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When Eating Makes You Cry: Crocodile Tears Syndrome

by | Feb 1, 2026 | Manuscripts | 0 comments

Avantika Bind, B. Optom

M. Optom Student, The Sankara Nethralaya Academy, Chennai, India

 

Crocodile Tears Syndrome is a condition named after F.A. Bogorad, a Russian Neuropathologist, and is often described as “gustatory lacrimation”. The phrase “crocodile tears” originates from the old myth that crocodiles cry while devouring their prey. (1,2) Bogorad syndrome refers to an uncommon condition in which individuals recovering from an injury to the facial nerve (cranial nerve VII) experience tear production during activities such as eating, chewing, drinking, or even smelling food. (1,2)

It commonly develops as a complication of facial nerve injury, particularly after Bell’s Palsy, trauma, or surgical procedures. During recovery, the facial nerve may regenerate abnormally, causing its autonomic fibres to redirect toward the lacrimal gland rather than the salivary gland. As a result, chewing triggers inappropriate lacrimal gland activation and excessive tearing. (3,4)

 

Figure 1: Image showing layers of the tear film

Image Courtesy: https://www.shutterstock.com/image-vector/tear-film-formation-260nw-128669381.jpg

Etiology

Crocodile tears syndrome arises when the facial nerve is damaged, most often after an episode of Bell’s palsy. However, trauma, surgical procedures, and infections involving the nerve can also trigger it. (5)

Several explanations have been proposed to clarify how the condition develops. The leading theory suggests that, during recovery from facial nerve paralysis or injury to the nervus intermedius (during surgery for acoustic neuroma), the nerve fibres regenerate incorrectly. Instead of reconnecting with their usual targets, some fibres mistakenly link to the lacrimal gland, causing tearing whenever the person eats. Since the miswiring occurs slowly, symptoms typically appear months later, usually around six months after the injury. (6,7)
 

Key Clinical Features

  • Usually presents with unilateral tearing during eating, drinking, or smelling food (rarely bilateral). (8,9)
  • No associated eye irritation, photophobia, or pain. (8,9)
  • Eye and lacrimal structures appear normal on clinical and slit-lamp examination. (8,9)

 

As understanding of ocular surface physiology has advanced, the Tear Film and Ocular Surface Society (TFOS) DEWS III has emphasised the idea of ‘non-disruptive assessment’ where diagnostic tests are designed to maintain the natural tear environment and provide accurate physiological measurements. (7,8) This change is based on the evidence that metrics like tear film breakup time, lipid layer behaviour, tear osmolarity, and blink dynamics are more dependable when measured without mechanical interference. As a result, non-invasive methods such as Non-Invasive Tear Breakup Time (NITBUT), interferometry, meibography, tear meniscus height, and blink pattern analysis have become more effective tools for the objective and consistent evaluation of DED. (9,10) These technologies help clinicians with early diagnosis of DED and differentiate the subtypes of DED with good accuracy, also improving patient comfort and clinical efficiency.

Category Details
Diagnostic Considerations
  • Lacrimal syringing confirms normal drainage and helps rule out Nasolacrimal Duct Obstruction (NLDO) (8,10,11)
  • Other causes of epiphora must be excluded, including: (8,10,11)
    • Punctal stenosis
    • Conjunctivitis
    • Corneal pathology
    • Conjunctival foreign bodies
Neurological Findings
  • In cases related to Vestibular Schwannoma, an absent corneal reflex may be present, requiring trigeminal nerve testing. (8)
  • Evaluation of vestibulocochlear nerve function, including hearing assessment, is necessary. (8)
  • Examination for signs of healed exposure keratopathy from prior lagophthalmos is essential. (8)

Table 1: Table showing diagnostic approach and relevant neurological findings

 

Treatment and Management

  • Management depends on symptom severity: mild cases often need only reassurance, monitoring, and lubricating eye drops for comfort. (8)
  • Botulinum toxin injection into the lacrimal gland is the most effective and widely used treatment, reducing abnormal tearing by blocking acetylcholine release along misdirected nerve fibres. (12)
  • Surgical procedures (e.g., lacrimal gland resection) are rarely used today because they are invasive and may lead to permanent complications. (8)

 

Conclusion

Crocodile Tears Syndrome is a rare but well-recognised sequela of facial nerve injury, most commonly following Bell’s palsy or surgical trauma. Misguided regeneration of parasympathetic fibres leads to inappropriate lacrimation during eating or other gustatory stimulation. Although the condition is benign, it may significantly impact quality of life. Diagnosis is clinical, supported by exclusion of other causes of tearing. Botulinum toxin injection remains the most effective and minimally invasive treatment option. With proper recognition and management, most patients achieve substantial symptomatic relief.

References

    1. McCoy, F. J., & Goodman, R. C. (1979). The crocodile tear syndrome. Plastic and reconstructive surgery, 63(1), 58-62.
    2. Tripathy, K., & Arsiwalla, T. (2025). Crocodile tears syndrome. In StatPearls [Internet]. StatPearls Publishing.
    3. Lima-Fontes, M., Leuzinger-Dias, M., Falcão-Reis, F., & Sousa, C. (2022). Injection of Botulinum Toxin A in the Lacrimal Gland for Treatment of Epiphora in Crocodile Tears Syndrome–A Case Report. International Medical Case Reports Journal, 537-542.
    4. Kirtane, M. V., Ogale, S. B., & Merchant, S. N. (1984). Vidian neurectomy for crocodile tears. Indian Journal of Ophthalmology, 32(4), 221-223.
    5. Gore, Y. A., Doshi, J., & Muzumdar, D. P. (2023). Crocodile tears syndrome after vestibular schwannoma surgery: A case report. International Journal of Surgery Case Reports, 111, 108850.
    6. GARDNER, W. J. (1966). Cross talk—the paradoxical transmission of a nerve impulse. Archives of neurology, 14(2), 149-156.
    7. Sadjadpour, K. (1975). Postfacial palsy phenomena: faulty nerve regeneration or ephaptic transmission?. Brain research, 95(2-3), 403-406.
    8. Tripathy, K., & Arsiwalla, T. (2025). Crocodile tears syndrome. In StatPearls [Internet]. StatPearls Publishing.
    9. Greene, J., & Al-Dhahir, M. A. (2023). Acoustic neuroma. In StatPearls [Internet]. StatPearls Publishing.
    10. Guntinas-Lichius, O., Volk, G. F., Olsen, K. D., Mäkitie, A. A., Silver, C. E., Zafereo, M. E., … & Ferlito, A. (2020). Facial nerve electrodiagnostics for patients with facial palsy: a clinical practice guideline. European Archives of Oto-Rhino-Laryngology, 277(7), 1855-1874.
    11. Stevens, S. (2009). Lacrimal syringing. Community Eye Health, 22(70), 31.
    12. Nava-Castaneda, A., Tovilla-Canales, J. L., Boullosa, V., Tovilla-y-Pomar, J. L., Monroy-Serrano, M. H., Tapia-Guerra, V., & Garfias, Y. (2006). Duration of botulinum toxin effect in the treatment of crocodile tears. Ophthalmic Plastic & Reconstructive Surgery, 22(6), 453-456.

 

 

About the Author

Avantika Bind

M. Optom Student
The Sankara Nethralaya Academy, Chennai, India

 

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