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Mervi Kanerva, Lars Jonsson, Thomas Berg, Sara Axelsson, Anna Stjernquist-Desatnik, Mats Engstrm and Anne
Sunnybrook and House-Brackmann Systems in 5397 Facial Gradings

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Otolaryngology
Head and Neck Surgery
XX(X) 1 5
American Academy of
OtolaryngologyHead and Neck
Surgery Foundation 2011
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DOI: 10.1177/0194599810397497
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Sponsorships or competing interests that may be relevant to content are
disclosed at the end of this article.
Abstract
Objectives. To study the correlation between Sunnybrook and
House-Brackmann facial grading systems at different time
points during the course of peripheral facial palsy.
Study Design. Prospective multicenter trial.
Setting. Seventeen otorhinolaryngological centers.
Subjects and Methods. Data are part of the Scandinavian Bells palsy
study. The facial function of 1920 patients with peripheral facial
palsy was assessed 5397 times with both Sunnybrook and House-
Brackmann (H-B) facial grading systems. Grading was done at ini-
tial visit, at days 11 to 17 of palsy onset, and at 1 month, 2 months,
3 months, 6 months, and 12 months. Statistical evaluation was by
Spearman correlation coefficient and box plot analysis.
Results. Spearman correlation coefficient varied from 0.81 to
0.96, with the weakest correlation found at initial visit. Box
plot analysis for all assessments revealed that Sunnybrook
scores were widely spread over different H-B grades. With
50% of the results closest to the median, Sunnybrook com-
posite scores varied in H-B grades as follows: H-B I, 100; H-B
II, 71 to 90; H-B III, 43 to 62; H-B IV, 26 to 43; H-B V, 13 to 25;
and H-B VI, 5 to 14.
Conclusion. Gradings correlated better in follow-up assess-
ments than at initial visit. As shown by the wide overlap of the
grading results, subjective grading systems are only approxi-
mate. However, a conversion table for Sunnybrook and H-B
gradings was obtained and is included in the article. It can be
used for further development of facial grading systems.
Keywords
facial palsy, facial paralysis, facial nerve, Bells palsy, facial grad-
ing, grading
Received September 10, 2010; revised November 8, 2010; accepted
December 20, 2010.
E
valuations of the severity of facial palsy, progression of
the disease, and the possible achievements of interven-
tions are doomed to be inaccurate until an objective
method with reliable and repeatable results is developed. Pre-
liminary objective grading systems are being used and tested
by different research groups.
1
A clinically relevant system that
can be incorporated into everyday use to test the function of
the entire face (rather than just a specified region) as well as
secondary defects of different types of facial palsy (Bells
palsy, reanimation results, etc) is still to be developed.
For the time being, we have to settle for subjective methods
of evaluating the facial function of the patient with palsy. The
House-Brackmann (H-B) facial grading system
2
has been
considered the golden standard of facial grading. It contains 6
grades, I to VI, where I is normal facial function and VI total
paralysis. The H-B grading system is a gross scale, not origi-
nally intended for specifying the delicate movements of facial
function. The system has been criticized over the years and
was published recently with certain changes, nevertheless
with the conclusion that the new scale maintains agreement
comparable to the original scale.
3
At the time of the
Scandinavian Bells palsy study (SBPS),
4
only the original
H-B system was published and used.
The Sunnybrook facial grading system
5
is a regional
weighted system that takes into consideration the resting sym-
metry of the face and the degree of voluntary movement. It
also grades synkinesis regionally. The composite score varies
from 0 to 100, where 0 stands for total paralysis and 100 for
397497OTOXXX10.1177/0194599810397497Kane
rva et alOtolaryngologyHead and Neck Surgery
The Author(s) 2010
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1
Helsinki University Central Hospital, Helsinki University, Finland
2
Uppsala University Hospital, Sweden
3
Lund University Hospital, Sweden
Sunnybrook and House-Brackmann Systems in 5397 Facial Gradings was
presented as a scientific program poster at the 2010 AAO-HNSF Annual
Meeting & OTO EXPO; September 26-29, 2010; Boston, Massachusetts.
Corresponding Author:
Mervi Kanerva, Department of Otorhinolaryngology, Helsinki University
Central Hospital, POB 220, FIN-00029 HUS
Email: mervi.kanerva@gmail.com
Sunnybrook and House-Brackmann
Systems in 5397 Facial Gradings
Mervi Kanerva, MD, PhD
1
, Lars Jonsson, MD, PhD
2
,
Thomas Berg, MD, PhD
2
, Sara Axelsson, MD
3
,
Anna Stjernquist-Desatnik, MD, PhD
3
,
Mats Engstrm, MD, PhD
2
, and Anne Pitkranta, MD, PhD
1
Original Research
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2 OtolaryngologyHead and Neck Surgery XX(X)
normal facial function. The Sunnybrook system has been
reported to be the leading instrument in clinical use.
6
The Sunnybrook and H-B grading systems are used world-
wide. Some studies have proposed correlation between the 2
systems (see Discussion), but the results are few, are ambigu-
ous, and consist of a low number of gradings. The aim of the
present prospective study was therefore to correlate Sunnybrook
and H-B grading systems in a large number of patients with
peripheral facial palsy. Our interest was to investigate whether
Sunnybrook composite scores and H-B grades follow a pattern,
thereby permitting us to develop a transfer table between the 2
systems. We also studied the association between the 2 systems
at different times of palsy duration. The large numbers of
patients (1920) and gradings (5397), in addition to the prospec-
tive study design, are unique in medical literature.
Subjects and Methods
Study data are from the prospective, randomized, double-
blind, placebo-controlled, multicenter SBPS.
4
Patients with
Bells palsy, 18 to 75 years old with onset of palsy within 72
hours, were randomized to treatment with placebo, predniso-
lone, valacyclovir, or a combination of the latter 2 drugs.
Follow-up time was 12 months. The study was conducted at
16 public otorhinolaryngological centers in Sweden and 1 in
Finland.
Facial grading was assessed for each patient by 2 facial
grading systems, the Sunnybrook system and the H-B system
(printed forms were used). Assessments were made within 72
hours of palsy onset (initial visit), at days 11 to 17 of the palsy,
and at 1 month, 2 months, 3 months, 6 months, and 12 months.
If the patient had recovered completely at 2 or 3 months, the
next visit was at 12 months.
Of the 839 patients who were assigned a treatment group in
the SBPS, 10 did not take any study drugs and were excluded
from the modified intention-to-treat analysis (n = 829).
However, the present study concentrated on grading, and at
initial visit all 839 patients were included patients and will
be referred to as such. Six patients did not have their facial
grading done with both Sunnybrook and H-B and were thus
excluded (initial visit patient n = 833).
In addition to the patients who were included in the SBPS,
1114 patients screened at initial visit were excluded because
they did not meet the inclusion criteria. Most of these patients
had Bells palsy, and the most common reasons for noninclu-
sion were: (a) more than 72 hours had elapsed since the onset
of palsy, (b) patient was younger than 18 years or older than
75 years, and (c) patient was unwilling to participate.
4
Of the
1114 patients screened, 1087 had both Sunnybrook and H-B
gradings performed simultaneously at their initial visit and
were included in our study. Because the material is from the
SBPS, these patients are referred to in the text and figures as
not-included patients in reference to the SBPS.
Altogether, facial function was assessed 5397 times in
1920 patients by both Sunnybrook and H-B facial grading sys-
tems concurrently. Of these 1920 patients, 833 were patients
with Bells palsy who were included in the SBPS (eventually
829 in the intention-to-treat analysis) and their facial function
was measured repeatedly as described previously, altogether
4310 times.
The study protocol was approved by the Helsinki University
Central Hospital Ethics Committee in Finland and by the
Regional Ethical Review Boards, Universities of Uppsala,
Lund, Stockholm, and Gothenburg in Sweden. The study was
done in accordance with the Declaration of Helsinki and good
clinical practice guidelines. Written informed consent was
obtained from all patients.
Statistical Evaluation
To investigate the association between Sunnybrook and H-B
systems, box plot analysis was used to show how Sunnybrook
composite scores from 0 to 100 relate to H-B grades I to VI,
that is, what Sunnybrook score range would represent each
H-B grade. Eleven different groupings of gradings were
assessed: gradings of not-included patients at initial visit
(group 1), included patients at initial visit (group 2), and both
not-included and included patients at initial visit (group 3);
gradings at day 11 to 17 of palsy onset (group 4), 1 month
(group 5), 2 months (group 6), 3 months (group 7), 6 months
(group 8), and 12 months (group 9); all included patients
gradings together (group 10); and finally all 5397 gradings
together (group 11). Spearman correlation coefficients were
also calculated for these same groupings.
In the box plots, the rectangle shows the interquartile range
(IQR) and includes the median (Q2) (Figures 1 and 2). The
lower border of the rectangle (Q1) represents the first quartile
(the 25th percentile) and the higher border (Q3) the third quar-
tile (the 75th percentile). IQR is defined as Q3 to Q1. The
HouseBrackmann Scale
S
u
n
n
y
b
r
o
o
k

S
c
a
l
e
I II III IV V VI
0
5
10
15
20
25
30
35
40
45
50
55
60
65
70
75
80
85
90
95
100
1170 1061 817 869 97 N = 1383
Figure 1. Sunnybrook composite score grading results (0-100) in
relation to House-Brackmann grades (I-VI) with box plot analysis
of 5397 facial gradings. The boxes indicate the lower and upper
quartiles. The central line is the median. The ends of the whiskers
show the maximum and minimum values. Outliers are presented as
open circles.
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Kanerva et al 3
whiskers extend from the minimum value to the maximum
unless the distance from the minimum value to Q1 or from Q3
to the maximum value is more than 1.5 times the IQR. In that
case, the whisker extends to the smallest or largest value
within 1.5 times the IQR. Hollow circles show values (called
outliers) that are smaller or larger than the whiskers.
Results
Spearman correlation coefficient varied from 0.814 to 0.965.
It was 0.830 in initial visit gradings of not-included patients
(group 1, n = 1087); 0.814 in initial visit gradings of included
patients (group 2, n = 833); 0.824 in initial visit gradings of
not-included and included patients together (group 3, n =
1920); 0.920 in gradings from day 11 to 17 (group 4, n = 804);
0.957 in 1-month gradings (group 5, n = 719); 0.965 in
2-month gradings (group 6, n = 636); 0.955 in 3-month grad-
ings (group 7, n = 334); 0.918 in 6-month gradings (group 8,
n = 241); 0.902 in 12-month gradings (group 9, n = 743);
0.958 in all included patients gradings (group 10, n = 4310);
and 0.949 in all 5397 gradings together (group 11).
The range of Sunnybrook composite scores (0-100) from
minimum to maximum values in different H-B grades (I-VI)
A
HouseBrackmann Scale
S
u
n
n
y
b
r
o
o
k

S
c
a
l
e
II III IV V VI
0
5
10
15
20
25
30
35
40
45
50
55
60
65
70
75
80
85
90
95
100
110 266 213 217 27 N=
B
HouseBrackmann Scale
S
u
n
n
y
b
r
o
o
k

S
c
a
l
e
I II III IV V VI
0
5
10
15
20
25
30
35
40
45
50
55
60
65
70
75
80
85
90
95
100
62 217 189 141 182 13 N=
C
HouseBrackmann Scale
S
u
n
n
y
b
r
o
o
k

S
c
a
l
e
I II III IV V
0
5
10
15
20
25
30
35
40
45
50
55
60
65
70
75
80
85
90
95
100
552 127 45 17 2 N=
Figure 2. Sunnybrook composite score grading results (0-100) in relation to House-Brackmann grades (I-VI) with box plot analysis of patients
included in the Scandinavian Bells palsy study. (A) Initial visit gradings within 72 hours from palsy onset (n = 833). (B) Gradings from days 11 to
17 from palsy onset (n = 804). (C) Gradings at 12 months from palsy onset (n = 743). The boxes indicate the lower and upper quartiles. The
central line is the median. The ends of the whiskers show the maximum and minimum values. Outliers are presented as open circles.
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4 OtolaryngologyHead and Neck Surgery XX(X)
in 5397 gradings varied as follows (Figure 1): H-B I, 79 to
100; H-B II, 17 to 100; H-B III, 11 to 92; H-B IV, 4 to 84; H-B
V, 1 to 91; H-B VI, 3 to 69. When the range is defined by the
whiskers, Sunnybrook composite scores in different H-B
grades were H-B I, 100; H-B II, 43 to 100; H-B III, 16 to 88;
H-B IV, 4 to 67; H-B V, 1 to 43; H-B VI, 3 to 23.
In box plot analysis, the values between Q1 and Q3 repre-
sent 50% of the results closest to the median. Figure 1 shows
the results of all 5397 gradings, IQR, and median. Figure 2A,
2B, and 2C shows individual groups 2, 4, and 9, respectively.
Remaining groups are given in Table 1. The exact numbers of
group 11 (all 5397 gradings) can be seen in Table 2, which is
referred to in the Discussion.
Discussion
Because of the limitations and subjectivity of the H-B system,
several new scales with varying degrees of objectivity and
ease of use have been introduced.
7
The present study com-
pared the H-B and Sunnybrook facial grading systems. As
long as evaluation of facial function relies on subjective sys-
tems, however, the results can only be approximate, as was
shown here.
Spearman correlation coefficient results were close to 1,
which indicates the nature of the 2 systems studied: when the
H-B number goes up (toward total paralysis and grade VI), the
Sunnybrook composite score result falls toward zero and total
paralysis. When the congruence between H-B and Sunnybrook
was evaluated over time, the lowest correlation was demon-
strated at initial visit. This difference can also be illustrated by
comparing the grading results of the initial visit to the
12-month follow-up visit by box plot (Figure 2). In H-B
grade II at initial visit, Sunnybrook Q1-Q3 ranged from 59 to
76 points, whereas the Q1-Q3 range at 12 months was 79 to
92. This means that more severe palsies were graded H-B
grade II at the initial visit than at 12 months. When we com-
pare the initial visit with the 11- to 17-day visit (Figure 2),
the difference in grading results can again be seen in H-B
grade II. The Q1-Q3 of the initial visit was 59 to 76 versus 71
to 88 at days 11 to 17.
The difference in the gradings of the initial visit compared
with the 12-month visit may be explained by the observation
that palsies not recovered at 12 months have other characteris-
tics (eg, sequelae) than acute-stage palsies. It may also be
speculated that in early stages, facial weakness varies along
the different branches of the facial nerve and the global H-B
system may then not reflect the score of the weakest branch,
8

with subsequent incongruence between the systems.
Furthermore, because of the magnitude of the study and for
practical reasons, the initial visit gradings in the SBPS were
often done by a resident on call, whereas the gradings at
follow-up visits, including days 11 to 17, were done by ear,
nose, and throat specialists; more experienced doctors may be
more critical and demanding and thereby prone to place
patients in H-B grade III rather than grade II.
Few studies relate H-B grading levels to Sunnybrook com-
posite scores. Ross et al
5
included 28 gradings with both sys-
tems (values estimated from a figure): H-B II (only 2 gradings)
corresponds to Sunnybrook 76 and 86; H-B III to Sunnybrook
27 to 83; and H-B IV to Sunnybrook 27 to 44. Kim et al
9
used
H-B grade II equivalent to Sunnybrook 70; H-B III to
Sunnybrook 40; H-B IV to Sunnybrook 40; and H-B V
to Sunnybrook 20. Lin et al
10
assessed the patients only by
Sunnybrook but state that H-B III is equal to Sunnybrook 51
to 75. Coulson et al
11
studied the agreement between assessors
comparing H-B and Sunnybrook but did not report any grad-
ing levels.
Table 2. Sunnybrook Composite Score Interquartile Range (IQR)
and Median (Q2) as Defined by Box Plot Analysis in Relation to
House-Brackmann (H-B) Grades (I-VI) in Different Studies
This Study
(n = 5397)
Kanerva et al
13

(n = 432)
Berg et al
14

(n =100)
H-B I 100 (100) 100 (100)
H-B II 71-90 (81) 70-88 (81) 66-75 (70)
H-B III 43-62 (53) 42-64 (53) 39-54 (47)
H-B IV 26-43 (34) 25-45 (35) 23-40 (29)
H-B V 13-25 (18) 15-30 (22) 10-24 (16.5)
H-B VI 5-14 (9) 9-15 (9)
All values are IQR (Q2). n, number of gradings.
Table 1. Interquartile Range (IQR) and Median (Q2) of Box Plot Analysis of Sunnybrook Composite Scores in Different House-Brackmann
(H-B) Grades (I-VI)
H-B I H-B II H-B III H-B IV H-B V H-B VI
Group 1 92 (92) 60-76 (71) 38-58 (49) 25-41 (33) 13-25 (18) 5-13 (5)
Group 3 92 (92) 59-76 (68) 39-58 (50) 26-42 (34) 13-25 (18) 5-14 (9)
Group 5 100 (100) 79-92 (87) 54-67 (61.5) 27-44 (34) 12-23 (17) 5-18 (14)
Group 6 100 (100) 79-92 (87) 50-67 (57) 25-46 (29) 13-25 (17.5) 5 (5)
Group 7 100 (100) 78-91 (83.5) 50-67 (57.5) 27-49 (38) 14-22 (19) 5 (5)
Group 8 99-100 (100) 76-92 (84) 45-60 (51) 31-44 (40) 22-34 (28.5)
Group 10 100 (100) 74-91 (83) 45-63 (54) 27-44 (34) 13-25 (18) 5-14 (9)
All values are IQR (Q2). Groups 1-10 represent the gradings (n = number of gradings) done at different time points of facial palsy duration. Group 1 (n =
1087): initial visit, patients not included in the Scandinavian Bells palsy study (SBPS); group 3 (n = 1920): initial visit, patients included and not included in SBPS;
group 5 (n = 719): gradings at 1 month from palsy onset; group 6 (n = 636): gradings at 2 months from palsy onset; group 7 (n = 334): gradings at 3 months
from palsy onset; group 8 (n = 241): gradings at 6 months from palsy onset; group 10 (n = 4310): all gradings of patients included in SBPS.
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Kanerva et al 5
In the present comparative study, considerable overlap
between the H-B and Sunnybrook gradings was found. The
same observation was reported by Neely et al.
12
If, however,
50% of the assessments closest to the median (IQR) are pre-
sented (Table 2), the overlapping intervals shorten and
thereby allow the construction of a more lucid conversion
table. The IQRs in the present study were in agreement with
the results in our previous H-B and Sunnybrook grading stud-
ies,
13,14
which included 432 and 100 gradings, respectively
(Table 2). Based on our previous and present results (a total
of 5929 concurrent assessments), we present in Table 3 a
conversion table for H-B and Sunnybrook grading systems.
The H-B facial grading system is a ranking scale whereas
Sunnybrook is a continuous scale, and therefore statistical
comparisons between the 2 may be precarious. Because of the
nature of a multicenter study with many assessors, interob-
server variation may have influenced the results. Another
drawback of the present study was its basis in subjective mea-
sures prone to observer error
7
of the scales used.
Conclusion
The congruence between the H-B and Sunnybrook grading sys-
tems was greater in follow-up assessments than at initial visit.
The wide overlap between H-B grades and Sunnybrook compos-
ite scores indicated that subjective grading systems are approxi-
mate. However, with 5397 concurrent gradings and the use of
IQRs, a pattern emerged between these 2 grading systems allow-
ing the introduction of a conversion table. Our results show the
need for a more accurate facial grading system both in everyday
clinical settings and for research purposes.
Acknowledgments
We thank Nermin Hadziosmanovic, biostatistician, Uppsala Clinical
Research Centre, for the statistics.
Author Contributions
Mervi Kanerva, study design and conduct, collection and interpre-
tation of data, primary writer; Lars Jonsson, study design, conduct,
and supervision, collection and interpretation of data, writer;
Thomas Berg, study design and conduct, collection and interpreta-
tion of data, article revision; Sara Axelsson, study design and con-
duct, collection and interpretation of data, article revision; Anna
Stjernquist-Desatnik, study design and conduct, collection and
interpretation of data, article revision; Mats Engstrm, study
design, conduct, and supervision, collection and interpretation of
data, writer; Anne Pitkranta, study design, conduct, and supervi-
sion, collection and interpretation of data, article revision.
Disclosures
Competing interests: None.
Sponsorships: None.
Funding sources: This study was supported in part by grants from the
Helsinki University Central Hospital Research Fund, Uppsala University,
Acta Otolaryngologica Foundation, and the County Council of Skne.
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Table 3. Conversion Table for Sunnybrook Composite Scores (0-
100) in Relation to House-Brackmann (H-B) grades I-VI
Sunnybrook Composite Score
H-B I 100
H-B II 70-99
H-B III 43-69
H-B IV 26-42
H-B V 13-25
H-B VI 0-12
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