First Bite Syndrome as a Presenting Symptom of Parapharyngeal Space Malignancy

Introduction: First bite syndrome (FBS) is a known complication after parapharyngeal space surgery. This syndrome is usually encountered when the parapharyngeal space surgery is extensive, but the parotid gland is preserved. Although the exact etiology remains unknown, a disruption in the balance between sympathetic and parasympathetic innervation to the parotid gland has been shown to play a role.

Objectives: The objectives of this report are to: (1) discuss a case of FBS as a presenting symptom of a parapharyngeal space malignancy, (2) review the literature on FBS, and (3) discuss treatment options.

Methods: This study is a report of one subject with a parapharyngeal space malignancy who presented with FBS before any surgical intervention. The presentation, intraoperative findings, radiological findings, management, and postoperative clinical course are reviewed.

Results: A 74-year-old woman was diagnosed with a parapharyngeal space tumor after initially presenting with severe left-sided jaw, neck, and ear pain that was exacerbated on eating the first bite of each meal. She also had evidence of Horner's syndrome. Biopsy showed that the tumor was a synovial sarcoma. The patient underwent resection of the tumor along with an ipsilateral parotidectomy. Intraoperatively, the sympathetic chain was found to be involved by tumor and therefore was sacrificed. Postoperatively, the patient's FBS symptoms immediately resolved.

Conclusions: There are no prior reports in the literature of FBS before undergoing parapharyngeal space surgery. First bite syndrome can be a presenting symptom of a parapharyngeal space neoplasm.