www.bjorl.org
Brazilian
Journal
of
OTORHINOLARYNGOLOGY
ORIGINAL
ARTICLE
Translation,
cultural
adaptation
and
validation
of
the
facial
disability
index
into
Brazilian
Portuguese
夽
Agnaldo
J.
Graciano
a,∗,
Marcela
M.
Bonin
b,
Marion
R.
Mory
b,
Adriana
Tessitore
b,
Jorge
R.
Paschoal
a,
Carlos
T.
Chone
aaUniversidadeEstadualdeCampinas(Unicamp),FaculdadedeCiênciaMédicas,DepartamentodeOtorrinolaringologia, Campinas,SP,Brazil
bHospitaldeClínicas,Servic¸odeFonoaudiologia,AmbulatóriodeParalisiaFacial,Campinas,SP,Brazil
Received26June2018;accepted2April2019 Availableonline18May2019
KEYWORDS Facialnerve; Facialparalysis; Complications; Assessmentof disability; PatientHealth Questionnaire Abstract
Introduction:Facialparalysis may occur due toa varietyofcauses. Itis associated tothe impairmentofsomebasicdailyactivitiessuchaseating,drinking,speakingandsocial commu-nication,which affects thequality oflifeofthesepatients. Thefacial disabilityindexisa shortformautoreportedoutcomequestionnaireusedtoassesspatientwithfacialparalysis. Ithasbeenvalidatedandprovedtobesuperiortoothergeneralhealthrelatedqualityoflife questionnaires.
Objective:Weaimtodotheculturaladaptationandvalidatethefacialdisabilityindexinto BrazilianPortuguese.
Methods:Translationandcultural-adaptationfollowingthestagesrecommendedbythe Inter-nationalSocietyofPharmacoeconomicsOutcomesResearchtaskforce.Thequestionnairewas administeredto100patientsforevaluationofreliabilityandvalidation.
Results:Thereliability ofthePortugueseversionofthefacialdisabilityindexwas foundto be adequate,with aCronbach’s alfacoefficient of0.73for thecomplete scale. Intra-class correlationwas0.79(95%CI:0.71---0.85)and0.85(95%CI:0.78---0.89)forthephysicalandsocial well-beingsubscales.Therewasasignificantcorrelationbetweenthesocialwell-beingsubscale ofthePortugueseversionofthefacialdisabilityindexandthesocialfunctionandmentalhealth componentsoftheSF-36.Therewasalsoacorrelationbetweenthefacialdisabilityindexand thedegreeoffacialdysfunctionaccordingtotheHouse---Brackmannglobalscale.
夽 Pleasecitethisarticleas:GracianoAJ,BoninMM,MoryMR,TessitoreA,PaschoalJR,ChoneCT.Translation,culturaladaptationand
validationoftheFacialDisabilityIndexintoBrazilianPortuguese.BrazJOtorhinolaryngol.2020;86:602---8.
∗Correspondingauthor.
E-mail:agnaldograciano@gmail.com(A.J.Graciano).
PeerReviewundertheresponsibilityofAssociac¸ãoBrasileiradeOtorrinolaringologiaeCirurgiaCérvico-Facial.
https://doi.org/10.1016/j.bjorl.2019.04.003
1808-8694/©2019Associac¸˜aoBrasileiradeOtorrinolaringologiaeCirurgiaC´ervico-Facial.PublishedbyElsevierEditoraLtda.Thisisanopen accessarticleundertheCCBYlicense(http://creativecommons.org/licenses/by/4.0/).
Conclusion: Thisadaptedversionofthefacial disabilityindexprovides avalid andreliable instrument to assess the physical and psychosocial impact of facial nerve dysfunction in Brazilian-speakingpatients.
© 2019 Associac¸˜ao Brasileira de Otorrinolaringologia e Cirurgia C´ervico-Facial. Published by Elsevier Editora Ltda. This is an open access article under the CC BY license (http:// creativecommons.org/licenses/by/4.0/). PALAVRAS-CHAVE Nervofacial; Paralisiafacial; Complicac¸ões; Avaliac¸ãoda deficiência; Questionáriode saúdedopaciente
Traduc¸ão,adaptac¸ãoculturalevalidac¸ãodofacialdisabilityindexparaoportuguês faladonoBrasil
Resumo
Introduc¸ão: Paralisiafacialperiféricapodeocorrerdevidoaumagrandevariedadedecausas eestáassociadaaocomprometimentodeatividadesdiáriasbásicas,comocomer,beber,falar e comunicac¸ão social,afeta aqualidade devida dospacientes. O facial disability indexé umquestionárioautoaplicadodesenvolvidoespecialmenteparaavaliaroimpactodadisfunc¸ão facialsobre aspectosfísicos epsicossociais dospacientes. Emboratenha sidovalidadoese mostradosuperioraoutrosquestionários,aindanãoforasubmetidoàadaptac¸ãotranscultural evalidac¸ãoparaalínguaportuguesa.
Objetivo: Realizaratraduc¸ão,adaptac¸ãoculturalevalidac¸ãodofacialdisabilityindexparao portuguêsfaladonoBrasil.
Método: A traduc¸ão e adaptac¸ão cultural do facial disability index foram realizadas em diferentes estágios conforme recomendac¸ões internacionais para adaptac¸ão de medidasde resultados.Paraaverificac¸ãodeconfiabilidadeevalidac¸ãodaversãoemportuguês,ofacial disabilityindexfoiaplicadoem100pacientesnaformadeteste/reteste.
Resultados: Aconfiabilidadedaversãoemportuguêsdofacialdisabilityindexfoiconsiderada adequada,comcoeficientealfadeCronbachde0,73.Aavaliac¸ãodecorrelac¸ãointraclassefoi de0,79(95%IC0,71---0,85),ede0,85(95%IC0,78---0,89)paraassubescalasfísicaedebem-estar social,respectivamente.Houveumacorrelac¸ãosignificativaentreaescaladebem-estarsocial da versãoem portuguêsdofacial disability indexe asdimensõesde func¸ão sociale saúde mentaldoquestionáriogeraldequalidadedevidaShortForm-36.Tambémfoidemonstrada umacorrelac¸ãoentreaversãoemportuguêsdofacialdisabilityindexeograudedisfunc¸ão facialdeacordocomaescalaglobaldeHouse-Brackmann.
Conclusão:A versãoadaptadadofacialdisabilityindexparaoportuguêsfaladonoBrasilse apresenta como um instrumento válidoe confiávelpara avaliac¸ão doimpacto dadisfunc¸ão facialsobreaspectosfísicosepsicossociaisdospacientes.
© 2019 Associac¸˜ao Brasileira de Otorrinolaringologia e Cirurgia C´ervico-Facial. Publicado por Elsevier Editora Ltda. Este ´e um artigo Open Access sob uma licenc¸a CC BY (http:// creativecommons.org/licenses/by/4.0/).
Introduction
Facialparalysis canresultfromawidevariety ofclinical, traumatic,andiatrogeniccauses.1,2
Dysfunction of orofacial motricity resultingfrom these conditions can lead to different degrees of basic func-tion alterations such as eating,drinking and speaking, in addition to expected impairment in facial mimetics and itsconsequences inthe capacityof interactionandsocial expression.3Consequently,facialdisabilityreflectsthe
over-all perception of patients about their health and quality of life.One ofthe main obstaclestothe subjective eval-uation of quality of life in patients with facial paralysis is thelimitation ofgeneral questionnairestodiscriminate thespecificdifficultiesfacedbytheseindividuals.Although somequestionnairesweredevelopedtoassesspatientswith facialparalysis,fewhavebeenadequatelyvalidated.4The
FacialDisabilityIndex(FDI)isaself-reportedquestionnaire thatassessesqualityoflifeaspectsrelatedtothephysical andpsychosociallimitationsresultingfromorofacialmotor alterations.It has been shown tobe validand more spe-cificthanothergeneralqualityoflifeassessmenttoolsfor patientswithfacialparalysis.5Althoughithasbeenusedin
severalstudiesandadaptedforotherlanguages,6---8theFDI
hasnot yet undergone cultural adaptation and validation intoPortuguese. Therefore, the aim of this study was to performthetranslation,culturaladaptationandvalidation oftheFacialDisabilityIndexintoBrazilianPortuguese.
Patients
and
methods
Thisstudywasapprovedbytheinstitution’sResearchEthics Committee(CAAE: 49967415.0.0000.5404) and all partici-pants gave their written free and informed consent to
participate in the study, according to the Declaration of Helsinki.
TheFDIquestionnaireconsistsof10items,separatedinto physicalandsocialwell-beingsubscales,eachwith5items quantifiedona6-pointscaleandtransformedintoascoreof upto100pointsthatwouldindicateunalteredphysicaland social well-beingfunctions. The physical subscale investi-gatesproblemswheneating,drinking,speaking,performing oralhygiene,andocularsymptoms,suchastearingor ocu-lardryness.Thesocialwelfaresubscaleinvestigatesaspects relatedtoanxiety,irritabilityandsocialinteraction.
TheauthorizationoftheAmericanPhysicalTherapy Asso-ciation, which holds the publication rights, was obtained forthetranslationandculturaladaptationoftheFDI.The techniqueusedfollowedtheinternationalrecommendations fortranslationandculturaladaptationofmeasuresof self-reportedresults,9includingthefollowingsteps:
1) InitialtranslationbasedontheoriginalFDIinAmerican English into Portuguese, carried out by two indepen-dent qualified translators, whose first language was Portuguese.
2) The reconciliationof the obtained versions were eval-uated by tworesearchers involved in the project and compared for differences and preparation of a single initialversionofthePortuguesetranslation.
3) Back-translation: in this phase the initial Portuguese version wasback-translated into English by two other translatorswhoarenativespeakersofAmericanEnglish andwhowereunawareoftheoriginalquestionnaire. 4) Review of back-translations: comparing them withthe
original questionnaireandthereconciliation versionto determine iftheyshowedliteralresults differentfrom theoriginaltool,orsimilarones,maintainingtheconcept ofthequestionnaire.Atthisphase,thedeveloperofthe original questionnaire was contacted toclarify doubts abouttheconceptofsomeitems.
5) AsecondversionoftheFDIwascarriedoutbya commit-teeinvolvedinthestudybasedontheharmonizationof thecomparisonsofthePortuguesetranslationsandthe back-translations.
6) Cognitiveresearch:Atthisphase,thetestversionofthe questionnaire was appliedto 20patients to verifythe need for theuse ofalternative words,interpretability, comprehensibility, andculturalrelevance ofthe trans-lation.The questionnaire wasself-administeredbythe patients and afteranswering it, the researchersasked them to record the understanding of each itemon an analoguescale,graduatingitfrom1to10(fromthemost difficulttounderstandtotheeasiest).Theclarityindex of eachquestionwasobtainedbythemeanofthe val-uesoverthenumberofpatients,andscoreslowerthan 0.4 wouldrepresentmisinterpretedquestion wordings; between0.5and0.7,unclearwordingsand,above0.8, clearwordings,asproposedbyTavaresetal.10
7) Thecommitteeinvolvedinthetranslationevaluatedthe unfolding of the cognitive research and comparedthe versionsobtainedinthepreviousstepstodetermine dis-crepanciesoftheoriginalintendedmeaning,creatingthe finalversionoftheFDIinPortuguese(Pt-FDI).
ForthevalidationofPt-FDI,thefinalversionofthe ques-tionnairewasappliedusingthetest-retestformatinagroup of100outpatientsdiagnosedwithperipheralfacial paraly-sis.
Inclusioncriteria
Adult patients over 18 years of age with a diagnosis of peripheralfacialparalysis.
Exclusioncriteria
Illiteratepatients,orsignificantcognitivelimitations. Exploratory data analysiswas performed through sum-mary measures (mean, standard deviation, minimum, median,maximumvalues,frequencyandpercentage).
TheinternalconsistencyofthePortugueseversionofthe FDIwasevaluatedthroughFactorialAnalysisandCronbach’s alphaforeachofthesubscales.
The agreement between the FDI application times (Test---Retest)wasperformedusingtheIntraclassCorrelation Coefficient(ICC).
ToanalyzetheconstructvalidityofthePortuguese ver-sion of the FDI questionnaire, the obtained results were comparedwiththedegree of facialdysfunctionaccording totheHouse---Brackmannscaleforfacialparalysis.11
ThecomparisonoftheFDIbetweenthedegreesof paral-ysiswasperformedusingtheKruskal---Wallistest, followed byDunntestformultiplecomparisons.
TheresultsofthePortugueseFDIquestionnairesubscales werecomparedwiththefunctionalcapacity,socialaspects andmentalhealthdataoftheSF-36(MedicalOutcomeStudy 36 --- ShortForm Health SurveyItem) translated and vali-datedintoPortuguese12andansweredby50patients).The
correlationoftheFDIwithSF-36wasassessedusing Spear-man’scoefficient.Thelevelofsignificancewassetat5%.
Results
The validation of the Portuguese version of the FDI self-reportedquestionnairewascarriedoutbetweenMarch2015 andJuly2017,withtheparticipationof100adultpatients aged18---85years(meanof48.5years)withfacialparalysis ofdifferentetiologies(58%duetosurgicalsequela,42%due toothercauses),treatedattheFacialParalysisOutpatient Clinicofatertiaryinstitution.
ThePortuguese versionof theFDI wasconsideredeasy tounderstandbypatients,withallitemsshowingan under-standingscoreabove0.96forallquestions.
The final version of the FDI in Portuguese has been translatedliterally for most of theitems, considering the objectivityoftheoriginalquestionnaireandthepossibility ofpreservingthemeaningofthequestions(Table1).A con-ceptualandculturaladaptationwasmadetoItem3:‘‘How much difficulty didyou have saying specific sounds while speaking?’’,whichhasbeenadaptedto:‘‘Howdifficultwas itforyoutospeak?’’;andalsotoItem9:‘‘Howoftendid you wake up early or wake upseveral timesduring your nighttimesleep?’’,whichwasadaptedto:‘‘Howoftendid you lose yoursleep or woke up several times duringthe
Table1 Brazilian-PortugueseVersionoftheFacialDisabilityIndex. ÍndicedeDisfunc¸ãoFacial
Porfavor,escolhaarespostamaisapropriadaparaasseguintesquestõesrelacionadasaproblemasassociadoscoma func¸ãodeseusmúsculosfaciais
Paracadapergunta,consideresuafunc¸ãofacialduranteoúltimomês: Func¸ãoFísica
1.Quantadificuldadevocêteveparamanteracomidanaboca,moveracomidadentrodabocaouporficarcomacomida paradanabochechaenquantocomia?
Geralmentecomicom 5=Nenhumadificuldade 4=Umpoucodedificuldade 3=Algumadificuldade 2=Muitadificuldade
1=Geralmentenãocomipormotivodesaúde 0=Geralmentenãocomiporoutrasrazões 2.Quantadificuldadevocêteveparabebercomcopo?
Geralmentebebicom 5=Nenhumadificuldade 4=Umpoucodedificuldade 3=Algumadificuldade 2=Muitadificuldade
1=Geralmentenãobebipormotivosdesaúde 0=Geralmentenãobebiporoutrasrazões 3.Quantadificuldadevocêteveparafalar?
Geralmentefaleicom 5=Nenhumadificuldade 4=Umpoucodedificuldade 3=Algumadificuldade 2=Muitadificuldade
1=Geralmentenãofaleipormotivodedoenc¸a 0=Geralmentenãofaleiporoutrasrazões
4.Quantadificuldadevocêteveporficarcomseuolholacrimejandoexcessivamenteouporficarcomoolhoressecado? Geralmentetive
5=Nenhumadificuldade 4=Umpoucodedificuldade 3=Algumadificuldade 2=Muitadificuldade
1=Geralmentenãoobserveipormotivodesaúde 0=Geralmentenãoobserveiporoutrosmotivos
5.Quantadificuldadevocêteveparaescovarosdentesouenxaguaraboca? Geralmentetive
5=Nenhumadificuldade 4=Umpoucodedificuldade 3=Algumadificuldade 2=Muitadificuldade
1=Geralmentenãoescoveiosdentesouenxagueiabocapormotivodesaúde 0=Geralmentenãoescoveiosdentesouenxagueiabocaporoutrasrazões Func¸ãoBem-estarSocial
6.Comquefrequênciavocêsesentiucalmoetranquilo? 6=Otempotodo
5=Amaiorpartedotempo 4=Umaboapartedotempo 3=Algumasvezes
2=Poucasvezes 1=Nenhumavez
Table1(Continued)
7.Comquefrequênciavocêseisoloudaspessoasaoseuredor? 1=Otempotodo
2=Amaiorpartedotempo 3=Umaboapartedotempo 4=Algumasvezes
5=Poucasvezes 6=Nenhumavez
8.Comquefrequênciavocêficouirritadocomaspessoasaoseuredor? 1=Otempotodo
2=Amaiorpartedotempo 3=Umaboapartedotempo 4=Algumasvezes
5=Poucasvezes 6=Nenhumavez
9.Comquefrequênciavocêperdeuosonoouacordouváriasvezesduranteanoite? 1=Todasasnoites
2=Amaioriadasnoites 3=Váriasnoites 4=Algumasnoites 5=Poucasnoites 6=Nenhumanoite
10.Comquefrequênciasuafunc¸ãofaciallheimpediudesairparacomer,fazercomprasouparticipardeatividades familiaresousociais?
1=Otempotodo
2=Amaiorpartedotempo 3=Umaboapartedotempo 4=Algumasvezes
5=Poucasvezes 6=Nenhumavez EscoreFunc¸ãoFísica
Pontuac¸ão(questões1-5)---N×25=
EscoreFunc¸ãoSocial/Bem-Estar Pontuac¸ão(questões6-10)---N×20=
N N
EscoreFDItotal=escorefunc¸ãofísica+escorefunc¸ãosocial/bem-estar= 200
night?’’.Thesechanges wereconsiderednecessary bythe groupinvolved inthecultural adaptationof the question-naire,aimingtofacilitatetheunderstandingofthewordings inPortuguese.
TheinternalconsistencyofthePortugueseversionofthe FDIwasconsideredadequate,withaCronbach’salpha coef-ficientof0.73(Table2).
Thereliabilitydeterminedinthetest/retestshowedan IntraclassCorrelationCoefficient(ICC)of0.79forthe phys-icalsubscale,0.85for thesocial well-beingsubscale,and 0.88fortheentirequestionnaire(Table3).
ComparisonofFDIsubscaleswithcomponentsofthe SF-36demonstratedacorrelationbetweentheFDIsocial well-beingscaleandthementalhealthmeasures,socialaspects, andfunctional capacity of the SF-36. On the other hand, theFDIphysicalfunctionscaledidnotcorrelatewiththese measures(Table4),asobservedintheoriginalFDIstudy.5
TheFDIphysicalsubscalecorrelatedwiththedegreeof facialdysfunctionassessedbytheHBscale,withsignificant differencesin thephysical functionmeans among individ-uals with mild facial dysfunction (House---Brackmann-2),
Table2 Evaluationofreliabilityandinternalconsistency ofthePt-FDI.
Item AlphaifItemwasexcluded
Q1 0.6314 Q2 0.7042 Q3 0.6509 Q4 0.7713 Q5 0.7114 Q6 0.7367 Q7 0.7387 Q8 0.7022 Q9 0.7367 Q10 0.6893 Global 0.735 Q,Question.
moderate(HB-3),moderatelysevere(HB-4),orsevere/total facialdysfunction(HB-5/6)(p<0.0001).Inthepaired com-parisonbetweenthedegreesofdysfunction,itwasobserved thatthemeansofthephysicalfunctionsubscalecorrelated
Table3 Evaluation ofthe Pt-FDI Test-Retest agreement (n=100).
Variable Mean SD ICC 95%CI
FF---Q1 66.2 17.7 0.79 0.71---0.86 FF---Q2 66.6 19.1 FBES---Q1 69.4 21.6 0.85 0.79---0.90 FBES--- Q2 71.6 22.7 Total--- Q1 0.68 0.17 0.88 0.82---0.92 Total--- Q2 0.69 0.23
Pt-FDI,FDIinPortuguese;SD,standarddeviation;ICC,Intraclass CorrelationCoefficient;CI,confidenceInterval.
with the differencebetween mild dysfunctions compared to moderate or severe dysfunctions. The mean scores of the social well-being subscale were also correlated with the degree of facialdysfunction (p=0.0023); being more evidentwhen comparingindividualswithmild dysfunction (HB-2)versusmoderatelysevere(HB-4)(p=0.02)orsevere (HB-5/6)dysfunction(p=0.0012)(Table5).
Discussion
ThisstudydemonstratesthatthePortugueseversionofthe FDIquestionnaireisavalidandreliabletoolforthe evalua-tionofpatientswithfacialparalysis.AnoverallCronbach’s alpha coefficient of the questionnaire>0.7 was observed, andtheintraclasscorrelationcoefficientwasaround0.8for bothsubscales.Theseresultsaresimilartothoseobserved by Gonzales-Cardero et al.8 who observed a Cronbach’s
alphacoefficientof0.8fortheSpanishversionoftheFDI. Itispossiblethattherelativelyloweralphavalueobserved intheSpanishstudy mayhavebeeninfluencedbytheuse ofalargersample,includingpatientswithfacialparalysis of different etiologies, whereasthis study evaluatedonly patientssubmittedtoparotidectomy,whogenerallyhavea lowerdegree offacialparalysis andnoinvolvementof all branchesofthefacialnerve.
Weobservedasignificantcorrelationbetweenthe mea-sures of the social well-being subscale of the Portuguese versionoftheFDIwiththecomponentsofmentalhealthand social aspectsofthe SF-36global qualityof life question-naire.This correlation hasalso been demonstratedin the originalFDIdevelopmentworkdescribedbyVanSwearingen andBrach,5suggestingtheeffectivenessoftheFDIto
eval-uatetheimpactoffacialparalysisonpsychosocialaspects.
Table 5 Correlation between the Pt-FDI subscales and the degree of facial dysfunction according to the House---Brackmannscale(Kruskal---Wallistest/Dunntest). Variable HBgrade N Mean SD pvalue Physical function 2 18 87.78 11.14 <0.001 3 24 68.13 15.24 4 43 58.02 14.89 5/6 15 60 14.02 2vs.3 19.65 0.0001 2vs.4 29.75 <0.0001 2vs.5/6 27.78 <0.0001 3vs.4 10.1 0.03 3vs.5/6 8.125 0.31 4vs.5/6 −1.98 0.96 Social well-being function 2 83.78 18.38 0.002 3 70.29 21.03 4 67.19 20.31 5/6 56.27 22.4 2vs.3 13.49 0.15 2vs.4 16.59 0.02 2vs.5/6 27.51 0.001 3vs.4 3.1 0.93 3vs.5/5 14.02 0.16 4vs.5/6 10.92 0.29
Pt-FDI, Facial Disability Index in Portuguese; HB, House---Brackmann; N, number of patients; SD, standard deviation.
As expected from the literature data, a correlation between the functional capacity measured by the SF-36 questionnaireandtheFDIphysicalscalemeasureswasnot observed.Becauseitisan overallqualityof life question-naire,theSF-36evaluates functionalaspectsthatarenot directlyrelatedtothephysicalincapacitycausedbyfacial paralysis. Therefore, FDI would be more specific for the evaluationof physical alterations relatedtofacial neuro-musculardysfunction.5
Weobserved thatthemeanvaluesofthephysical sub-scale measurementsof the Portuguese version of the FDI were significantly related to the degree of facial paraly-sisaccordingtotheHouse---Brackmannscale,confirmingthe validityoftheFDItoassesstheassociationbetweenfacial dysfunctionandphysicaldisability.Thecorrelationbetween thephysical scaleof theFDIandthedegree offacial dys-functionwasalsodemonstratedbyPaveseetal.6whoused
Table4 BivariatecorrelationofPearsonandSpearmanbetweenthePt-FDIquestionnaireandtheSF-36.
Bivariatecorrelation Pearson’scorr Pearson’s95%CI Spearman’srank Spearmen’s95%CI pvalue
MHSF36/SWB---FDI 0.59 0.38to0.75 0.57 0.34to0.73 <0.0001 PASF36/SWB---FDI 0.52 0.28to0.70 <0.0001 FCSF36/SWB---FDI 0.27 −0.005to0.51 0.05 PASF36/PF---FDI 0.24 −0.039to0.48 0.09 FCSF36/PF---FDI 0.21 −0.06to0.46 0.13 MHSF36/PF---FDI 0.12 −0.16to0.38 0.4
Pt-FDI,FacialDisabilityIndexinPortuguese;SF,ShortFormQuestionnaire;Corr.,Correlation;CI,ConfidenceInterval;MH,MentalHealth; SWB,SocialWell-Being;PA,PhysicalAspects;PF,PhysicalFunction;FC,FunctionalCapacity.
theSunnybrooksystemfortheclassificationoffacial paral-ysis.Recently,Pratz-Golceretal.13 demonstratedthatthe
associationbetween thephysical scale ofthe FDIandthe degreeoffacialparalysispersiststhroughoutpatientclinical evolution.
Consideringthelackoftoolstranslatedandvalidatedinto Portuguesetoevaluateresultsinpatientswithfacial paral-ysis,weobservedthatthisversionofFDIisausefultoolin dailyclinicalpractice.Itissimpleandeasytounderstand, allowingitsmultidisciplinaryuse,andcanbeappliedinthe follow-upofspecifictreatmentsor toevaluatetheimpact ofsurgicalproceduresonfacialfunction.
Conclusion
TheBrazilian-PortugueseversionoftheFDIquestionnaireis avalidtoolfortheevaluationofpatientswithfacial paral-ysis.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
Appendix
A.
Supplementary
data
Supplementary data associated with this article can be found, in the online version, at doi:10.1016/j.bjorl.2019. 04.003.
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