Laryngopharyngeal Reflux and GERD: Correlation Between Reflux Symptom Index and Reflux Finding Score

Abstract

To study the relationship between laryngopharyngeal reflux (LPR) and gastroesophageal reflux disease (GERD) using clinical scoring and endoscopy. Data was collected from a sample of 100 patients with GERD symptoms who presented to ENT out-patient department, for a duration of 2 years. Patients were evaluated using Reflux Symptom Index (RSI) questionnaire and Reflux Finding Score (RFS). All patients underwent videolaryngoscopy and upper gastrointestinal endoscopy. Patient with positive findings underwent treatment with proton pump inhibitors and were followed up for 3 months. Out of 100 patients, 23 had LPR, 19 had GERD, 40 had LPR + GERD, 18 were normal. Among the LPR group, the predominant symptoms were hoarseness of voice, globus sensation and heartburn. Majority of GERD group had globus sensation, dysphagia and heartburn as their predominant symptoms. On laryngoscopy, in both LPR and LPR + GERD group, most common finding was interarytenoid erythema and vocal cord edema. On esophagogastroduodenoscopy, in both GERD and LPR + GERD group, esophagitis was the most common finding. RSI value was highest in patients with LPR + GERD. RFS value was high in LPR group followed by groups of LPR + GERD and GERD. RSI and RFS are easily administered, highly reproducible, low cost clinical scoring symptom questionnaire which can identify the patients with LPR. 82.6% of LPR patients had significant RFS scoring but with no significant findings in OGD. This study also illustrates the importance of PPI therapy in LPR patients with no evidence of GERD.

Introduction

The word REFLUX is a Greek word which means “backflow”. It refers to backflow of the stomach contents. Reflux was initially thought to be a disease and was first reported in 1935 by Winkelstein [1] who described it as “peptic ulcer of the esophagus”. He postulated that injury of the esophagus occurred as a consequence of backflow of the contents from stomach.

Gastroesophageal reflux disease (GERD) has been regarded as an etiology for laryngopharyngeal reflux (LPR). LPR refers to backflow of stomach contents into larynx and pharynx characterized by chronic laryngeal symptoms. Patients usually complain of throat burning, constant throat clearing, chronic dry cough, hoarseness of voice, globus sensation which occur secondary to laryngeal inflammation due to the reflux [2].

Materials and Methods

A descriptive and comparative study was done from October 2014 to October 2016 in the Department of ENT, JSS Medical College and Hospital, Mysuru with a sample size of 100 patients. Patients between 18 and 60 years of age with symptoms of chronic dry cough/globus sensation/dysphonia/throat pain > 3 weeks/constant throat clearing, with or without heartburn, with or without regurgitation symptom were included in the study. Malignancy of larynx and oropharynx, infective conditions of larynx, benign vocal cord lesions and patients with history of intubation of less than 12 weeks were excluded from the study.

Patients were evaluated using Reflux Symptom Index (RSI) questionnaire and Reflux Finding Score (RFS) in the outpatient department of ENT. All the patients underwent videolaryngoscopy and upper gastrointestinal endoscopy. Patient with positive findings underwent treatment with proton pump inhibitors and were followed up for 3 months.

Reflux Symptom Index (RSI) is a 9 item patient questionnaire scoring system in order to assess severity of symptoms of LPR. Symptoms which were assessed included heartburn, regurgitation, dysphonia, globus, constant throat clearing, dry cough, presence of excessive mucus, choking episodes of coughing during lying down [3] (Table 1).

Table 1.

Reflux Symptom Index (RSI)

Within the last month, how did the following problems affect you?	0 = No problem
	5 = Severe problem
1. Hoarseness or a problem with your voice	0	1	2	3	4	5
2. Clearing your throat	0	1	2	3	4	5
3. Excess throat mucus or postnasal drip	0	1	2	3	4	5
4. Difficulty swallowing food, liquids, pills	0	1	2	3	4	5
5. Coughing after you ate or after lying down	0	1	2	3	4	5
6. Breathing difficulties or choking episodes	0	1	2	3	4	5
7. Troublesome or annoying cough	0	1	2	3	4	5
8. Sensation of something sticking in your throat or lump in your throat	0	1	2	3	4	5
9. Heartburn, chest pain, indigestion or stomach acid coming up	0	1	2	3	4	5
Total

Reflux Finding Score is a 9-item clinical severity scale based on findings during videolaryngoscopy. Scale ranges from 0 (no abnormal findings) to a maximum 26 (worst score possible); items being derived from a pool of the most common laryngeal findings of patients with LPR [4] (Table 2).

Table 2.

Reflux Finding Score

Subglottic edema	0-Absent, -present
Ventricular obliteration	2-Partial, 4-complete
Interarytenoid erythema/hyperemia	2-Arytenoids only, 4-diffuse
Vocal cord edema	1-Mild, 2-moderate, 3-severe
Diffuse laryngeal edema	1-Mild, 2-moderate, 3-severe, 4-obstructing
Posterior commissure hypertrophy	1-Mild, 2-moderate, 3-severe, 4-obstructing
Granuloma/granulation tissue	0-Absent, 2-present
Thick endolaryngeal mucus	0-Absent, 2-present
Pseudosulcus	0-Absent, 2-present

Oesophagogastroduodenoscopy (OGD)

This was done on patients after an overnight fast. Grading was based upon the Los Angeles classification of Esophagitis [5] (Table 3).

Table 3.

Los Angeles classification of esophagitis

LA (A)	One (or more) mucosal break not longer than 5 mm that does not extend between the tops of two mucosal folds
LA (B)	One (or more) mucosal break more than 5 mm that does not extend between the tops of two mucosal folds
LA (C)	One (or more) mucosal break that is continuous between the tops of two or more mucosal folds but involves < 75% of the circumference
LA (D)	One (or more) mucosal break involving at least 75% of the esophageal circumference

Statistical analysis was done using Statistical Package for Social Sciences (SPSS) version 13.0 software. Mean and standard deviations were used for analysis of quantitative data while ratios/rates/proportions for Qualitative data. Chi square test was employed to infer about association of GERD with LPR. P < 0.05 was taken as significant.

Results

Out of 100 patients, 23 had laryngopharyngeal reflux, 19 patients had GERD, 40 had LPR + GERD, 18 were normal. Out of the 23 LPR patients, 60.9% were males and 39.1% were females. Among 19 patients of GERD, 52.6% were males and 47.4% females and out of 40 patients, who had both GERD and LPR, 52.5% were males and 47.5% were females. Majority of the LPR patients were between the age group of 41–50 years and the age-range distribution was almost equal among the GERD and LPR and GERD group.

Based on the distribution of symptoms, among the LPR group, the predominant symptoms were hoarseness of voice (73.9%), globus sensation (69.6%) and heartburn (56.5%) and throat clearing in (21.7%). In the GERD group, the predominant symptoms were heartburn (84.2%), globus (42.1%), dysphagia (36.8%). Among the GERD and LPR patients, predominant symptoms were heartburn (80%), globus (57.5%), throat clearing (40%), hoarseness of voice (37.5%), dysphagia (32.5%) and postnasal drip (32.5%).

Based on laryngoscopic findings, among the LPR patients, the findings were inter-arytenoid erythema (91.3%), vocal cord edema (78.3%), ventricular obliteration (73.9%), diffuse laryngeal edema (73.9%), posterior commissure hypertrophy (65.2%), pseudosulcus (60.9%) (Table 4).

Table 4.

Laryngoscopic findings among LPR and LPR + GERD groups

Laryngopharyngeal Reflux: 23	LPR + GERD = 40
	% in LPR patients	% in LPR and GERD group
Interarytenoid erythema	91.3	92.5
Vocal cord edema	78.3	62.5
Ventricular obliteration	73.9	62.5
Diffuse laryngeal edema	73.9	47.5
Subglottic edema	17.4	10
Posterior commissure hypertrophy	65.2	40
Pseudosulcus	60.9	52.5
Thick endolaryngeal mucus	8.7	27.5
Granuloma/granulation tissue	4.3	0

Among the LPR and GERD group, Inter-arytenoid erythema was the predominant symptom (92.5%) followed by Vocal cord edema (62.5%), Ventricular obliteration (62.5%), pseudosulcus (52.5%), Diffuse laryngeal edema (47.5%), Posterior commissure hypertrophy (40%), Thick endolaryngeal mucus (27.5%) (Table 4; Figs. 1, 2).

Fig. 1.

Laryngoscopic image showing diffuse laryngeal edema

Fig. 2.

Laryngoscopic image showing inter arytenoid erythema

The mean RSI value in LPR group was 8.9, in LPR + GERD group was 10.07 whereas in GERD group it was 5.78 and in normals 6.77. Correlation was found with respect to RSI in LPR group and LPR + GERD group of patients which was statistically significant.

No correlation was found with respect to RSI in GERD group and LPR + GERD group.

Mean RFS value was 11.47 in LPR group, 9.27 in LPR + GERD group, 3.60 in GERD group whereas in normals it was found to be 0.22. Correlation was found with respect to RFS value in LPR group and LPR + GERD group of patients. However there was no correlation found with respect to RFS in GERD group and LPR + GERD group.

After 3 months of Proton pump inhibitor therapy, follow up revealed improvement in 82.6% LPR, 78.9% GERD and 70% LPR + GERD patients.

Discussion

Laryngopharyngeal reflux refers to backflow of stomach contents into larynx and pharynx (voice box and throat). LPR can occur during day or night, and many people who have LPR will not have heartburn and hence it is sometimes called ‘silent reflux’ [2]. The primary cause of the laryngeal symptoms is reflux of gastric contents through the upper esophageal sphincter producing laryngeal inflammation [2].

Gastroesophageal reflux disease on the other hand refers to abnormal reflux of gastric acid into esophagus resulting in injury to the mucosa; most common symptoms of which are heartburn and regurgitation.

Belafsky et al. [3] developed Reflux Symptom Index (RSI) which is a nine-item symptom questionnaire for LPR patients. They observed that in a study of 25 patients diagnosed with LPR by 24 h pH study, symptom scores improved significantly from pre-treatment to post-treatment with proton pump inhibitors. They concluded that RSI is easily administered and highly reproducible, exhibiting high construct and criterion based validity.

In our study, we administered RSI in groups of patients with a suspicion of LPR and GERD and found that the symptom scores were higher in patients suspected of LPR + GERD and LPR group as compared to GERD group.

Belafsky et al. [4] evaluated 40 patients of LPR, diagnosed based on dual probe pH monitoring who were evaluated during pre-treatment, 2 months, 4 months and 6 months after treatment with proton pump inhibitor. They evaluated at each visit using laryngoscopy by Reflux Finding Score (RFS) based on findings. RFS showed improvement in each visit following PPI therapy by which they documented that RFS accurately documents treatment efficacy in patients with LPR and it also demonstrates excellent inter and intra-observer reproducibility.

In our study we found RFS to be higher in patients with LPR and LPR + GERD as compared to GERD group. After 3 months of treatment by PPI, patients were followed up which revealed improvement in 78.9% of GERD and 70% of LPR + GERD denoting RFS efficacy in assessment.

Powitzky et al. [6] analyzed laryngoscopic findings in 37 patients with LPR and found that posterior commissure hypertrophy (94%) and vocal cord edema (57%) were most common findings.

In our study, we found in LPR patients, interarytenoid erythema, posterior commissure hypertrophy, vocal cord edema as the most common findings.

Jonaitis et al. [7] suggested mucosal lesions of interarytenoid area, vocal cords, edema of vocal cords as the most significant finding for diagnosis of LPR. Results of findings in our study were the same.

Hickson et al. [8] conducted a study on 20 patients and found laryngeal pseudosulcus as an accurate predictor of LPR as seen in 90% cases. In our study, pseudosulcus was evident in 60.9% of patients.

The association between helicobacter pylori and laryngopharyngeal reflux in laryngeal pathologies is not well established. Cekin et al. [9] found no association between helicobacter pylori status and LPR status in their study.

In our study, we didn’t study the relationship between LPR and helicobacter pylori.

Although, in our study it was found that RSI and RFS are highly efficacious clinical scoring systems for assessment, the gold standard investigation i.e. 24 h pH monitoring and other investigations like barium swallow or esophageal manometry were not done which is a limitation of this study.

Conclusion

Administration of RSI in groups of patients with a suspicion of LPR and GERD was easy and highly reproducible. Symptom scores were higher in patients suspected of LPR + GERD and LPR group as compared to GERD group. Similarly, by the use of Reflux Finding Score, it was found that patients having LPR had a higher score than LPR + GERD group. Thus, RFS and RSI were found mutually complementary to each other. After 3 months of proton pump inhibitor treatment, patients were followed up and improvement was seen in 78.9% of GERD and 70% of LPR and GERD denoting efficacy of RFS in assessment.

Compliance with Ethical Standards

Conflict of interest

All the authors declare they have no conflicts of interest and have not received any funding.

Informed Consent

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

Ethical Approval

All procedures performed in the study were in accordance with the ethical standards of the institution.