We thank Alicandri-Ciufelli et al. for their communication and appreciate their comments, which we would like to address in a point-by-point fashion. First, we believe that in routine clinical practice, evaluation of a patient should be performed thoroughly by all health care professionals (not just physicians) but concede that the method used is at the discretion of the clinician. In our experience, but admittedly not quantified or researched specifically, the use of the Sunnybrook Facial Grading Scale takes a few minutes and is routinely performed by the facial therapist and the physician, allowing interrater comparison within a team. The rough facial grading system is very simplified in that it does not take into account the regional differences of facial palsy affecting specific divisions of the nerve.
We also argue that it demonstrates good interrater reliability largely because the groups are so broadly defined. This is the same issue with the House-Brackmann scale, the most widely used system1 against which the rough facial grading system was validated. Indeed, Dr. Alicandri-Ciufelli et al. (and others) have previously stated that the broader the definitions of categories, the greater the interrater agreement.2,3 They also go on to argue that the broader these categories, the less informative any scale would be. We agree with this concept and suggest that the rough facial grading system is a step backward in that high interrater reliability does not necessarily confer sufficient information for a thorough facial nerve evaluation. For a scale to be of value, it needs to be specific, sensitive, and simple to use, and our objective analysis suggests that the Sunnybrook Facial Grading Scale best meets these criteria. The rough facial grading system is simple to use, with high interrater agreement, but is not specific or sensitive.
Second, the idea that computer-based objective systems will supersede clinical examination has been around for a long time. We agree that as technology progresses, such objective analyses will become cheaper, faster, and more widespread. Our report evaluates the current state of facial nerve assessment, and although larger medical facilities in the developed world may be able to access such devices, it will be a long time before such technology is universally available. In addition, the objective assessment of facial animation omits one other important aspect of facial difference: the subjective assessment of appearance. This can be divided into subjective self-assessment (the realm of patient-reported outcome measures) and observer-based subjective assessment. The latter is automatically incorporated into the physician’s assessment and, some would argue, unconsciously biases their assessment, whatever facial grading scale they use. This is the human dynamic emotional interaction that will defy quantification for some time to come. In addition, whatever advanced computerized system is used, it will need to be validated against the current criterion standard, which is clinical examination.
Third, we completely agree with the comment that the quality of life as reported by the patients is (perhaps) the most important measure of therapeutic benefit. The patient-reported outcome measures and the functional scoring systems are both required, providing a broader picture of patient wellness, and one need not exclude the other. Furthermore, the correlation between functional scores and patient-reported outcome measures is increasingly being recognized as nonlinear.4 As we state in our study, this has been addressed in another publication5 and was not the purpose of our report. We thank Alicandri-Ciufelli et al. for the opportunity to clarify these points and hope that our work will continue to stimulate debate among the different groups of health care professionals that manage patients with facial palsy.
The authors have no commercial associations or financial disclosures that might pose or create a conflict of interest with any of the information presented in this communication.
Adel Y. Fattah, Ph.D., F.R.C.S.(Plast.)
Dilnath A. Gurusinghe, M.R.C.S.(Eng.)
Facial Nerve Programme
Regional Paediatric Burns and Plastic Surgery Service
Alder Hey Children’s NHS Foundation Trust
Liverpool, United Kingdom
Javier Gavilan, M.D.
Department of Otolaryngology
La Paz University Hospital
Tessa Hadlock, M.D.
Harvard Medical School
Massachusetts Eye and Ear Facial Nerve Center
Jeff Marcus, M.D.
Division of Plastic, Reconstructive, Oral,
and Maxillofacial Surgery
Duke University Medical Center
Henri Marres, M.D., Ph.D.
Radboud University Medical Center
Nijmegen, The Netherlands
Charles Nduka, M.A., M.D.
Queen Victoria Hospital Foundation NHS Trust
East Grinstead, West Sussex, United Kingdom
William H. Slattery, M.D.
University of Southern California
Los Angeles, Calif.
Alison Snyder-Warwick, M.D.
Washington School of Medicine
St. Louis, Mo.
On behalf of the Sir Charles Bell Society
1. Fattah AY, Gavilan J, Hadlock TA, et al. Survey of methods of facial palsy documentation in use by members of the Sir Charles Bell Society. Laryngoscope. 2014;124:2247–2251
2. Yanagihara N.Fisch U. Grading of facial palsy. In: Facial Nerve Surgery. 1977 Birmingham, Ala Aesculapius Publishing:533–535
3. Alicandri-Ciufelli M, Piccinini A, Grammatica A, et al. A step backward: The ‘rough’ facial nerve grading system. J Craniomaxillofac Surg. 2013;41:e175–e179
4. Walker DT, Hallam MJ, Ni Mhurchadha S, McCabe P, Nduka C.. The psychosocial impact of facial palsy: Our experience in one hundred and twenty six patients. Clin Otolaryngol. 2012;37:474–477
5. Ho AL, Scott AM, Klassen AF, Cano SJ, Pusic AL, Van Laeken N.. Measuring quality of life and patient satisfaction in facial paralysis patients. Plast Reconstr Surg. 2012;130:91–99
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