Criteria

House-Brackmann scale[17]

The House-Brackmann scale is a grading tool developed by two neuro-otologists to assist with facial nerve evaluation after lateral skull base surgery.[17] The scale is used widely to determine the severity of facial paralysis; however, it does not account for different degrees of severity between regions of the face, and does not adequately assess changes in facial symmetry after interventions.[18]

Classification using the scale is as follows:[17]

  • Grade I = normal

  • Grade II = slight weakness/asymmetry

  • Grade III = obvious weakness with movement but absence of disfigurement at rest; intact ability to close the eye

  • Grade IV = obvious weakness with movement and disfigurement at rest; inability to fully close the eye

  • Grade V = barely perceptible movement

  • Grade VI = no movement.

Sunnybrook facial grading system[19]

The Sunnybrook facial grading system is slightly more nuanced grading tool than the House-Brackmann scale and is preferred by facial palsy researchers.[19][20][21]​​​ It consists of ordinal-scale scoring of multiple parameters within three domains:[19]

  • Resting symmetry (eye, nasolabial fold, and mouth)

  • Symmetry of voluntary movement (brow elevation, gentle eye closure, open mouth smile, snarl, and lip pucker)

  • Synkinesis (same parameters as voluntary movement).

Sunnybrook facial grading system domain scores are combined to form a weighted composite score from 0 (complete flaccid paralysis) to 100 (normal function).[19] While the complexity of the grading scale typically requires use of a paper or digital form for scoring and documentation, its use permits tracking of clinical recovery with higher precision over time, making it better suited for research use compared with the House-Brackmann scale.[19]

Electronic facial paralysis assessment (eFACE)[22]

The eFACE is a grading system that allows for comparative scoring across time, and for high fidelity analysis by incorporating variation in paralysis between regions of the face.[22]

It consists of clinician-graded continuous visual analogue scales within three domains:[22]

  • Static symmetry (resting brow, resting palpebral fissure width, resting nasolabial fold depth, oral commissure resting position)

  • Dynamic symmetry (brow elevation, gentle and full eye closure, nasolabial fold depth and orientation with smile, oral commissure excursion with smile, lower lip movement with 'eeeee' [the photographer will ask the person to say 'eeeee' when capturing movement of the lower lip])

  • Synkinesis (ocular, midfacial, mentalis, platysmal).

The tool is available as a downloadable application with a graphical user interface that allows for touch-screen scoring and, when linked to a database, immediate graphical comparison to previous scores. This grading tool has also been validated for use with standardised patient photos and videos.[23][24] One systematic review concluded that eFACE was the most comprehensive tool available for the assessment of blink function.[25]

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