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Fırat Tıp Dergisi
2024, Cilt 29, Sayı 2, Sayfa(lar) 091-096
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The Relationship Between Social Phobia and the Stage of the Disease in Patients with Facial Paralysis
Berzan HAZNEDAR1, Muhammed AYRAL2
1Gazi Yaşargil Education and Research Hospital, Otolaryngology, Diyarbakır, Türkiye
2Dicle of University Medical Faculty, Otolaryngology, Diyarbakır, Türkiye
Keywords: Merkezi Yüz Felci, Periferik Yüz Felci, Sosyal Fobi, Central Facial Paralysis, Peripheral Facial Paralysis, Social Phobia
Summary
Objective: Considering the social communication problems this situation will cause, we studied the relationship between facial paralysis and social phobia.

Material and Method: Our study was approved by Gazi Yaşargil Training and Research Hospital Ethics Committee, and we worked on 80 people as 40 control and 40 case groups. All patients signed informed consent form after objectives and methods of study were explained to them. Patients were examined after signing the informed consent form by experienced physicians. Paralysis of the patients was graded with the House-Brackmann scale. The Liebowitz social phobia symptoms scale was used to measure the level of social phobia. p< 0.05 and 95% confidence interval were accepted as statistical significance.

Results: Everyone who experienced facial paralysis and its effects has anxiety about being in public and social environments. This condition mani-fested itself as a social phobia. In correlation analysis, we realized that a significant correlation was found between the severity of phobia and fact that facial paralysis is in an advanced stage: as a result of Pearson correlation analysis conducted, a weak significant positive correlation was found be-tween the House-Brackmann Grading score and the Liebowitz Social Phobia Symptoms Scale score (r= 0,281, p< 0.05). Our study noted the patients' undergraduate status, marital status, and age. However, no relationship was found between these values and social phobia.

Conclusion: Our study found a high incidence of social phobia in patients with facial paralysis. The severity of this phobia correlates with the severi-ty of the disease.

  • Top
  • Summary
  • Introduction
  • Methods
  • Results
  • Disscussion
  • References
  • Introduction
    Facial Paralysis is a picture of paralysis that develops due to dysfunction or damage in any place along the entire traces of the facial nerves. There are two types of facial paralysis: central facial paralysis and peripheral facial paralysis1.

    Central Facial Paralysis unilateral damage to the corti-cobulbar pathway between the cortex and the pons at any level causes upper motor neuron-type paralysis in the lower Dec of the face on the opposite side of the lesion1.

    Peripheral facial paralysis is the loss of function in the facial muscles innervated by the damaged fibers resulting from damage to the motor fibers of the nerve any-where between the motor nuclei in the medulla and its most extreme branch. A unilateral facial paralysis occurs when the facial nerve is damaged on the periphery (1).90% of peripheral facial paralysis (PFP) is idiopathic (Bell's paralysis)2. Bell's paralysis is a partial or complete paralysis of the face that begins acutely, usually unilateral. Sir Charles Bell first described it in the 1800s. It occurs with a frequency of 13-34 per 100,000 in the general population and constitutes 60-70% of all facial paralysis. It was seen most often at the age of 15-40 years. The incidence of men and women is equal 3. Many diagnostic tests with differ-ent diagnostic and prognostic values, such as serum laboratory tests, viral serological tests, computed to-mography, magnetic resonance imaging (MRI), and electrodiagnostic tests, have been used in the evalua-tion of patients with Bell paralysis3.

    While the most common cause of peripheral facial paralysis in adults is BP, it is trauma in children2.

    As a treatment method, oral antiviral is recommended for ten days in combination with prednisone. The etiology of Bell's palsy includes facial nerve edema caused by viral diseases and facial nerve demyelination that develops secondary to it. The medial foramen of the labyrinth, located proximal to the segment, is the nar-rowest place in the course of the nerve in the temporal bone with a diameter of 0.68 mm and usually causes edema compression here. Herpes simplex virus is the most common viral agent detected by serological methods.

    The diagnosis is made primarily based on anamnesis and physical examination. Initial symptoms include numbness of the face, watery eyes, hyperacusia or decausia, taste disorders, decreased tears, and facial weakness/paralysis progresses within a day or two, reaching its maximum level within three weeks. The most crucial goal in the treatment protocol is to accel-erate recovery, ensure that recovery is close to full, to prevent corneal complications and other possible se-quelae. Corticosteroids are recommended for treatment because they provide a decrease in edema, an increase in nerve regeneration, and an improvement in motor function. Antiviral therapy is helpful if it is started within 72 hours after the appearance of paralysis. Ac-cording to various authors, the complete recovery rate of idiopathic Bell's palsy is 60%-85%; the indication rate for the operation is 6%. Surgical decompression is considered if more than 90% degeneration and volun-tary facial electromyographic (EMG) activity on the affected side are not detected in electroneurography (EnoG) within two to three weeks compared to the unaffected side4.

    The causes of facial paralysis include congenital abnormalities, infections, inflammatory processes, neo-plasms, iatrogenic injury, and trauma Dec. The facial nerve and associated muscles are an integral part of closing the eyes, the proper tearing mechanism, support for breathing through the nose, the formation of a smile, the oral phase of eating, speech production, and emotional transfer5.

    In the case of peripheral facial paralysis, asymmetry occurs on the patient's face with movement or at rest, as there will be dysfunction of the facial muscles. This condition can cause many psychological problems with patients' changes in aesthetic appearance and functional impairment2. It can be destructive, negatively im-pacting function, quality of life, and social interaction.

    Considering that this condition may cause social pho-bia, we investigated the relationship between facial paralysis and social phobia.

  • Top
  • Summary
  • Introduction
  • Methods
  • Results
  • Disscussion
  • References
  • Methods
    In December 2021 and March 2022, patients with faci-al paralysis who applied to our outpatient clinics of physical medicine and rehabilitation and otolaryngology were included in the study.

    This study was planned as cross-sectional. Approval was obtained from the Ethics committee of Gazi Yaşargil Training and Research Hospital. All patients signed the informed consent form after the objectives and methods of the study were explained to them. The patients were examined after signing the informed consent form by experienced physicians. Physicians assessed whether patients were eligible to participate in the study. Magnetic resonance imaging, magnetic reso-nance angiography, computed tomography, and elec-tromyography were used in the examination. In addi-tion, the hearing functions of the patients were evaluat-ed before all the tests. Persons with impaired hearing functions were not included in the study.

    Forty patients aged 18 years and over who were diagnosed with facial paralysis and whose sequelae contin-ued despite the completion of clinical treatment were included in the study. Demographic characteristics of the participants such as age, gender, marital status, profession, education status, height, and weight were recorded.

    Persons with a disease related to the central nervous system, current Bell's palsy, concomitant movement disorders, heart failure, pulmonary, renal, or hepatic insufficiency, or any malignancy were excluded from the study. In addition, patients with cognitive impair-ment, which led to the inability to answer the questions asked reliably, were not included in the study.

    Eighty people, including 40 cases and 40 controls, participated in the study. There are 20 women and 20 men in the case group, while 21 women and 19 men are in the control group. The mean age of the case group was 37.35, the standard deviation was 6.71, the mean age of the control group was 36.475, and the standard deviation was 7.77. While 21 of the case group were married and had undergraduate education level, it revealed that 17 of the control group were married and 18 were undergraduates.

    The patients were evaluated with the House-Brackmann scale. The Liebowitz social phobia symptoms scale was used to measure the level of social phobia.

    House-Brackmann Scale
    The House-Brackmann Scale is an analysis tool developed to evaluate facial functions and determine the degree of paresis/paralysis globally. The House-Brackmann scale was first defined in 1985 in Los An-geles by otolaryngologists Dr. John W. House and Dr. Derald E. Brackmann. It is a widely accepted system. Its application is simple. However, it is sensitive, gives accurate results, and is reliable.

    The scale was translated into Turkish by two independent researchers at the beginning. After that, two researchers came together and completed the final ver-sion of the translation. Another researcher specializing in neurotology has translated the Turkish version of the scale back into English. At these stages, validity and reliability tests have been completed.

    When calculating the score, the upward movement of the middle of the eyebrow and the outward movement of the oral commissure are taken as a basis. 1 point is given for every 0.25 cm movement up to a maximum of 1 cm for eyebrow and oral commissure movement. If the structures can be moved by 1 cm in both move-ments, 8 points are scored, the maximum score. From the point of view of its objectivity, movements are made both on the normal and affected sides.

    Facial functions are graded in 6 stages according to the scores obtained. H-B1 indicates that facial functions are normal, and H-B6 indicates that there is total paralysis6-8.

    Liebowitz Social Phobia Symptoms Scale
    Michael Liebowitz developed the Liebowitz Social Phobia Symptoms Scale in 1987 to evaluate the social relationship and performance situations in which indi-viduals with social phobia exhibit fear and/or avoidance behavior. The validity and reliability studies of the scale were conducted by Heimberg et al.9, and the validity and reliability study of the Turkish form was conducted by Soykan et al.10. The Cronbach alpha coefficient for the whole scale was found to be 0.98. The Cronbach's alpha coefficient for the fear or anxiety and avoidance subscales is 0.96 and 0.95, re-spectively11.

    There are 24 items on the scale, 11 of which are social relations and 13 of which are performance. The scale consists of Likert-type items scored between 1-4. The total score is obtained by summing the fear and avoid-ance scores12. 55-65 points indicate mild social phobia, 65-80 points indicate moderate social phobia, 80-95 points indicate severe social phobia and 95+ points indicate very severe social phobia13.

    Statistical Analysis
    Calculations were made with the SPSS 18 (SPSS, Chi-cago, Ill., USA). Kolmogorov-Smirnov test was used to evaluate whether the data were in accordance with the normal distribution. Comparisons between the groups were made using the independent samples t-test or the Mann Whitney U test according to the suitability of the data for the normal distribution. The difference between the proportional variables was calculated using the Chi-square test. Spearman correlation analysis assessed the relationship between facial paralysis and social phobia development. p< 0.05 and 95% confi-dence interval were considered statistically significant.

  • Top
  • Summary
  • Introduction
  • Methods
  • Results
  • Disscussion
  • References
  • Results
    As a result of the Kolmogorov-Smirnov test, which was carried out to determine whether there was a sig-nificant difference between the Liebowitz Social Pho-bia Symptoms Scale scores of the case group and the control group was observed that the data were not nor-mally distributed (p< 0.05) (Table 1).


    Click Here to Zoom
    Table 1: Descriptive statistics.

    As a result of the Mann Whitney U test, which was conducted to examine whether there was a significant difference between the Liebowitz Social Phobia Symp-toms Scale scores of the case group and the control group, there was a significant difference between the groups. (U= 644,000, p< 0.05) (Table 2).


    Click Here to Zoom
    Table 2: Mann Whitney U Test Conducted to Examine the Scores of the Liebowitz Social Phobia Symptoms Scale Between the Case Dec Control Group.

    Pearson correlation analysis was performed to examine whether there was a significant relationship between the participants' House-Brackmann Grading and Lie-bowitz Social Phobia Symptoms Scale scores (Table 3).


    Click Here to Zoom
    Table 3: Pearson Correlation Analysis of the House-Brackmann Grading and Liebowitz Social Phobia Symptoms Scale Scores.

    As a result of the Pearson correlation analysis, a weak significant positive correlation was found between the House-Brackmann Grading score and the Liebowitz Social Phobia Symptoms Scale score (r= 0,281, p< 0.05).

  • Top
  • Summary
  • Introduction
  • Methods
  • Results
  • Disscussion
  • References
  • Discussion
    FP is usually presented in the form of Bell palsy, which is found in the case of peripheral facial paralysis with a generally very unknown etiology. Although there is a dominant incidence in the female gender, its existence is mentioned in studies that do not make significant gender distinctions. In addition, it has been reported many times that the incidence of FP increases with age 14.

    In the study performed by Kang et al.15 with 250 patients diagnosed with FP, 54.8% were female, and 45.2% were male, and it was reported that the frequency of their patients was generally seen between the ages of 50-60. Garanhani et al.16 also drew attention to the superiority of the female gender with a rate of 60.9% in FP patients they diagnosed between 1999 and 2003. However, Rowlands et al.17 reported no significant gender variability for 2473 patients with Bell's palsy. Moreover, the incidence of FP increased signifi-cantly in patients with 0 onset age and was divided into 15-year periods.

    Similarly, in our study, it was observed that the gender distribution of our patients 51.3% were female, 48.7% were male, and the mean age was between 23-33 and 43-55 years.

    In the study conducted by Özdemir et al.18, when patients with a mean admission time of 2.76±2.07 (range=1-7 days) were classified according to the Hou-se-Brackmann Scale (HBS) system. Grade 3 facial paralysis was observed most frequently with a rate of 40.0% (n= 40), followed by grade 4 with 26% (n= 26), grade 5 with 20% (n= 20) and grade 6 with 8% (n= 8), and grade 2 with 6% (n= 6) respectively. When the mean admission times of the cases were evaluated according to the HBS Grading, a statistically signifi-cant difference was found between the groups (p= 0.003). The longest mean time to admission (3.78±2.527 days) was observed in patients in the grade 3 group, while the shortest mean time to admission (1.63±1.061 days) was observed in the grade 6 group.

    When congenital and genetic causes are examined, Melkersson-Rosenthal Syndrome (MRS) and familial facial paralysis are the leading causes of recurrent facial paralysis19. MRS is a neuro-mucocutaneous granulomatous disease characterized by the triad of recurrent peripheral facial paralysis, painless and non-pitting orofacial edema, and fissured tongue20. It is a clinically diagnosed disease. The physical examination findings of our cases did not support MRS. Pitts et al.21 reported the incidence of familial peripheral facial paralysis as 22.8% in their study. It has been reported that familial facial paralysis may be inherited autosomal dominant and may also have variations22. None of our cases had a familial history of facial paralysis.

    Appropriate treatment options should be evaluated by determining the prognosis in FP patients according to the duration of paralysis and disease severity. For this reason, the time between the patient's application to a health institution after the onset of symptoms is vital23.

    In addition, Savettieri et al.24 made a door-to-door study by using all the data belonging to municipalities in Sicily, with 13,510 participants over the age of 12, and determined that patients with FP applied late or did not apply to health institutions because of mild severe loss of function, short-term paralysis and completely healed symptoms, and highlighted the difficulties in determining the true incidence.

    Moreover, it is known that previous FP stories have prognostic value. However, Lee et al.25 emphasized that it is both physical and psychological benefits for patients with early facial paralysis symptoms to apply to health institutions as soon as possible.

    In our study, a classification was made as 39 cases and 39 controls since 1 person filled in the demographic data and left later. House grading scores were high because everyone in the case group had previous facial paralysis. There was a significant difference in the social phobia scores in the case group looking for both groups. Everyone who has had facial paralysis and has seen its effects has anxiety about going out in public and being in social environments. This situation shows itself as social phobia, and in the correlation analysis, a significant correlation was found between the severity of the phobia and the advanced stage of facial paralysis.

    In our study, the patients' license status, marital status, and age were noted. However, no relationship was found between these values on social phobia.

    Conclusions and Recommendations
    • The incidence of social phobia is high in people with facial paralysis • The severity of this phobia correlates with the severity of the disease. • This situation is not affected by license status, marital status, age, or gender. • More specific results can be obtained with higher numbers of analyzes. • In studies conducted by noting the duration of the disease, it can be examined when social phobia occurs. • Patients with facial paralysis can also be referred for psychiatry when they come to ENT and FTR outpatient clinics. Therapeutic intervention points related to SSRIs used for general anxiety and phobia can be ex-amined.

    Conflict of interest
    There is no conflict of interest in this study.

    Limitations
    The fact that the number of cases in our study is small can be shown as a limitation. Future studies with high case series are needed. The duration of the disease was not taken into account in our study.

    Financial support
    No financial support was received in this study.

  • Top
  • Summary
  • Introduction
  • Methods
  • Results
  • Discussion
  • References
  • References

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  • Top
  • Summary
  • Introduction
  • Methods
  • Results
  • Discussion
  • References
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