Facial Grading System

Original Editor - Wendy Walker

Lead Editors - Vidya Acharya

One Page Owner - Wendy Walker as part of the One Page Project 

Introduction[edit | edit source]

The Facial Grading System [FGS] is also known as the Sunnybrook Facial Grading System as it was devised and established at the Sunnybrook Health Sciences Centre in Toronto. The clinicians who developed the FGS intended to create a measure which provided a quantitative score for reporting purposes, which would be sensitive enough to detect clinically important change over time or with treatment[1].

Objective[edit | edit source]

The Facial Grading System is a tool used for clinical evaluation of Facial Nerve function. It scores range of movement of the facial muscles, and records the score as a % where full range movement = 100%. It is easy for the clinician to compare range of movement on the affected side of the face to the contralateral side.

Intended Population[edit | edit source]

The FGS is intended for use on people with Facial Palsy irrespective of the cause of the facial palsy or weakness.

Method of Use[edit | edit source]

The FGS comprises 3 areas of evaluation[1]:

  1. Evaluation of resting symmetry
  2. Degree of voluntary excursion of facial muscles
  3. Degree of synkinesis associated with specific voluntary movement

The regions of the face are evaluated separately, with the use of 5 standard expressions:

  • eyebrow raise
  • eye closure
  • open mouth smile
  • lip pucker
  • snarl/show teeth

All the above items are evaluated on point scales, and a cumulative composite score is calculated.

Reliability[edit | edit source]

Studies have round the FGS to have good intrarater and inter-rater reliability[2][3][4].

One study[3] concluded "The intrarater reliability coefficients for the raters ranged from .838 to .929... The FGS is as reliable when applied by novice users as by expert users."

Comparison to other Facial Nerve Grading Instruments[edit | edit source]

One comprehensive 2015 study[5] examined a large number of grading instruments of facial nerve function, scoring each system against the e following criteria:

  • convenience of clinical use
  • regional scoring
  • static and dynamic measures
  • features secondary to facial palsy (e.g., synkinesis),
  • reproducibility with low inter-observer and intra-observer variability
  • sensitivity to changes over time and/or following interventions.

The authors concluded that they "recommend widespread adoption of the Sunnybrook Facial Grading Scale as the current standard in reporting outcomes of facial nerve disorders."

A prospective follow-up study comparing patient-reported facial and psychosocial function (FaCE scale and FDI outcome measures) with physician-graded facial function (Sunnybrook and House-Brackmann grading) in early and follow-up stages in Bell’s palsy patients showed low to fair correlation between FaCE/FDI and Sunnybrook score in early stages, suggesting a quality of life (QOL) designs are less suited for the acute stage, and higher correlations at follow-ups suggest using of questionnaires for QoL evaluation with time[6].

Usefulness in Physiotherapy for Facial Palsy[edit | edit source]

The FGS is extremely useful for measuring improvements made in physiotherapy/facial rehabilitation. Its sensitivity means that even small changes in range of movement will be recognised, and the Synkinesis section of the system enables an increased score even when there is no increase in range of movement, provided that synkinesis is reduced.

These factors mean that the FGS can be used on a regular basis to quantify progress made in therapy, providing useful feedback to the patient of the gains made, and helping with motivation.

It is for these reasons that many physiotherapists working with facial palsy use the FGS in preference to the House-Brackmann Scale.

References[edit | edit source]

  1. 1.0 1.1 Ross BG, Fradet G, Nedzelski JM. Development of a sensitive clinical facial grading system Otolaryngol Head Neck Surg. 1996 Mar:114(3):380-6
  2. Neely JG, Cherian NG, Dickerson CB, Nedzelski JM. Sunnybrook facial grading system: reliability and criteria for grading. Laryngoscope. 2010 May;120(5):1038-45
  3. 3.0 3.1 Hu WL, Ross B, Nedzelski J. Reliability of the Sunnybrook Facaial Grading System by novice users. J Otolaryngol. 2001 Aug;30(4):208-11
  4. Kanerva M, Poussa T, Pitkaranta A. Sunnybrook and House-Brackman Facial Grading Systems: intrater repeatability and interrater agreement. Otolaryngol Head Neck Surg. 2006 Dec; 135(6): 865-71
  5. Fattah AY, Gurusinghe AD, Gavilan J, Hadlock TA, et al. Facial nerve grading instruments: systematic review of the literature and suggestion for uniformity. Plast Reconstr Surg. 2015 Feb;135(2):569-79.
  6. Bylund N, Hultcrantz M, Jonsson L, Marsk E. Quality of Life in Bell's Palsy: Correlation with Sunnybrook and House‐Brackmann Over Time. The Laryngoscope. 2021 Feb;131(2):E612-8.