After multiple examinations, the pain was localized to a mass in the deep lobe of the parotid gland. After tumorectomy, the FBS pain was significantly relieved. The postoperative pathological examination determined that the excised mass was a nonspecific adenocarcinoma. Reviewing the literature, we found that primary FBS was mostly caused by malignant tumors in the inferior temporal fossa, the deep lobe of the parotid gland, and (or) the parapharyngeal space. Surgery was reported to be an effective treatment.

CONCLUSION

The case highlights the critical importance of identifying the etiology of primary FBS. When manifested with a primary FBS, malignant tumors must be high on the differential diagnosis list, especially those in the region of the inferior temporal fossa, the deep lobe of the parotid gland, and the parapharyngeal space.

First Bite Syndrome Following Rhytidectomy: A Case Report

Background:

First bite syndrome (FBS) is a known complication of parotid gland resection, parapharyngeal space dissection, and cervical sympathetic chain injury. It can be described as severe cramping or spasms in the parotid region triggered by the first bite of a meal, with the pain lessening during each subsequent bite. Although dissection for a rhytidectomy is in the vicinity of the parotid parenchyma, face-lift is not typically characterized as a procedure that can lead to FBS.

Case description:

A 53-year-old female underwent a deep plane face-lift to address her goals of improving jowls, nasolabial folds, and cervicomental angle. Intraoperatively, the dissection proceeded without any complications. Initially, her postoperative course was uneventful; 3 weeks after surgery, she noticed pain at the start of mastication that would improve throughout the course of a meal. She elected to proceed with observation. At 6 months after surgery, she began to experience improvement in her symptoms, and shortly thereafter had complete resolution.

Discussion:

First bite syndrome is a complication associated with deep lobe parotid resection, first described in 1998. The innervation of the parotid gland is complex and includes contributions from the auriculotemporal nerve, the great auricular nerve, and the cervical sympathetic chain. During rhytidectomy, dissection occurs along the parotidomasseteric fascia in order to elevate a flap of the superficial musculoaponeurotic system. Inadvertent injury to the parotid parenchyma can lead to damage to the postganglionic sympathetic fibers innervating the myoepithelial cells. Ultimately, expectant management is the mainstay of treatment and symptoms typically resolve within 6 months to 1 year.

Conclusion:

First bite syndrome is a complication that can be seen with a variety of facial surgeries. In the case of rhytidectomy, FBS should be considered a potential risk, as dissection into the parenchyma of the parotid gland can result in postoperative autonomic dysfunction.

First bite syndrome: the complication to keep in mind

The First Bite Syndrome is a rare late (1-2 months) post operation complication of surgery in the infratemporal fossa, parapharyngeal space and especially involving the deep lobe of parotid gland. Sometimes it can significantly worsen the patient's quality of life. Acute, sudden, short time pain in the parotid gland region with irradiation to the ear during the first bite a meal is a characteristic for this syndrome. The correct diagnosis and individual approach in choosing a treatment method is the key to success in treating this complication. The purpose of our article is to supplement scanty data on this complication in Polish literature.

Evidence Based Tailored Parotidectomy in Treating External Auditory Canal Carcinoma

Carcinoma of the external auditory canal (EAC) is a rare tumor and little information is available regarding parotid gland in surgically treating EAC carcinomas. This study aimed to investigate the mode of parotid involvement in EAC carcinoma through staging and histopathological analysis, and to establish surgical guidelines for the parotid gland management when there is no clinical evidence of parotid involvement. Sixty-five patients with EAC carcinoma who underwent temporal bone resection and any type of parotidectomy simultaneously were retrospectively reviewed. The rate of direct parotid invasion and parotid nodal involvement was analyzed according to the stage and histopathological findings. Among the 65 patients, 39 were confirmed to have squamous cell carcinoma (SCC) and 26 were confirmed to have adenoid cystic carcinoma (ACC). Direct parotid invasion occurred in 7 of 39 patients with SCC, only in the advanced stages, and in 15 of 26 patients with ACC, regardless of stage. Metastasis to the parotid node was noted in 6 patients with advanced-stage SCC, whereas no patient with ACC showed parotid nodal metastasis. For adequate tumor control with low risk of surgical complications, evidence based tailored parotidectomy should be applied. With no evidence of parotid involvement, an elective parotidectomy can be excluded in early SCC, whereas a total parotidectomy is recommended for advanced SCC. In ACC, basal resection of the parotid gland rather than a superficial or total parotidectomy should be performed at all disease stages.

First bite syndrome: a complication of carotid endarterectomy

First bite syndrome (FBS) is an uncommon pain syndrome characterised by severe cramping or spasm in the parotid region with the first bite of each meal. The proposed pathogenesis is sympathetic denervation of the parotid gland secondary to iatrogenic injury with resultant cross-stimulatory parasympathetic hypersensitivity response. FBS is a potential sequela of surgeries involving the infratemporal fossa, parapharyngeal space and/or deep lobe of the parotid gland, however, only four cases of FBS secondary to carotid endarterectomy have been documented to date. We present a case and management of a 77-year-old man who developed FBS after an ipsilateral carotid endarterectomy, to raise awareness of this complication among surgeons who operate in the neck region.