Facial nerve palsy grading in table
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Facial Nerve Palsy Grading - House-Brackmann System
The House-Brackmann (HB) scale is the gold standard for grading facial nerve function, endorsed by the American Academy of Otolaryngology - Head and Neck Surgery (AAO-HNS).
| Grade | Degree of Dysfunction | Clinical Features |
|---|---|---|
| I | Normal | Normal symmetrical function in all areas |
| II | Mild (barely noticeable) | - Slight weakness noticeable only on close inspection - Complete eye closure with minimum effort - Slight asymmetry of smile with maximal effort - Synkinesis barely noticeable; no contracture or spasm |
| III | Moderate (obvious difference) | - Obvious weakness, but not disfiguring - May not be able to lift eyebrow - Complete eye closure with strong but asymmetric mouth movement with maximal effort - Obvious but not disfiguring synkinesis, mass movement or spasm |
| IV | Moderately Severe | - Obvious disfiguring weakness - Inability to lift eyebrow - Incomplete eye closure; asymmetry of mouth with maximal effort - Severe synkinesis, mass movement, spasm |
| V | Severe | - Motion barely perceptible - Incomplete eye closure; slight movement of corner of mouth - Synkinesis, contracture and spasm usually absent |
| VI | Total Paralysis | No movement; loss of tone; no synkinesis, contracture, or spasm |
Key Memory Aids
| Grade | Eye Closure | Forehead Movement | Synkinesis |
|---|---|---|---|
| I | Normal | Normal | None |
| II | Complete (min. effort) | Present | Barely noticeable |
| III | Complete (strong effort) | May be absent | Obvious, not disfiguring |
| IV | Incomplete | Absent | Severe |
| V | Incomplete | Absent | Usually absent |
| VI | None | None | None |
Other Grading Systems
| System | Description |
|---|---|
| Sunnybrook Scale | Regional scoring (brow, eye, mouth) with synkinesis scoring; more precise for differential palsy |
| Burres-Fisch | Requires multiple measurements of movement at different facial points; correlates with HB but more complex |
| Nottingham System | Subjective estimation at multiple facial points; simpler than Burres-Fisch; correlates well with HB |
Sunderland Nerve Injury Classification (structural basis for grading)
| Degree | Injury Type | Structures Involved | Prognosis |
|---|---|---|---|
| 1st | Neuropraxia | Axoplasm flow blockage | Excellent |
| 2nd | Axonotmesis | Axon + myelin | Good (Wallerian degeneration) |
| 3rd | Neurotmesis | Axon + myelin + endoneurium | Poor |
| 4th | Neurotmesis | + perineurium | Poor |
| 5th | Neuromesis | All layers of nerve sheath | Very poor |
Clinical note: A single global HB score primarily reflects eye function. For cases with differential regional palsy, the HB grade should be reported separately for the forehead, eye, nose, and mouth for a more precise evaluation.
Sources: Scott-Brown's Otorhinolaryngology Head & Neck Surgery Vol 2, Table 112.2; K.J. Lee's Essential Otolaryngology
Summarise the table
House-Brackmann Facial Nerve Grading - Quick Summary
| Grade | Severity | One-Line Description |
|---|---|---|
| I | Normal | Full symmetrical function |
| II | Mild | Slight weakness; eye closes easily; minor smile asymmetry |
| III | Moderate | Obvious but non-disfiguring weakness; eye still closes fully |
| IV | Moderately Severe | Disfiguring weakness; eye cannot close fully; no forehead movement |
| V | Severe | Barely any movement; only a flicker at the mouth corner |
| VI | Total Paralysis | No movement at all |
The critical divide is between Grade III and IV - complete vs. incomplete eye closure. Grades I-III have complete eye closure; Grades IV-VI do not.
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