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Facial Nerve Anatomy & Function

>House-Brackmann Grading System

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CAUSES OF FACIAL PARALYSIS

House-Brackmann Grading System

Facial paralysis can result from trauma, infection, congenital, metabolic, neoplastic, toxic, iatrogenic, or idiopathic etiologies.

Whatever the cause, the consequences for the patient can be devastating depending on the level of facial dysfunction. Several modalities exist to clinically rate the degree of facial function; including the widely used House-Brackman classification.

HOUSE-BRACKMANN CLASSIFICATION of Facial Function

GRADE	CHARACTERISTICS
I. Normal	Normal facial function in all areas
II. Mild Dysfunction	Gross · Slight weakness noticeable on close inspection · May have slight synkinesis · At rest, normal symmetry and tone Motion · Forehead - Moderate-to-good function · Eye - Complete closure with minimal effort · Mouth - Slight asymmetry
III. Moderate Dysfunction	Gross · Obvious but not disfiguring difference between the two sides · Noticeable but not severe synkinesis, contracture, or hemifacial spasm · At rest, normal symmetry and tone Motion · Forehead - Slight-to-moderate movement · Eye - Complete closure with effort · Mouth - Slightly weak with maximum effort
IV. Moderately 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
V. Severe Dysfunction	Gross · Only barely perceptible motion · At rest, asymmetry Motion · Forehead - None · Eye - Incomplete closure · Mouth - Slight movement
VI. Total Paralysis	No movement

The House-Brackmann (H-B) grading scale was published in 1985 and describes six grades of facial function (I. Normal to VI. Total paralysis). 1 This same year it was adopted as the universal standard by the Facial Nerve Disorders Committee of The American Academy of Otolaryngology-Head and Neck Surgery. In subsequent years, new grading scales were devised in an attempt to replace the H-B scale. One such system is the Burres-Fisch (B-F) grading method which is more objective and quantitative in comparison to the H-B scale, which is subjective and qualitative. The B-F method is very time-consuming and requires complex calculations to ascertain a percentage score. In a head-to-head comparison study, these two grading scales were found to be highly correlated when used on facial paralysis patients. 2 In another study, the Fisch Detailed Evaluation of Facial Symmetry (DEFS) was also compared to H-B scale and found to have a high correlation in global assessment. 3 In short, the H-B scale, although subjective and observer dependent, seems to correlate well with other facial paralysis grading scales while remaining easy to use and time efficient.

Still yet, these grading scales do not take into account the quality of life of the patients who suffer from the effects of facial paralysis. Facial asymmetry, incomplete eye and mouth closure, nasal airway obstruction and oral incompetence can drastically change a person’s quality of life. The degree of dysfunction most likely correlates to the extent of facial paralysis; however, this may not always correlate with the individual patient’s psychosocial effects. Furthermore, at what level of paralysis do the patients’ psychosocial issues significantly deteriorate. A recent study compared the H-B scale, the Yanagihara method, and self-evaluation by patients. 4 This study showed that while the paralysis scores and grades from these two methods correlated well with self-evaluations, the patient’s didn’t always rate their subjective symptoms as being consistent with the scores they were given. 4 In a condition where the patient’s perception of their symptoms is just as important as the actual symptoms, it would seem relevant to include the patient’s psychosocial effects in the evaluation of their facial paralysis

Before a grading system can be devised which accounts for both the degree of facial paralysis and the individual patient’s psychosocial effects from the paralysis, the degree of facial paralysis needs to be compared to the amount of psychosocial stress endured by a patient due to the facial paralysis.