Keywords facial paralysis - Bell paralysis - case studies - psychosocial impact
Palavras-chave paralisia facial - paralisia de Bell - estudos de casos - impacto psicossocial
Introduction
The non-verbal communication, frequently expressed through the face, has important
subjective function[1 ], and is an essential element to the development of the eastern individual, because,
while traces and facial expressions are involved in the communication and socialization
process, they are essential for the individualization, revealing the interiority and
the feelings of each person[2 ].
Considering the communicative importance addressed to the face, it is interesting
to discuss the limitations and consequences that the peripheral facial paralysis (PFP)
causes in the life of an individual who suffers this condition.
In organic terms, the PFP results from the reduction or interruption of the axonal
transport to the VII cranial nerve resulting in complete or partial paralysis of the
facial movements. The facial nerve is frequently the most affected of the human body[3 ]. It runs a osseous path of approximately 35mm and is thus vulnerable to the action
of compressive and infectious processes of various kinds that can interrupt its nervous
influx, leading to a complete blockage of its functions[4 ].
Alterations may occur in speech, chewing, swallowing, tasting, salivation and tearing,
hyperacusis and hypoesthesia in the external auditory canal[5 ]
[6 ]
[7 ]
[8 ]. Aesthetically, the disharmony between the facial movements and the speech is embarrassing,
not only for the affected individuals but also for those around them[1 ]. Therefore, this condition causes functional and aesthetical disorders important
for the individual[9 ].
Regarding etiology, several studies show that Bell Paralysis, or idiopathic, is the
most common diagnosis, reaching half the cases[10 ]
[11 ], and is a diagnosis based on the absence of serological test for infections, trauma,
tumors and/or herpes zoster[12 ]
[13 ].
The recovering time of PFP is undetermined, a total or partial regeneration of the
facial movements is possible, depending on the degree of the lesion of the facial
nerve, of its various etiologies, the patient's age and how the case was conducted
by the health professionals involved[14 ].
In its initial phase, the PFP is called flaccid, and are observed: flaccidity of the
muscles at rest and hypofunction of the movements, with partial or total incapacity
to perform mimes and sphincter movements of the face[15 ].
With the regeneration of the facial nerve, there is a possibility of recovery of the
facial movements[16 ], occurring a gradual return of the movements, which can evolve to the total recovery
of the facial movements and expressions, without sequelae[15 ].
However, when this regeneration is partial, there may be found sequelae, such as:
synkinesis, post-paralytic hemifacial spasm and/or persistence of motor deficit with
muscle contractures[17 ]
[18 ]. Another characteristics of the sequelae can be the remaining of the hypofunction
of the affected facial muscles, typical of the flaccid phase of PFP[19 ].
The facial deformity and involuntary and undesired movements, common after the establishment
of the sequelae, besides damaging the aesthetics and functionality, can significantly
interfere in the interpersonal communication. Such condition limits the expressiveness
of the individual, causing a variety of psychosocial problems such as depression,
anxiety, rejection and paranoia[20 ].
In the rehabilitation in cases of PFP, traditionally, the phonoaudiologist develops
a work focused on the stomatognathic system, based on the investigation of the damages
caused on the facial muscles by the lesion of the facial nerve. This approach evaluates
the functions related to these muscles, intervening with the purpose of promoting
the recovery of the functional and aesthetical aspects. However, it is desirable that
the psychological and social aspects associated with this clinical condition are not
neglected[21 ].
After these considerations we can observe, in short, that the difficulties to use
the facial movements, besides the changes in speech, cause suffering to the individual;
often causing physical, psychological and social associated disorders[21 ].
From the exposed, this study focuses in PFP under the point of view of the subjects
who suffer with its consequences and, in this perspective, aims to contribute to the
effectiveness of the clinical phonoaudiological method.
Considering these aspects, this study has as main objective: to investigate the psychological
contents and the social effects associated to PFP in adult subjects, and as specific
objective: to compare these data in three groups of patients, namely, in flaccid,
recovery and sequela phases.
Method
Nature of the research: quantitative and qualitative clinical research, developed
through case studies.
Casuistry: 16 adult subjects with PFP, 4 in flaccid phase, 6 in recovery phase and
6 in sequela phase.
Inclusion criteria
There were selected subjects being treated in the Phonoaudiology sector of the Institution
in which the research was performed.
Adults, of both sexes, above 18 years of age; since the occurrence of PFP in the pediatric
population (1-15 years) is three times smaller than the found in the adult population[22 ].
PFP was of unknown origin or idiopathic, since most of the cases did not present other
associated diseases[11 ].
PFP phase was determined from the realization of the otorhinolaryngological and phonoaudiological
evaluations. Besides, was considered the time of installation of PFP and the observation
of clinical signs which indicated the stagnation, evolution or installation of sequelae.
These subjects manifested moderate deformity (III), grave moderate dysfunction (IV)
and grave dysfunction (V), according to the evaluation scale of HOUSE & BRACKMANN[23 ] which begins in degree I and goes to degree VI.
The evaluation of the facial movements was based on the protocol used in the Phonoaudiological
Rehabilitation Sector of the institution where the research was performed[24 ].
Exclusion criteria
Procedure
Stage 1: Personal data (age, gender, profession and complaints), as well as medical
history, installation of PFP, previous exams, diagnostics and therapeutic conduction,
were brought up on the medical records of the patients in treatment.
Stage 2: The functional condition of the face was classified on phases flaccid, recovery
and sequela, following the protocol used by the Institution and described on the casuistry,
therefore confirming the subjects' PFP condition.
At the evaluation of the mobility of facial muscles was asked that each movement be
executed 5 times, for better accuracy of the quotation in one of five degrees (0 -
contraction not visible to the naked eye nor to the oblique light; to 4 - the movement
is executed widely, with synchrony and symmetry, in relation to the healthy side)[24 ].
Stage 3: The interviews were open, individual, with average length of 50 minutes and
aiming to let the subjects express themselves freely, especially regarding subjective
aspects of PFP, from the following question: What were the consequences of PFP on your social and emotional life?
When necessary, the researcher intervened during the interview, focusing on the objective
of the research. They also sought to encourage the spontaneous report from the patient,
without coaching, aiming to detect the manifestations of the mental function in its
verbal and non-verbal dimensions[25 ].
Recording and storage of data
The assessment of the functional condition of the subjects was photographed and filmed,
so there would be registration and proof.
The interviews were recorded in audio and video and stored in DVD-ROM, so that they
could later be fully transcribed in regular orthography and analyzed more rigorously.
Analysis of the results
Phase 1: The interpretation of the material obtained in interviews was marked on the
category analysis[26 ]. From the investigation of what each element has in common with the others, the
categories were organized and grouped. The structuring of this process depends on
the isolation of the elements (inventory) and the organization of the messages (classification)[26 ].
Phase 2: Description of the convergent and divergent categories among the statements
of all subjects, through simple statistics.
Phase 3: Comparison between the categories present on the group of patients on phase
flaccid, recovery and sequela, through simple statistics.
Phase 4: The material obtained in the interviews was analyzed from references from
theoreticians of psychoanalysis (psychological contents), social psychology (Theory
of Stigma) and phonoaudiology (symptomatological collection).
Evaluation guide
The guide of evaluation of the psychological contentes and social effects associated
to PFP was prepared from the results obtained in this research and is structured in
thematic blocks, based on categorical analysis[26 ] of the contents of the interviews with the studied subjects.
Ethics
According to the proposed ethical standards for research using humans, participated
on the research only those subjects who agreed to sign the “Term of Free and Informed
Consent” (TFIC). The identity of the subjects was preserved; therefore, their names
were replaced by numbers. The research was approved by the Committee of Ethics of
the Institution, n° 251/09.
Results
The sample consisted of 16 patients who had PFP: 11 (68,7%) were female and 5 (31,3%)
were male.
[Table 1 ] shows the frequencies and general percentages and percentages for each phase of
PFP in relation to the occurrence of each psychological content. The factors with
highest frequency in the overall sample were fright at the moment of PFP and dismay
after PFP, each reported by 12 (75%) patients.
Table 1.
Frequencies and percentages of psychological contents.
Occasion
Content
Flaccid Phase
Recovery Phase
Sequela Phase
Total of Sample
N
%
N
%
N
%
N
%
Before
Sadness without factual reason
1
25
1
16,7
0
−
2
13
Sadness with factual reason
0
−
1
16,7
4
66,7
5
31
Revolt with factual reason
0
−
0
−
2
33,3
2
13
Stress
1
25
2
33,3
5
83,3
8
50
Nothing relevant
2
50
3
50
1
16,7
6
38
At the moment
Calm
1
25
3
50
0
−
4
25
Fright
3
75
3
50
6
100
12
75
Despair
0
−
1
16,7
2
33,3
3
19
Confusion with stroke
1
25
0
−
3
50
4
25
After
Irritation
3
75
1
16,7
1
16,7
5
31
Dispersion
1
25
1
16,7
1
16,7
3
19
Anxiety
4
100
1
16,7
2
33,3
7
44
Dismay
4
100
3
50
5
83,3
12
75
Shame
2
50
2
33,3
4
66,7
8
50
Fear of repetition of symptom
0
−
0
−
1
16,7
1
6
Frustration for the absence of defined etiology
2
50
0
−
0
−
2
13
Impatience
3
75
1
16,7
0
−
4
25
Horror in face of the condition
25
1
16,7
3
50
5
31
Revolt
1
25
2
33,3
0
−
3
19
Sadness
2
50
2
33,3
6
100
10
63
Gratitude for the cares of family, friends and/or health professionals.
0
−
3
50
4
66,7
7
44
Abandonment of family, friends and/or health professionals
1
25
1
16,7
0
−
2
13
Nuisance, feeling that everyone is looking to the
1
25
2
33,3
2
33,3
5
31
Nothing Relevant
0
−
3
50
0
−
3
19
Total
4
25
6
37,5
6
37,5
16
100
The factors with highest frequency in flaccid phase were anxiety, dismay after PFP,
each reported by 4 (100%) patients.
At recovery phase was observed a smaller frequency, reaching 50% for the contents:
calm and fright at the moment of PFP; dismay, sadness and nothing relevant after PFP.
Sequela phase presented the highest frequency of answers, with fright at the moment
of PFP and sadness after PFP reported by 6 patients (100%) and stress before PFP,
dismay reported by 5 (83,3%) patients.
For each patient was calculated the number of psychological contents. [Table 2 ] presents the observed values of the descriptive statistics for the number of psychological
contents per patient, gender, age group, phase and hemiface. The values of the number
of psychological contents observed in each patient are represented on [Figure 1 ].
Figure 1. Individual and average values of the Number of psychological contentes per patient
in each category of Gender, Age group, Hemiface and Phase •: average.
Table 2.
Descriptive statistics for the Number of psychological contentes per patient in each
category of Gender, Age group, Hemiface and Phase.
N
%
Average
Standard Deviation
Minimum
Median
Maximum
Gender
female
11
68,7
7,9
3,6
4
7
16
male
5
31,3
7,2
3,0
3
7
11
Age group
under 60
9
56,2
8,9
3,6
4
9
16
60 or more
7
43,8
6,1
2,6
3
6
11
Hemiface
Right
11
68,7
7,1
2,3
4
7
11
Left
5
31,3
9,0
5,1
3
10
16
Phase
Flaccid
4
25
8,5
2,4
6
8,5
11
Recovery
6
37,5
6,0
3,2
3
4,5
11
Sequela
6
37,5
8,8
3,9
5
7,5
16
Total
16
100
7,7
3,4
3
7
16
Similar behavior is observed in both genders, that is, people of both sexes tend to
present, in average, the same number of psychological contents: the elderly present,
in average, lower number of contents than the youngest, the subjects in recovery present
lower average of number of contents than those on the other phases, and those who
have the right hemiface affected present lower average of number of contents than
those who have the left face affected.
In the analysis of the social effects were adopted the same procedures used on the
psychological contents analysis.
The frequencies and percentages of general occurrences and occurrences on each phase
of PFP of social effects are presented on [Table 3 ]. The effects with most frequency are related to isolation.
Table 3.
Frequencies and percentages of the social effects.
Subjects/ Established environments
Flaccid Phase
Recovery Phase
Sequela Phase
Total of sample
N
%
N
%
N
%
N
%
Isolation
Avoids leaving the house
2
50
2
33,3
4
66,7
8
50
Tries to go out, but can't
1
25
1
16,7
3
50
5
31
Avoids meeting people
3
75
1
16,7
5
83,3
9
56
Avoids talking to people
2
50
1
16,7
5
83,3
8
50
Refusals
Avoids taking pictures
2
50
1
16,7
3
50
6
38
Avoids taking part on eating scenes
2
50
1
16,7
4
66,7
7
44
Avoids participating on parties
2
50
0
−
3
50
5
31
Avoids religious rictuals
1
25
0
−
1
16,7
2
13
Professional Difficulties
1
25
0
−
1
16,7
2
13
Marital Difficulties
1
25
0
−
3
50
4
25
Total
4
25
6
37,5
6
37,5
16
100
On flaccid phase the category isolation: avoids meeting people was reported by 3 patients,
that is, 75% of the sample. The recovery phase presented frequency of answers below
40%, highlighting only isolation: avoids leaving the house, reported by 2 (33,3%)
patients.
Sequela phase stands out for presenting mostly frequencies of answer above 50% for
the established categories, evidencing that the categories of isolation: avoids talking
and meeting people, were reported by 5 (83,3%) patients.
For each patient was calculated the number of social effects reported. [Table 4 ] shows the observed values of descriptive statistics for the number of effects per
patient, gender, age group, phase and hemiface. The values of number of social effects
observed in each patient are represented on [Figure 2 ].
Figure 2. Individual and average values of the Number of social effects per patient in each
category of Gender, Age group, Hemiface and Phase •: average.
Table 4.
Descriptive statistics for the Number of social effects per patient in each category
of Gender, Age group, Hemiface e Phase.
N
%
Average
Standard Deviation
Minimum
Median
Maximum
Gender
Female
11
68,7
3,4
3,3
0
4
10
Male
5
31,3
3,8
4,1
0
3
9
Age group
under 60
9
56,2
4,2
3,5
0
4
10
60 or more
7
43,8
2,6
3,4
0
0
7
Hemiface
Right
11
68,7
3,2
3,3
0
3
9
Left
5
31,3
4,2
4,0
0
4
10
Phase
Recovery
6
25
1,2
1,8
0
0
4
Flaccid
4
37,5
4,3
4,4
0
4
9
Sequela
6
37,5
5,3
3,1
1
5
10
Total
16
100
3,5
3,4
0
3,5
10
The number of social effects per patient does not depend on gender, and is, in average,
lower in those with 60 or more years, having a higher average on those with left hemiface
affected, and is higher, in average, on those with sequela.
Discussion
Regarding the gathering and characterization of the subjects, there is a prevalence
of females (68,7%) in relation to males (31,3%). Valença , Valença and Lima
[18 ], had already pointed out the prevalence of women in their study, obtaining a similar
percentage, 66,7% of the sample. Garanhani , Capelli and Ribeiro
[27 ], in their study, also found this prevalence of women with PFP (60,8%).
Psychological Contents
On the ocasion previous to PFP, 32% of the interviewed reported sadness due to factual
reasons. Those, in every case, were revealed because the subjects felt and announced
that the moment of the interview was established as place of exposure and reception
of these sufferings, as exposed by Ávila
[28 ] in psychosomatic affectations. Below, an example:
“So, it's like, my problem came from another problem. Because you see, I have a son
and he is, it's that he started using drugs. When it was the same day my son decided
to tell me, then when he told me, I froze.”
“I think it all came together. Problem of husband that drunk, then problem that my
father died, next problem of my son, then I gathered all this, when I thought that
I wasn't all crooked. Then that's it, until today, until today that I am, I ask God
every day to give me patience, strength and courage to go on.” (Subject 14 - Sequela Phase).
As highlighted by Ávila
[28 ], the symptoms shan't be minimize or dismissed, it is necessary an investigation
of the personal life of the patient every time the etiology of a specific disease
appears confuse or incomplete. Beyond that, it should be considered that the treatment
consists in making the individual overcome the alienation that keeps him a stranger
to himself, to make him admit himself as a subject, without establishing a relation
of subordination and dependency between patient and health professional[29 ].
Lipowski
[30 ] pointed out that in the somatization, precipitating factors include vital events
and personally stressing situations, due to its subjective meaning of loss or threat
to the individual.
An important aspect of the personality of the patients is the one called trace of
“neuroticism” and the vulnerability to stress[28 ]. Lipowski
[30 ] also stresses that the tendency of these patients to deal with difficulties in life,
their multiplicity in conflicts, through the adoption of a “sick role”, with which
they try to gain the support and attention of their family, as well as avoid social
and familiar obligations.
It is necessary to remember, that the patient, in this frail condition, needs to be
welcomed and listened, taking in consideration the aspects that he associated with
his disease process[28 ]
[31 ].
The research of Rebelo , Rolim and Ferreira
[32 ] reminds that the person initiates a course of inner suffering when sick, including
emotions and feelings of deep discomfort, anxiety, impatience and sadness.
It is highlighted that 75% (12 subjects) of the respondents claimed that after PFP
they felt dismay:
“I cried a lot, I didn't sleep. It messed with my appetite, messed with my sleep,
I cried because, regardless of us feeling terrible, ridiculous, ugly, it really messes
with the nervous system, with me it messed a lot, a lot, a lot.” (Subject 5 - Recovery Phase).
This data agrees with the study of Byrne
[33 ] which points out the tendency of the depressive symptom (65%) in subjects with PFP.
Facing these quotes it is interesting to stress that the process of educating the
individual about what leads him to illness in the physical, mental and social spheres
can provide the change of negative aspects that contribute to this state of disharmony.
The discovery of stressing factors that influence in disease is fundamental to the
occurrence of the changes that also refer to the awareness of patterns of behavior
harmful to the person, both physical and emotional[34 ].
Regarding the feeling of shame (50%) it is interesting to remember the work of Silva and Müller
[34 ] about skin diseases, where the individual makes use of camouflage to hide the skin
problems, or avoid the routine activities, for noticing the negative reaction of others,
which provokes the feeling of shame.
“It's like, you're used to your physiognomy and all of a sudden you see yourself crooked,
the face deformed, understand? You laugh a lot and it looks like someone ripped your
mouth and put it up. You know, it's devastating, devastating. It crashes our self-esteem,
your ego goes right down, mine did. I felt terrible, didn't want to look into the
mirror, you know. I was ashamed to eat in front of the others and smiling, no way.” (Subject 5 - Recovery Phase).
The fact that idiopathic PFP is not an organically severe affection makes us underestimate
the condition, and that may be similar to the reported by Silva and Pais -Ribeiro
[35 ] in the condition of macular degenerescence, and may distance the relation between
the patient and the health professional.
“if you look at a person with facial paralysis, you don't imagine that it is a big
deal, but it does. I would never imagine that it messed up so much with myself, understand,
because of all the problems I've had with my health it was the one that messed with
me the most, on the inside.” (Subject 5 - Recovery Phase).
One of the subjects claimed to avoid looking at his face in the mirror and it's noteworthy
that it's been six[6 ] years that PFP has installed itself.
“So, many times I don't even look at myself in the mirror, because every time I look
I feel very sad.” (Subject 14 - Sequela Phase).
Analyzing what Sant' Anna
[36 ] affirmed about the subjective intentions revealed through the study of the face,
it is important to highlight the psychological impact caused by a facial alteration
as drastic as PFP. The difficulty to recognize onself and express through the face,
brought the impossibility of subject 14 to look in the mirror.
Closing this section, we can observe that the discussion was permeated with references
of researches and literature that brought up subjective aspects of the history of
the face and psychosomatic aspects involved in several pathologies. On the other hand,
it was found a lack of specific references of researches about PFP, and the specific
works on the theme presented general data relative to behavioral changes without explaining
them after the installation of PFP.
Social Effects
On this item were exposed the variety of strategies the stigmatized subjects employed
to deal with the peer rejection and the complexity of types of information about themselves
that they project on others, as established by goffman
[37 ].
“It's not that I hid that I... of course, I was worried, you know, I was worried because
people deserve this care, this respect of our speech, of our face. Our face is everything.
It's the image that goes everywhere.” (Subject 16 - Recovery Phase).
Avoid leaving the house (50%), in places specifically established and use resources
to avoid been seen was a much commented event throughout the interviews:
“Because I live (...) almost thirty five years, then we know everybody, the neighbors,
everyone, even going out the street is kind of troubled, even have to put dark clothes,
looks like a robber, looks like you're running from the. and like, because it is,
let's assume, it's logical, you're a very polite person, someone will ask an you'll
stop and answer, won't you?” (Subject 7 - Flaccid Phase).
In this case, the individual that suffers with his stigma feels depotentiated to attend
to certain places, because he assumes that the others, even though don't know him,
will notice his difference[37 ].
Coulson , O'dwyer , Adams and Croxson
[38 ] assessed the impact of PFP on the life quality of these individuals through open
questionnaires, finding that the higher the damage of movements of the facial muscles,
there is a considerable decrease of the social function, which is consistent with
the results gathered in this research.
“(...) I had my bear, listened to live music, danced over there. Outside, where there
are the bars, stayed outside. I liked a lot to go, to listen the music and have fun
and now I don't go anymore.” (Subject 8 - Sequela Phase).
38% of the subjects interviewed avoid having their pictures taken:
“I don't take. I didn't take before becouse I was very shy, but I took and everything,
not now. Never took again. See, if today I have to take a picture for a document,
I won't take.” (Subject 9 - Flaccid Phase).
With this condition almost completely incapacitating of facial expression, even if
the condition is of lesser expression of feelings, like in the case of 3 × 4 photos
for documents, the subjects feels uncomfortable to register his face in pictures.
With the muscular malleability it is possible to deduce the feelings of an individual
only by paying attention to the facial expressions[39 ]. With PFP it becomes hard to have this malleability.
44% of the subjects avoid participating in feeding scenes:
“the food fall from the mouth for everyone to see, you even lose the appetite. The
appetite ends, you don't want to eat. I lost more than three kilos in four months
and it ended me, I mean, of course I needed to lose weight anyway (laugh), but it
was devastating. Water you can't drink anymore, you drink water, the water falls on
your clothes and that's terrible.” (Subject 5 - Recovery Phase).
On Goffman's
[37 ] considerations, for the stigmatized, society reduces the opportunities, efforts
and movements, doesn't value, imposes loss of social identity and determines a deteriorated
image, according to the model that suits the society. The different assumes a category
of “harmful”, “incapable”, out of the parameter society takes as standard. He remains
at the edge and has to answer to what society determines. The social tries to conserve
the deteriorate image as a constant effort to maintain the effectiveness of the symbolic
and hide what interests, which is the maintenance of the social control system[37 ].
Conclusion
The results indicate that, comparatively, the subjects with sequelae show greater
statistically significance of psychological contents and social effects associated
with PFP. Followed, respectively, by those on flaccid and recovery phases.
However, mainly, the reports of the studied subjects revealed wide and significant
range of subjective contents that must be investigated and incorporated by phonoaudiologists
on the treatment of PFP, in order to promote greater effectiveness of the phonoaudiological
clinical method.
We suggest the continuity of researches about the theme with expanded casuistry and
focus on the following strands: the listening to patients' treatment and the clinical
implication of biopsychosocial approach of PFP.
Annex.
Script of the evaluation of psychological contents and social effects associated with
PFP.
BLOCK I - IDENTIFICATION
Name:
Date of Birth: Age:
Civil Status: Profession:
BLOCK II - Phase of PFP
[ ] flaccid [ ] recovery [ ] sequela
BLOCK III - History of PFP.
1. When PFP occurred?
2. What sensations and signals were noticed before the installation of PFP?
3. What were the measures taken?
BLOCK IV - Psychological contents
4. Were there alterations in your emotional state before the installation of PFP?
Report.
5. Which was your emotional reaction during the installation of PFP? Report.
6. Which were your emotional reactions after the installation of PFP? Report.
BLOCK V - Social effects
4. Were there any difficulties on your social life after the installation of PFP?
Report.
5. Did you isolate yourself from social interaction due to physical consequences of
PFP? Report.
6. Did you refuse to perform activities, performed frequently before, after PFP? Report.
7. Were there any professional difficulties after PFP? Report.
8. Were there marital relationship problems after PFP? Report.
BLOCK VI - Complementary observations.
