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The Facial Nerve

Facial Nerve Palsy (right) Grade VI House-Brackmann Scale


At rest 

On maximal eye closure


Read more on http://emedicine.medscape.com/article/835286-overview

Facial Nerve Paralysis/Paresis: House-Brackmann Scale

Grade I   

Normal symmetrical function in all areas


Grade II  

Slight weakness noticeable only on close inspection
Complete eye closure with minimal effort
Slight asymmetry of smile with maximal effort
Synkinesis barely noticeable, contracture, or spasm absent


Grade III 

Obvious weakness, but not disfiguring

May not be able to lift eyebrow

Complete eye closure and strong but asymmetrical mouth movement with maximal effort

Obvious, but not disfiguring synkinesis, mass movement or spasm


Grade IV 

Obvious, but not disfiguring synkinesis, mass movement or spasm


Grade V 

Obvious disfiguring weakness
Inability to lift brow
Incomplete eye closure and asymmetry of mouth with maximal effort
Severe synkinesis, mass movement, spasm


Grade VI 

No movement, loss of tone, no synkinesis, contracture, or spasm


House, J.W. and Brackmann, D.E. (1985) Facial nerve grading system. Otolaryngol. Head Neck Surg., 93, 142-147

Intraoperative Facial Nerve Monitoring

Electrodes in place with the nerve monitor seen at the background.

A screen capture or nerve monitor interphase (NIM-Response 3.0 by Medtronic) showing placement site of the respective electrode - colour coded.

The Facial Nerve: Intraoperative View


 T- Parotid tumour, P- pinna lobule, S- sternomastoid muscle.

Arrow- tragal pointer.

Facial nerve stimulator tip is pointing to the main trunk of right facial nerve as it exits the stylomastoid foramen



The main branches of left facial nerve. 

White arrow- main trunk, Blue arrow- upper trunk, Green arrow- lower trunk,

T- parotid tumour


Figure shows facial nerve course in relation to posterior belly of digastric.

The superficial lobe still attached and retracted inferiorly. [SP- sternomastoid muscle, M- masseter muscle, SP- superficial lobe of parotid gland, L- lobule of left ear, yellow arrow- posterior belly of digastric tendon, green arrow- intraparotid veins, black arrow- main trunk of facial nerve before its branches]

The full extracranial branches of right facial nerve after total conservative parotidectomy. 

Yellow rubber retracting the main trunk of facial nere. 

Angle of mandible (M) and preserved intraparotid vein were seen clearly. 


An intraparotid lymph node [circle] occasionally seen and need to be sent for histopathological diagnosis. 

N- neck, H- head, sm- sternomastoid muscle,

green arrow- tragal pointer,blue arrows- main brainches of facial nerve.

Pinna Vesicular Eruption in Ramsay-Hunt Syndrome

Vesicles of Herpes-Zoster oticus involving mainly the conchal bowl of pinna. 


 Dried lesion of similar area of involvement in another patient.


These two patients had ipsilateral lower motor neurone facial palsy. 

Bell's Sign in Lower Motor Neurone Facial Nerve Palsy

The eyeball on the affected side turn up when the patient 

attempts to close the eyelid (right side in this figure).

Lower Lid Ectropion in Lower Motor Neurone Facial Nerve Palsy

Right lower lid ectropion at rest (top figure) and upon eye closure (bottom figure).  Incomplete Bell's sign phenomena present.