Objective method for facial motricity grading in healthy individuals and in
patients with unilateral peripheral facial palsy
Edson Ibrahim Mitre, MD, PhD
, Paulo Roberto Lazarini, MD, PhD,
Jose´ Eduardo Lutaif Dolci, MD, PhD
Departamento de Otorrinolaringologia da Santa Casa de Sa˜o Paulo, Sa˜o Paulo, Brazil
Received 10 August 2006
Purposes: This study aimed (a) to associate the House and Brackmann grading system with a
method of photographic evaluation and distance measuring between predetermined facial points, (b)
to evaluate the objectivity of the method presented, and (c) to establish the grading pattern values for
this method and their corresponding degrees in the House and Brackmann grading system.
Methods: This study presents a method for determining distances on each side of the face (eyebrow
position and horizontal and vertical positions of mouth angle) related to 2 reference lines drawn from
the internal ocular angles in photographs of 5 different facial expressions (at rest, eyes closed,
eyebrows raised, smiling, and whistling) of 49 individuals with facial function from normal to total
unilateral peripheral facial palsy.
Results: With this, an overall percentage of facial asymmetry was established.
Conclusions: 1) It was possible to establish a correlation between the House and Brackmann grading
system and a photographic evaluation method with measuring and comparative analysis of distances
between predetermined facial points. 2) The method presented is objective. 3) Six percentages were
established, which correlate to the 6 degrees of the House and Brackmann grading system. 4) The
presented objective method is useful for documentation and following up of patients with peripheral
facial palsy, particularly in university or medical training research studies.
D 2008 Published by Elsevier Inc.
Precise determination of the degree of facial motor
impairment is an important part of the evaluation of patients
with peripheral facial palsy (PFP), and it influences the
therapeutic decisions for each case. In addition, it allows for
adequate monitoring of patients’ clinical progress so that
treatment responses can be better evaluated.
The lack of a universally accepted PFP grading system is
a widely recognized problem and the subject of numerous
discussions and studies despite almost 20 years of proposals
and deliberations. The existing methods differ dramatically
in their methods for evaluating. Moreover, little attention
has been given to their validity and reproducibility.
At present, the most widely known and applied PFP
grading method is the one proposed by House and
Brackmann , which is considered the gold standard by
the Facial Nerve Committee of the American Academy of
Otolaryngology–Head and Neck Surgery , although it is
Several PFP grading methods have been proposed based
on points attributed to facial motricity [3-10] compared to
the unaffected side of the face.
House  presented a detailed study in which numerous
facial nerve functions were analyzed by 15 different
otolaryngologists with extensive experience with PFP. He
concluded that all scales were equivalent in evaluating
normal facial function or complete facial palsy but failed in
assessing intermediate degrees. He also concluded that
global evaluating methods worked best because they
presented less interobserver discrepancy. Based on these
data, he proposed a new grading system with 6 categories,
0196-0709/$ – see front matter D 2008 Published by Elsevier Inc.
4 Corresponding author. Rua Peixoto Gomide, 515 – 168 andar -
01409-001 Sa˜o Paulo - SP -Brazil. Tel.: +55 11 3287 1666.
E-mail address: firstname.lastname@example.org (E.I. Mitre).
American Journal of Otolaryngology–Head and Neck Medicine and Surgery 29 (2008) 51 – 57