|Year : 1984 | Volume
| Issue : 4 | Page : 221-223
Vidian neurectomy for crocodile tears
MV Kirtane, SB Ogale, SN Merchant
Department of Otolaryngology, Seth G.S. Medical College & KE.M Hospital, Parel, Mumbai, India
M V Kirtane
'Gokul', Tejpal Road, Mumbai 400 007
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Kirtane M V, Ogale S B, Merchant S N. Vidian neurectomy for crocodile tears. Indian J Ophthalmol 1984;32:221-3
The term `crocodile tears' is a bizarre sequelae lesion of the facial nerve at or proximal to the geniculate ganglion, after the facial paralysis with incomplete recovery and synkinesia, or may occur without antecedent facial paralysis e.g. due to syphilis of the geniculate ganglion or after section of the greater superficial petrosal nerve for headache.
The Vidian nerve carries parasympathetic secretomotor fibres to the lacrimal gland and to the glands of the nasal mucosa and palate. Vidian neurectomy is usually performed for vasomotor rhinitis, but, among other effects, it also abolishes lacrimal secretions and hence, can be used to relieve crocodile tears. The transnasal approach, as practised and advocated by us, is simple, safe, without complications and therefore can be practised with impunity.
This paper deals with our experience with transnasal Vidian neurectomy for the treatment of crocodile tears.
| Materials and methods|| |
The operation of transnasal preganglionic Vidian neurectomy is performed under local anaesthesia using an operating microscope. A long bladed nasal speculum is advanced under the middle turbinate till its posterior end is visualised. The mucoperiosteum is then incised, the sphenopalatine foramen identified, and a specially designed insulated probe advanced through the foramen into the pterygopalatine fossa till the funnel-shaped opeing of the Vidian canal. The Vidian nerve is then cauterised. The entire procedure takes about 10 minutes and no nasal packing is needed, The patient goes home the same afternoon.
| Observations|| |
All the cases were males, aged between 24 and 57 years. The phenomenon of crocodile tears had occurred after a previous severe; idiopathic (Bell's) paralysis of the facial nerves in five out of these seven cases. The other two cases had a traumatic lower motor neurone, ,sub . type of facial paralysis following which they suffered from crocodile tears.
Every case of crocodile tears had complete relief of symptoms immediately after surgery. The results were confirmed objectively by the Schirmer's test. The relatively dry eye caused no discomfort to the patient, nor were there any ocular side effects. Not a single case had any major intra or post-operative complication. Follow up of the patients showed that the obtained was sustained without recurrence of crocodile tearing.
| Discussion|| |
Crocodile tears result from an abnormal gustatory reflex in which salivary fibres from the glossopharngeal nerve establish functional connection with those destined for the lacrimal gland. Secretomotor fibres to the parotid gland leave the glossopharyneal nerve via its tympanic branch and then course in the lesser superficial petrosal nerve to reach the parotid gland. In cases of crocodile tears, these fibres establish abnormal connections with the greater superficial petrosal nerve-a branch of the facial nerve. The later carries secretomotor lacrimal fibres. Thus, an abnormal gustatory reflex arc is set up whereby any stimulus that causes parotid secretion also induces profuse lacrimation.
Vidian neurectomy is predominantly parasympathectomy in its effects,,. After a Vidian neurectomy the relatively dry eye can be shown by Schirmer's test. However, there is no risk of keratoconjunctivitis sicca since the goblet cells of the conjunctiva remain active. Even in hot, dry and dusty climates, there is no evidence that keratoconjunctivitis sicca occurs 6. Further, the use of contact lenses is not hindered at all after a Vidian neurectomy.
Though the efficacy of Vidian neurectomy in relieving vasomotor rhinitis and crocodile tears is well established, the variety of approaches practised by various workers (transmaxillary. trans-septal, transpalatal, trans-ethmoidal),,, belies the fact that no single one is entirely satisfactory. The associated certain complications have always deterred many surgeons from practising these.
The transnasal approach, on the other hand, bypasses the contents of the pterygopalatine fossa altogether, precluding any injury to the maxillary nerve or the sphenopalatine ganglion. Further, there is no risk of overpenetration of the Vidian canal and ophthalmoplegia, as the transnasal probe makes a definite angle with the direction of the Vidian canal, and when advanced, this against its lateral wall. Hence in our 270 cases of Vidian neurectomy including the seven for corococile tears, there has not been a single ophthalmoplegia. In addition, the procedure is done under local anaesthesia, no nasal packing or hospitalization is required, making it almost like an office procedure rather than a major surgical operation, as for example, with the transmaxillary route.
| Conclusion|| |
Crocodile tears which may occur as a sequelae of a severe facial palsy result from an abnormal gustatory reflex, can be alleviated by doing a Vidian neurectomy: Such a neurectomy reduces the lacrimation from the ipsilateral eye but has no ocular side effects.
| Acknowledgements|| |
We are grateful to the Dean, Seth G.S. Medical College and KE.M. Hospital, Bombay, for permission to use the hospital records.
| References|| |
Singer and Kellner, 1930, Gyogyaszat, 2:946.
Boyer, F.C. and Gardner, W.J., 1949, Arch. Neurol Psychiat. (Chic), 61:56.
Rose, K.G., Ortmann, R, Wustrow, F. and Seegers, De., 1979, Arch. oto-rhino-laryngol 224:157.
Malcomson, KG., 1959, The J. Laryngol & Otol. 73:73.
Golding-Wood, P.H., 1961, J. Laryngol. & Otol. 75:232.
Gregson, A.E.W., 1970, Jour. Laryngol. & Otol. 84:221.
Golding-Wood, P.H., 1979, In Scott Brown's Diseases of the Ear, Nose & Throat, Vol. 3, p.449. Butterworth & Co., Ltd., London.
Golding-Wood, P.H., 1973, Laryngoscope 83:1673.
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