TMJ dysfunction does not constitute a diagnostic problem, as jaw movements and palpation of the TMJ do not cause pain in these patients. Differential diagnosis typically includes TMJ dysfunction, gastro-esophageal reflux, Eagle syndrome, and trigeminal or glossopharyngeal neuralgia. The similarity in pain pattern is what connects idiopathic FBS to traditional FBS. In most cases, these patients have been misdiagnosed at first. Idiopathic FBS has rarely been reported in the literature. The pain in these cases is attributed to the denervation of the parotid’s sympathetic innervation, due to compression or infiltration, and is resolved with surgical removal of the mass. A follow-up scan should take place after six to nine months, as FBS may precede radiological detection of the mass. Rarely, tumors originating from the aforementioned spaces can manifest FBS even if they are not detectable during an initial radiological examination. Postoperative FBS has been reported in head and neck surgeries involving the PPS, the infratemporal fossa (ITF), the deep lobe of the parotid gland, the carotid space, the retropharyngeal space, the masticator space, and even after TMJ replacement. The prevailing theory for the pathogenesis of FBS is the derangement of the autonomous innervation of the parotid gland’s myoepithelial cells. Authors have since embraced Netterville’s description. Gardner and Abdullah were the first who, in 1955, reported facial pain with characteristics much like the ones described as FBS, regarding patients with superior cervical ganglionectomy. It appeared in the early postoperative period in the ipsilateral side of the removed vagal paraganglioma. The pain was severe, located in the parotid area, had sudden onset during the first bite of each meal, and subsided over the next bites. again used this term to characterize an early postoperative pain syndrome occurring in patients who underwent surgery for vagal paraganglioma. ![]() Haubrich in 1986 to describe clinical features characterized by the occasional onset of pharyngeal blockage of food at the first bite of a meal, without prodromal symptoms and sometimes accompanied by retrosternal chest pain. The term “first bite syndrome” was first used by W.S. The patient underwent a panoramic x-ray, computed tomography (CT), and magnetic resonance imaging (MRI) of the head and neck, in order to exclude Eagle syndrome and tumors arising from the salivary glands or parapharyngeal space (PPS), as can be seen in Figures Figures1 1- -3 3. Lastly, examination of the ipsilateral eye revealed a normal pupillary light reflex and no ptosis of the upper eyelid nor enophthalmos. The function of all cranial nerves was evaluated as normal and flexible fiberoptic nasopharyngolaryngoscopy revealed no pathology. The pain was only provoked when a sour solution was applied to the right section of the tongue and not when biting a cotton swab or through jaw movements. Milking the parotid glands resulted in clear saliva secretion, with no pain. Tenderness was evoked on mild palpation of the right parotid gland, not in the same intensity as the pain described, but not of the TMJ. Throughout the clinical examination, no signs of the pathology of the salivary glands, masticatory muscles, teeth, temporomandibular joint (TMJ), or external auditory canal (EAC) were observed. His vitals and ECG were normal, as was a complete blood count test except for high blood glucose and hemoglobin A1c levels (11.89%, normal range 4%-6.2%). He reported no history of injury or surgery in the head and neck region. ![]() The patient suffered from poorly regulated type I diabetes mellitus and described occasional abdominal bloating and constipation that responded well to dietary changes. He had been treated three months prior, with anti-inflammatory agents, due to suspicion of TMJ disorder, with no benefit. The intensity of the pain was stronger with the consumption of acid foods but irrelevant to the time of day a meal was consumed. The pain was characterized as paroxysmal, 10/10 on the Pain Numerical Rating Scale, occurred at the first bite of each meal immediately when the bolus reached the posterior section of the tongue, diminished in severity with subsequent bites and resided completely a few minutes after completion of the meal. A 34-year-old male presented to the ENT department with a three-month history of dysphagia due to severe pain in the right parotid area, radiating to the right periauricular region.
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