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C&P Exam Prep: Seventh (Facial) Cranial Nerve, Paralysis of

DC 8207 neurological 38 CFR 4.124a

DBQ Overview

Interview + Physical
Form Name
Cranial_Nerve_Conditions
Form Code
Cranial_Nerve_Conditions
Page Count
8
Examiner Type
Neurologist or Physician
Estimated Duration
30-45 minutes
Exam Format
Interview + Physical

What to Expect During Your Exam

Exam Overview

To document the current severity of seventh (facial) cranial nerve paralysis under 38 CFR - 4.124a DC 8207, including the degree of facial muscle innervation loss (complete, severe incomplete, or moderate incomplete), associated functional impairments, and impact on daily activities such as eating, speaking, and eye closure.

What the examiner evaluates:

  • Degree of facial muscle paralysis (complete vs. incomplete) and which specific muscle groups are affected
  • Symmetry of facial expression at rest and with voluntary movement (forehead wrinkling, eye closure, smiling, puffing cheeks)
  • Ability to fully close the eye on the affected side (lagophthalmos) and associated corneal exposure risk
  • Presence and severity of pain - constant excruciating, intermittent, or dull facial pain
  • Paresthesias and/or dysesthesias of the face
  • Numbness of facial distribution
  • Difficulty chewing (mastication) and swallowing
  • Difficulty speaking (dysarthria)
  • Alterations in salivation - increased or decreased
  • Gastrointestinal symptoms related to autonomic involvement
  • Presence of synkinesis (involuntary co-movements) or hemifacial spasm
  • Taste disturbance on anterior two-thirds of tongue (chorda tympani involvement)
  • Tear production abnormalities (dry eye or excessive tearing/crocodile tears)
  • Presence of scars or disfigurement related to the condition or surgical treatment
  • Functional impact on work, social interactions, and activities of daily living
  • Results of prior EMG/nerve conduction studies or neuroimaging
  • Treatment history including physical therapy, eye protection measures, surgical interventions

Exam will include both a history interview and a direct neurological physical examination of the face. The examiner will observe facial symmetry at rest, test voluntary facial movements, assess eye closure completeness, and evaluate the territories served by the facial nerve branches. Bring any prior nerve conduction or EMG reports, ophthalmology records documenting corneal exposure, and photographs documenting facial asymmetry if available.

Typical duration: 30-45 minutes

Facial Symmetry Assessment - Voluntary Movement Testing

The examiner observes your ability to voluntarily activate each branch of the facial nerve: forehead (temporal branch), eye closure (zygomatic branch), cheek/smile (buccal branch), lip depression (marginal mandibular branch), and neck (cervical branch). This directly maps to the rating criteria's 'relative loss of innervation of facial muscles' under DC 8207.

What to expect:

The examiner will ask you to raise your eyebrows, wrinkle your forehead, close both eyes tightly, smile, show your teeth, puff out your cheeks, and frown. They will observe for weakness, asymmetry, incomplete movement, or total absence of movement on the affected side.

Key thresholds:

  • Complete paralysis - no voluntary movement of any facial musculature on affected side — 30% rating under DC 8207
  • Incomplete, severe - markedly reduced voluntary movement affecting multiple facial muscle groups; significant facial asymmetry; inability to fully close eye — 20% rating under DC 8207
  • Incomplete, moderate - partial weakness in one or more facial muscle groups; noticeable asymmetry; some preserved function — 10% rating under DC 8207

Tips:

  • Do not consciously compensate or try harder during the exam than you do in daily life - demonstrate your typical functional level.
  • If your symptoms fluctuate, perform the movements as you do on an average or bad day.
  • If you experience fatigue or worsening with repeated facial movements, tell the examiner before and after the test.
  • Report any pain or discomfort during facial movement, including eye pain with forced closure attempts.

Pain considerations: If attempting to close the affected eye or perform facial movements causes pain, aching, or burning, clearly state this during the assessment. Pain during voluntary movement is a relevant symptom that should be documented.

Eye Closure Completeness Testing (Lagophthalmos Assessment)

Measures whether the eye on the affected side can fully close, partially close, or cannot close at all. Incomplete eye closure (lagophthalmos) indicates zygomatic/upper facial branch involvement and creates serious corneal exposure risk. This is a critical functional finding that supports higher ratings.

What to expect:

The examiner will ask you to gently and then forcefully close both eyes and will observe the gap remaining on the affected side. They may measure the gap in millimeters. They will also check Bell's phenomenon (upward eye roll with closure attempt) as a protective mechanism.

Key thresholds:

  • Complete inability to close eye (lagophthalmos with full gap) — Supports complete paralysis - 30% rating
  • Partial eye closure with significant gap (>3-4mm) — Supports severe incomplete paralysis - 20% rating
  • Near-complete closure with minor gap or reduced forcefulness — Supports moderate incomplete paralysis - 10% rating

Tips:

  • If you experience eye dryness, redness, tearing, or need to use eye drops due to incomplete closure, bring documentation and mention it explicitly.
  • If you have been prescribed eye lubricants, protective eyewear, or eye patching, bring your prescriptions or bottles to the exam.
  • Any history of corneal abrasions or ophthalmology visits for eye exposure should be disclosed.
  • Describe whether you must consciously tape your eye shut at night to sleep safely.

Pain considerations: Eye pain, grittiness, burning, or sensitivity to light (photophobia) from corneal exposure secondary to incomplete eye closure are significant symptoms. Describe frequency, severity on a 0-10 scale, and any emergency or unplanned ophthalmology visits.

Facial Nerve Sensory and Autonomic Assessment

Although CN VII is primarily a motor nerve, it carries autonomic fibers (to lacrimal, submandibular, and sublingual glands) and special sensory fibers (taste, anterior two-thirds of tongue via chorda tympani). The examiner will assess taste disturbance, salivation abnormalities, tearing abnormalities, and any facial paresthesias or numbness.

What to expect:

The examiner may ask you to describe taste sensation, whether you experience dry mouth, excessive drooling, crocodile tears (gustatory lacrimation), or abnormal tearing. They may lightly touch the face to assess for sensory changes, though primary sensory testing of the face tests CN V, which may also be involved.

Key thresholds:

  • Ageusia (complete loss of taste on anterior two-thirds of tongue) combined with motor paralysis — Supports completeness of nerve lesion - reinforces 30% rating evidence
  • Significantly decreased salivation causing difficulty eating or dry mouth symptoms — DBQ checkbox item - documents functional autonomic involvement
  • Increased salivation or drooling due to orbicularis oris weakness — DBQ checkbox item - functional impairment documentation

Tips:

  • If you experience dry eyes requiring lubricating drops, this reflects lacrimal gland hyposecretion from CN VII autonomic fiber involvement.
  • Crocodile tears (tearing while eating) is a recognized sequela of aberrant CN VII regeneration - mention if present.
  • Describe any taste changes accurately: complete loss, partial loss, or distorted taste (dysgeusia).
  • Salivation problems (too much drooling from lip weakness, or too little from gland involvement) should both be mentioned.

Pain considerations: Describe any facial numbness, tingling, burning, or hypersensitivity in the distribution of the face. Even though these may overlap with CN V territory, they are relevant to the overall functional picture and should be documented.

Functional Speech, Chewing, and Swallowing Assessment

The orbicularis oris and buccinator muscles controlled by CN VII are essential for articulating labial sounds (b, p, m, f, v), controlling food and liquid in the mouth during chewing, and preventing drooling. The examiner will assess whether facial paralysis affects these critical oral functions.

What to expect:

The examiner may ask you to speak, read a sentence aloud, or describe eating difficulties. They will listen for slurred or imprecise labial consonants and observe for drooling or food spillage from the corner of the mouth.

Key thresholds:

  • Significant difficulty speaking (labial dysarthria) - others cannot understand you clearly — DBQ checkbox - supports severe functional impairment at 20-30% level
  • Difficulty chewing - food falls out of mouth, cannot create oral seal, avoids certain foods — DBQ checkbox and DC 5325 minimum 10% floor if mastication is affected
  • Difficulty swallowing - pooling in oral cavity, choking on thin liquids — DBQ checkbox - significant functional finding

Tips:

  • Describe specific foods you can no longer eat or that cause problems (soups, thin liquids, hard foods requiring lip seal).
  • If you have changed your diet because of chewing or swallowing difficulties, describe this specifically.
  • Mention if speaking difficulties cause you to avoid social situations, phone calls, or affect your work.
  • Note any dental consequences from altered chewing patterns or food accumulating in the cheek (buccinator weakness).

Pain considerations: Jaw fatigue, facial muscle soreness after eating, or pain with prolonged speaking should be described. Describe how long you can eat or speak before symptoms worsen, and quantify in minutes if possible.

Estimate

Rating Criteria Breakdown

30% Complete paralysis of the seventh (facial) cranial nerve. To ...

Complete paralysis of the seventh (facial) cranial nerve. Total loss of innervation of all facial muscles on the affected side - no voluntary movement of forehead, inability to close eye (lagophthalmos), complete facial droop at rest, no ability to smile, retract lips, or wrinkle forehead. Significant functional consequences including eye exposure, inability to form oral seal, severe dysarthria, and disfigurement.

Key Symptoms

  • Complete facial immobility on affected side - no voluntary facial movement of any kind
  • Total inability to close eye (complete lagophthalmos) - corneal exposure requiring protective measures
  • Complete facial droop at rest with visible marked asymmetry
  • Total inability to raise eyebrow or wrinkle forehead on affected side
  • No ability to smile, retract corner of mouth, or show teeth on affected side
  • Complete loss of oral seal - drooling, food spillage, inability to drink from a cup normally
  • Severe labial dysarthria - speech significantly impaired for labial consonants
  • Loss of taste on anterior two-thirds of tongue (chorda tympani involvement)
  • Significant autonomic involvement - severely reduced tearing or salivation
  • Facial pain that may be constant and at times excruciating
  • Significant disfigurement affecting social interaction and emotional wellbeing

CFR: 38 CFR - 4.124a DC 8207: 'Paralysis of: Complete 30' - dependent upon complete loss of innervation of all facial muscles.

20% Incomplete, severe paralysis of the seventh (facial) cranial ...

Incomplete, severe paralysis of the seventh (facial) cranial nerve. Markedly reduced but not completely absent voluntary facial movement. Significant functional consequences present but some residual innervation preserved. Multiple facial muscle groups affected with severe weakness - near inability to close eye, marked facial asymmetry at rest and with movement, severe chewing or speaking difficulty.

Key Symptoms

  • Markedly reduced voluntary facial movement - nearly absent but some weak flicker preserved
  • Near-complete inability to close eye with significant gap remaining - requires eye protection
  • Marked facial asymmetry at rest and with attempted voluntary movement
  • Severe weakness of forehead elevation - very limited or trace movement only
  • Severe oral incompetence - significant drooling, major difficulty creating oral seal
  • Severe labial dysarthria noticeably affecting speech intelligibility
  • Significant difficulty chewing - avoids many foods, altered diet required
  • Significant pain - intermittent severe facial pain or constant dull pain
  • Paresthesias or dysesthesias of the face causing ongoing distress
  • Significant autonomic symptoms - reduced tearing, abnormal salivation
  • Marked disfigurement affecting social functioning and quality of life

CFR: 38 CFR - 4.124a DC 8207: 'Paralysis of: Incomplete, severe 20' - markedly impaired innervation of facial muscles with near-complete functional loss.

10% Incomplete, moderate paralysis of the seventh (facial) crani ...

Incomplete, moderate paralysis of the seventh (facial) cranial nerve. Partial loss of innervation of facial muscles with noticeable but not severe functional impairment. Some voluntary movement preserved in most muscle groups but with measurable weakness and asymmetry. Symptoms are present and functionally limiting but less debilitating than severe incomplete paralysis. Also the minimum rating under DC 5325 if mastication is affected to any extent.

Key Symptoms

  • Partial weakness of facial muscles - voluntary movement present but reduced and asymmetric
  • Incomplete eye closure with mild gap or reduced forcefulness - some protective function preserved
  • Noticeable facial asymmetry that worsens with voluntary movement attempts
  • Mild-to-moderate forehead weakness - reduced but present eyebrow elevation
  • Mild oral incompetence - occasional drooling, minor difficulty with oral seal particularly for liquids
  • Mild labial dysarthria - speech affected but generally intelligible
  • Some difficulty chewing certain foods - mastication affected to at least some extent
  • Intermittent or dull facial pain
  • Mild paresthesias or numbness in facial distribution
  • Mild autonomic involvement - intermittent tearing or minor salivation changes
  • Visible asymmetry causing self-consciousness or mild social impact

CFR: 38 CFR - 4.124a DC 8207: 'Paralysis of: Incomplete, moderate 10' - partial loss of innervation of facial muscles. Also DC 5325 minimum 10% when mastication is affected to any extent.

How to Describe Your Symptoms

Facial Movement and Muscle Weakness

How to describe:

Describe which specific facial movements you cannot perform or can only perform weakly. Be specific: 'I cannot raise my left eyebrow at all,' 'I can only partially close my left eye and it remains open about a centimeter even when I try my hardest,' 'When I smile my face only moves on the right side.' Describe the degree of asymmetry others notice and how you perceive it in the mirror.

Worst-day example:

“On my worst days, I cannot close my left eye at all even pressing my finger to my lid, my entire left side of my face is completely drooped with no movement, I drool uncontrollably, and I cannot form words that begin with B, P, or M clearly enough for anyone to understand me on the phone.”

What the examiner listens for:

The examiner wants to know which muscle groups are affected, how severely, and whether the weakness is partial (incomplete paralysis) or total (complete paralysis). They are specifically mapping your symptoms to the 'relative loss of innervation of facial muscles' language in DC 8207.

Understatements to avoid:

Do not say 'my face is a little weak' - specify which movements are absent or reduced. Do not say 'it's mostly fine' if you have compensated over time. Describe your actual functional deficits, not how well you have adapted.

Eye Closure and Corneal Protection

How to describe:

Specify whether you can fully close your eye, and if not, how large the gap remains in millimeters if known. Describe your eye protection routine: 'I use lubricating eye drops every hour,' 'I tape my eye shut every night with medical tape,' 'I wear an eye patch or moisture chamber glasses.' Describe any corneal problems, eye infections, or emergency eye care visits.

Worst-day example:

“On bad days my eye is so dry and painful from exposure that I cannot focus on reading or working on a computer for more than 10 minutes. The burning sensation wakes me up at night even with tape on my eye. I had to go to the emergency room twice for corneal abrasions because my eye dried out while I slept.”

What the examiner listens for:

The examiner is assessing whether lagophthalmos is present and whether it constitutes a severe or complete functional deficit. The inability to protect the cornea is a serious and ratable consequence of CN VII paralysis that substantiates higher rating levels.

Understatements to avoid:

Do not minimize eye symptoms as 'just dryness.' Corneal exposure from incomplete eye closure is a direct and serious complication of facial nerve paralysis. Describe every eye care measure you take and every symptom you experience.

Pain - Facial, Ear, and Periorbital

How to describe:

Classify your pain as the DBQ does: constant pain that is at times excruciating, intermittent pain, or dull ongoing pain. Give a 0-10 severity rating for your average day and your worst day. Describe the location precisely: behind the ear (mastoid), across the cheek, around the eye socket, or radiating. Describe triggers and duration of pain episodes.

Worst-day example:

“On my worst days I have a constant burning and stabbing pain rating a 9 out of 10 that starts behind my left ear and radiates across my entire left face. It lasts all day regardless of what I take for it. Even wind touching my face or a light breeze triggers severe pain that leaves me unable to work or concentrate.”

What the examiner listens for:

The examiner will document which pain checkbox applies - constant/excruciating, intermittent, or dull - and the specific location and severity. These pain characteristics directly map to DBQ fields that influence the overall disability picture the rater uses alongside the motor findings.

Understatements to avoid:

Do not say 'I just take Tylenol for it.' Describe the actual severity and functional impact of your pain. If pain keeps you from sleeping, working, socializing, or performing activities of daily living, state this specifically and quantify it.

Eating, Chewing, and Swallowing Difficulties

How to describe:

Describe specific foods you can no longer eat or avoid due to the facial paralysis (tough meats, hard vegetables, soups/liquids that spill). Describe whether food accumulates in your cheek (a sign of buccinator weakness). Explain if you drool during meals or if food falls out of your mouth. Describe any swallowing difficulties and whether you have choked or aspirated liquids.

Worst-day example:

“On bad days I cannot eat anything that requires a proper lip seal or significant chewing. I stick to soft pureed foods because I cannot control food in my left cheek - it just collects there. When I try to eat soup or drink water I spill it down my chin. Meals that used to take 15 minutes now take 45 minutes and leave me exhausted. I have lost weight because eating is so difficult and embarrassing.”

What the examiner listens for:

The examiner is documenting whether difficulty chewing (mastication) is present at any level. Under DC 5325, even any interference with mastication supports a minimum 10% rating. Swallowing difficulty suggests involvement beyond pure motor paralysis and adds to the functional picture.

Understatements to avoid:

Do not say 'I manage okay' if you have changed your diet, eat more slowly, or avoid certain foods. Adaptations and diet modifications due to your condition are evidence of functional impairment, not evidence that your condition is under control.

Speech Difficulties

How to describe:

Describe which sounds or words are difficult - labial consonants (B, P, M, F, V, W) are typically most affected. Describe how often others ask you to repeat yourself, whether you avoid phone calls or speaking in groups, and whether your speech difficulty has affected your work or social life. Rate severity on your average day versus your worst day.

Worst-day example:

“On my worst days people cannot understand me over the phone at all. I have to spell out words or ask someone else to make calls for me. I have stopped attending meetings at work and avoid speaking in public because I am embarrassed and frequently misunderstood. My supervisor has noticed the change in my speech.”

What the examiner listens for:

The examiner will listen to your natural speech during the interview. Mention speech difficulty proactively even if the examiner does not specifically test it. Describe the practical impact - avoiding social situations, job tasks, or communication because of speech impairment.

Understatements to avoid:

Do not avoid mentioning speech difficulty because it seems minor compared to the eye or motor symptoms. Dysarthria from CN VII paralysis is documented on the DBQ and contributes to the functional impairment picture.

Salivation, Taste, and Autonomic Symptoms

How to describe:

Describe whether your saliva production has changed: 'My mouth is extremely dry and I cannot eat dry foods without large amounts of water,' or 'I drool uncontrollably, especially when my attention is elsewhere or during sleep.' For taste, describe whether foods taste different, absent, or distorted on one side of your tongue. For tearing, describe whether your eye is constantly dry or whether you experience excessive tearing while eating.

Worst-day example:

“My taste on the left side of my tongue has been gone since the paralysis began. I cannot taste sweet or salty on that side at all. Additionally, when I eat, my left eye tears up uncontrollably - my doctor called it crocodile tears. This is embarrassing in social situations and I have stopped eating in public.”

What the examiner listens for:

The examiner is checking for involvement of the chorda tympani (taste, submandibular gland secretion) and the greater petrosal nerve (lacrimal gland). These autonomic and special sensory findings indicate the level and completeness of the nerve lesion.

Understatements to avoid:

Do not assume taste or tearing symptoms are unrelated or unimportant. These are direct functions of CN VII and their impairment substantiates the completeness of the nerve lesion, which supports higher rating levels.

Disfigurement and Psychosocial Impact

How to describe:

Describe the visible facial asymmetry and its impact on your daily social life, employment, and mental health. Be specific: 'I no longer make eye contact with people because of my facial droop,' 'I have stopped attending family events or social gatherings,' 'I was passed over for a promotion because of my appearance,' 'I have developed depression and social anxiety secondary to the disfigurement.'

Worst-day example:

“On bad days I cannot look in the mirror without severe distress. I have canceled social plans, avoided family photos, and stopped going to my place of worship because of the stares I receive. I have begun wearing masks even outside of required situations to hide my face. I have sought counseling for depression directly caused by the change in my appearance.”

What the examiner listens for:

The DBQ specifically asks about scars and disfigurement. Disfigurement from facial nerve paralysis may be separately ratable under DC 7800. The examiner documents these findings, and the rater may assign additional ratings for disfigurement if separate and distinct.

Understatements to avoid:

Do not understate the emotional and social impact of a visible facial deformity. The VA recognizes disfigurement as independently ratable. If you have sought mental health treatment for depression or anxiety related to your facial condition, mention this and provide records.

Common Mistakes to Avoid

Prep Checklist

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Before Your Exam

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After the Exam

Your Rights During a C&P Exam

  • You have the right to an adequate C&P examination - one that is thorough enough to rate your condition under the applicable diagnostic codes. If the examination is inadequate, you can request a new one.
  • You have the right to request audio or video recording of your C&P examination in most states. Check your state's consent laws and VA policy before your appointment.
  • You have the right to review the completed DBQ report after it is finalized and to submit a written statement correcting inaccuracies in the factual findings.
  • You have the right to submit buddy statements (VA Form 21-10210) from lay witnesses who can describe the functional impact of your facial nerve paralysis as they observe it in your daily life.
  • You have the right to have your claim rated at the level warranted by the complete evidentiary record, not solely based on the examiner's label. Per M21-1, the rating activity reviews all objective findings - the rater is not bound by the examiner's characterization of severity level.
  • You have the right to submit a Nexus letter or Independent Medical Opinion (IMO) from your own treating neurologist that may contradict or supplement the C&P examiner's findings.
  • You have the right to request the benefit of the doubt. Under 38 USC - 5107(b), when there is an approximate balance of positive and negative evidence, the VA must resolve the matter in your favor.
  • You have the right to appeal a rating decision you disagree with through the Supplemental Claim, Higher-Level Review, or Board of Veterans' Appeals lanes under the Appeals Modernization Act.
  • You have the right to a free VSO representative to assist with your claim at no charge. VSOs include the DAV, American Legion, VFW, and many others.
  • You have the right to seek a separate rating for disfigurement under DC 7800 if your facial nerve paralysis has resulted in a disfiguring scar or permanent facial deformity, in addition to your DC 8207 rating.

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This C&P exam preparation guide is for educational purposes only and does not constitute legal, medical, or claims advice. Always consult with a qualified Veterans Service Organization (VSO) representative or VA-accredited attorney for guidance specific to your claim. Never exaggerate, minimize, or fabricate symptoms during a C&P examination.