Therapy options
Treatments for first-bite syndrome offer variable results. Treatment outcomes experienced by patients in the various studies focusing on first-bite and Horner’s syndromes are summarized in Table 2, with only a few therapies having reported positive effects. Concomitant amitriptyline (25 mg at bedtime) reduced the intensity as well as the duration of pain, as reported by Phillips and Farquhar-Smith.9 In the cases from Chiu et al,8 two of three patients with first-bite syndrome found slight pain relief following tympanic neurectomy. Another patient found that amitriptyline and carbamazepine reduced the pain to only the first few bites.9 Casserly et al1 reported on a patient with Horner’s syndrome and first-bite syndrome whose pain improved with pregabalin (Lyrica).
Perhaps the most promising treatment is botulinum toxin. In a study by Ali et al,5 a woman who received no benefit from multiple narcotics and surgeries received an injection of botulinum toxin into the side of the parotid gland, where the pain was most intense. Four months after undergoing tympanic neurectomy (to relieve the symptoms of four surgical resections including mandibular osteotomies and parapharyngeal-space dissection), the patient received an injection of 75 units of botulinum toxin diluted in 2 mL of saline solution into the right parotid gland. Less than 48 hours later, the patient reported that the pain was markedly improved.5 If untreated, the pain associated with first-bite syndrome goes; it has been reported to resolve gradually, up to 21 months following its original onset.
Conclusion
The potential for first-bite syndrome should be included in the preoperative discussion for those undergoing surgery of the parotid gland, neck, and/or parapharyngeal space. Patients who undergo external carotid artery ligation as part of these surgeries or who develop Horner’s syndrome postoperatively appear to be at highest risk for development of firstbite syndrome. Additional reports on the efficacy of botulinum toxin in alleviating the pain associated with firstbite syndrome are eagerly awaited.
Disclosures
The authors have no conflicts of interest to disclose. Funding was provided by the University of South Carolina and the South Carolina Center of Economic Excellence Center for Medication Safety initiative (C.L.B.).
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