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First Bite Syndrome

return to: Parotidectomy with Facial Nerve Dissection

Acute and intense pain in the parotid gland region associated with the initial bite of a meal is thought to result from damage to the sympathetic innervation of the parotid gland leading to parasympathetic overactivity. Not all patients who have undergone section of the cervical sympathetic chain develop first bite syndrome - leading to continued discussion about the etiology.

Definition according to Netterville et al (1998): First bite syndrome is facial pain characterized by a severe cramping or spasm with the first bite of each meal that diminishes with time - occurring in the parotid region.

Characteristically the pain is worst with the first meal of the day or following a several hour period without food and last a few seconds. 

Initial treatment of 5 patients with 30 units of botulinum neurotoxin A (3 sites in the parotid) by Costales-Marcos et al (2017) results in decrease in intensity of the pain in 4 patients from intense pain (6 to 8/10 pain scale) down to mild to moderate (2 to 6/10) at 6 month f/u. The pain did not go completely away in any patient at one month followup but did so in one patient at 3 months followup. Two patients received an additional 50 units through injection at 6 weeks after the initial injection and a third patient received 50 units 7 months after the initial injection. These investigators identify that the severity of the symptoms tends to diminish over time with some reported to resolve spontaneously.

According to Costales-Marcos et al 2017

Ineffective Treatment

Incompletely Effective Treatment

Effective Treatment


Changes to diet

"Anti-epileptic drugs"

a. pregabalin

b. gabapentin

c. carbamazepine

Botulinum toxin injection to the parotid gland


Non-steroidal anti-inflammatory medication



(*not justified according to authors)


Surgical resection of tympanic or auriculo-temporal nerve




Additional treatments mentioned by Linkov et al (2012) include total parotidectomy, acupuncture and adaptive behaviors techniques.

Exaggerated myoepithelial cell contraction resulting from stimulation from parasympathetic hyperactivation is thought to be the cause of the pain - with benefit seen from Botulinum toxin type A injection to the parotid gland 'chemodenervation' is supported as a management option.


Costales-Marcos M, López Álvarez F, Fernández-Vanes ˜ L, Gómez J, Llorente JL. [in English:Treatment of the first bite syndrome]  Tratamiento con toxina botulínica del síndrome del primer mordisco. Acta Otorrinolaringol Esp. 2017;68:284---288.

Avinçsal MÖ, Hiroshima Y, Shinomiya H, Shinomiya H, Otsuki N, Nibu K.First bite syndrome - An 11-year experience.Auris Nasus Larynx. 2017 Jun;44(3):302-305. doi: 10.1016/j.anl.2016.07.012. Epub 2016 Aug 12

Netterville JL, Jackson CG, Miller FR, Wanamaker JR, Glasscock ME. Vagal paraganglioma: a review of 46 patients treated during a 20-year period. Arch Otolaryngol Head Neck Surg 1998;124:1133–40

Laccourreye O, Werner A, Garcia D, Malinvaud D, Tran Ba Huy P, Bonfils P. First bite syndrome. Eur Ann Otorhinolaryngol Head Neck Dis 2013;130:269–73.

Linkov G, Morris LG, Shah JP, Kraus DH. First bite syndrome: incidence, risk factors, treatment, and outcomes. Laryngoscope 2012;122: 1773–8.

Sharma PK, Massey BL. Gabapentin for the treatment of first bite syndrome following parapharyngeal space surgery. Otolaryngol Head Neck Surg 2005;133:173–4.