Psychometric Validation of the FACE-Q Craniofacial Module for Facial Nerve Paralysis

Measuring Patient-Reported Outcomes After Facial Paralysis Reconstruction Surgery Using the FACE-Q

Background: Patients affected by facial paralysis often experience significant psychosocial impairment, it is, therefore, essential to incorporate their perspective when assessing surgical outcomes. Objective: To study the effect of various patient- and treatment-specific factors on patient satisfaction after facial paralysis reconstruction as measured by FACE-Q. Methods: Seventy-two patients who underwent facial paralysis procedures by our senior author from 2000 to 2020 received the FACE-Q by email. Patient characteristics, duration of paralysis before surgery, type of surgery, complications, and secondary procedures were recorded. Results: Forty-one patients successfully completed the questionnaire. We found that men were significantly more satisfied with the decision to undergo surgery, older patients had significantly lower satisfaction scores with their face and psychosocial well-being, and uninsured patients had higher satisfaction scores with their face and their social and psychosocial well-being, whereas those items were significantly lower in patients with a long-standing facial paralysis. No differences were found between static and dynamic techniques, the presence of complications or the need for secondary procedures. Conclusions: This study found that decreased patient satisfaction was associated with older age, female sex, insured patients, and longer duration of the paralysis before treatment for facial paralysis reconstruction.

Translation and validation of the German version of the FACE-Q paralysis module in adult patients with unilateral peripheral facial palsy

The aim was to develop and validate a German version of the FACE-Q paralysis module, a patient-reported outcome measure to assess health-related quality of life in adult patients with unilateral facial palsy. The FACE-Q craniofacial questionnaire, which includes the paralysis module, was translated. 213 patients with facial palsy completed the German FACE-Q paralysis along with the established FDI and FaCE questionnaires. Regression analyses were performed to examine the relationships between the different FACE-Q domains and patient and therapy characteristics. The FACE-Q scales had high internal consistency (Cronbach's alpha all > 0.6). High correlations were found between the FACE-Q and the FDI and FaCE (mean rho = 0.5), as well as within the FACE-Q (mean rho = 0.522). Unifactorial influences were found for all domains except Breathing (all p < 0.05). Multivariate independent predictors were found for some FACE-Q domains. Most influential predictors (> 8 subdomains): Patients who received physical therapy scored lower in ten subdomains than those who did not (all p < 0.05). Patients who had surgery scored lower in nine subdomains than patients without surgery (all p < 0.05). The German version of the FACE-Q Paralysis Module can now be used as a patient-reported outcome instrument in adult patients with facial nerve palsy.

A scoping review of Rasch analysis and item response theory in otolaryngology: Implications and future possibilities

Objective

Item response theory (IRT) is a methodological approach to studying the psychometric performance of outcome measures. This study aims to determine and summarize the use of IRT in otolaryngological scientific literature.

Methods

A systematic search of the Medline, Embase, and the Cochrane Library databases was performed for original English-language published studies indexed up to January 28, 2023, per the following search strategy: ("item response theory" OR "irt" OR "rasch" OR "latent trait theory" OR "modern mental test theory") AND ("ent" OR "otorhinolaryngology" OR "ear" OR "nose" OR "throat" OR "otology" OR "audiology" OR "rhinology" OR "laryngology" OR "neurotology" OR "facial plastic surgery").

Results

Fifty-five studies were included in this review. IRT was used across all subspecialties in otolaryngology, and most studies utilizing IRT methodology were published within the last decade. Most studies analyzed polytomous response data, and the most commonly used IRT models were the partial credit and the rating scale model. There was considerable heterogeneity in reporting the main assumptions and results of IRT.

Conclusion

IRT is increasingly being used in the otolaryngological scientific literature. In the otolaryngology literature, IRT is most frequently used in the study of patient-reported outcome measures and many different IRT-based methods have been used. Future IRT-based outcome studies, using standardized reporting guidelines, might improve otolaryngology-outcome research sustainably by improving response rates and reducing patient response burden.

Level of evidence

2.

Recommendations for assessing appearance concerns related to plexiform and cutaneous neurofibromas in neurofibromatosis 1 clinical trials

BACKGROUND/AIMS

Individuals with neurofibromatosis 1 may experience changes in their appearance due to physical manifestations of the disorders and/or treatment sequelae. Appearance concerns related to these physical changes can lead to psychological distress and poorer quality of life. While many neurofibromatosis 1 clinical trials focus on assessing changes in tumor volume, evaluating patients' perspectives on corresponding changes in symptoms such as physical appearance can be key secondary outcomes. We aimed to determine whether any existing patient-reported outcome measures are appropriate for evaluating changes in appearance concerns within neurofibromatosis 1 clinical trials.

METHODS

After updating our previously published systematic review process, we used it to identify and rate existing patient-reported outcome measures related to disfigurement and appearance. Using a systematic literature search and initial triage process, we focused on identifying patient-reported outcome measures that could be used to evaluate changes in appearance concerns in plexiform or cutaneous neurofibroma clinical trials in neurofibromatosis 1. Our revised Patient-Reported Outcome Rating and Acceptance Tool for Endpoints then was used to evaluate each published patient-reported outcome measures in five domains, including (1) respondent characteristics, (2) content validity, (3) scoring format and interpretability, (4) psychometric data, and (5) feasibility. The highest-rated patient-reported outcome measures were then re-reviewed in a side-by-side comparison to generate a final consensus recommendation.

RESULTS

Eleven measures assessing appearance concerns were reviewed and rated; no measures were explicitly designed to assess appearance concerns related to neurofibromatosis 1. The FACE-Q Craniofacial Module-Appearance Distress scale was the top-rated measure for potential use in neurofibromatosis 1 clinical trials. Strengths of the measure included that it was rigorously developed, included individuals with neurofibromatosis 1 in the validation sample, was applicable to children and adults, covered item topics deemed important by neurofibromatosis 1 patient representatives, exhibited good psychometric properties, and was feasible for use in neurofibromatosis 1 trials. Limitations included a lack of validation in older adults, no published information regarding sensitivity to change in clinical trials, and limited availability in languages other than English.

CONCLUSION

The Response Evaluation in Neurofibromatosis and Schwannomatosis patient-reported outcome working group currently recommends the FACE-Q Craniofacial Module Appearance Distress scale to evaluate patient-reported changes in appearance concerns in clinical trials for neurofibromatosis 1-related plexiform or cutaneous neurofibromas. Additional research is needed to validate this measure in people with neurofibromatosis 1, including older adults and those with tumors in various body locations, and explore the effects of nontumor manifestations on appearance concerns in people with neurofibromatosis 1 and schwannomatosis.

The Emerging Role of Artificial Intelligence Tools for Outcome Measurement in Facial Reanimation Surgery: A Review

Importance: Surgeons treating facial paralysis with reanimation surgery measure the outcomes of surgery and adjust treatment to each patient's needs. Our objective is to review the current subjective facial paralysis assessment tools and the emerging computer-based objective analysis, which may involve artificial intelligence. Observations: In recent years, many new automated approaches to outcome measurement in facial reanimation surgery have been developed. Most of these tools utilize artificial intelligence to analyze emotional expression and symmetry of facial landmarks. Other tools have provided automated approaches to existing clinician-guided scales. Conclusions: Newly developed computer-based tools using artificial intelligence have been developed to both improve existing clinician-graded scales and provide new approaches to facial symmetry and emotional expressivity analysis.

Effect of Filler Therapy on Psychosocial Distress in Facial Paralysis: Patients with Major Asymmetry Derive Greater Benefit

Background: Facial filler is an effective nonsurgical treatment option for improving facial symmetry in patients with facial paralysis (FP). Objective: To compare the effects of filler among patients with FP that is self-perceived as major or minor asymmetry, by measuring psychosocial distress. Methods: In this prospective cohort study of patients with FP undergoing filler at a tertiary academic center, patients were classified as having minor or major self-perceived asymmetry using a visual analog scale (VAS). FACE-Q Appearance-Related Psychosocial Distress was administered before and after filler. Descriptive statistics and a random-effects generalized linear model assessed the relationship between perceived facial asymmetry and change in psychosocial distress. Results: A total of 28 patients participated. Twenty-five (89%) patients were female with median age of 54 (interquartile range [IQR]: 49-66). Median VAS score was 2 (IQR: 1-3.5, 0 = completely asymmetric, 10 = no asymmetry). Psychosocial distress improved in all patients after filler. In multivariable modeling, patients with major asymmetry experienced 2.45 (confidence interval: 0.46-4.44, p = 0.016) points more improvement in psychosocial distress than patients with minor asymmetry. Age, gender, and FP duration were not associated with change in psychosocial distress. Conclusion: Facial filler treatment was seen to improve psychosocial distress in patients with FP, especially by those with more self-perceived deficit.

Facial nerve palsy: Narrative review on the importance of the eye and its assessment

New solutions are emerging that address specific facial regions in facial nerve palsy (FNP). However the most dreaded consequence of FNP is paralytic lagophthalmos threatening the eye. A way to prioritize these regions is thus required. A review of the literature is conduced to capture the current concepts in evaluating FNP. Overall, patients are assessed from three perspectives: from the clinician's perspective using validated clinician-based grading instruments, from patient's perspective based on FNP-specific patient-reported outcome measures, and from the perspective of the layperson. The existing tools however provide limited information regarding the relative importance of different regions of the face. The eye appears to be an area of great concern for the patient where most surgical therapies are directed at. Addressing ocular problems in FNP carry a high priority but this is not clearly reflected by the standard systems.

Validation of the Finnish FACE-Q for use in patients undergoing surgery for functional problems or malignancy

The aim of this study was to produce a Finnish version of the FACE-Q scales Satisfaction with Forehead and Eyebrows, Adverse effects: Forehead, Eyebrows and Scalp, and Adverse effects: Cheeks, Lower face and Neck, and assess the performance of these scales and the Satisfaction with Facial Appearance, Satisfaction with Outcome and Appearance-related Psychosocial Distress in patients who had undergone surgery for functional problems or malignancy affecting the forehead or cheeks. The general health-related outcomes instrument 15 D was used as a reference. Patients who had undergone a frontal lift, a direct brow lift, a facelift or an excision of a facial tumor in Helsinki University Hospital plastic surgery department in 2009-2019 were identified. A postal survey study was conducted with 305 patients, of whom 135 (44%) responded. Diagnoses included facial nerve dysfunction (53%), brow ptosis (21%) and skin, mucosal or salivary gland tumor (20%). The FACE-Q scales displayed high internal consistency (Cronbach's alphas ≥0.80) and good reliability on repeat administration. The exploratory factor analysis revealed unifactorial influences for all scales except the Adverse effects: Forehead, Eyebrows and Scalp. Weak correlations with 15 D dimensions were detected. The FACE-Q scales evaluated here are suitable for use in patients with functional problems or malignancy.

FACE-Q Craniofacial Module: Part 1 validation of CLEFT-Q scales for use in children and young adults with facial conditions

BACKGROUND

The CLEFT-Q includes 12 independently functioning scales that measure appearance (face, nose, nostrils, teeth, lips, jaws), health-related quality of life (psychological, social, school, speech distress), and speech function, and an eating/drinking checklist. Previous qualitative research revealed that the CLEFT-Q has content validity in noncleft craniofacial conditions. This study aimed to examine the psychometric performance of the CLEFT-Q in an international sample of patients with a broad range of facial conditions.

METHODS

Data were collected between October 2016 and December 2019 from 2132 patients aged 8 to 29 years with noncleft facial conditions. Rasch measurement theory (RMT) analysis was used to examine Differential Item Function (DIF) by comparing the original CLEFT-Q sample and the new FACE-Q craniofacial sample. Reliability and validity of the scales in a combined cleft and craniofacial sample (n=4743) were examined.

RESULTS

DIF was found for 23 CLEFT-Q items when the datasets for the two samples were compared. When items with DIF were split by sample, correlations between the original and split person locations showed that DIF had negligible impact on scale scoring (correlations ≥0.995). In the combined sample, RMT analysis led to the retention of original content for ten CLEFT-Q scales, modification of the Teeth scale, and the addition of an Eating/Drinking scale. Data obtained fit with the Rasch model for 11 scales (exception School, p=0.04). Person Separation Index and Cronbach alpha values met the criteria.

CONCLUSION

The scales described in this study can be used to measure outcomes in children and young adults with cleft and noncleft craniofacial conditions.

FACE-Q craniofacial module: Part 2 Psychometric properties of newly developed scales for children and young adults with facial conditions

BACKGROUND

The FACE-Q Craniofacial Module is a patient-reported outcome measure designed for patients aged 8 to 29 years with conditions associated with a facial difference. In part 1, we describe the psychometric findings for the original CLEFT-Q scales tested in patients with cleft and noncleft facial conditions. The aim of this study was to examine psychometric performance of new FACE-Q Craniofacial Module scales.

METHODS

Data were collected between December 2016 and December 2019 from patients aged 8 to 29 years with conditions associated with a visible or functional facial difference. Rasch measurement theory (RMT) analysis was used to examine psychometric properties of each scale. Scores were transformed from 0 (worst) to 100 (best) for tests of construct validity.

RESULTS

1495 participants were recruited with a broad range of conditions (e.g., birthmarks, facial paralysis, craniosynostosis, craniofacial microsomia, etc.) RMT analysis resulted in the refinement of 7 appearance scales (Birthmark, Cheeks, Chin, Eyes, Forehead, Head Shape, Smile), two function scales (Breathing, Facial), and an Appearance Distress scale. Person separation index and Cronbach alpha values met criteria. Three checklists were also formed (Eye Function, and Eye and Face Adverse Effects). Significantly lower scores on eight of nine scales were reported by participants whose appearance or functional difference was rated as a major rather than minor or no difference. Higher appearance distress correlated with lower appearance scale scores.

CONCLUSION

The FACE-Q Craniofacial Module scales can be used to collect and compare patient reported outcomes data in children and young adults with a facial condition.