Bruins, Tessa E.

van Veen, Martinus M.

Werker, Paul M.N.

Yoon, Seung-Jae

English

Seung‐Jae Yoon

Tessa E. Bruins

Paul M. N. Werker

Martinus M. van Veen

Crossref

 scale underestimates social well‐being and synkinesis in overall facial palsy‐specific quality of life: A cross‐sectional study in 80 patients 

ARTS repository - University of Groningen

   University of GroningenThe Facial Clinimetric Evaluation scale underestimates social well-being and synkinesis inoverall facial palsy-specific quality of lifeYoon, Seung-Jae; Bruins, Tessa E.; Werker, Paul M.N.; van Veen, Martinus M.Published in:Clinical OtolaryngologyDOI:10.1111/coa.14082IMPORTANT NOTE: You are advised to consult the publisher's version (publisher's PDF) if you wish to cite fromit. Please check the document version below.Document VersionPublisher's PDF, also known as Version of recordPublication date:2023Link to publication in University of Groningen/UMCG research databaseCitation for published version (APA):Yoon, S-J., Bruins, T. E., Werker, P. M. N., & van Veen, M. M. (2023). The Facial Clinimetric Evaluationscale underestimates social well-being and synkinesis in overall facial palsy-specific quality of life: A cross-sectional study in 80 patients. Clinical Otolaryngology, 48(5), 790-793. 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For technical reasons thenumber of authors shown on this cover page is limited to 10 maximum.C L I N I C A L E X P E R I E N C EThe Facial Clinimetric Evaluation scale underestimates socialwell-being and synkinesis in overall facial palsy-specific qualityof life: A cross-sectional study in 80 patients1 | INTRODUCTIONPatient-reported outcome measures (PROM) are essential for the evalu-ation of facial palsy. The most used PROM for facial palsy is the FacialClinimetric Evaluation (FaCE) scale, which consists of 15 questions witha five-point Likert scale.1,2 It consists of six subscales—facial movement,facial comfort, oral function, eye comfort, lacrimal control and socialfunction—which sum up to a total score representing ‘overall’ facialpalsy-related quality of life. The current importance of each subscale incalculating the total score is determined by the number of questionscomposing each subscale. It has not been analysed whether FaCE sub-scales' weight in the total score reflects the subscales' importance tooverall facial palsy-specific quality of life. In this study, we aim to calcu-late the contribution of the FaCE subscales to overall quality of life.2 | METHODSInstitutional review board approval was acquired before the start of thisstudy (METc 2019/491). Facial palsy patients older than 18 years and flu-ent in Dutch visiting the outpatient clinic of our tertiary plastic surgerycentre were invited for participation between June and August 2020.Patients were asked to complete the validated Dutch FaCE ques-tionnaire and, using a novel Visual Analogue Scale (VAS), to holisticallyscore how physically and mentally burdensome their facial palsy hadbeen in the past week. The VAS score, ranging from 0 to 100, repre-sented overall facial palsy-related burden. The period of a week wasselected for the VAS as this is also the period the FaCE scale addresses.The reliability and validity of the novel VAS were tested in a sepa-rate group of patients visiting the same outpatient clinic. This VAS val-idation group completed both the FaCE scale and the VAS on twooccasions (T1 and T2), 1-week apart.2.1 | Statistical analysisDescriptive statistics are presented using numbers and percentages,mean and standard deviation or median and interquartile range (IQR)when appropriate. Patients with missing or incomplete responseswere excluded from all analyses.The test–retest reliability of the VAS was analysed with the intra-class correlation coefficient (ICC, two-way random effects model,absolute agreement, single measures). To evaluate validity, the VASscore was correlated to the FaCE total score.Two multiple linear regression models were examined to answerour research question. First, the FaCE subscale scores were correlatedwith total FaCE score. The regression coefficient of each subscale rep-resents the degree of the subscale's correlation with the total FaCEscore, which should reflect the number of questions in each subscale.Second, a linear regression analysis between the FaCE subscalesand a transformed VAS score was performed. The original VAS scoreswere subtracted from 100 so that a higher number indicated betterquality of life. The coefficients of the two regression models werecompared to determine if each FaCE subscale contributes equally tothe total FaCE score and the transformed VAS score.The presence of multicollinearity in the second regression analysiswas checked for by looking at the correlation, tolerance and variationinflation factor (VIF) between each variable. A tolerance larger than .2and a VIF less than 10 was considered to indicate the absence ofmulticollinearity.All analyses were performed in the Statistical Package for theSocial Sciences (SPSS) version 26 (IBM Corporation, NY).3 | RESULTSIn the VAS validation group, 21 individuals responded, of whom3 were excluded for not submitting a second VAS score. A slightmajority of the 18 participants was female (n = 10 [56%]) and median(IQR) age was 71 (55–76) years. The most common aetiology of facialpalsy was parotid gland tumour (n = 8 [28%]), followed by acousticneuroma (n = 2 [11%]). Median time since diagnosis of facial palsy(IQR) was 1.8 (.8–8.7) years. A median time of 7 days elapsedbetween the responses. Median (IQR) VAS score was 60 (23–74) atT1 and 61 (17–73) at T2. There was a moderate, positive correlationbetween the VAS score and FaCE total score that was statisticallyReceived: 5 December 2022 Accepted: 18 June 2023DOI: 10.1111/coa.14082This is an open access article under the terms of the Creative Commons Attribution-NonCommercial License, which permits use, distribution and reproduction in anymedium, provided the original work is properly cited and is not used for commercial purposes.© 2023 The Authors. Clinical Otolaryngology published by John Wiley & Sons Ltd.790 Clinical Otolaryngology. 2023;48:790–793.wileyonlinelibrary.com/journal/coasignificant (rs = .561, p < .001), indicating acceptable validity. Test–retest reliability was high, with an ICC of .91 (95% CI = .78–.97).A total of 80 participants were included in the linear regressionanalyses; of the 130 eligible patients, 14 were not interested inparticipating, 28 did not respond to the invitation for the followingmeasurement and 8 respondents submitted incomplete responses.Forty-one participants were male (51%), and median (IQR) age was63 (51–73) years (Table 1). Median (IQR) duration of facial palsy was17.1 (9.6–33.1) years, and the most common aetiology was acousticneuroma (n = 22 [27.5%]). Median (IQR) FaCE total and VAS scoreswere 51.7 (38.3–62.9) and 70 (52–93), respectively. Median (IQR)Sunnybrook composite score was 27 (18–34). Twenty-nine (36.3%)participants were treated for facial palsy in the past year, the majorityof whom received Botox injections (12.5%).The multivariate linear regression analysis of the FaCE subscalescores on the FaCE total score resulted in regression coefficients thatwere exactly proportional to the number of questions contained inthe subscales (Table 2). In the second regression analysis, social func-tion and facial comfort contributed significantly to the VAS score(Table 3). Social function showed a higher regression coefficient thanin the first regression analysis (β = .456; +.189 compared to the origi-nal coefficient), as did facial comfort (β = .334; +.134 compared tooriginal coefficient). All other subscales were non-significant contribu-tors to the VAS score. The explained variance in the model was 50.4%(R2 = .504). The mean (range) values for tolerance and VIF were .85(.756–.912) and 1.18 (1.096–1.323), respectively, indicating nomulticollinearity.4 | DISCUSSION4.1 | Key findingsThis study aimed to determine the true contribution of FaCE subscalesto overall facial palsy-specific quality of life. According to our findings,social well-being and synkinesis are the most relevant components of‘overall’ facial palsy-related quality of life. Both constructs are currentlyunderestimated in the calculation of the FaCE total score.Our analysis shows that the social burden patients experience isthe most important component of ‘overall’ quality of life and is under-estimated in the FaCE total score. Our results suggest that almost halfof ‘overall’ facial palsy-related quality of life is socially related. Withthis, our findings more closely reflect a different PROM: the FacialDisability Index (FDI), which consists of 10 questions evenly splitbetween the physical and social domains.Synkinesis, which is described in the facial comfort subscale, wasfound to be the second most important component of ‘overall’ facialpalsy-related quality of life, and the only other statistically significantlycontributing subscale. In a previous study, synkinesis was a significantpredictor of quality of life.3 A high degree of synkinesis was alsofound to be associated with ‘non-effective’ self-reported emotionalexpression.4 Synkinesis may thus reduce quality of life by both caus-ing physical discomfort and impairing social function, and it shouldTABLE 1 Patient characteristics in the sample used in the linearregression analyses.N = 80Age (median [IQR]), in years 63 (51–73)Male gender (n [%]) 41 (51)Duration of palsy (median [IQR]), in years 17.1 (9.6–33.1)Sunnybrook composite score, 0–100 scale,n = 55 (median [IQR])27 (18–34)Side affected (n [%])Right 40 (50.0)Left 38 (47.5)Bilateral 2 (2.5)Aetiology (n [%])Acoustic neuroma 22 (27.5)Trauma 8 (10.0)Congenital 8 (10.0)Brain tumour 6 (7.5)Parotid tumour 5 (6.3)Bell's palsy 4 (5.0)Other/unknown 27 (33.8)Treated in the past year (n [%]) 29 (36.3)Botox injection 10 (12.5)Static reconstruction 7 (8.8)Mime therapy or physiotherapy 5 (6.3)Botox injection with static reconstruction 1 (1.3)Dynamic reconstruction 1 (1.3)Other 5 (6.3)Key points1. The Facial Clinimetric Evaluation (FaCE) scale, consistingof six subscales, measures facial palsy-specific qualityof life.2. Each subscale's weight in the total FaCE score is basedon the number of questions but may not reflect the sub-scale's true contributions to ‘overall’ facial palsy-specificquality of life.3. In 80 patients, we analysed the subscales' correlationswith a validated Visual Analogue Scale (VAS) score thatquantifies overall facial palsy-related burden.4. Social function and facial comfort had stronger correla-tions with overall facial palsy-related quality of life thantheir weights in the FaCE total score suggests.5. Greater importance should be placed on social functionand facial comfort when estimating the quality of life ofpatients with facial palsy.YOON ET AL. 791 17494486, 2023, 5, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/coa.14082 by Universiteitsbibliotheek, Wiley Online Library on [26/09/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons Licenseform a larger component of facial palsy-specific quality of lifeassessment.Surprisingly, eye comfort and lacrimal control were insignificantpredictors of overall quality of life. This is in line with previousresearch suggesting that periocular muscle function is of low impor-tance in estimating quality of life.5 However, this is not in line withour clinical expertise or the findings of other researchers that thetreatment of periocular complaints leads to a significant improvementin total FaCE score.6 A possible explanation for this discrepancy couldbe that most patients in our sample already received periocular treat-ment, and therefore no longer experience periocular problems. This isespecially plausible in our sample of chronic facial palsy patients butrequires further investigation.4.2 | LimitationsThere were various limitations to the current study. First, the samplesize to evaluate validity and reliability of the VAS was relatively small.Second, our sample was selected from a tertiary care setting and hada long median duration of facial palsy. The character of complaintsexperienced by patients has been reported to evolve over time,7which suggests that the relative importance of each FaCE subscale inacute facial palsy may differ from our findings. The long-standing,severe nature of cases at our tertiary care centre, combined with thehigh treatment rate in the past year, makes it highly likely that almostall participants received facial palsy-oriented therapy. Additionally,our most common aetiology was acoustic neuroma, rather than Bell'spalsy as is seen in the general facial palsy population. Such character-istics in our participants may make the interpretation of our findingschallenging in acute and less severe cases of facial palsy.4.3 | ImplicationsOur study suggests that the current weight of the FaCE subscales incalculating the FaCE total score does not actually reflect the trueweight of each component in calculating ‘overall’ facial palsy-relatedquality of life. Our findings can be used when developing a revisedversion of the FaCE scale or a novel facial palsy-specific PROM.5 | CONCLUSIONSocial function is more important in estimating overall facial palsy-specific quality of life than indicated by its weight in the FaCE totalscore. Additionally, more questions regarding synkinesis are indicatedand should be included in, perhaps, a novel questionnaire.KEYWORDSFacial Clinimetric Evaluation scale, facial comfort, facial palsy, qualityof life, social function, synkinesisAUTHOR CONTRIBUTIONSTessa E. Bruins and Martinus M. van Veen designed the study andacquired data. Seung-Jae Yoon analysed and interpreted data anddrafted the manuscript. Seung-Jae Yoon, Tessa E. Bruins, MartinusM. van Veen and Paul M. N. Werker revised and approved the manu-script. Seung-Jae Yoon, Tessa E. Bruins, Martinus M. van Veen and PaulM. N. Werker agree to be accountable for all aspects of the work.ACKNOWLEDGEMENTSThis research has received no external funding.FUNDING INFORMATIONThere are no financial conflicts of interest to disclose.TABLE 2 Multivariate linearregression analysis of FaCE subscalescores on FaCE total score, with thenumber of questions in each subscale.B (CI) p Number of questionsFacial movement .200 (.200–.201) .000 3Facial comfort .200 (.199–.200) .000 3Oral function .133 (.133–.134) .000 2Eye comfort .133 (.133–.134) .000 2Lacrimal control .067 (.066–.067) .000 1Social function .267 (.266–.267) .000 4Constant .006 (.046 to .034) .763 N/ANote: R2 = 1.00.Abbreviation: CI, 95% confidence interval.TABLE 3 Multivariate linear regression analysis of FaCE subscalescores on a transformed VAS score.B (CI) pFacial movement .180 (.387 to .027) .087Facial comfort .334 (.183 to .485) .000Oral function .135 (.012 to .282) .071Eye comfort .079 (.227 to .069) .293Lacrimal control .032 (.099 to .164) .626Social function .456 (.281 to .631) .000Constant 16.653 (.722 to 32.584) .041Note: R2 = .504.Abbreviation: CI, 95% confidence interval.792 YOON ET AL. 17494486, 2023, 5, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/coa.14082 by Universiteitsbibliotheek, Wiley Online Library on [26/09/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons LicenseCONFLICT OF INTEREST STATEMENTThe authors declare no conflicts of interest.PEER REVIEWThe peer review history for this article is available at https://www.webofscience.com/api/gateway/wos/peer-review/10.1111/coa.14082.DATA AVAILABILITY STATEMENTData are available at request from the corresponding author.ETHICS STATEMENTThe cross-sectional study was approved by the local ethics reviewboard committee, Medisch Ethische Toetsingcommissie UMC Gro-ningen, protocol number 2019/491.Seung-Jae YoonTessa E. BruinsPaul M. N. WerkerMartinus M. van VeenDepartment of Plastic Surgery, University Medical Center Groningen,University of Groningen, Groningen, The NetherlandsCorrespondenceSeung-Jae Yoon, Department of Plastic Surgery, University MedicalCenter Groningen, University of Groningen, Groningen,The Netherlands.Email: s.j.yoon@umcg.nlORCIDSeung-Jae Yoon https://orcid.org/0000-0002-9404-0702Tessa E. Bruins https://orcid.org/0000-0003-1169-1639Paul M. N. Werker https://orcid.org/0000-0003-1053-0200Martinus M. van Veen https://orcid.org/0000-0003-2233-2068REFERENCES1. Kahn JB, Gliklich RE, Boyev KP, Stewart MG, Metson RB,McKenna MJ. Validation of a patient-graded instrument for facialnerve paralysis: the FaCE scale. Laryngoscope. 2001;111(3):387–98.https://doi.org/10.1097/00005537-200103000-000052. Fattah AY, Gavilan J, Hadlock TA, Marcus JR, Marres H, Nduka C, et al.Survey of methods of facial palsy documentation in use by members ofthe Sir Charles Bell Society. 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