Abstract
Laryngopharyngeal Reflux Disease (LPRD) is caused due to reflux of gastric content into the larynx and pharynx. The present study was done to assess the role of Reflux Symptom Index (RSI) and Reflux Finding Score (RFS) in the treatment outcomes in symptomatic patients with LPRD. This is a prospective analytical study conducted on 200 patients for a period of 2 years, from January 2020 to February 2022. Patients suspected with LPR were evaluated using RSI and RFS, and both pre and post treatment scores were compared to assess the change in scores of RSI and RFS following 8 weeks of treatment with PPI (Proton pump inhibitor). The patients experienced a greater incidence of moderate symptoms in RSI. Wilcoxon signed-rank test showed significant difference between pre and post treatment scores with respect to reflux symptoms and reflux findings (p < 0.05). Implementation of RSI and RFS scoring system helped for early diagnosis of LPR, and a significant difference was seen between pre and post treatment scores in both RSI and RFS.
Keywords: Laryngopharyngeal reflux disease, Laryngoscopy, Reflux finding score, Reflux symptom index
Introduction
Laryngopharyngeal Reflux Disease (LPRD) is characterized by a retrograde passage of stomach contents into the upper aerodigestive tract [1], and so is defined as the reflux of gastric contents into the larynx and pharynx. In the year 2020, the prevalence of LPRD in Indian population was estimated to be 11% based on a Reflux Symptom Index (RSI) score of > 13. Males and females had a similar prevalence; women with a rate of 11.2%, while men 10.6%. Heartburn was the most common symptom of LPR, followed by clearing of the throat and excess throat mucus. The prevalence rate of LPRD ranges from 5 to 30% worldwide [2]. LPR symptoms were thought to be present in 5% to 30% of people depending on their location, nutrition, and lifestyle patterns [3]. The symptoms and signs of LPR is a result of exposure of the upper airway to gastric juice.Cough, sore throat, hoarseness, dysphonia, and globus are some of the laryngeal symptoms of LPR, and also laryngeal irritation signs seen during laryngoscopy [4].
There is wide disagreement in the various methodologies used by investigators to diagnose LPR.A meticulous history of symptoms and laryngoscopic examination are crucial to diagnose LPRD [2]. LPR can be diagnosed with presence of laryngoscopic signs such as erythema, edema, ventricular obliteration, postcricoid hyperplasia, and pseudosulcus. Vocal cord edema, erythema, ventricular obliteration, and pseudosulcus vocalis are the common laryngoscopic abnormalities associated with LPR [5]. Posterior commissure hypertrophy, vocal fold edema, hyperemia, and widespread laryngeal edema are also LPR signs. Early and quick clinical diagnosis is imperative as this clinical entity has a significant impact on the patient’s quality of life [6].
If left undiagnosed or untreated, it may lead to various chronic laryngeal conditions like subglottic stenosis, laryngeal carcinoma, granulomas, contact ulcers, and vocal nodules. Sedentary lifestyle, use of tobacco and alcohol are identified as significant risk factors for this condition [2].
The larynx and pharynx lack a normal acid clearance mechanism, so even three episodes of reflux per week appears to be associated with a significant disease [7]. Direct and indirect exposure of the larynx to harmful stomach contents are the two most common pathophysiological causes for LPR [8]. The direct exposure of acid, pepsin, bile acid, and trypsin to laryngopharyngeal mucosa causes laryngeal injury [7, 8]. The mucosa of the laryngopharynx lacks a protective mechanism against the acidopeptic activities of stomach contents leading to the damage [7]. The indirect exposure is a result of refluxate interactions with structures distal to the larynx triggering a vagus nerve-mediated response to bronchoconstriction [8].
LPR is diagnosed in the same way as Gastroesophageal Reflux Disease (GERD). Symptom evaluation is one of the most important methods. Reflux evidence monitoring and upper GI endoscopy are the other ways to diagnose LPR [9]. PH monitoring is an invasive procedure which involves inserting a probe into the esophagus which is connected to the monitor.
The RSI is the most widely used type of symptom evaluation, and its validity and reliability are widely recognized around the globe [9]. Reflux Finding Score (RFS) is another way of diagnosing LPR, in which the laryngopharyngeal mucosa is inspected through 90degree endoscopic evaluation of larynx to assess vocal cord edema, diffuse laryngeal edema, etc. RFS also measures non-specific LPR symptoms. For example, smoking, drinking and laryngopharyngeal allergy might create similar kind of manifestations in people. Hypertrophy of the lingual tonsils, hypo-erythema or oropharyngeal erythema, and edema are also the characteristics of LPR [9].
LPR is often reported with abnormal subjective voice characteristics such as musculoskeletal tension, hard glottal attack, glottal fry, vocal forcing, forcing sensations, clamping, vocal fatigue, prolonged voice warm-up time, and restricted tone placement [6]. Pre- and post-therapeutic RSI and RFS were compared using Wilcoxon signed-rank test [10].
Belafsky, et al., suggested the reflux symptom index (RSI), in order to reduce the subjectivity of diagnosis, it is a validated questionnaire of 9 questions self administered by symptomatic patients on a scale of 5.The endoscopic grading scale (reflux finding score) was also developed based on 8 laryngeal findings [4]. A study by Nunes, et al., compared RFS and RSI in the practice of Otorhinolaryngology, and the results demonstrated that RSI and RFS can easily be included in ENT routine as objective parameters, with low cost and good practicality [11]. In a prospective study, it was found that 28% to 58% of patients with endoscopic evidence of GERD had at least one item on the Comprehensive Reflux Symptom Scale, supporting the Montreal agreement on an LPR-GERD continuum [12].
The aim of our study was to assess the role of RSI and RFS which is a validated clinical evaluation method based on signs and symptoms of LPR, in assessing the outcomes post medical treatment of symptomatic patients with LPRD.
Method
This was a prospective analytical study conducted in the Department of ENT at a medical college hospital in Bangalore after obtaining the ethical clearance from Institutional Ethical Committee. The study was conducted for a period of 2 years, from January 2020 to February 2022. A total of 200 patients were recruited for this study. Informed consent were taken from all 200 study participants.The severity of symptoms were graded as per the RSI questionnaire (Table 1),for the convenience of patients the 5 point scale of symptoms were modified into 0-No problem,1-mild problem,2-moderate, 3-moderately severe and 5 as severe problem.Each patient underwent thorough ENT examination followed by laryngeal endoscopy using 90degree laryngoscope by investigator, and pre-treatment RSI (Table 1) and RFS were assigned (Table 3).
Table 1.
Overall symptoms in RSI and their occurrence
| Reflux Symptom Index | Score–0 = No Problem | Column N (%) |
|---|---|---|
| 5 = Severe Problem | ||
| Hoarseness or a problem with your voice | No symptom | 13.5 |
| Mild symptom | 34.0 | |
| Moderate symptom | 38.5 | |
| Severe symptom | 13.5 | |
| Extreme symptom | 0.5 | |
| Profound symptom | 0.0 | |
| Clearing your throat | No symptom | 0.5 |
| Mild symptom | 36.0 | |
| Moderate symptom | 42.5 | |
| Severe symptom | 17.5 | |
| Extreme symptom | 3.5 | |
| Profound symptom | 0.0 | |
| Excess throat mucus or postnasal drip | No symptom | 0.5 |
| Mild symptom | 15.0 | |
| Moderate symptom | 51.0 | |
| Severe symptom | 28.5 | |
| Extreme symptom | 5.0 | |
| Profound symptom | 0.0 | |
| Difficulty swallowing food, liquids, or pills | No symptom | 0.5 |
| Mild symptom | 15.0 | |
| Moderate symptom | 49.0 | |
| Severe symptom | 32.0 | |
| Extreme symptom | 3.5 | |
| Profound symptom | 0.0 | |
| Coughing after you ate or after lying down | No symptom | 1.5 |
| Mild symptom | 13.5 | |
| Moderate symptom | 50.5 | |
| Severe symptom | 31.0 | |
| Extreme symptom | 3.5 | |
| Profound symptom | 0.0 | |
| Breathing difficulties or choking episodes | No symptom | 1.5 |
| Mild symptom | 16.0 | |
| Moderate symptom | 49.0 | |
| Severe symptom | 28.0 | |
| Extreme symptom | 5.5 | |
| Profound symptom | 0.0 | |
| Troublesome or annoying cough | No symptom | 0.0 |
| Mild symptom | 17.0 | |
| Moderate symptom | 47.5 | |
| Severe symptom | 31.0 | |
| Extreme symptom | 4.5 | |
| Profound symptom | 0.0 | |
| Sensation of something sticking in your throat or a lump in your throat | No symptom | 0.0 |
| Mild symptom | 20.0 | |
| Moderate symptom | 45.5 | |
| Severe symptom | 32.0 | |
| Extreme symptom | 2.5 | |
| Profound symptom | 0.0 | |
| Heartburn, chest pain, indigestion, or stomach acid coming up | No symptom | 1.0 |
| Mild symptom | 16.0 | |
| Moderate symptom | 51.5 | |
| Severe symptom | 29.0 | |
| Extreme symptom | 2.5 | |
| Profound symptom | 0.0 |
Table 3.
Signs in RFS and their occurrence
| Reflux finding score | ||
|---|---|---|
| Finding | Severity Score | Column N (%) |
| Subglottic edema | Edema absent 0 | 22.5 |
| Edema present 2 | 77.5 | |
| Ventricular obliteration | Absent 2 | 14.5 |
| Partial obliteration 4 | 85.5 | |
| Erythema/hyperemia | Absent 0 | 2.0 |
| Arytenoids 2 | 52.0 | |
| Diffuse 4 | 44.5 | |
| Vocal cord edema | Mild edema 1 | 22.0 |
| Moderate edema 2 | 25.0 | |
| Severe edema 3 | 31.5 | |
| Polypoidal 4 | 21.5 | |
| Diffuse laryngeal edema | Absent 0 | 2.5 |
| Mild 1 | 21.0 | |
| Moderate 2 | 41.0 | |
| Severe 3 | 29.5 | |
| Obstructing 4 | 6.0 | |
| Posterior commissure hypertrophy | Absent 0 | 1.0 |
| Mild hypertrophy 1 | 48.5 | |
| Moderate hypertrophy 2 | 42.0 | |
| Severe hypertrophy 3 | 8.0 | |
| Obstructing hypertrophy 4 | 0.5 | |
| Granuloma/granulation | Absent 0 | 37.0 |
| Present 2 | 63.0 | |
| Thick endolaryngeal mucus/other | Absent 0 | 15.0 |
| Present 2 | 85.0 |
These patients were empirically started on PPI (Proton pump inhibitors) pantoprazole molecule 40 mg twice a day in empty stomach for 8 weeks was used. They were also also adviced to modify their lifestyle like doing exercise, avoid smoking and to reduce alcohol intake. These patients were followed after 8 weeks and again the RSI and RFS were graded post treatment. The RFS and RSI scores before and after treatment were compared using Wilcoxon signed-rank test.
Inclusion Criteria
Patients included in the study were above 18 years of age with signs and symptoms of LPR, such as choking sensation in the night, feeling of lumps in the throat, and chronic recurrent episodes of throat pains for last six to eight weeks. The patients were enrolled based on RSI greater than 13 and RFS greater than 7.
All the patients meeting inclusion criteria were asked regarding demographic status, tobacco use, smoking, alcohol consumption, and presence of symptoms such as hoarseness or other voice problems, clearing throat, excess throat mucus or postnasal drip, difficulty swallowing food or liquid or pills, coughing after eating or after lying down, breathing difficulties or choking episodes, troublesome or annoying cough, sensations of something sticking in throat or lump in throat, heartburn, chest pain, indigestion, or stomach acid coming up. All patients underwent laryngoscopic assessment using 90 degree laryngoscope to examine the presence of RSI symptoms. Scoring was given for RSI and RFS. The score of severity scale ranged from 0 (no problem) to 5 (severe problem). Patients were started on treatment with proton pump inhibitors (pantoprazole 40 mg twice a day for 8 weeks) and assessed for RSI and RFS pre and post treatment.
Exclusion Criteria
Patients under the age of 18, pregnant or lactating mother, and who did not like to participate in the study were excluded. Patients with other causes of signs and symptoms such as laryngeal infection, cancer or malignancy, and chronic disease and diagnosed cases of reflux secondary to hiatus hernia, barrets esophagus on upper GI endoscopy were also excluded.
Results
A total of 200 patients were eligible for this study conducted from January 2020 to February 2022. All patients underwent routine ENT examination followed by laryngeal endoscopy. Of these participants, 96 were male (48.0%) and 104 were female (52.0%). LPR risk factors were found in 9.0% patients aged 21–30, 19.5% patients aged 31–40, 26.0% patients aged 41–50, 23.5% patients aged 51–60, 19.5% patients aged 61–70, and 2.5% patients aged 71–80. The age of patients ranged from 21 to 80 years with a mean age of 48. A history of smoking was present in 42.0% and absent in 58.0% of the cases, and alcohol consumption or intake was found in 53.5% and missing in 46.5% of the cases.
Reflux Symptom Index
The overall symptoms in RSI and occurrence are shown in Table 1. Patients experienced greater incidence of moderate degree of symptoms in RSI with hoarseness or a problem with voice; clearing the throat; excess throat mucus or postnasal drip; difficulty swallowing food, liquids, or pills; coughing after eating or lying down; breathing difficulties or choking episodes; troublesome or annoying cough; sensation of something sticking in the throat or a lump in the throat; heartburn; chest pain; indigestion; or stomach acid coming up. Clearing of throat and choking were the common symptom and the mean pre treatment score was 18.76 and post treatment was 6.11 Test for normality demonstrated that there was no significant difference between pre and post treatment scores with respect to reflux symptoms and the findings suggested that it was deviating from normal distribution. Wilcoxon signed-rank test as shown in Table 2 (p < 0.05) was significant. It means that there is a significant difference between pre and post treatment scores with respect to reflux symptoms with PPI.
Table 2.
Wilcoxon signed-rank test
| Ranks | |||||
|---|---|---|---|---|---|
| Reflux symptom score | N | Mean Rank | Sum of Ranks | p-value | |
| post treatment score–pre-treatment score | Negative Ranks | 200a | 100.50 | 20,100.00 | 0.000 < 0.05 (Significant) |
| Positive Ranks | 0b | .00 | .00 | ||
| Ties | 0c | ||||
| Total | 200 | ||||
apost treatment score < pre-treatment score
bpost treatment score > pre-treatment score
cpost treatment score = pre-treatment score
Reflux Finding Score
The signs in RFS and their occurrence are shown in Table 3. Test for normality demonstrated that there was no significant difference between pre and post treatment scores with respect to reflux symptoms and the findings suggested that it was deviating from normal distribution. Wilcoxon signed-rank test as shown in Table 4 demonstrated that p-value (p < 0.05) was significant. It means that there is a significant difference between pre and post treatment scores with respect to reflux symptoms, and it showed improvement in both the groups of patients and the difference was found to be statistically significant with treatment of PPI.
Table 4.
Wilcoxon signed-rank test
| Ranks | |||||
|---|---|---|---|---|---|
| Reflux findings | N | Mean Rank | Sum of Ranks | p-value | |
| post treatment score–pre-treatment score | Negative Ranks | 199a | 100.00 | 19,900.00 | 0.000 < 0.05 (Significant) |
| Positive Ranks | 0b | 0.00 | 0.00 | ||
| Ties | 1c | ||||
| Total | 200 | ||||
apost treatment score < pre-treatment score
bpost treatment score > pre-treatment score
cpost treatment score = pre-treatment score
Discussion
As LPR is a multifactorial clinical entity with a variety of clinical manifestations, it requires a multidisciplinary approach. LPR is characterized with a wide range of nonspecific symptoms and signs which is caused due to the backflow of the gastric contents into the larynx and pharynx. The esophageal refluxate damages the lining epithelium of larynx. The LPR symptoms significantly overlap with symptoms of other disorders [7]. Laryngopharyngeal reflux can cause sore throat, globus pharyngeus, chronic cough and choking sensation. LPR is considered as an etiological factor for several upper GI tract disorders. As this common disease has a diagnostic diellema a clinically applicable method using scoring system is useful as patients with LPR show variable response to PPI in comparison to GERD [13].
In this study it was found 42% were smokers and 58% alcoholics.These patients were Adviced to stop smoking and limit alcohol intake along with medications of pantoprazole 40 mg twice a day for 8 weeks.
According to previous studies, smoking and drinking are significant risks and contributes to reflux. Patients with suspected LPR had a personal history of drinking (10%) and smoking (12%) [4]. Smoking (24.39%) and alcohol (22%) use were also risk factors for LPR in patients [8]. In contrast, a history of smoking was discovered in 84 (42.0%) of the patients, and alcohol usage or ingestion was reported in 107 (53.5%) of the cases in our research.While as Kamani et al. have found alcohol not to be a risk factor for LPR related symptoms [14]. Studies suggest variable effects of smoking tobacco and drinking on laryngopharyngeal reflux.
In our study 48% were males and 52% were females and almost 49% of patients were in the 3rd and 4th decade. Zhi liu et al. reported a higher positive rate of LPR and RSI score in females than males and increase in prevalence of acid reflux with age [15] (2022), Medical literature suggest diet and lifestyle modification, physical exercise are effective interventions for GERD and LPR. The various pharmacological agents used for treatment are H2 receptor antagonists, prokinetic agents, mucosal surface protectors and proton pump inhibitors.PPI are the mainstay of medical treatment of LPR and require higher dosage and long duration to achieve symptomatic improvement.In our study all patients with a significant score were treated with pantoprozole 40 mg twice daily for 8 weeks [16]. A study done by Reichel et al. in 2008 report symptom and laryngeal sign improvement in LPR patients on treatment with esmeprazole 20 mg twice daily for 3 months.
A large number of studies have been published in medical literature over the last few years on comparing the difference between RSI and RFS. In a study done by Vázquez de la Iglesia, et al., a statistically significant RSI and RFS correlation was obtained (p = 0.007).13 Branski RC, et al., discovered that laryngoscopic findings alone were quite subjective as a diagnostic tool. RSI combined with RFS will be effective in evaluating patients with LPR to rule out overlapping signs and symptoms with other conditions [8, 17], and Belafsky PC, et al., confirmed RSI as a diagnostic measure of LPR, in 2001. Thus, RSI as a diagnostic measure of LPR was effective in reducing the subjective assessment of RSI. The RSI is easily administered and highly reproducible and exhibits excellent construct and criterion-based validity [18].
Martinucci I, et al., despite the controversies regarding the effects of smoking and drinking on LPR, recommended lifestyle modifications for treatment of LPR including smoking cessation and limiting alcohol intake [19]. Satish D, et al., study result showed no correlation between the RSI and RFS (p = 0.136). LPR has been diagnosed with a variety of diagnostic methods, including laryngoscopy and proximal pH monitoring. Despite this, several investigations have found that their specificity and sensitivity are as low as 75% to 80% [20]. A study conducted by Gelardi M, et al., on 3932 patients with LPR showed a moderate correlation between RSI and RFS (r = 0.484, p < 0.0001); with minimal cost and great practicality, RSI and RFS may readily be added in the LPR work-up as objective and consistent metrics [21]. Mesallam TA, et al., studied 40 patients and concluded of a statistically significant correlation between the RFS and RSI (r = 0.86; p < 0.0001). Additionally, hoarseness was highly correlated with vocal fold edema and thick laryngeal mucus (p < 0.01), and excessive throat clearing correlated significantly with thick endolaryngeal mucus (p < 0.01) [22].
Comparison of RFS and RSI scores before and after treatment revealed improvement in both groups and the difference was statistically significant (p < 0.001) in a study by Pokharel M, et al., in patients with LPR [8]. In a similar manner, in our study RFS and RSI scores before and after treatment with pantoprazole 40 mg twice a day for 8 weeks were compared by using Wilcoxon signed-rank test, and showed improvement in both the groups of patients and found to have statistically significant difference (p < 0.05).
Conclusion
Laryngopharyngeal reflux can cause diagnostic dilemma in clinical practice. In the present study, and based on our analysis it is concluded that RSI and RFS are very useful tools for assessing and diagnosing the efficacy of treatment in patients with LPR. Implementation of RSI and RFS helped to achieve early diagnosis of LPR and reduce the complications due to it. Patients with RSI showed higher frequency of moderate symptoms. There was a significant difference between pre and post treatment scores in both RSI and RFS.
Author Contributions
All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by Dr Dechu Muddaiah, Dr Prashanth V, Dr Vybhavi MK and Dr lavanya Manjunath. The first draft of the manuscript was written by Dr Dechu Muddaiah and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.
Funding
The authors have no relevant financial or non-financial interests to disclose.
Declarations
Conflict of interests
The authors did not receive support from any organization for the submitted work. The authors have no competing interests to declare that are relevant to the content of this article. This material is the authors’ own original work, which has not been previously published elsewhere. The paper properly credits the meaningful contributions of co-authors and co-researchers. The results are appropriately placed in the context of prior and existing research. There is no competing interest and informed consent was taken from all study participants.
Ethical Approval
Ethical clearance was taken from the institutional ethical committee before conduct of study.
Footnotes
Publisher's Note
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Contributor Information
Dechu Muddaiah, Email: dechu23@yahoo.com.
V. Prashanth, Email: prashanthenthns@gmail.com
M. K. Vybhavi, Email: vybhavi999@gmail.com
V. Srinivas, Email: dr_sri@hotmail.com
M. Lavanya, Email: lavanyamanjunath06@gmail.com
References
- 1.Gaur S, Panakkal AS, Arora U, Singh V. Clinical correlation of reflux finding score with reflux symptom index in diagnosis & management of laryngopharyngeal reflex disease in a tertiary care hospital. Western Up ENT-Updates. 2021;11(1):14–17. doi: 10.5152/entupdates.2021.867913. [DOI] [Google Scholar]
- 2.Mishra P, Agrawal D, Chauhan K, Kaushik M. Prevalence of laryngopharyngeal reflux disease in Indian population. Indian J Otolaryngol Head Neck Surg. 2020;20:1–5. doi: 10.1007/s12070-020-01882-1. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Lechien JR, Saussez S, Muls V, Barillari MR, Chiesa-Estomba CM, Hans S, et al. Laryngopharyngeal reflux: a state-of-the-art algorithm management for primary care physicians. J Clin Med. 2020;9(11):3618. doi: 10.3390/jcm9113618. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Bhargava A, Shakeel M, Srivastava AP, Varshney P, Saxena S, Agarwal E. Role of reflux symptom index and reflux finding score in evaluation of treatment outcome in patients with laryngopharyngeal reflux. Int J Phonosurg Laryngol. 2017;7(2):39–43. doi: 10.5005/jp-journals-10023-1141. [DOI] [Google Scholar]
- 5.Patel DA, Blanco M, Vaezi MF. Laryngopharyngeal reflux and functional laryngeal disorder: perspective and common practice of the general gastroenterologist. Gastroenterol Hepatol. 2018;14(9):512–520. [PMC free article] [PubMed] [Google Scholar]
- 6.Lechien JR, Huet K, Khalife M, Fourneau AF, Delvaux V, Piccaluga M, et al. Impact of laryngopharyngeal reflux on subjective and objective voice assessments: a prospective study. J Otolaryngo Head Neck Surg. 2016;45(1):1–9. doi: 10.1186/s40463-016-0171-1. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Sharma A, Paudel DR. Correlation between reflux symptom index and reflux finding score in laryngopharyngeal reflux. JNGMC. 2020;18(2):51–54. [Google Scholar]
- 8.Pokharel M, Shrestha I, Dhakal A, Purbey B, Amatya RCM. Reflux symptom index and reflux finding score in diagnosis of laryngopharyngeal reflux. Kathmandu Univ Med J. 2016;56(4):332–336. [PubMed] [Google Scholar]
- 9.Wang JY, Peng T, Zhao LL, Feng GJ, Liu YL. Poor consistency between reflux symptom index and laryngopharyngeal pH monitoring in laryngopharyngeal reflux diagnosis in Chinese population. Ann Transl Med. 2021;9(1):1–9. doi: 10.21037/atm-20-4783. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Habermann W, Schmid C, Neumann K, DeVaney T, Hammer HF. Reflux symptom index and reflux finding score in otolaryngologic practice. J Voice. 2012;26(3):e123–e127. doi: 10.1016/j.jvoice.2011.02.004. [DOI] [PubMed] [Google Scholar]
- 11.Nunes HS, Pinto JA, Zavanela AR, Cavallini AF, Freitas GS, Garcia FE. Comparison between the reflux finding score and the reflux symptom index in the practice of otorhinolaryngology. Int Arch Otorhinolaryngol. 2016;20:218–221. doi: 10.1055/s-0036-1579557. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Mosli M, Alkhathlan B, Abumohssin A, Merdad M, Alherabi A, Marglani O, et al. Prevalence and clinical predictors of LPR among patients diagnosed with GERD according to the reflux symptom index questionnaire. Saudi J Gastroenterol. 2018;24(4):236–241. doi: 10.4103/sjg.SJG_518_17. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Vazquez de la Iglesia F, González SF, de la Cámara Gómez M. Laryngopharyngeal reflux: correlation between symptoms and signs by means of clinical assessment questionnaires and fibroendoscopy is this sufficient for diagnosis? Acta Otorrinolaringol. 2007;58(9):421–425. [PubMed] [Google Scholar]
- 14.Kamani T, Pemmy S, Midra I, Pothula V. The prevalence of laryngopharyngeal reflux in English population. Eur Arch otolaryngol. 2012;269(9):2219–225. doi: 10.1007/s00405-012-2028-1. [DOI] [PubMed] [Google Scholar]
- 15.Zhi L, Chun Z, Xiaoyu W, Jinhong Z, Lianlian L, Jiasen W, Jing Z, Shizhen Z, Xin M, Jinrang L, Characteristics of Laryngopharyngeal Reflux in Patients of Different Genders and Ages. J Voice [DOI] [PubMed]
- 16.Berard RA. A critical evaluation of proton pump inhibitors in the treatment of gastroesophageal reflux disease. Am J Manag Care. 2000;6(9):5491–5505. [PubMed] [Google Scholar]
- 17.Branski RC, Bhattacharyya N, Shapiro J. The reliability of the assessment of endoscopic laryngeal findings associated with laryngopharyngeal reflux disease. Laryngoscope. 2002;112(6):1019–1024. doi: 10.1097/00005537-200206000-00016. [DOI] [PubMed] [Google Scholar]
- 18.Belafsky PC, Postma GN, Koufman JA. Validity and reliability of the reflux symptom index (RSI) J Voice. 2002;16(2):274–277. doi: 10.1016/S0892-1997(02)00097-8. [DOI] [PubMed] [Google Scholar]
- 19.Martinucci I, de Bortoli N, Savarino E, Nacci A, Romeo SO, Bellini M, et al. Optimal treatment of laryngopharyngeal reflux disease. Ther Adv Chronic Dis. 2013;4(6):287–301. doi: 10.1177/2040622313503485. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20.Satish D, Datta HC, Manjula BV, Poojari BA, Molluru BR. Correlation between reflux symptom index and reflux finding score in patients with laryngopharyngeal reflux: our experience. J Adv Clin Res Insights. 2016;3:13–17. doi: 10.15713/ins.jcri.96. [DOI] [Google Scholar]
- 21.Gelardi M, Silvestri M, Ciprandi G. Correlation between the reflux finding score and the reflux symptom index in patients with laryngopharyngeal reflux. J Biol Regul Homeost Agents. 2018;32(2):29–31. [PubMed] [Google Scholar]
- 22.Mesallam TA, Stemple JC, Sobeih TM, Elluru RG. Reflux symptom index versus reflux finding score. Ann Otol Rhinol Laryngol. 2007;116(6):436–440. doi: 10.1177/000348940711600608. [DOI] [PubMed] [Google Scholar]