Impact of Laryngopharyngeal Reflux in Patients with Voice Disorders

Abstract

Objective

The aim of this study is to evaluate the presence of laryngopharyngeal reflux in patients with voice disorders thereby aiding in the early management and improving the quality of life.

Study Design

Cross Sectional study.

Methods

This cross sectional study was carried out in a tertiary care hospital, patients with history of voice change for more than 3 weeks were included, and divided into 4 groups depending upon the level of voice use. Patients were asked to fill Koufmann Reflux Symptom Index questionnaire followed by video laryngoscopy and findings were plotted according to Reflux Finding Score. Based on the scoring, impact of LPRD in patient with voice disorders was analysed.

Results

Among the 90 study participants, 74 (82.2%) were found to have LPRD. The mean age was 42.76 ± 10.33 years. Majority (43.2%) belong to the age group of 41–50 years, with female predominance (70.3%). Majority (41.9%) of them were level IV voice users. 59.5% were positive Koufman reflex symptom index, 67.6% were positive Reflex finding score. Hoarseness (58.1%) the most common symptom.

Conclusion

Laryngopharyngeal reflux disease has to be considered in patients presenting with hoarseness of voice for more than three weeks. Simple and highly reproducible scores like Reflux Symptom Index and Reflux Finding Score proven useful and valuable tools in diagnosing LPRD thereby aiding in early diagnosis and prompt management and improves the patient’s quality of life.

Level of Evidence

Level 1.

Introduction

LPRD, an inflammatory condition which is defined as the backflow of gastric contents into the laryngopharynx, where it comes in contact with the tissues of the upper aerodigestive tract [1]. The prevalence of LPRD observed in patients who present to the otolaryngology department is about 4–30%.

Studies have shown significant association between LPRD and voice disorder. The causes of voice disorders can be classified as organic, functional and psychogenic. In patients who present with voice change for a duration of more than 3 months, the prime causative factor observed is LPRD with its prevalence in these patients ranging from about 55–79% [2]

LPRD can be diagnosed by varies tools like Reflux symptom index, Reflux finding score, videostroboscopy, trans-nasal esophagoscophy, pH manometry studies, salivary pepsin assay, bile acid detection. Among these diagnostic tools Reflux Symptom Index (RSI) and Reflux Finding Score (RFS) are simple, non-invasive and economic tool most commonly used in outpatient department for diagnosing LPRD [3].

All these patients who are diagnosed with LPRD, are treated empirically with proton pump inhibitors (PPI)sover a period of 12 weeks along with dietary and lifestyle modifications. And these patients have shown significant improvement in symptoms [4].

The aim of this study is to evaluate the presence of laryngopharyngeal reflux in patients with voice disorders thereby aiding in the early management and improving the quality of life.

Subjects and Methods

After obtaining approval from Institutional Human Ethical Committee approval, this cross sectional study was conducted in a tertiary care hospital from January 2021 to June 2022. Sample size = 90.

Patients who presented with history of voice change for more than 3 weeks and age more than 18 years were included in the study. Patients with known laryngeal pathologies like papillomatosis, carcinoma or vocal cord palsy, history of gastroesophageal reflux disease, patients who are on proton pump inhibitors, H₂ receptor antagonists and systemic steroids, pregnancy, thyroid disorders were excluded from the study.

Patients who had voice change for more than 3 weeks were assessed clinically with endoscopy and questionnaire.

A detailed history of the patient was taken which included age, sex, profession, level of voice use, history of voice abuse, addictions, diet, and use of any drug. Detailed history was taken and all patients was divided into one of the following level of voice users:

Level I - elite vocal performers (singers & actors).

Level II - professional voice users (teachers, lecturers, barristers).

Level III - non-vocal professionals (businessmen, doctors & lawyers).

Level IV - non-vocal non-professionals (housewives & farmers).

Patient then underwent a video laryngoscopic examination with Hopkins 70° rigid endoscope followed by assessment of the severity of symptoms for reflux disease using Koufman reflux symptom index (KRSI). Laryngopharyngeal reflux on video laryngoscopy was assessed by using reflux finding score (RFS).

1. Koufman Reflux Symptom index: All patients were assessed by a questionnaire. It had 9 questions. Patients were requested to award scores according to their symptoms. Koufman Reflux Symptom Index score of more than 13 indicates reflux disease.

2. Videolaryngoscopic assessment and findings charted by Reflux finding score was used to assess reflux disease, scoring was done based on changes seen through videolaryngoscope.

Total score ranged from 0 to 26. A score of 7 indicated presence of reflux disease.

Koufman Reflux Symptom Index Questionnaire

Within last month how did the following problems affect you?

0 = No problem, 5 = severe problem.

1. Hoarseness of voice / voice problems: scores 0–5.

2. Clearing your throat: scores 0–5.

3. Excess throat mucous / post nasal drip: scores 0–5.

4. Difficulty in swallowing food / liquids / pills: scores 0–5.

5. Cough after eating / lying down: scores 0–5.

6. Breathing difficulty / choking: scores 0–5.

7. Annoying cough: scores 0–5.

8. Sticky sensation in throat / lump in throat: scores 0–5.

9. Heart burn / chest pain: scores 0–5.

Score of more than 13 indicates laryngopharyngeal reflux.

Reflux Finding Score

1. Subglottic oedema: 0 - absent, 2 - present.

2. Ventricular obliteration: 2 - partial, 4 - complete.

3. Erythema / Hyperemia: 2 - arytenoids involved, 4 - diffuse.

4. Vocal fold oedema: 1 - mild, 2 - moderate, 3 - severe, 4 - polypoidal.

5. Diffuse laryngeal oedema: 1 - mild, 2 - moderate, 3 - severe, 4 - obstruction. (Fig. 1 and 2)

6. Posterior commissure hypertrophy: 1 - mild, 2 - moderate, 3 - severe and 4 - obstruction posterior airway.

7. Granuloma / Granulation: 0 - absent, 2 - present.

8. Thick mucous: 0 - absent, 2 - present.

Fig. 1.

Normal video laryngoscopic image

Fig. 2.

Presence inter-arytenoid edema

Total score: from 0 to 26.

A score of 7 indicated presence of laryngopharyngeal reflux.

The collected data was charted and results were analyzed.

Privacy and confidentiality of the patients were maintained.

Results

The mean age of the study participants was 42.76 ± 10.33 years. Among those who were positive for LPR, majority (43.2%) were in the age group of 41–50 years, followed by 25.7% in 31–40, 14.9% in 51–60, 13.5% in 18–30 and 2.7% in > 60. Maximum age was 69 years and minimum age was 16 years. Majority of the study participants who was positive for LPR were females (70.3%).

Among the 90 study participants, 74 (82.2%) had presence of LPR. 26.7% were positive for Koufmann Reflux Symptom Index (KRSI), 33.3% were positive for Reflux finding score (RFS) and 22.2% for both KRSI and RFS.

Among those who was positive for LPR, majority (41.9%) was level IV voice users, followed by 36.5% in level III, 18.9% in level II and 2.7% in level I.

The most common presentation for those with positive LPRD was hoarseness (58.1%), followed by throat clearing (51.4%), heart burn (47.3%), difficulty swallowing (43.2%), after feed cough (43.2%), postnasal drip (37.8%), chocking (37.8%), cough (33.8%) and sticky (23%).

Discussion

Laryngopharyngeal reflux disease (LPRD), an inflammatory condition which is defined as the backflow of gastric contents into the laryngopharynx, where it comes in contact with the tissues of the upper aerodigestive tract. James Koufman et al. and Peter Belafsky et al. stated that the prevalence of LPRD is around 50% in patients with voice disorders [5]. The prevalence of LPRD (Table 1) observed in our study was 82.2% which was more than that seen in other studies, which can be due to the increased female population in our study (Fig. 3). Patients who were positive for RSI score was about 26.7%, positive for RFS was 33.3% and 22.2% were positive for both.

Table 1.

Prevalence of LPRD

S No	LPRD	Frequency	Percentage
1	No LPRD	16	17.8
2	Presence of LPRD	74	82.2
	2.1 KRSI	24	26.7
	2.2 RFS	30	33.3
	2.3 KRSI and RFS	20	22.2

Fig. 3.

Prevalence of LPRD

The mean age of patients who had LPRD in our study was 42.76 ± 10.33 years ranging from 18 to 65 years which was in the same range as in previous studies. LPRD was commonly observed in the 40–50 age group. Raghunandhan et al., reported that the most common presenting age group is 40–50 years [6]. And the mean age in their study was 46.1 years. In a study by W Massawe et al., the mean age group was found to be 41.38 years [7].

There was a slight female predominance 52.73% in our study which was similar to a study done by Junaid M et al. [8] Another study conducted by Jerome et al. observed that females had more primary complaints about dysphonia than males. They also stated that greater voice quality disorders and lower scores of quality of life were observed in females.

Patients were categorised into four levels of voice users. Depending on the profession, Koufman and Blalock grading was used to divide them into various levels of voice usage.In our study, LPRD was commonly seen in patients with Level IV (Table 2) voice users (Non vocal, non professional voice users like housewives and farmers) (Fig. 4). This was similar to a study done by Hansa Banjara et al. [9] This could be attributed to the fact that Level IV voice users are non-vocal, non – professional, who are not hindered from doing their routine work despite experiencing some kind of dysphonia.

Table 2.

Prevalence of LPRD in different level of voice users

Level of voice users	Positive for LPRD
Level I	2 (2.7%)
Level II	14 (18.9%)
Level III	27 (36.5%)
Level IV	31 (41.9%)

Fig. 4.

Prevalence of LPRD in different level of voice users

LPRD presents with variety of laryngopharyngeal symptoms. In our study we foundthe most common presentation for those with positive LPRD was hoarseness (58.1%) (Table 3), followed by throat clearing (51.4%), heart burn (47.3%), difficulty swallowing (43.2%), after feed cough (43.2%), postnasal drip (37.8%), choking (37.8%), cough (33.8%) and sticky sensation of throat (23%) (Fig. 5). In a study by Khurshid et al., found throat clearing being the most common symptom (62.67), followed by dry cough (56%), soreness (53.33), post nasal discharge (42%),husky voice (41.33%), globus sensation (30.7%), nasal discharge (28.7%), heartburn (25.3%) and chocking (17.3%) [10]. In a prospective study by Sumitha et al., the most common presenting symptom in LPRD was hoarseness followed by throat clearing, globus sensation which is similar to our study [11].

Table 3.

Association of symptoms with LPRD

Symptoms	Positive for LPRD
Hoarseness	43 (58.1%)
Throat clearing	38 (51.4%)
Heart burn	35 (47.3%)
Difficulty swallowing	32 (43.2%)
After feed cough	32 (43.2%)
Postnasal drip	28 (37.8%)
Chocking	28 (37.8%)
Cough	25 (33.8%)
Sticky	17 (23%)

Fig. 5.

Association of symptoms with LPRD

Conclusion

Based on the observations of our study, laryngopharyngeal reflux disease has to be considered in patients presenting with hoarseness of voice for a duration of more than three weeks. Simple and highly reproducible scores like Reflux Symptom Index and Reflux Finding Score prove to be useful and valuable tools in diagnosing LPRD thereby aiding in early diagnosis and prompt management, which in turn helps to improve the patient’s quality of life. The prevalence of LPRD was 82.2% with female predominance and was most in Level IV voice users with a prevalence of 41.9%.

Funding

Not applicable.

Declarations

Conflict of Interest

Not applicable.

Ethical Approval

Approved from Institutional Human Ethical Committee from our university.

Informed Consent

Informed consent was obtained individually from all participants in the study.