The House-Brackmann Facial Nerve Grading System

The facial nerve grading system of House and Brackmann separates facial nerve paralysis into 6 grades based on the severity of findings.

Parameters evaluated during the examination:

(1) overall macroscopic/gross appearance

(2) appearance at rest

(3) forehead movement

(4) eyelid closure

(5) mouth appearance

(6) synkinesis, contracture, hemifacial spasm

Parameter	Grade I	Grade II	Grade III
overall appearance	normal	slight weakness on close inspection	obvious but not disfiguring difference between both sides
at rest	normal symmetry	normal symmetry	normal symmetry
forehead movement	normal with excellent function	moderate-to-good function	slight-to-moderate
eyelid closure	normal closure	complete with minimum effort	complete with maximal effort
mouth	normal and symmetrical	slight asymmetry	slight asymmetry with maximum effort
synkinesis, contracture, hemifacial spasm	none	may have very slight synkinesis; no contracture or hemifacial spasm	obvious but not disfiguring synkinesis, contracture and/or hemifacial spasm

Parameter	Grade IV	Grade V	Grade VI
overall appearance	obvious weakness and/or dysfiguring asymmetry	only barely perceptible motion	no movement
at rest	normal symmetry	asymmetry	asymmetry
forehead movement	none	none	none
eyelid closure	incomplete with maximal effort	incomplete with maximal effort	no movement
mouth	asymmetry with maximum effort	slight movement	no movement
synkinesis, contracture, hemifacial spasm	synkinesis, contracture and/or hemifacial spasm disfiguring or severe enough to interfere with function	synkinesis, contracture and/or hemifacial spasm usually absent	no movement

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