Table 2. House-Brackmann Facial Nerve Grading System
Grade Severity Defined by:
1 Normal • Normal facial function in all areas
2 Mild
dysfunction
• Slight paresis/paralysis noticeable only on close inspection
• At rest: normal symmetry of forehead, ability to close eye with
minimal effort and slight asymmetry, ability to move corners of
mouth with maximal effort and slight asymmetry
• No synkinesis, contracture, or hemifacial spasm
3 Moderate
dysfunction
• Obvious but not disfiguring difference between 2 sides, no
functional impairment; noticeable but not severe synkinesis,
contracture, and/or hemifacial spasm
• At rest: normal symmetry and tone
• Motion: slight to no movement of forehead, ability to close eye
with maximal effort and obvious asymmetry, ability to move
corners of mouth with maximal effort and obvious asymmetry
• Patients who have obvious but no disfiguring synkinesis,
contracture, and/or hemifacial spasm are grade 3 regardless of
degree of motor activity
4 Moderately
severe
dysfunction
• Obvious paresis/paralysis and/or disfiguring asymmetry
• At rest: normal symmetry and tone
• Motion: no movement of forehead; inability to close eye
completely with maximal effort
• Patients with synkinesis, mass action, and/or hemifacial spasm
severe enough to interfere with function are grade 4 regardless of
motor activity
5 Severe
dysfunction
• Only barely perceptible motion
• At rest: possible asymmetry with droop of corner of mouth and
decreased or absence of nasal labial fold
• Motion: no movement of forehead, incomplete closure of eye
and only slight movement of lid with maximal effort, slight
movement of corner of mouth
• Synkinesis, contracture, and hemifacial spasm usually absent
6 Total
paralysis
• Loss of tone; asymmetry; no motion; no synkinesis, contracture,
or hemifacial spasm
Table 3. Etiologies and Clinical Features of Facial Paralysis
Type Condition
Etiologic
Agent Distinguishing Factors
Autoimmune Guillain-Barré Autoimmune/
infectious
Acute polyneuropathy; ascending
paresis/paralysis; paresis/paralysis of
hands, feet progressing to the trunk
Melkersson-
Rosenthal syndrome
Unknown Recurrent facial paresis/paralysis;
swelling of face/lips; fissures or folds
in tongue
Multiple sclerosis Unknown Abnormal neurologic exam with
intermittent symptoms
Sarcoidosis Unknown May be bilateral; abnormal laboratory
test results including ACE level
Diagnosis
