First Bite Syndrome Following Carotid Endarterectomy

J Stroke Cerebrovasc Dis. 2020 Dec;29(12):105364. doi: 10.1016/j.jstrokecerebrovasdis.2020.105364. Epub 2020 Oct 9.


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.

Keywords: Carotid endarterectomy; Carotid stenosis; First bite syndrome; Sympathetic denervation.

Publication types

  • Case Reports

MeSH terms

  • Aged
  • Carotid Stenosis / surgery*
  • Endarterectomy, Carotid / adverse effects*
  • Facial Neuralgia / diagnosis
  • Facial Neuralgia / etiology*
  • Facial Neuralgia / physiopathology
  • Humans
  • Male
  • Mastication*
  • Pain, Postoperative / diagnostic imaging
  • Pain, Postoperative / etiology*
  • Pain, Postoperative / physiopathology
  • Parasympathetic Nervous System / physiopathology
  • Parotid Gland / innervation*
  • Sympathetic Nervous System / injuries*
  • Sympathetic Nervous System / physiopathology
  • Treatment Outcome