House–Brackmann Scale

Original Editor - Oyemi Sillo

Top Contributors - Wendy Walker, Oyemi Sillo, Angeliki Chorti, WikiSysop, Kim Jackson and Alexandra Stead  

Objective

The House-Brackmann Scale is one of the most commonly used tools internationally for the clinical evaluation of facial nerve function. The scale is based upon functional impairment, with six grades ranging between I (normal) and VI (no movement). This classification system was first described in 1985 by Dr John W. House and Dr Derald E. Brackmann, otolaryngologists in Los Angeles. 

Intended Population

The scale is used to determine the severity of facial nerve dysfunction in people with facial palsy. It helps determine facial weakness, asymmetry, and progress by evaluating specific movements like eyebrow elevation and mouth movement.

The House-Brackmann Scale can be used irrespective of the cause of the palsy.

Method of Use

The score is determined by measuring: 

1. the upwards movement of the midportion of the top of the eyebrow
2. the outwards movement of the oral commissure

For both the eyebrow and oral commissure movement, 1 point is assigned for every 0.25 cm motion up to a maximum of 1cm. The scores for each structure are added together to give the House-Brackmann score. The maximum score obtainable is 8, if both structures move the full 1cm.

For objectivity, measurements should be made on both the normal and the affected side.

You can watch this video for better understanding the fascial nerve paralysis grading system:

You can also find the grading system criteria and scoring categories below.

_{House-Brackmann Facial Nerve Grading system criteria}

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-Brackmann Facial Nerve Grading system scoring}

Grade	Description	Measurement	Function %	Estimated Function %
I	Normal	8/8	100	100
II	Slight	7/8	76 - 99	80
III	Moderate	5/8 - 6/8	51 - 75	60
IV	Moderately Severe	3/8 - 4/8	26 - 50	40
V	Severe	1/8 - 2/8	1 - 25	20
VI	Total	0/8	0	0

Evidence

The House-Brackmann grading system has been found to be of high reliability, however, grading of individual items may be more challenging between trained observersand sensitivity to subtle changes is lower.

Clinical Relevance

Although the House-Brackmann grading system is widely established, its clinical usefulness has marked limitations. Having only 6 possible grades on gross motor function, it does not provide detailed information about specific dysfunctional areas in the face, but a simplistic overview.

There is no specific evaluation of synkinesis (aberrant linking of movements which is a sequelae of moderate to severe facial nerve damage) or contracture of the face.

Some report its lack of acknowledging other important areas of fascial palsy (i.e. other than motor) such as emotional expression, aesthetics or impact on quality of life.

But its main limitation for physiotherapists is that it is not sensitive enough to detect the small changes that occur during a course of rehabilitation.

Due to the above limitations, many physiotherapists working with facial palsy do not use this scale but instead use other alternatives such as the Sunnybrook Facial Grading System, the Facial Nerve Grading System 2.0, the Repaired Facial Nerve Recovery Scale (RFNRS) and the FaCE scale.

Resources

House-Brackmann - Fascial Nerve Grading (real patients)