On the seventh postoperative day, the patient began to complain of sudden-onset, severe, sharp pain at the right mandibular angle and parotid region. The ICA was shortened and straightened with posterior plication and closed with bovine pericardial patch. Based on the aortic arch and the plaque quality, the patient was a suboptimal candidate for trans-femoral carotid stent placement, hence a right CEA was performed. The aortic arch was significantly calcified as well. The carotid bifurcation was relatively high, and the ICA had severe tortuosity, displacing the artery behind the pharynx. To our knowledge, this report is only the eighth presentation of FBS in the literature related to CEA. We present our case of FBS that developed after elective carotid endarterectomy (CEA) to alert vascular surgeons to the unique presentation, pathophysiology, and available treatment options of this rare surgical complication. įBS can develop after carotid surgery, but it is rarely reported. Selective disruption of those postganglionic fibers that innervate the parotid gland are necessary for FBS to appear. However, in the latter case, the remaining residual autonomous activity of the SCG may prevent the development of FBS. Postganglionic sympathetic fiber disruption adjacent to the ICA or SCG and main sympathetic trunk injury causes Horner’s-type symptoms. Fibers along the ICA innervate the eyelid, the pupil, and the sweat glands of the forehead. It is important to note that the fibers next to the ECA innervate the parotid gland and the sweat glands on the face. It is approximately 3 cm long and the postganglionic fibers run along the external carotid artery (ECA) and the ICA. The SCG lies posterior to the carotid artery. It contains the internal carotid artery (ICA), the internal jugular vein, cranial nerves (IX, X, XI, XII), lymph nodes, and the cervical sympathetic chain with the superior cervical ganglion (SCG) and its postganglionic fibers. The PPS is a tight upside-down pyramidal space bordered by the skull base superiorly, the hyoid bone inferiorly, the mandibular ramus and parotid gland laterally, and finally the pharynx medially. The anatomic and pathophysiologic theories behind FBS are relatively complex and related specifically to the parapharyngeal space (PPS). The pain only lasts for seconds, then rapidly resolves despite continued mastication. The symptoms typically present between the fifth and seventh postoperative day in the form of severe, sharp pain in the parotid gland, pharynx, and mandible, at the first bite of food. Remarkably, both Gardner and Netterville speculated that the symptoms were related to a problem with the parotid gland‘s postganglionic sympathetic innervation.Īlthough there are potentially many causes of pain in the head and neck region (e.g., Eagle’s syndrome, glossopharyngeal neuralgia, trigeminal neuralgia, temporomandibular joint arthralgia, infection, and malignancy), none of them share the distinguishing characteristic presentation of FBS. In his report, he named the complication FBS, which remains in effect today. In 1988, Netterville, an otolaryngologist, noted the syndrome described by Gardner on his postoperative patients who underwent skull base vagal paraganglioma resections. This operation was used as a therapeutic procedure for variable diseases at the time. The first description in the literature of the herein discussed syndrome appeared in Gardner and Abdullah’s neurosurgery report as a complication of superior cervical ganglion excision in 1955. He attributed the symptoms to esophageal spasm. While this information is noted here for historical completeness, what we describe as FBS today is completely unrelated to this. In 1986, he described recurrent episodes of dysphagia, which was associated with retrosternal pain in his patients. 2, 2018.The original use of the term “first-bite syndrome” (FBS) is connected to a gastroenterologist Dr. Mind-body considerations in orofacial pain. National Center for Complementary and Integrative Health. Comparative effectiveness of traditional Chinese medicine and psychosocial care in the treatment of temporomandibular disorders-associated chronic facial pain. Rochester, Minn.: Mayo Foundation for Medical Education and Research 2018. Philadelphia, Pa.: Saunders Elsevier 2015. In: Cummings Otolaryngology: Head & Neck Surgery. In: Kelley and Firestein's Textbook of Rheumatology. National Institute of Dental and Craniofacial Research.
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