Abstract
Objective
To find a better screening test by correlating between history and video-laryngoscopy in patients with laryngopharyngeal reflux disease. To compare the Reflux Symptom Index (RSI) and the Reflux Finding Score (RFS).
Method
Patients with the signs and symptoms of LPRD were scored based on RSI. Those with RSI above 13 were included in study and evaluated further by videolaryngoscopy examination and rated according to RFS. The correlation between RSI and RFS was analysed.
Result
Out of the 107 patients included in study 55% were females. Among these patients positive RFS score (i.e. > 7) was seen in 58.3%. The average RSI was 18.22, and average RFS was 7.45. According to RSI the most common symptom was heartburn/indigestion (44.5%) and from RFS the most common finding was posterior commissure hypertrophy (95%). Correlation between RSI and total RFS was found to be 0.184 with a p value of 0.159 which was not significant.
Conclusion
LPRD is more common in females and in the middle age group. A correlation of RSI and RFS was not found to be significant suggesting that both should be used for diagnosis of LPRD instead of relying on only one. RFS and RSI are easy, quick and out patient based screening tools and when used together can be more reliable for LPRD diagnosis.
Keywords: LPRD, Screening, Videolaryngoscopy, RSI, RFS
Introduction
Laryngopharyngeal reflux disease (LPRD) is defined as the retrograde flow of gastric contents into the larynx and pharynx leading to upper aerodigestive system symptoms like hoarseness, globus pharyngeus, dysphagia, cough, chronic throat clearing, postnasal drip, and wheezing [1].
LPRD not only has a significant negative impact on patient’s quality of life but it can also predispose to many laryngeal diseases such as reflux laryngitis, subglottic stenosis, laryngeal carcinoma, granulomas, contact ulcers and vocal nodules [2].
In 2002, Belafsky et al. published the Reflux Symptom Index (RSI), a classification of symptoms of laryngopharyngeal reflux [3]. There is wide divergence among specialists on the diagnosis of LPRD. Therefore, Belafsky et al. recently proposed the Reflux Finding Score (RFS), through videolaryngoscopic (VLS) findings, to decrease the subjectivity of diagnosis [3].
Most patients with LPRD are diagnosed clinically by history taking and examination with flexible or rigid laryngeal endoscopy [4]. Further investigations are indicated for those patients in whom the diagnosis is in doubt or those who do not respond to treatment.
To minimize the under diagnosis of LPRD, this study aims to compare the Reflux Finding Score (RFS) with the Reflux Symptom Index (RSI) in the practice of ENT.
Methods
This is a cross-sectional observational study done between August 2018 and March 2019, in a tertiary care centre in Pune, India. Informed consent was obtained from all individual participants included in the study. Patients reporting to the ENT OPD with symptoms of LPRD, and willing to be part of the study were scored based on RSI (Table 1), which consisted of 9 questions. Each symptom was scored by the patient themselves, from 0 to 5 based on severity, with a maximum score of 45. Those with a score of 13 or more, suggestive of LPRD, were further evaluated by videolaryngosopy on OPD basis and scored according to RFS.
Table 1.
Reflux Symptom Index (RSI) according to Belfasky et al.
Source: Center for voice disorders of Wake Forest University. Reprinted with permission
| Reflux Symptom Index | ||||||
|---|---|---|---|---|---|---|
| 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 mucous or postnasal drip | 0 | 1 | 2 | 3 | 4 | 5 |
| 4. Difficulty swallowing food, liquids, or 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. Sensations of something sticking in your throat or a 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 | ||||||
A sample size of 107 patients with positive RSI were selected after excluding those with active throat infection, organic laryngeal disorders and those already taking long term proton pump inhibitors(PPI). They were investigated using a rigid 70 degree Karl Storz endoscope with recording system. These findings were graded from 0 to 4 according to RFS (Table 2). RFS is an 8-item clinical severity scale used to interpret the most common laryngoscopic findings related to LPR, with a maximum score of 26. An RFS of more than 7 indicates that the patient has LPR with 95% certainty.
Table 2.
Reflux Finding Score (RFS) according to Belfasky et al.
Source: Center for voice disorders of Wake Forest University. Reprinted with permission
| Reflux Finding Score |
|---|
| Subglottic edema |
| 2 = present |
| 0 = absent |
| Ventricular obliteration |
| 2 = partial |
| 4 = complete |
| Erythema/hyperemia |
| 2 = arytenoids only |
| 4 = diffuse |
| Vocal fold oedema |
| 1 = mild |
| 2 = moderate |
| 3 = severe |
| 4 = obstructing |
| Diffuse laryngeal edema |
| 1 = mild |
| 2 = moderate |
| 3 = severe |
| 4 = obstructing |
| Posterior commissure hypertrophy |
| 1 = mild |
| 2 = moderate |
| 3 = severe |
| 4 = obstructing |
| Granuloma/granulation |
| 2 = present |
| 0 = absent |
| Thick endolaryngeal mucus |
| 2 = present |
| 0 = absent |
| Total: |
The findings based on history (RSI) and videolaryngoscopy (RFS) were correlated with each other using Spearman’s correlation coefficient.
Results
Out of the 107 patients with RSI more than 13, included in the study, 55% were females and 45% were males. Majority (61%), were between 21 and 40 years of age (mean—35.7 years). RSI ranged from 13 to 42 with an average of 18.22. The most common presenting complaint was throat pain (25%) and excessive clearing of throat (21.6%). On self scoring of symptoms according to RSI, the most common symptom was found to be heartburn/indigestion (44.5%), frequent clearing of throat (38.8%) and sticky sensation in throat (32%) (Fig. 1).
Fig. 1.
Symptom distribution according to Reflux Symptom Index scoring system
When further evaluated by VLS for RFS record, the most common findings were posterior commissure hypertrophy (95%) and laryngeal erythema (90%). Vocal fold oedema was seen in 70% patients, diffuse laryngeal oedema in 61.7%, thick endolaryngeal mucous in 60%, ventricular obliteration in 40%, subglottic oedema in 6.7% and granulations in 1.7%.The RFS ranged from 2 to 20 (average—7.45) and was positive (> 7) in 58.3% patients (Figs. 2, 3).
Fig. 2.
Posterior commissure hypertrophy diffuse erythema
Fig. 3.
Diffuse laryngeal erythema subglottic oedema thick endolaryngeal mucous vocal fold oedema
Correlation between RSI and total RFS was found to be 0.184 according to Spearman’s correlation coefficient with a p value of 0.159 (not significant). Hence it was concluded that both RSI and RFS should be utilised in order to achieve a diagnosis of LPRD.
Discussion
Up to 15% of all visits to otolaryngology offices can be related to LPR [5]. More specifically, at least 50% of patients with laryngeal or voice disorders on presentation may have LPR [6]. However, the estimates may be inflated because of the lack of a gold standard in diagnosing LPR. Previously 24 h pH monitoring was taken as the gold standard for diagnosis.
Reflux of stomach contents can be associated with LPR via two main mechanisms. The first is the result of direct exposure of the laryngopharyngeal mucosa to gastric contents. The second is an indirect mechanism, in which the interaction between the reflux material and structures more distal to the larynx leads to bronchoconstriction via a vagally mediated response [7]. In LPR, the former mechanism may be more important. The larynx is more susceptible to reflux injury than the esophagus because it lacks both the extrinsic and the intrinsic epithelial defenses (antireflux barrier) of the esophagus.
Belfasky et al. developed simple, non invasive, economical instruments for diagnosis of LPRD which they called RSI and RFS [8]. These measurement tools were used in this study to reach the diagnosis of LPRD, as well as to determine the correlation between the presenting symptoms and their physical laryngoscopic findings in order to assess the reliability of RFS. These tools have been validated, are easy to use, non-invasive and can be used in outpatient setting [9].
Statistically, some authors state that there is a 95% probability of someone having LPR if his or her RSI score is ≥ 13 (the maximum is 45 points) and RFS score reaches ≥ 7 (out of a maximum of 26); however, the RSI and RFS specificities are low when both tools are used independently [3]. The sensitivity of RSI and RFS is 75.6% and 80.7% respectively, for a definitive diagnosis of LPRD and specificity is 18.8% for RSI, and 37.5% for RFS [10]. Feng et al. have found that laryngopharyngeal pH monitoring and RSI scoring have the same value in diagnosing LPRD [11].
The data collected in the present study was comparable with that of previous studies done on LPRD (Tables 3, 4, 5). However this study did not find a significant correlation between total RSI and RFS. Mesallam et al. [12] and Karakara et al. [13] found a strong positive correlation between RSI and total RFS in LPR patients (p value < 0.01). Similarly a positive correlation between the two scores (p value = 0.001), was also found by Dawood et al. in 2018 [14]. A moderate correlation was found according to a study by Gelardi et al. on 3932 patients [15].
Table 3.
Comparison of similar studies with present study
| Study | Sample size | Male/female (%) | Average age (years) | Mean RSI | Mean RFS | Most common symptom | Most common sign |
|---|---|---|---|---|---|---|---|
| Present study | 100 | 45/55 | 35.7 | 18.2 | 7.5 | Heartburn | Posterior commissure hypertrophy |
| Mesallam et al. | 40 | 35/65 | 41.7 | 20.2 | 9.3 | Lump in throat | Erythema |
| Nunes et al. | 126 | 30.2/69.8 | 52.4 | 20.7 | 9.5 | Cough | Vocal fold oedema |
| Dawood et al. | 78 | 35.9/64.1 | 41.8 | 18.6 | 9.7 | Hoarseness | Posterior commissure hypertrophy |
| Karakaya et al. | 54 | 37/63 | 39.09 | 18.3 | 14.2 | Hoarseness | Vocal fold oedema and posterior commissure hypertrophy |
Table 4.
Common symptoms of LPRD according to various studies (as graded by RSI)
| Symptom | Present study | Mesallam et al. | Dawood et al. | Karakaya et al. |
|---|---|---|---|---|
| Hoarseness | 23.4 | 27.5 | 89.7 | 98.2 |
| Lump in throat sensation | 32 | 37.5 | 69.2 | 71.3 |
| Heartburn | 44.5 | 17.5 | 0 | 86.3 |
| Frequent throat clearing | 38.8 | 17.5 | 76.9 | 92.7 |
Table 5.
Frequency of findings on video laryngoscopy according to RFS
| Sign | Present study | Mesallam et al. | Dawood et al. | Karakaya et al. |
|---|---|---|---|---|
| Vocal fold oedema | 70 | 75 | 79.5 | 100 |
| Posterior commissure hypertrophy | 95 | 75 | 87.2 | 100 |
| Erythema | 90 | 85 | 74.35 | 98.2 |
| Diffuse laryngeal oedema | 61.7 | 77.5 | 51.28 | 98.2 |
| Thick endolaryngeal mucous | 60 | 55 | 53.8 | 18.2 |
| Ventricular obliteration | 40 | 50 | 35.9 | 71.3 |
| Subglottic oedema | 6.7 | 12.5 | 69.2 | 36.2 |
| Granuloma | 1.7 | 10.25 | 0 |
Thus, RSI and RFS can easily be included in the LPRD work-up in clinical practice, as objective and consistent parameters, with low cost and high practicality. Both RSI and RFS are subjective score and can be have subtle variations based on individuals and that definitely is a limiting factor of these assessment. The use 24 Hr pH metry as the gold standard for diagnosis has also not been well accepted by many studies considering the fact that many patients are without symptoms inspite of positive on pH metry [16, 17] Besides availability of this investigation at all centers is also a limiting factor. Thus its use can be justified if patient is posive on history and Vlscopy findings and is not improving with antireflux treatment.
After many years of research, and numerous studies, there is still no gold standard investigation for diagnosis or treatment. pH monitoring method has also been questioned by several authors for its diagnosis, who concluded that it did not have 100% sensitivity. Hence more studies are required that are concerned with consensus for diagnosis of LPRD in order to establish proper management of this problem and to improve patients quality of life, and this study is one in that direction suggesting to use both the history and Vlscopy for LPRD diagnosis.
Conclusion
As per this study, LPRD is more common in females and in the middle age group. The most common symptom according to RSI was heartburn and most common finding according to RFS was posterior commissure hypertrophy. There was no statistically significant correlation found between RSI and RFS suggesting that both should be used for diagnosis of LPRD instead of relying on only one.
The aim of this study is to increase the awareness about subtle signs of LPRD and about using both RSI and RFS for early diagnosis. These scoring systems can easily be included in routine ENT practice. RFS and RSI are easy, quick and out patient based screening tools and when used together can be more reliable for LPRD diagnosis.
Acknowledgements
Dr. Maitri Kaushik Prof & HOD for allowing the conduct of this study.
Funding
None.
Compliance with Ethical Standards
Conflict of interest
All authors confirm that there is no conflict of interest in this study.
Footnotes
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Contributor Information
Prasun Mishra, Email: entprasun@gmail.com.
Deeksha Agrawal, Email: 48deeksha@gmail.com.
Purva Artham, Email: purvaartham@gmail.com.
References
- 1.Koufman JA, Aviv JE, Casiano RR, Shaw GY. Laryngopharyngeal reflux: position statement of the committee on speech, voice, and swallowing disorders of the American Academy of Otolaryngology-Head and Neck Surgery. Otolaryngol Head Neck Surg. 2002;127(1):32–35. doi: 10.1067/mhn.2002.125760. [DOI] [PubMed] [Google Scholar]
- 2.Campagnolo AM, Priston J, Thoen RH, Medeiros T, Assunção AR. Laryngopharyngeal reflux: diagnosis, treatment, and latest research. Int Arch Otorhinolaryngol. 2014;18(2):184–191. doi: 10.1055/s-0033-1352504. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Belafsky PC, Postma GN, Koufman JA. The validity and reliability of the reflux finding score (RFS) Laryngoscope. 2001;111(8):1313–1317. doi: 10.1097/00005537-200108000-00001. [DOI] [PubMed] [Google Scholar]
- 4.Watson MG. Review article: laryngopharyngeal reflux: the ear, nose and throat patients. Aliment Pharmacol Ther. 2011;33(Suppl 1):53–57. [Google Scholar]
- 5.Vaezi MF. Laryngitis: from the gastroenterologist’s point of view. In: Vaezi MF, editor. Extraesophageal reflux. San Diego: Plural; 2009. pp. 37–47. [Google Scholar]
- 6.Koufman JA, Amin MR, Panetti M. Prevalence of reflux in 113 consecutive patients with laryngeal and voice disorders. Otolaryngol Head Neck Surg. 2000;123(4):385–388. doi: 10.1067/mhn.2000.109935. [DOI] [PubMed] [Google Scholar]
- 7.Hanson DG, Jiang JJ. Diagnosis and management of chronic laryngitis associated with reflux. Am J Med. 2000;108(Suppl 4a):112S–119S. doi: 10.1016/S0002-9343(99)00349-6. [DOI] [PubMed] [Google Scholar]
- 8.Belfasky GC, Postma GN, Koufman JA. Validity and reliability of the reflux symptom index(RSI) Voice. 2002;16(2):274–277. doi: 10.1016/S0892-1997(02)00097-8. [DOI] [PubMed] [Google Scholar]
- 9.Carrau RL, Khidr A, Crawley JA. The impact of laryngopharyngeal reflux on patient-reported quality of life. Laryngoscope. 2004;114:670–674. doi: 10.1097/00005537-200404000-00014. [DOI] [PubMed] [Google Scholar]
- 10.Kendall KA. Controversies in the diagnosis and management of laryngopharyngeal reflux disease. Curr Opin Otolaryngol Head Neck Surg. 2006;14:113–115. doi: 10.1097/01.moo.0000193195.47720.c3. [DOI] [PubMed] [Google Scholar]
- 11.Feng GH, Zhang LH, Zhao LL, Liu YL. A pilot study on diagnosinf laryngopharyngeal reflux disease by pH monitoring in laryngopharynx. Zhonghua Yi Xue Za Zhi. 2008;88(12):805–808. [PubMed] [Google Scholar]
- 12.Mesallam TA, Stemple JC, Sobeih TM, Elluru RG. Reflux symptom index versus reflux finding score. Ann Otol Rhinol Laryngol. 2007;116:436–440. doi: 10.1177/000348940711600608. [DOI] [PubMed] [Google Scholar]
- 13.Karakaya NE, Akbulut S, Altıntaş H, Demir MG, Demir N, Berk D. The reflux finding score: reliability and correlation to the reflux symptom index. J Acad Res Med. 2015;5(2):68–74. doi: 10.5152/jarem.2015.698. [DOI] [Google Scholar]
- 14.Dawood MR. A clinical diagnoses of laryngopharyngeal reflux in patients with voice related problems via correlation between reflux symptoms and laryngoscopic findings. Madridge J Otorhinolaryngol. 2018;2(1):56–60. [Google Scholar]
- 15.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(1 Suppl. 2):29–31. [PubMed] [Google Scholar]
- 16.Formánek M, et al. Comparison of impedance and pepsin detection in the laryngeal mucosa to determine impedance values that indicate pathological laryngopharyngeal reflux. Clin Transl Gastroenterol. 2017;8(10):e123. doi: 10.1038/ctg.2017.49. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17.Hoppo T, Sanz AF, Nason KS, et al. How much pharyngeal exposure is “normal”? Normative data for laryngopharyngeal reflux events using hypopharyngeal multichannel intraluminal impedance (HMII) J Gastrointest Surg. 2012;16:16–25. doi: 10.1007/s11605-011-1741-1. [DOI] [PMC free article] [PubMed] [Google Scholar]