Scales of degree of facial paralysis: analysis of agreement

To analyze the inter- and intra-rater agreement of the scales of degree of facial paralysis and to elicit point of view of the appraisers regarding their use.

METHODS:

Cross-sectional observational clinical study of the Chevalier and House & Brackmann scales performed by five speech therapists with clinical experience, who analyzed the facial expression of 30 adult subjects with impaired facial movements two times, with a one week interval between evaluations. The kappa analysis was employed.

RESULTS:

There was excellent inter-rater agreement for both scales (kappa > 0.80), and on the Chevalier scale a substantial intra-rater agreement in the first assessment (kappa = 0.792) and an excellent agreement in the second assessment (kappa = 0.928). The House & Brackmann scale showed excellent agreement at both assessments (kappa = 0.850 and 0.857). As for the appraisers' point of view, one appraiser thought prior training is necessary for the Chevalier scale and, four appraisers felt that training is important for the House & Brackmann scale.

CONCLUSION:

Both scales have good inter- and intra-rater agreement and most of the appraisers agree on the ease and relevance of the application of these scales.

Facial paralysis; Evaluation; Scales; Classification; Speech therapy

Level	Description
0	Contraction not visible to the naked eye nor with oblique light incidence
1	Small mobility of skin
2	The skin has more mobility. Wrinkles are lightly perceived
3	The skin moves more clearly. The number of wrinkles increases, as well as their depth
4	The movement takes place with a wide, synchronous, and symmetrical manner, with respect to the uninjured side

Grade	Description	At rest	In movement
I	Normal	Symmetry	Normal facial function
II	Mild dysfunction	Normal symmetry and tone	Forehead: moderate to good function Eye: complete closure with minimum effort Mouth: slight asymmetry
III	Moderate dysfunction	Normal symmetry and tone	Forehead: slight to moderate movement Eye: complete closure with effort Mouth: slight weakness with maximum effort
IV	Moderately severe dysfunction	Normal symmetry and tone	Front: none Eye: incomplete closure Mouth: asymmetric with maximum effort
V	Severe dysfunction	Asymmetry	Front: none Eye: incomplete closure Mouth: slight movement
VI	Total paralysis	Asymmetry	No movement

Reviewer	Chevalier kappa value	L.L.	U.L.	House & Brackmann kappa value	L.L.	U.L.
1	0.900	0.807	0.963	0.929	0.864	0.959
2	0.853	0.719	0.935	0.899	0.806	0.956
3	0.912	0.836	0.955	0.851	0.719	0.926
4	0.923	0.858	0.968	0.809	0.659	0.897
5	0.831	0.533	0.984	0.935	0.876	0.972

Review iteration	Chevalier kappa value	L.L.	U.L.	House & Brackmann kappa value	L.L.	U.L.
First	0.792	0.659	0.884	0.850	0.747	0.915
Second	0.928	0.885	0.952	0.857	0.762	0.909

Questions		Chevalier		House & Brackmann
		n	%	n	%
Do you think that the proposed scales are easy to apply?	Yes	5	100	4	80
Do you think that the proposed scales are easy to apply?	No	–	–	1	20

Do you think that there is need of prior training for speech therapists?	Yes	1	20	4	80
	No	4	80	1	20

How do you rate the scales for phonoaudiological evaluation?	Relevant	5	100	4	80
	Limited relevance	–	–	1	20
	Not relevant	–	–	–	–

Do you think that the scales cover all possibilities?	Yes	1	20	1	20
Do you think that the scales cover all possibilities?	No	4	80	4	80

Associação Brasileira de Otorrinolaringologia e Cirurgia Cérvico-Facial. Sede da Associação Brasileira de Otorrinolaringologia e Cirurgia Cérvico Facial, Av. Indianópolia, 1287, 04063-002 São Paulo/SP Brasil, Tel.: (0xx11) 5053-7500, Fax: (0xx11) 5053-7512 - São Paulo - SP - Brazil
E-mail: revista@aborlccf.org.br

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[1] * Corresponding author. E-mail: laelia@uol.com.br (L.C.C. Vicente).