Abstract
Objectives
First bite syndrome (FBS) is an early postoperative pain syndrome characterized by the sudden onset of pain in the parotid region at the first bite of each meal. The etiology is not certain, hence a standardized therapy does not exist.
Methods
A 50-year old woman referred to us complaining of a swelling in the right parotid region. Fine-needle aspiration biopsy (FNAB) was diagnostic for pleomorphus adenoma of the deep lobe of the parotid gland. A 50-year old man presented with a mass in the right side of the neck, FNAB was diagnostic for parapharyngeal space neurinoma. The first patient was submitted to total parotidectomy with facial nerve preservation, the second to extracapsular dissection of the tumor. A week after surgery both patients developed FBS. A qualitative/quantitative description of pain was obtained by means of a self-coded questionnaire. The score ranges from 8 to 44, corresponding to the lowest and the highest discomfort possible, respectively. Acupuncture was used to treat these 2 patients. The treatment protocol comprised 6 sessions, one per week, lasting 30 minutes each.
Results
Our questionnaire was administered before and after treatment and the score dropped from 33 to 25 in the female, from 30 to 15 in the male patient.
Conclusion
FBS is a complication of upper cervical surgery with a high morbidity rate. We describe the first two cases of FBS that were successfully treated with acupuncture in our ENT department. We believe that this procedure may represent a valid therapeutic alternative in the future.
1
Introduction
In 1998, Netterville described “first bite syndrome” (FBS) as an early postoperative pain syndrome characterized by the sudden onset of pain in the parotid region at the first bite of each meal. Following this publication, several papers concerning FBS were published and different clinical variants were reported. More than 95% of published cases correspond to postoperative syndromes following upper neck surgery, such as resection of mixed and/or cervical sympathetic nerve tumors, deep cervical lymph node dissection, parotid gland surgery, particularly involving its deep lobe, parapharyngeal and infratemporal fossa surgery, carotid bifurcation and/or internal carotid artery surgery, and resection of the styloid process. Moreover, Deganello and other authors from then on , described FBS as a presenting symptom of parapharyngeal space tumors.
The etiology is not certain, hence a standardized therapy does not exist. The pain may occasionally resolve spontaneously , nevertheless many treatment options were described over the years , none of which proved to be effective in the long-term.
A randomized controlled trial supported the potential role of acupuncture in “shoulder syndrome” (SS), a syndrome whose main characteristics are pain and dysfunction after neck dissection. Due to the encouraging results that we obtained treating a preliminary case series of patients presenting SS with acupuncture, we extended its application to patients complaining of FBS.
Herein we show the excellent outcome obtained in the first two cases of FBS after upper neck surgery for a pleomorphus adenoma of the parotid gland and a cervical sympathetic chain neurinoma, which we treated with acupuncture.
2
Materials and methods
A 50-year old woman presented to our ENT Department complaining of a swelling in the right parotid region. The lesion was submitted to ultrasound-guided fine-needle aspiration biopsy (FNAB) which suggested a diagnosis of pleomorphus adenoma of the deep lobe of the parotid gland. We performed total parotidectomy with facial nerve preservation through a standard cervicotomic approach.
A 50-year old man presented to our ENT Clinic after the onset of a mass on the right side of the neck. The FNAB revealed parapharyngeal space neurinoma. The contrast-enhanced CT scan raised suspicion for a cervical sympathetic chain neurinoma. Hence, the patient was submitted to extracapsular dissection of the tumor via a cervical approach. They both had neither previous nor concomitant pathologies.
A week after surgery both patients developed a “first-bite syndrome”. The diagnosis was made upon clinical criteria. The second patient also developed a Horner’s syndrome within a few hours after surgery.
In order to classify pain we used a self-coded subjective questionnaire that was called the “AG Questionnaire”. The first 3 questions refer to a “qualitative” description of pain. Questions number 4 to 8 evaluate both elicited and spontaneous pain, referring to a “quantitative” description of pain. ( Tables 1 and 2a–2b )
| 1 | Trigger mechanism | a. Chewing | b. Swallowing | c. Following contact with food | d. Other | ||
| 2 | Trigger agent | a. Acidic food | b. Sweet food | c. Bitter food | d. Salty | e. Alcohol | f. Air contact |
| 3 | Type of pain | a. Electric shock | b. Stabbing | c. Other |
| ELICITED PAIN | |||||
|---|---|---|---|---|---|
| SCORE | 1 | 2 | 3 | 4 | |
| 4 | Pain intensity a | ||||
| 5 | Duration of pain | a. < 30 s | b. 30–60 s | c. 60–120 s | d. > 120 s |
| 6 | Pain course | a. Absence of pain | b. Great improvement | c. Low improvement | d. Not improved |
| 7 | Reflex effect | a. No need for chewing to stop | b. Need for chewing to stop | ||
a The score ranges from 1 to 10 (1 = less pain possible, 10 = worst pain possible).
| SPONTANEOUS PAIN | |||||
|---|---|---|---|---|---|
| SCORE | 1 | 2 | 3 | 4 | |
| 4.1 | Pain intensity a | ||||
| 5.1 | Duration of pain | a. < 30 s | b. 30–60 s | c. 60–120 s | d. > 120 s |
| 6.1 | Pain course | a. Absence of pain | b. Great improvement | c. Low improvement | d. Not improved |
| 7.1 | Reflex effect | a. No need for chewing stop | b. Need for chewing stop | ||
| 8.1 | Frequency | a. 1–3 times daily | b. 4–6 times daily | c. 7–10 times daily | d. > 10 times daily |
a The score ranges from 1 to 10 (1 = less pain possible, 10 = worst pain possible)
The final score is eventually calculated by adding the scores: 8 is considered the lowest, 44 the highest discomfort possible.
We used acupuncture to treat these 2 patients. The procedure was performed by the same physician specialized in alternative techniques of the traditional Chinese medicine, by means of disposable needles. The scheme comprised 6 sessions, one per week, lasting 30 min each.
Fig. 1 represents points and methodic of acupuncture administration.
