Assessing Facial Palsy: Does Feedback Improve Assessment Using the eFACE and Sunnybrook Facial Grading System?

OBJECTIVE(S): To explore learning effects when applying the clinician-graded electronic facial function scale (eFACE) and the Sunnybrook Facial Grading System (Sunnybrook). METHODS: Surgeons, facial rehabilitation therapists, and medical students were randomly allocated to the eFACE (n = 7) or Sunnybrook (n = 6) and graded 60 videos (Massachusetts Eye and Ear Infirmary open-source standard set); 10 persons with normal facial function and 50 patients with a wide variation of facial palsy severity. Participants received an introduction and individual feedback after each set of 10 videos. Scores were compared to the reference score provided with the set. Multilevel analysis was performed to analyze learning effect. RESULTS: A learning effect was only found for the eFACE, with significant difference scores in set 1 and 2 compared to set 6, and no significant difference scores in the following sets. The difference score was associated with the reference score (severity of facial palsy) for eFACE (ß = -0.19; SE = 0.04; p < 0.001) and Sunnybrook (ß = -0.15; SE = 0.04; p < 0.001). Age of participants was also associated with the difference score in the eFACE group (ß = 0.18; SE = 0.03; p < 0.001). No differences in scores were found between groups of participants. CONCLUSION: The eFACE showed a learning effect of feedback while the Sunnybrook did not. LEVEL OF EVIDENCE: NA Laryngoscope, 134:3105-3111, 2024.

A cross-sectional analysis of facial palsy-related quality of life in 125 patients: Comparing linear, quadratic and cubic regression analyses.

INTRODUCTION: Facial function correlates with quality of life in facial palsy. Previous studies have examined a linear relationship; based on clinical experience, we hypothesize a curved regression (i.e. quadratic or cubic) will be more fitting to show the correlation between quality of life and facial function. METHODS: We compared the fit of a linear regression model between Sunnybrook scores (facial function) and FaCE and FDI scores (quality of life) to a quadratic and cubic regression model in 125 patients cross-sectionally. RESULTS: A total of 125 patients were included, 53.6% female with a mean (standard deviation) age of 56.6 (16.7) and a median (interquartile range) duration of palsy of 6.6 (1.5; 18.3) years. The quadratic regression proved a significant improvement over a linear regression analysis in the model using the FaCE total score (linear R2 =.346, quadratic R2 = .378, p = .033) and the FDI physical score (linear R2 = .245, quadratic R2 =.276, p = .034). The cubic regression analysis was no significant improvement over a quadratic regression. DISCUSSION: The relationship between facial function and quality of life in facial palsy is not linear meaning that there is a lot of variation in QoL in cases with severe and moderate facial impairment. This is most applicable to patients suffering from post-paralysis synkinesis, proving the highly individually experienced burden of synkinesis. As the relationship is not linear it should not be included as such in future research studies.

Therapists' perceptions and attitudes in facial palsy rehabilitation therapy: A mixed methods study.

BACKGROUND: Facial palsy rehabilitation therapy plays an essential role in treating facial palsy. PURPOSE: This study aimed to gain insight into therapists' perceptions and attitudes toward facial palsy rehabilitation therapy and to examine whether therapists could be categorized into distinct groups based on these attitudes and perceptions. METHODS: Thirteen semi-structured, in-depth interviews were conducted in a purposive sample of therapists. Interviews were analyzed using thematic analysis. Next, a questionnaire containing questions about therapists' characteristics and perceptions and attitudes toward facial palsy rehabilitation therapy was sent to all facial palsy rehabilitation therapists in the Netherlands and Flanders (n = 292). Latent class analysis (LCA) was performed to identify and analyze distinct groups of therapists. RESULTS: Seven themes were derived from the interviews: treatment goals, therapy content, indications, measurement instruments, factors influencing success, emotional support, and cooperation with colleagues. The questionnaire was filled out by 127 therapists. A 2-group structure consisting of a positive class and a negative class was found to fit the questionnaire data best. No distinction could be made regarding therapists' characteristics. CONCLUSION: Considerable variation in stated treatment practices was present among therapists. Therapists could be classified into 2 groups. This study raises several hypotheses that require further study.

Interpreting Quality-of-Life Questionnaires in Patients with Long-Standing Facial Palsy.

Objective(s): To interpret change in quality-of-life scores in facial palsy patients by calculating the smallest detectable change (SDC) and minimal important change (MIC) for the Facial Disability Index (FDI), Facial Clinimetric Evaluation (FaCE) scale, and Synkinesis Assessment Questionnaire (SAQ). Materials and Methods: The SDC, for individuals and groups, was calculated using previously collected test-retest data (2-week interval). The MIC (predictive modeling method) was calculated in a second similar facial palsy population using two measurements (1-1.5-year interval) and an anchor question assessing perceived change. Results: SDCindividual of FaCE was 17.6 and SAQ was 28.2. SDCgroup of FaCE was 2.9 and SAQ was 4.6 (n = 62). Baseline FaCE and SAQ scores were 43.3 (interquartile range [IQR]: 35.8;55.0) and 51.1 (IQR: 32.2;60.0), respectively. MIC for important improvement of FDI physical/social function, FaCE total, and SAQ total were 4.4, 0.4, 0.7, and 2.8, respectively (n = 88). MIC for deterioration was 8.2, -1.8, -8.5, and 0.6, respectively. Baseline scores were 70.0 (IQR: 60.0;80.0), 76.0 (68.0;88.0), 55.0 (IQR: 40.0;61.7), and 26.7 (IQR: 22.2;35.6), respectively. Number of participants reporting important change for the different questionnaires ranged from 3 to 23 per subscale. Conclusion: Interpreting change scores of the FDI, FaCE, and SAQ is appropriate for groups, but for individual patients it is limited by a substantial SDC.

Associations Between Clinician-Graded Facial Function and Patient-Reported Quality of Life in Adults With Peripheral Facial Palsy: A Systematic Review and Meta-analysis.

Importance: Understanding how the quality of life of adults (≥18 years) with peripheral facial palsy can be estimated using clinician measures of facial function and patient-reported variables might aid in counseling patients and in conducting research. Objectives: To analyze associations between clinician-graded facial function and patient-reported quality of life in adults with peripheral facial palsy, compare associations between facial function and the physical and social functions of quality of life, and examine factors that might influence the associations. Data Sources: A literature search was conducted in PubMed, Embase, CINAHL, Web of Science and PsycInfo on June 4, 2020, with no restrictions on the start date. Study Selection: Twenty-three studies reporting an association between clinician-graded facial function and patient-reported quality of life in adults with peripheral facial palsy were included. Facial function instruments included the House-Brackmann, Sunnybrook Facial Grading System, and electronic clinician-graded facial function assessment. Quality-of-life instruments included the Facial Disability Index and Facial Clinimetric Evaluation Scale. Data Extraction and Synthesis: Data extraction and qualitative synthesis were performed according to the Meta-analysis of Observational Studies in Epidemiology guidelines. Record screening, data extraction, and quality assessments were done by 2 researchers independently. Data were pooled using random-effects models. Main Outcomes and Measures: The main outcome was the association between facial function and quality of life, quantified by Pearson r, Spearman ρ, or regression analysis. Results: In total, 23 studies (3746 participants) were included. In the 21 studies that reported on the sex of the cohorts, there were 2073 women (57.3%). Mean or median age ranged from 21 to 64 years and mean or median duration of palsy ranged from newly diagnosed to 12 years. Bell palsy (n = 1397), benign tumor (n = 980), and infection (n = 257) were the most common etiologic factors. Pooled correlation coefficients were 0.424 (95% CI, 0.375-0.471) to 0.533 (95% CI, 0.447-0.610) between facial function and Facial Clinimetric Evaluation Scale total, 0.324 (95% CI, 0.128-0.495) to 0.397 (95% CI, 0.242-0.532) between facial function and Facial Clinimetric Evaluation Scale social function, 0.423 (95% CI, 0.322-0.514) to 0.605 (95% CI, -0.124-0.910) between facial function and Facial Disability Index physical function, and 0.166 (95% CI, 0.044-0.283) to 0.208 (95% CI, 0.031-0.373) between facial function and Facial Disability Index social function. Conclusions and Relevance: Associations noted in this systematic review and meta-analysis were overall low to moderate, suggesting that only a small part of quality of life is explained by facial function. Associations were higher between facial function and physical function than social function of quality of life.

Health-related quality of life in facial palsy: translation and validation of the Dutch version Facial Disability Index.

PURPOSE: Patient-reported outcome measures are essential in the evaluation of facial palsy. Aim of this study was to translate and validate the Facial Disability Index (FDI) for use in the Netherlands. METHODS: The FDI was translated into Dutch according to a forward-backward method. Construct validity was assessed by formulating 22 hypotheses regarding associations of FDI scores with the Facial Clinimetric Evaluation scale, the Synkinesis Assessment Questionnaire, the Short Form-12 and the Sunnybrook Facial Grading System. Validity was considered adequate if at least 75% (i.e. 17 out of 22) of the hypotheses were confirmed. Additionally, confirmatory factor analysis was performed. Cronbach's α was calculated as a measure of internal consistency. Participants were asked to fill out the FDI a second time after 2 weeks to analyse test-retest reliability. Lastly, smallest detectable change was calculated. RESULTS: In total, 19 hypotheses (86.4%) were confirmed. Confirmatory factor analysis showed acceptable fit for the two factor structure of the original FDI (root mean square error of approximation = 0.064, standardized root mean square residual = 0.081, comparative fit index = 0.925, Chi-square = 50.22 with 34 degrees of freedom). Internal consistency for the FDI physical function scale was good (α > 0.720). Internal consistency for the FDI social/well-being scale was slightly less (α > 0.574). Test-retest reliability for both scales was good (intraclass correlation coefficients > 0.786). Smallest detectable change at the level of the individual was 17.6 points for the physical function and 17.7 points for the social/well-being function, and at group level 1.9 points for both scales. CONCLUSION: The Dutch version FDI shows good psychometric properties. The relatively large values for individual smallest detectable change may limit clinical use. The translation and widespread use of the FDI in multiple languages can help to compare treatment results internationally.

Association of Socioeconomic, Personality, and Mental Health Factors With Health-Related Quality of Life in Patients With Facial Palsy.

Importance: Knowledge of factors associated with health-related quality of life in patients with facial palsy may aid in better interpreting outcomes of research and treatment. Objective: To identify factors associated with health-related quality of life in patients with facial palsy. Design, Setting, and Participants: The inclusion period for participants in this cross-sectional study at the University Medical Center Groningen, a tertiary referral center for facial reanimation surgery, was March 1 to June 1, 2019. Patients aged at least 18 years with facial palsy who had undergone surgery for facial palsy between January 1, 2007, and January 1, 2018, and patients visiting the outpatient clinic of the University of Groningen Department of Plastic Surgery for their facial palsy between March 1 and June 1, 2019, were also asked to participate. Of 276 patients invited, 145 gave informed consent. Twenty patients did not respond after consent, 3 patients withdrew from the study, and 1 patient was wrongly included. Main Outcomes and Measures: Health-related quality of life was measured using the Facial Clinimetric Evaluation Scale and the Facial Disability Index (physical score and social score). Facial function was assessed with the Sunnybrook Facial Grading System. Other variables were investigated using validated questionnaires, including the Duke University Religion Index, Ten-Item Personality Inventory, and Hospital Anxiety and Depression Scale. Multivariable linear regression analyses with stepwise backward selection were performed to identify associations with health-related quality of life. Because 44 Sunnybrook composite scores were missing, a sensitivity analysis was performed that excluded the Sunnybrook composite scores from the multivariable analysis. Results: In total, 121 patients with facial palsy were included; their median age was 62 years (interquartile range, 48-71 years), and 63 (52%) were women. Sunnybrook composite score (ß = 0.4; 95% CI, 0.2-0.5), extraversion (ß = 2.6; 95% CI, 0.4-4.8), and anxiety (ß = -2.4; 95% CI, -4.1 to -0.8) were associated with the Facial Clinimetric Evaluation Scale total score (R2 = 0.380; 95% CI, 0.212-0.548). The Sunnybrook composite score was associated with the Facial Disability Index physical score (ß = 0.2; 95% CI, 0.0-0.4) (R2 = 0.084; 95% CI, -0.037 to 0.205). Bilateral facial palsy (ß = -21.2; 95% CI, -32.3 to -10.1), extraversion (ß = 2.7; 95% CI, 1.3-4.1), conscientiousness (ß = 2.7; 95% CI, 0.2-5.2), emotional stability (ß = 3.3; 95% CI, 1.7-4.8), and depression (ß = -1.3; 95% CI, -2.5 to -0.1) were associated with the Facial Disability Index social score (R2 = 0.400; 95% CI, 0.262-0.538). In the sensitivity analysis, the Sunnybrook composite score was associated with age (Spearman ρ = -0.252). Conclusions and Relevance: Bilateral facial palsy, age, severity of facial palsy, mental distress, and personality traits should be taken into account in future research and treatment of patients with facial palsy.