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Table of Contents    
Year : 2021  |  Volume : 69  |  Issue : 2  |  Page : 526-527

Iatrogenic Lagophthalmos or Lid Lag. An Uncommon Occurrence Following Scalp Block

Department of Anaesthesiology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India

Date of Submission10-May-2019
Date of Decision04-Nov-2019
Date of Acceptance07-Jan-2020
Date of Web Publication24-Apr-2021

Correspondence Address:
Rudrashish Haldar
Department of Anaesthesiology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0028-3886.314563

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How to cite this article:
Singh MK, Haldar R, Kannaujia AK, Das KK. Iatrogenic Lagophthalmos or Lid Lag. An Uncommon Occurrence Following Scalp Block. Neurol India 2021;69:526-7

How to cite this URL:
Singh MK, Haldar R, Kannaujia AK, Das KK. Iatrogenic Lagophthalmos or Lid Lag. An Uncommon Occurrence Following Scalp Block. Neurol India [serial online] 2021 [cited 2021 May 14];69:526-7. Available from:


Scalp block is an inimitable technique with proven efficacy in diverse neurosurgical procedures such as awake craniotomies, burr hole, deep brain stimulation, and stereotactic surgeries. However, this technique has its fair share of reported complications which include intravascular injection causing systemic toxicity, subarachnoid injection, hypertension,[1] ptosis,[2] and neural damage. A previous exhaustive review on the scalp block had speculated regarding the potential of the development of facial nerve paralysis.[1],[3],[4] We encountered a situation where a patient developed transient palsy of specific divisions of the facial nerve following the application of the scalp block. After obtaining written and informed consent from the patient we desire to report this unusual incident.

A 39-year-old male patient scheduled for a stereotactic biopsy of right frontoparietal glioma was administered a scalp block wherein the supraorbital, supratrochlear, zygomaticotemporal, auriculotemporal, lesser and greater occipital nerves were blocked bilaterally. About 10 min following the block, the patient complained of incomplete closure of the left eye [Figure 1]. Additionally, there was a slight asymmetry while raising the eyebrows and the corneal reflex was impaired on the left side. However, the patient had no sensory loss on the left side of the face or facial asymmetry. He could show his teeth and puff his cheeks properly. A provisional diagnosis of an inadvertent block of branches of the left facial nerve by local anesthetic was made and the patient was reassured. Lubricating eye drop was applied in the affected eye and it was taped shut lightly and the procedure was started. Within 2 hours, the patient started regaining slight activity of the left eyelid and by 6 hours his eyelid could close normally as before. The procedure completed uneventfully.
Figure 1: Incomplete closure of left eye following scalp block

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The facial nerve's extracranial segment traverses through the parotid gland and ramifies into five terminal branches which include the upper temporal and zygomatic branches. The temporal and zygomatic branches supply the orbicularis oculi (upper and lower half, respectively) which is the muscle necessary for voluntary closure of the eyelid.[5] Additionally, the temporal branch supplies the frontalis and corrugator supercilii muscles which help in raising the eyebrows and frowning.[6] and along with the zygomatic branch are the efferent limb of corneal reflex. The facial nerve's terminal branches (frontal and zygomatic) lie in close anatomical proximity of the zygomaticotemporal and auriculotemporal nerves which are targeted during the scalp block and might be affected by the spread of the infiltrated local anesthetic. Although an accurate localization may not be possible retrospectively, by tracing the course of the facial nerve and correlating the specific deficits produced, it is highly possible that these terminal branches of facial nerves got blocked while either of these nerves was being anesthetized. This is further supported by the transient and reversible nature of the patient's deficits.

Clinicians thus should be mindful of this complication of scalp block so that they can recognize the same if it occurs. Judicious volumes and ultrasound-guided super selective injection of local anesthetics are strategies to avoid the same.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Osborne I, Sabeo J. ''Scalp block'' during craniotomy: A classic technique revisited. J Neurosurg Anesthesiol 2010;22:187-94.  Back to cited text no. 1
Hassan MH, Hassan WM, Kandasamy R, Chong SE. Unilateral complete ptosis after scalp block for awake craniotomy: A rare complication. J Neuroanaesthesiol Crit Care 2018;5:111-3.  Back to cited text no. 2
McNicholas E, Bilotta F, Titi L, Chandler J, Rosa G, Koht A. Transient facial nerve palsy after auriculotemporal nerve block in awake craniotomy patients. A A Case Rep 2014;2:40-3.  Back to cited text no. 3
Sargın M, Samancıoğlu H, Uluer MS. Transient facial nerve palsy after the scalp block for burr hole evacuation of subdural hematoma. Turk J Anaesthesiol Reanim 2018;46:238-40.  Back to cited text no. 4
Ouattara D, Vacher C, de Vasconcellos JJ, Kassanyou S, Gnanazan G, N'Guessan B. Anatomical study of the variations in innervation of the orbicularis oculi by the facial nerve. Surg Radiol Anat 2004;26:51-3.  Back to cited text no. 5
Emamhadi MR, Mahmoudi D. Recovery of facial nerve paralysis after temporal nerve reconstruction: A case report. Trauma Mon 2015;20:e20578.  Back to cited text no. 6


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