Case Report
First Bite Syndrome Following Carotid Endarterectomy

https://doi.org/10.1016/j.jstrokecerebrovasdis.2020.105364Get rights and content

Highlights

Abstract

A 67-year-old man with a high position carotid plaque presented with severe pain in ipsilateral parotid region several days after carotid endarterectomy (CEA). The pain occurred at the first bite of each meal and resolved as further bite. We diagnosed the pain as first bite syndrome (FBS). FBS is infrequent but known as a complication associated with parapharyngeal space surgery. The pain is characterized by sharp pain in the parotid region associated with mastication. The cause is unclear but thought to the result from sympathetic denervation of the parotid gland, followed by parasympathetic nerve hypersensitivity. Only five cases associated with carotid endarterectomy (CEA) have been reported. We should be in mind that CEA for high position plaque is one of the risk factors to cause FBS associated with CEA. Neurologists and vascular surgeons as well as otolaryngologists should all be informed FBS as one of the complications after carotid endarterectomy.

Section snippets

Case Report

A 67-year-old man underwent left carotid endarterectomy (CEA). The plaque was extended to the top end of the C2 vertebral body. We dissected the parotid gland deeply and revealed internal carotid artery (ICA) well above the hypoglossal nerve due to the high position plaque (Fig A, B). He presented with sharp pain around the ipsilateral parotid region several days after the surgery. The pain occurred at starting mastication and rapidly resolved as further eating. We diagnosed the pain as first

Discussion

FBS is uncommon pain mainly associated with parapharyngeal space surgeries such as parotidectomy and vagal paraganglioma.1, 2, 3, 4 FBS presents cramping pain in the parotid region triggered by the first bite of each meal. Typically, the pain lasts several seconds, diminishes over subsequent mastication, but recurs at the next meal.2,3 The pain is worsened by sialagogue and occurs within two weeks after surgery, not just after the surgery.1,2

The pathogenesis is unclear but proposed that the

Conclusion

We present a rare case of FBS following ipsilateral CEA. FBS interferes quality of life although frequently self-resolving. Most of these symptoms might have been recognized as a postoperative wound pain and may be overlooked in cases conducting CEA. We think that neurologists and vascular surgeons as well as otolaryngologists should all be informed FBS as one of the complications after carotid endarterectomy.

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