Descrbe briefly House-Brackman Grading system of facial nerve paralysis.

The most commonly used clinical grading scale is the House Brackmann (HB) facial nerve grading system which has proposed a six point scale for reporting the result of surgery for acoustic tumours. This system was modified and called House Brackmann system. The American academy of Otolaryngy0logy – Head and Neck surgery has adopted this system to standardize the reporting of disorder of the facial nerve and treatment result. It differentiates six grades of facial function (I-IV), grade I is normal function and grade VI complete absence of facial motor function and grades II-V are intermediate. It has two domains of assessment:

1) Gross observation

2)Movement of forehead/eye/mouth


GradeDescription of degree of injuryCharacterstics
INormalNormal symmetrical function is all area
IIMild dysfunction (1-2)(Briefly noticeable)Gross- Slightly weakness noticeable only on close inspection, very slightly synkiness.
At rest- Normal symmetry and tone
Motion: Forehead- moderate to good fxn
Eye- Complete closure c minimum effort
Mouth- Slight asymmetry of smile c maximumal effort
Contractuce and spasm
IIIModerate dysfunction (2-3) (ovious difference)Gross: Obvious but not disfiguring difference b/w 2 sides
At rest: Normal symmetric and tone.
Motion: Forehead symmetric and tone
Motion: Forehead- slight to moderate movement
Eye- Complete closure c maximal effort
mouth- Asymmetric c maximum effort
Noticeable but severe synkiness contache or spasm
IVModerately serve dysfxn(3)Grass: Obvious weekness or disfigueing
At rest: N symmetry and tone
Motion: Forehead- none
Eye- incomplete closure c max effort
mouth- asymmetric c max effort
Severe Synkiness mass movement and spasm
VSevere dusfunction (3-4)Gross: Motion barely perceptible
At rest: asymmetry
Motion: Forehead- none
Eye-incomplete closure
Mouth- slight movementcorhea
Synkiness, contracture and spasm usually
VITotal paralysisNo movement
Loss of tone
No synkiness/ Contracture or spasm


However, the House brackmann scale is not a perfect grading system because of:

  • the problems of inter-observer and intra-observer variability
  • It is applicable only to disorder of the nerve proximal to the pes-anserinus
  • It is not appropriate for single branch injuries such as penetrating injury to the face affecting only the buccal branch.

The House brackmann scale is not useful in assessing transected/ repaired nerves for 3 reasons

  • All repair causes mass movement
  • Most patients can eventually close their eyes and have good oral sphincter function
  • Almost no patients are able to raise the eyebrow or forehead .

The House brackmann system works well as long as there is an intact nerve sheath or incomplete nerve injury (sunderland grades I-IV)

Tags: , , , , , , , ,

Leave a Reply

Your email address will not be published. Required fields are marked *

error: Dr. R Content is Protected !!!
%d bloggers like this:
Skip to toolbar