House Brackmann

Bels Palsy Score

Facial nerve dysfunction (facial paralysis) manifests in various symptom patterns. To

objectively describe facial function, clinicians use a number of standardised scales the most common being the House-Brackmann facial nerve grading system.
Symptoms of facial nerve injury may vary due to age, facial anatomy and the extent
of nerve-damage. Frequent patient concerns relate to brow position, movement
abnormalities, eyelid closure issues, inability to smile, mid-facial asymmetries, poor
oral function and lower lip asymmetry.
A light degree of facial nerve weakness may only be visible as subtle asymmetries
following repeated and exhausting muscle function, whereas severe dysfunction can
be easily recognised even at rest.
Many of these symptoms will change over time, for example following a spontaneous
recovery of nerve function or as a result of different therapeutic modalities (i.e after
surgical treatment).
Standarised assessment of facial function
House-Brackmann (HB) is one of several analysis tools developed to quantify facial
function and provide reproducible information. It is a widely accepted system,
simple, sensitive, accurate and reliable - grading facial function in six steps from
normal (HB I) to total paralysis (HB VI).
At the Sorensen Clinic we routinely use the House-Brackmann scale to evaluate new
and existing patients. In addition we include a description of segmental weakness
(zone-specific information), changes in the facial soft tissues and synkinesis.
House-Brackmann facial nerve grading system
Grade I - Normal
Normal facial function in all areas

Grade II - Slight Dysfunction

Gross: slight weakness noticeable on close inspection; may have very slight
synkinesis
At rest: normal symmetry and tone
Motion: forehead - moderate to good function; eye - complete closure with minimum
effort; mouth - slight asymmetry.
Grade III - Moderate Dysfunction
Gross: obvious but not disfiguring difference between two sides; noticeable but not
severe synkinesis, contracture, and/or hemi-facial spasm.
At rest: normal symmetry and tone
Motion: forehead - slight to moderate movement; eye - complete closure with effort;
mouth - slightly weak with maximum effort.
Grade IV - Moderate Severe Dysfunction
Gross: obvious weakness and/or disfiguring asymmetry
At rest: normal symmetry and tone
Motion: forehead - none; eye - incomplete closure; mouth - asymmetric with
maximum effort.
Grade V - Severe Dysfunction
Gross: only barely perceptible motion
At rest: asymmetry
Motion: forehead - none; eye - incomplete closure; mouth - slight movement
Grade VI - Total Paralysis
No movement
House, J.W., Brackmann, D.E. Facial nerve grading system. Otolaryngol. Head Neck
Surg, [93] 146147. 1985.