First Bite Syndrome After Deep Lobe Parotidectomy: Case Report

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 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: 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.