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# Facial nerve exam and the House–Brackmann scale

- Examination

Testing the forehead, eyes and mouth tells a stroke from a facial nerve palsy; the House–Brackmann scale grades how weak the face is.

Updated Nov 5, 2026

## Key points

- Forehead spared = central lesion (for example, stroke); the whole half of the face weak = peripheral facial nerve lesion.
- Sudden facial droop with arm weakness, speech trouble or imbalance is a stroke until proven otherwise: call the emergency number.
- House–Brackmann goes from I (normal) to VI (total paralysis); grades I to III close the eye completely, IV to VI do not.
- Examine the ear: facial palsy with otitis media, cholesteatoma or ear vesicles changes management and needs urgent ENT care.
- Corticosteroids for idiopathic palsy work best when started within 3 days; eye protection starts at the first visit.

## What it is

The facial nerve exam answers three questions: is the weakness central (brain) or peripheral (facial nerve), where along the nerve is the lesion, and how severe is it? The forehead is the key: it is spared in central lesions because the upper face has a bilateral cortical supply. Tears, taste and hyperacusis help locate a peripheral lesion. The ear, parotid and mouth are examined for a cause, and the House–Brackmann scale (grades I to VI) records severity and tracks recovery. Most acute peripheral palsies are idiopathic (Bell palsy), but only about half of all facial palsies are, so the exam looks for the others.

## Findings and interpretation

- Peripheral lesion: forehead, eye closure and mouth are all weak on one side.
- Central lesion: the lower face is weak while forehead wrinkling and tight eye closure are largely preserved.
- A lesion proximal to the geniculate ganglion also reduces tears, saliva and taste and may cause hyperacusis.
- Weakness that progresses over weeks to months, or comes with other neurological signs, suggests a tumour or central cause: MRI.
- Bilateral facial palsy suggests Lyme disease or sarcoidosis rather than Bell palsy.
- After complete paralysis, about 90% recover fully if the nerve remains electrically excitable, and about 20% if it does not.

## How it is done

- Inspect at rest: forehead lines, width of the palpebral fissure, nasolabial fold and corner of the mouth on each side.
- Ask the patient to raise the eyebrows: the key test for central versus peripheral weakness.
- Ask for tight eye closure, then try to open the eyes against resistance; note incomplete closure and the eye rolling upward.
- Ask the patient to show the teeth, puff out the cheeks and purse the lips; compare both sides.
- Grade the weakness with House–Brackmann (I to VI) and record it with the date and time of onset.
- Examine the auricle, ear canal and eardrum (vesicles, discharge, mass), the parotid gland and the mouth.
- When the site of the lesion matters, ask about taste, dry eye and sensitivity to loud sounds (hyperacusis).
- Complete a neurological exam: other cranial nerves, limbs, speech and gait.

## House–Brackmann facial nerve grading

| Grade | Description | Eye closure |
| --- | --- | --- |
| I | Normal facial function | Complete |
| II | Mild weakness seen only on close inspection | Complete |
| III | Obvious but not disfiguring asymmetry; synkinesis may be present | Complete with effort |
| IV | Obvious weakness or disfiguring asymmetry; normal tone at rest | Incomplete |
| V | Barely perceptible movement; asymmetry at rest | Incomplete |
| VI | Total paralysis, no movement | Incomplete |

## Common mistakes

- Calling every facial palsy «Bell palsy»: only about half are idiopathic.
- Testing only the mouth: without the forehead test a stroke can be missed.
- Forgetting eye protection in a patient who cannot close the eye, which leads to corneal drying.
- Not looking in the ear, where otitis media, cholesteatoma or herpes zoster may be the cause.

## Next step / Initial management

- Facial weakness with forehead sparing or any other stroke sign: emergency stroke pathway (call the emergency number).
- Idiopathic peripheral palsy: an oral corticosteroid started within 3 days, eye lubricants and taping the eye closed at night; herpes simplex antivirals alone give no benefit.
- Facial palsy with acute otitis media, cholesteatoma, trauma or ear vesicles: urgent same-day referral to ENT.
- Gradual onset, progression over weeks to months, other cranial nerve signs or bilateral palsy: priority referral for MRI and specialist workup.

## Test yourself

Think of the answer, then tap the question to see it.

## A patient cannot raise the right eyebrow, close the right eye or smile on the right. Central or peripheral lesion?

Peripheral (right facial nerve): the whole half of the face, including the forehead, is weak.

## A 70-year-old has sudden right lower facial droop with normal forehead movement and a weak right arm. What is the concern?

Stroke (central lesion): forehead sparing plus limb weakness; emergency stroke pathway.

## Where is the eye-closure dividing line on the House–Brackmann scale?

Grades I to III close the eye completely (III with effort); from grade IV eye closure is incomplete.

## Which findings suggest a facial nerve lesion proximal to the geniculate ganglion?

Reduced tears and saliva, loss of taste and hyperacusis, in addition to facial weakness.

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## Connections

## Related 1

- [Facial nerve: course, branches and site of the lesion](https://durgical.com/en/ent/facial-nerve-course-branches-and-site-of-the-lesion/)

## Related conditions 1

- [Bell palsy](https://durgical.com/en/conditions/bell-palsy/)

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Educational content; it does not replace a medical assessment and is not a clinical instruction. For a real case, follow current guidelines and specialist advice.

Sources: [Facial Nerve Palsy](https://www.msdmanuals.com/professional/neurologic-disorders/neuro-ophthalmologic-and-cranial-nerve-disorders/facial-nerve-palsy) (MSD Manual Professional Edition, 2025); [Signs and Symptoms of Stroke](https://www.cdc.gov/stroke/signs-symptoms/index.html) (Centers for Disease Control and Prevention, 2026); [Acute Facial Palsy: Grading Severity (House–Brackmann)](https://www.rcemlearning.co.uk/modules/acute-facial-palsy/lessons/investigations-22/topic/grading-severity/) (RCEMLearning, Royal College of Emergency Medicine, 2026); [Otitis Media (Acute)](https://www.msdmanuals.com/professional/ear-nose-and-throat-disorders/middle-ear-and-tympanic-membrane-disorders/otitis-media-acute) (MSD Manual Professional Edition, 2026).

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Representative model, for educational purposes only.

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