House-Brackmann scale: Grades, scoring, and clinical use

Key takeaways

The House-Brackmann scale grades facial nerve function on six levels, from Grade I for normal movement to Grade VI for total paralysis.

You give the face one grade based on overall function, rather than scoring each region and averaging the results.

Resting symmetry separates Grade IV from Grade V, so look at the face before you ask for any movement.

Grades II to IV are where clinicians disagree most, and standardized wording for each instruction is what narrows that spread.

The scale does not score synkinesis, so record involuntary movement separately or move to Sunnybrook for recovery tracking.

Facial palsy is easy to spot and surprisingly hard to score. One side of the face droops, and you can see that in two seconds. Turning it into a number that the next clinician reads the same way is the harder part.

That is the job the House-Brackmann scale does. It folds forehead, eye, and mouth function into a single grade, from I for normal to VI for total paralysis. Yet two clinicians can watch the same patient and write down different grades.

Most of that variation traces back to a few fixable habits at the bedside. Start with what the grade is actually describing.

What the House-Brackmann scale actually measures

It rates facial nerve function on six levels, from Grade I for normal movement to Grade VI for no movement at all. The rating is a clinical judgment, made by watching the face at rest and then during movement.

Two otolaryngologists in Los Angeles, John W. House and Derald E. Brackmann, published it in 1985. The American Academy of Otolaryngology-Head and Neck Surgery, known as AAO-HNS, adopted it as its standard grading system. It has been the common language for facial palsy ever since.

Each grade pulls together four things: gross function, forehead movement, eye closure, and mouth movement. Grades I through IV also assume normal symmetry and tone while the face is at rest. Once resting asymmetry appears, the patient is Grade V or worse.

That resting criterion carries more weight than the movement columns suggest. It is the quickest way to separate a Grade IV from a Grade V.

The six grades, from normal function to total paralysis

Each row below pairs a severity label with what you should see in the forehead, the eye, and the mouth. Read across the row, then check it against how the face looks at rest.

One detail sits outside the table. Grades I to IV all assume the face looks even and holds normal tone at rest, while Grade V is where resting asymmetry appears. Grade VI adds the loss of any movement anywhere.

Picture a patient with no forehead movement and incomplete eye closure. While the face still rests evenly, that is Grade IV. The same patient becomes Grade V once the cheek sags and the mouth pulls across at rest.

How to grade a patient, step by step

Run the exam in the same order every time. Consistency between visits matters more than speed, because a grade only means something next to the last one.

1. Look at the face at rest. Do this before you ask for any movement. Compare brow height, eyelid opening, nasolabial fold depth, and the resting position of each mouth corner.
2. Ask for raised eyebrows. Use the same wording every visit. Count the forehead creases on each side and note whether movement is equal, reduced, or absent.
3. Ask for a gentle eye closure. Normal closure, no straining. Check whether the lid seals on the affected side, and record any lagophthalmos.
4. Ask for a tight eye closure. Look for the lashes disappearing on both sides. Try to open the lid gently against resistance and compare the two sides.
5. Ask for a smile, then a pucker. Compare how far each mouth corner travels, how deep the nasolabial folds get, and how firm the lip seal feels.

Then step back and give the face one grade. The findings from each region support that decision, but the grade describes overall function, so resist the urge to score three regions and average them.

Write the grade, the affected side, and the days since onset straight into the note. Digital intake forms keep that wording identical between clinicians, and that consistency is where most of the agreement between raters comes from.

Run this checklist before you finalize the grade

Five quick questions catch almost every avoidable grading error. Once they become habit, they add well under a minute to the exam.

• Did you look at the face at rest first? Resting asymmetry is what decides Grade V, and asking for a smile too early buries it.
• Did you use the same instructions as last time? “Raise your eyebrows” and “look surprised” pull different amounts of effort out of a patient.
• Did you record the affected side and the days since onset? A grade without both is hard to compare at the next visit.
• Did you grade the whole face? One number describes overall function, not the worst of three regions.
• Did you describe any synkinesis in words? The grade will not carry it, so the note has to.

Answer all five while the patient is still in the room. Memory fades quickly, and a grade written up at the end of clinic is closer to a guess than a measurement.

Common mistakes that push a grade off by a level

Grades usually drift for one of four reasons, and all four are procedural rather than clinical.

• Averaging the regions. Forehead, eye, and mouth findings inform the grade. They do not get scored and divided by three.
• Skipping the resting look. Open with a smile and you lose the criterion that separates Grade IV from Grade V.
• Calling any weak face Grade VI. Grade VI means no movement anywhere. Barely perceptible motion still counts as Grade V.
• Folding synkinesis into the number. A patient with a tight eye-and-smile link can still grade II or III.

Grading from a photograph the patient sent in does not work either. The scale depends on watching effort and resting tone, and a single frame shows neither.

What each grade means for the next appointment

The grade sets both the follow-up interval and the referral threshold. Grade I needs a baseline note and nothing else.

Grades II and III point to mild or moderate weakness. Bring these patients back promptly, and consider electrophysiological testing when recovery stalls or the picture worsens.

Grades IV to VI mean moderate to complete paralysis. They warrant urgent specialist assessment, often the same day, alongside baseline imaging and a decision on medical or surgical treatment.

Repeat the grading on a fixed schedule instead of by feel. Weekly through the first month, then monthly, gives you a curve you can show the patient. Structured note formats such as DAR notes keep those entries comparable.

Recovery work usually sits with rehabilitation teams. Facial retraining runs through physical therapy services, while speech therapy covers oral competence, eating, and speech.

Which conditions get graded this way

Any condition that weakens the facial nerve can be graded, whatever the cause. These are the presentations you will meet most often.

• Bell’s palsy: Sudden facial paralysis with no identified cause. It is the most common reason to reach for the scale in primary care and neurology.
• Acoustic neuroma: Also called vestibular schwannoma. Grades before and after surgery help you counsel patients on risk and track nerve recovery.
• Ramsay Hunt syndrome: Facial paralysis with ear pain and blisters. Grade it alongside the hearing and balance findings.
• Traumatic nerve injury: Penetrating or blunt trauma to the nerve. The baseline grade helps predict recovery and guide the timing of surgery.
• Palsy after parotid surgery: Serial grades separate a temporary bruising injury from a nerve that has been cut.
• Lyme disease: Facial palsy is a hallmark feature. The grade tracks severity and the response to antibiotics.

The scale travels across specialties for the same reason it has limits. One number is quick to write and quick to read, so a surgeon, a neurologist, and a therapist can all work from it.

Where the scale falls short

Three limits show up in daily use, and none of them are reasons to drop the scale.

Six grades are coarse. A patient can improve visibly without moving a grade, which is frustrating when you are trying to show progress at the four-week review.

Interrater reliability is moderate, and it is weakest through the middle of the range. Grades II to IV are where clinicians disagree most, even when everyone uses standardized instructions.

Synkinesis does not register. That involuntary movement, such as the eye narrowing whenever the patient smiles, affects roughly 30% of people recovering from Bell’s palsy. The scale does not score it, so a patient can hold a good grade and still describe a face that will not behave.

Resting tone problems, facial spasm, and hyperkinesis are missing too. Each needs its own line in the note or a different instrument altogether.

How it compares with Sunnybrook and eFACE

Two alternatives come up whenever those limits start to bite. Both capture synkinesis, and both cost more time at the chair.

Sunnybrook splits the face into regions and scores movement and synkinesis separately in each one. That granularity picks up the changes the House-Brackmann scale rounds away.

eFACE is graded by the clinician through a standardized digital app. You drag a slider along a visual analog scale for each parameter, and the app turns those ratings into regional and composite scores. Nothing is measured by computer vision, so the result still rests on the examiner’s eye.

Both take longer and need training, which is why the House-Brackmann scale still owns the bedside. Plenty of teams grade routinely with it and bring in Sunnybrook once synkinesis becomes the clinical question.

How Pabau keeps facial nerve grades in one record

Serial grading only pays off if the grades sit somewhere you can compare them. In many practices they end up buried in free-text notes, so building a recovery picture means rereading six months of entries.

Practice management software like Pabau handles it differently. You build the grading criteria into a form that attaches to the appointment. The grade then lands in a structured field in the client record, not in a paragraph of prose.

Because those entries are structured, everyone treating the patient reads the same history. The physician, the therapist, and the front desk all work from one timeline. Patient portal reminders then prompt the patient to book the next assessment on time.

The payoff is simple. When a patient asks whether they are genuinely getting better, you can answer with dates and grades instead of an impression.

Track facial nerve grades across every visit

Build the House-Brackmann criteria into a digital form, store each grade in the client record, and show patients a recovery curve they can follow.

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Conclusion

The House-Brackmann scale earns its place by being fast and universally understood, not by being precise. Treat the number as shared shorthand and it does that job well. Its standing as the AAO-HNS standard is not under threat.

Where it stops being enough is the recovery phase. Say a patient grades II or III but complains that the face moves in the wrong places. Reach for Sunnybrook, and describe the synkinesis in words.

Whichever instrument you pick, the value comes from repeating it the same way and keeping the results together. Book a demo to see how Pabau stores facial nerve grades in the client record and tracks recovery across visits.

Continue your research

Scoring another standardized clinical scale? Hospital del Mar criteria sets out the scoring, the interpretation, and where each threshold comes from.

Need a note format that keeps serial findings comparable? DAR notes walks through the data, action, and response structure with worked examples.

Prefer a different documentation layout? DAP notes cover the data, assessment, and plan format, plus a free template you can adapt.

Building out your special test library? Ober’s test covers the procedure, the interpretation, and what a positive result actually tells you.

Tracking functional recovery beyond the face? Star excursion balance test sets out the protocol, the scoring, and the reference norms.

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