A patient is drooling and cannot close the left eye. You would be concerned about all of the following EXCEPT:

Correct answer: B. Inability to sleep

• A. IS a genuine concern. Loss of the blink reflex and inability to close the lid leaves the cornea unprotected against foreign bodies and mechanical injury.
• B. CORRECT — this is the EXCEPTION. Facial nerve palsy causes a functional problem with the eyelid, not with the sleep cycle. Insomnia is not a recognised consequence of CN VII palsy. (The eye remaining open during sleep is a mechanical problem of lagophthalmos, requiring taping and lubricant — but the patient sleeps normally.)
• C. IS a genuine concern. Without blinking, the tear film is not distributed across the cornea and it dries rapidly.
• D. IS a genuine concern. Exposure keratitis, and potentially corneal ulceration and scarring, is the most serious ocular complication of facial palsy — which is why eye protection is the first management priority.

Note: Management priority in facial palsy is EYE PROTECTION: artificial tears during the day, ointment and taping or a moisture chamber at night, and ophthalmology referral if the exposure is prolonged.