NIHSS Facial Palsy 3 — Questions and Answers
Question 1: A patient after a lacunar infarct shows only slight asymmetry of the nasolabial fold at rest but symmetric smiling. What NIHSS Facial Palsy score is assigned?
- 0 – Normal
- 1 – Minor paralysis (Correct answer)
- 2 – Partial paralysis
- 3 – Complete paralysis
Correct answer: 1 – Minor paralysis
A minor resting nasolabial fold asymmetry without functional loss during smiling corresponds to a score of 1.
Question 2: Bilateral complete facial paralysis on the NIHSS Facial Palsy item would be scored as:
- 2
- 3 (Correct answer)
- 6 (sum of both sides)
- 9 – untestable
Correct answer: 3
A score of 3 applies whether the complete palsy is unilateral or bilateral, as per NIHSS scoring conventions.
Question 3: Which instruction is MOST appropriate when asking a cooperative patient to demonstrate facial function for NIHSS item 4?
- 'Open your mouth and say ahh'
- 'Show me your teeth or raise your eyebrows' (Correct answer)
- 'Puff out your cheeks and hold the air in'
- 'Stick out your tongue as far as you can'
Correct answer: 'Show me your teeth or raise your eyebrows'
Asking the patient to show teeth or raise eyebrows directly tests voluntary facial movement in upper and lower distributions.
Question 4: A patient demonstrates asymmetric eye closure: the left eye does not fully close during sleep or volitional effort, and the left lower face is completely flaccid. This pattern is most consistent with:
- Central (UMN) facial palsy, NIHSS score 2
- Peripheral (LMN) facial palsy, NIHSS score 3 (Correct answer)
- Normal variant, NIHSS score 0
- Partial central palsy, NIHSS score 1
Correct answer: Peripheral (LMN) facial palsy, NIHSS score 3
Inability to close the eye combined with lower facial flaccidity indicates peripheral (LMN) facial nerve palsy, scored 3 on NIHSS.
Question 5: On the NIHSS, when is it acceptable to score Facial Palsy as 'untestable' (NT)?
- When the patient is too sleepy to cooperate
- When facial trauma or bandaging prevents assessment (Correct answer)
- When the patient has a prior Bell's palsy
- When the patient is intubated
Correct answer: When facial trauma or bandaging prevents assessment
Physical obstruction such as facial trauma, dressings, or orotracheal tape that prevents visualization is a valid reason to score NT.
Question 6: Which finding would LOWER an initial Facial Palsy score of 2 to a score of 1 upon reassessment?
- The patient now has complete lower facial paralysis
- The nasolabial fold asymmetry has nearly resolved and smile is only mildly asymmetric (Correct answer)
- The patient can no longer close the affected eye
- Upper facial movement has become flaccid as well
Correct answer: The nasolabial fold asymmetry has nearly resolved and smile is only mildly asymmetric
Improvement to only mild nasolabial fold asymmetry or minor smile asymmetry corresponds to the score-1 descriptor.
Question 7: A stroke patient is asked to show their teeth. The right side of the mouth rises normally while the left corner does not move at all. Eye closure is intact bilaterally. What is the NIHSS Facial Palsy score?
- 1
- 2 (Correct answer)
- 3
- 0
Correct answer: 2
Complete absence of lower facial movement with intact upper facial (eye closure) function is partial paralysis, scored 2.
NIHSS Facial Palsy 3
A patient after a lacunar infarct shows only slight asymmetry of the nasolabial fold at rest but symmetric smiling.
What NIHSS Facial Palsy score is assigned?