Crocodile tears syndrome: botulinum toxin treatment
under EMG guidance
Sibel Kizkin
Selim Doganay
Handan Isin Ozisik
Cemal Ozcan
Faculty of Medicine, Inonu University and Turgut Ozal
Medical Center, Malatya, Turkey
Reprint requests to: Dr Sibel Kizkin
Inonu Universitesi Tıp Fakultesi
Noroloji Anabilim Dalı
TR-44160 Malatya, Turkey
E-mail: skizkin@inonu.edu.tr
Accepted for publication: February 17, 2005
Summary
Crocodile tears syndrome is one of the rare complica-
tions of facial paralysis. There have been several re-
ports of cases in which botulinum toxin was found to
be useful in the treatment of crocodile tears syndrome.
The adverse effects, due to the paralytic action of botu-
linum toxin, have been reported to involve the palpe-
bral muscle, lateral rectus and superior rectus. There-
fore, we considered that it might be more appropriate to
carry out the injection procedure under electromyo-
graphic guidance in order to inject botulinum toxin se-
lectively into the lacrimal gland and protect the above-
mentioned muscles.
In conclusion, we recommend EMG guidance in the
treatment of crocodile tears syndrome with botulinum
toxin.
KEY WORDS: botulinum toxin, crocodile tears syndrome, elec -
tromyography.
Introduction
Crocodile tears syndrome, also called gustolacrimal re-
flex, paroxysmal lacrimation and Bogorad’s syndrome,
is one of the rare complications of Bell’s palsy or trau-
matic facial paralysis. It was first described by a Russ-
ian neuropathologist in 1913, and is characterized by in-
appropriate and sometimes excessive lacrimation pro-
voked by eating (1,2).
Recently, there have been several reports of cases in
which botulinum toxin was found to be useful in the
treatment of crocodile tears syndrome (1-6). The ad-
verse effects, due to the paralytic action of botulinum
toxin, have been reported to involve the palpebral mus-
cle, lateral rectus and superior rectus (1,3-6). Therefore,
Functional Neurology 2005; 20(1): 35-37
we considered that it might be more appropriate to car-
ry out the injection procedure under electromyographic
(EMG) guidance, in order to inject botulinum toxin selec-
tively into the lacrimal gland and to protect the above-
mentioned muscles.
In this report, we present the findings of the injection of
botulinum toxin, under EMG guidance, via a conjunctival
approach, in a patient presenting crocodile tears syn-
drome following idiopathic peripheral facial paralysis
(PFP).
Case report
A 19-year-old male patient presented with a 6-month
history of left PFPwithout concomitant medication. Two
months after the onset of the PFP, his left eye had be-
gun to present tearing during meals. With the exception
of a slightly decreased left nasolabial fold, there were
no pathological findings on neurological examination.
PFP was categorized as Grade II according to the
House Brackmann Facial Nerve Grading System (at
rest: normal tone and symmetry; motion: complete clo-
sure of the eyelid with minimum effort, minimal oral
asymmetry). Blink reflexes were investigated by EMG
and a positive response was found after stimulation of
the ipsilateral supraorbital nerves, from both the m. or-
bicularis oculi and m. orbicularis oris, which suggested
aberrant reinnervation (Fig. 1). Ophthalmological exam-
ination showed normal visual acuity in both eyes. Fun-
dus examination was bilaterally normal. Cornea epithe-
lium was healthy and disclosed no epithelial surface
pathology.
The patient was examined clinically, and tearing was as-
sessed by Schirmer’s test before and 1, 4, 12 weeks af-
ter the injection. According to this test procedure, one
end of a strip of thin filter paper (5 mm wide and 30 mm
Figure 1 - Blink reflexes.
35
S. Kizkin et al.

long) was inserted into the lower conjunctival sac, while
the other end was allowed to hang over the margin of
the lower lid. The tears wet the strip of filter paper, pro-
ducing a moisture measurement. Basal tear secrection
and tear secrection after gustatory stimulation (the pa-
tient ate a sweet) were measured.
Basal tear secretion (without gustatory stimulation) was
found to be 15 mm in the right eye and 17 mm in the left
eye. Repetition of the Schirmer’s test during salivary
stimulation gave values of 16 mm and over 30 mm, re-
spectively (Tables I and II).
Table I - Schirmer’s test results without gustatory stimula-
tion.
tectable by EMG (Fig. 3). The needle only entered the
lacrimal gland. The treatment was not painful.
Within 4 days of the botulinum toxin injection, the patient
noticed a reduction of tear secretion during eating, and
a complete disappearance after 7 days. Side effects
such as eye burning, ptosis, double vision and visual
problems were not observed after botulinum toxin injec -
tion.
One week after treatment (Tables I and II), the
Schirmer’s test gave values of 14 mm (left eye) and 15
mm (right eye) during gustatory stimulation (eating a
sweet). The patient had no discomfort 12 weeks after
the procedure.

Right eye Left eye

Before treatment 15 mm 17 mm
1 week after treatment 16 mm 16 mm
4 weeks after treatment 15 mm 17 mm
12 weeks after treatment 16 mm 16 mm

Table II - Schirmer ’s test results with gustatory stimulation.

Right eye Left eye

Before treatment 16 mm over 30 mm

Figure 3 - Electrophysiological silence of the lacrimal gland.
1 week after treatment 15 mm 14 mm
4 weeks after treatment 15 mm 16 mm
12 weeks after treatment 16 mm 15 mm Discussion

Crocodile tears are seen in 3.3 to 6.5% of patients fol-

Before botulinum toxin injection, the conjunctiva mucosa
was anesthetized with proparacaine HCL(Alcaine 0.5%;
Alcon, Belgium). The EMG needle was inserted in the
palpebral portion of the lacrimal gland following ectropi-
onization of the upper eyelid. Six units of botulinum tox-
in (Botox; Allergan, Irvine, Calif.) were injected into the
palpebral portion of the lacrimal gland (Fig. 2), after it
had been established that muscle activity was not de-
Figure 2 - Botulinum toxin was injected into the palpebral por-
tion of the lacrimal gland.
lowing Bell’s palsy (7,8). The syndrome may also occur
following acoustic neurinoma surgery, in maxillofacial
trauma, lepra, Paget’s disease, vascular diseases and
cervicooculoacoustic syndrome (3,9,10).
A misdirection of regenerating parasympathetic fibres is
widely accepted as the pathogenetic mechanism under-
lying crocodile tears syndrome. Gustatory fibres from fa-
cial or glossopharyngeal nerves may be misled through
n. petrosus superficialis major to the lacrimal gland,
causing the eye on that same side to present tearing
when the patient eats or drinks (1,3,6). It may rarely be
accompanied by loss of taste and by facial spasm.
Many methods have been used to treat crocodile tears
including drugs such as antihistaminics, anticholinergics
(8), intraorbital alcohol or cocaine injection (1), Vidian
neurectomy (11,12), and subtotal resection of the
lacrimal gland (13). However, none of these treatment
options has been unanimously accepted due to persist-
ent side effects in some of them (e.g., eye burning in
Vidian neurectomy), or inadequate results.
Recent reports suggest that botulinum toxin injection in-
to the lacrimal gland of patients with crocodile tears syn-
drome may effectively abolish the reflex symptom. Bot-
ulinum toxin-A affects neurotransmission by inhibiting
the release of acetylcholine at the neuromuscular junc-
tion and at cholinergic autonomic nerve terminals (1,5,
6,14,15). Botulinum toxin has been applied both tran-

36 Functional Neurology 2005; 20(1): 35-37

EMG-guided botulinum toxin treatment of crocodile tears
scutaneously and transconjunctivally to the lacrimal
gland in patients with crocodile tears syndrome (2,5,6,
14). Riemann et al. (6) injected 2-5 U botulinum toxin in-
to the palpebral portion of the lacrimal gland, obtaining
a noticeable reduction in the patient’s complaint in a
week; moreover, no side effects were observed. Mon-
taya et al. (1), on the other hand, first applied 10 U tran-
scutaneously. When this proved ineffective, an addition-
al 10 U botulinum toxin was administered transconjunc-
tivally. But it was reported that this application caused
side effects such as eye burning and ptosis resulting
from involvement of the m. levator palpebra. However,
the desired result was achieved with a lower dose using
the transconjunctival rather than the transcutaneous
technique.
Botulinum toxin injection may have a paralytic effect on
m. levator palpebra, m. rectus superior, and m. rectus
lateralis due to the proximity of these muscles to the
lacrimal gland. To avoid these side effects, we per-
formed transconjunctival botulinum toxin injection under
EMG guidance. Symptoms completely improved one
week after application and no complications occurred in
the related eye and adnexes. Follow-up ophthalmologi-
cal examination with Schirmer’s test 12 weeks after in-
jection showed persistence of the botulinum toxin effect.
In conclusion, the use of EMG guidance could increase
the efficiency and safety of botulinum injection in cases
with crocodile tears syndrome. We recommend EMG
guidance in the treatment of crocodile tears syndrome
with botulinum toxin.
References
11. Montoya FJ, Riddell CE, Caesar R, Hague S. Treatment of
gustatory hyperlacrimation (crocodile tears) with injection
of botulinum toxin into the lacrimal gland. Eye 2002;16:
705-709
12. Morais Perez D, Dalmau Galofre J, Bernat Gili A, Ayerbe
Torrero V. Crocodile tears syndrome. Acta Otorrinolaringol
Esp 1990;41:175-177
Functional Neurology 2005; 20(1): 35-37
13. Yavuzer R, Basterzi Y, Akata F. Botulinum toxin A for the
treatment of crocodile tears. Plast Reconstr Surg 2002;
110:369-370
14. Keegan DJ, Geerling G, Lee JP, Blake G, Collin JR, Plant
GT. Botulinum toxin treatment for hyperlacrimation sec-
ondary to aberrant regenerated seventh nerve palsy or
salivary gland transplantation. Br J Ophthalmol 2002;86:
43-46
15. Hofmann RJ. Treatment of Frey’s syndrome (gustatory
sweating) and ‘crocodile tears’ (gustatory epiphora) with
purified botulinum toxin. Ophthal Plast Reconstr Surg
2000;16:289-291
16. Riemann R, Pfennigsdorf S, Riemann E, Naumann M.
Successful treatment of crocodile tears by injection of bot-
ulinum toxin into the lacrimal gland. Ophthalmology 1999;
106:2322-2324
17. Valenca MM, Valenca LP, Lima MC. Idiopathic facial paral-
ysis (Bell’s palsy): a study of 180 patients. Arq Neurop-
siquiatr 2001;59:733-739
18. Miszke A, Kotowiecki E. Crocodile tears syndrome. Neurol
Neurochir Pol 1975;9:81-87
19. Irving RM, Viani L, Hardy DG, Baguley DM, Moffat DA.
Nervus intermedius function after vestibular schwannoma
removal: clinical features and pathophysiological mecha-
nisms. Laryngoscope 1995;105:809-813
10. Magliulo G, Cordeschi S, Sepe C, de Vincentiis M. Taste
and lacrimation after acoustic neuroma surgery. Rev
Laryngol Otol Rhinol (Bord) 1998;119:167-170
11. Kirtane MV, Ogale SB, Merchant SN. Vidian neurectomy
for crocodile tears. Indian J Ophthalmol 1984;32:221-223
12. Chandra R. Treatment of a case of crocodile-tears by Vid-
ian neurectomy. J Laryngol Otol 1967;81:669-671
13. McCoy FJ, Goodman RC. The crocodile tear syndrome.
Plast Reconstr Surg 1979;63:58-62
14. Boroojerdi B, Ferbert A, Schwarz A, Herath H, Noth J. Bot-
ulinum toxin treatment of synkinesia and hyperlacrimation
after facial palsy. J Neurol Neurosurg Psychiatry 1998;
65:111-114
15. Kyrmizakis DE, Pangalos A, Papadakis CE, Logothetis J,
Maroudias NJ, Helidonis ES. The use of botulinum toxin
type A in the treatment of Frey and crocodile tears syn-
dromes. J Oral Maxillofac Surg 2004;62:840-844
37