Decades of clinical observation have led our subspecialty team to suspect that negative nasopharyngeal pressure is associated with attic retraction pocket formation. Furthermore, LaPlace's law, which states that the pressure within a sphere varies with the inverse of the radius, provides the dynamic explanation for why the attic area of the tympanic membrane tends to retract more frequently than the pars tensa.

The attic retraction pockets of 154 patients were classified into grades of severity (grades I–V). Impedance audiometry of middle-ear pressure was measured in the resting state, and after sniffing, swallowing and the Valsalva manoeuvre.

Negative nasopharyngeal pressure (sniffing) caused a diminution of middle-ear pressure of −5 daPa on average in normal ears, and of −24 daPa to −45 daPa for tympanic membranes with attic retraction pockets of grade I to grade V.

Attic retraction pockets are associated with greater collapse of middle-ear volume when negative pressure is created in the nasopharynx. LaPlace's law, and the composition of the pars flaccida, suggests an explanation for why the attic region retracts more than the pars tensa.

First bite syndrome is a condition characterised by severe facial pain brought on by the first bite of each meal. This can severely affect the patient's ability to eat.

We present a 70-year-old woman for whom we performed a laser ablation of the left ear tympanic plexus, as treatment of first bite syndrome. A permeatal approach was used to raise a tympanomeatal flap. The tympanic plexus was identified on the promontory and a 4 mm2 area of the plexus was ablated using CO2 laser. The flap was repositioned and a dressing was placed with topical antibiotics.

At two-month follow up, there was full resolution of the patient's symptoms.

First bite syndrome carries a high morbidity; treatment options are variable, and often unsuccessful. We describe the first documented case of laser tympanic plexus ablation, with a very effective initial response. This procedure represents a useful therapeutic option for first bite syndrome.