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ORIGINAL ARTICLE
Year : 2019  |  Volume : 9  |  Issue : 1  |  Page : 1-5

A study of relationship between reflux symptom index and reflux finding score in patients with laryngopharyngeal reflux


Department of Otorhinolaryngology, Bharati Vidyapeeth (Deemed to be University) Medical College and Hospital, Sangli, Maharashtra, India

Date of Submission09-Aug-2019
Date of Acceptance18-Nov-2019
Date of Web Publication14-May-2020

Correspondence Address:
Dr. Ankitha Puranik
Department of Otorhinolaryngology, Bharati Vidyapeeth (Deemed to be University) Medical College and Hospital, Wanlesswadi, Sangli - 416 414, Maharashtra
India
Sachin Nilakhe
Department of Otorhinolaryngology, Bharati Vidyapeeth (Deemed to be University) Medical College and Hospital, Sangli, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jlv.JLV_6_19

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   Abstract 


Background: Diagnosis of laryngopharyngeal reflux (LPR) is considered as a challenge by otorhinolaryngologists. Reflux symptom index (RSI) and reflux finding score (RFS) are two diagnostic tools which yield in the diagnosis of LPR. The aim of the study was to establish an association between RSI and RFS in patients with LPR. Materials and Methods: A cross-sectional analytical study was conducted on 30 patients who were enrolled. RSI score and RFS were obtained as per pro forma. RSI score ≥13 and RFS ≥7 were indicated to be positive for LPR. Results: Of the 30 patients enrolled, males and females were 16 and 14, respectively. Mean RSI score was 23.83 (standard deviation [SD] = 9.07) and mean RFS was 16.07 (SD = 7.31) were obtained. The most common presenting symptom was lump in the throat (80%) and the sign was hyperemia/erythema (83.33%). A strong correlation of 0.86 (P = 0.01) was established between RSI and RFS. Conclusion: LPR plays a key role in patients with laryngeal complaints. RSI and RFS can be implemented easily in the diagnosis of LPR.

Keywords: Laryngopharyngeal reflux, reflux finding score, reflux symptom index score


How to cite this article:
Nilakhe S, Purohit A, Puranik A. A study of relationship between reflux symptom index and reflux finding score in patients with laryngopharyngeal reflux. J Laryngol Voice 2019;9:1-5

How to cite this URL:
Nilakhe S, Purohit A, Puranik A. A study of relationship between reflux symptom index and reflux finding score in patients with laryngopharyngeal reflux. J Laryngol Voice [serial online] 2019 [cited 2020 Jul 8];9:1-5. Available from: http://www.laryngologyandvoice.org/text.asp?2019/9/1/1/284235




   Introduction Top


Laryngopharyngeal reflux (LPR) is defined as the “reflux of gastroesophageal contents into the larynx and pharynx.”[1]

LPR makes about 4%–10% of patients who attend otolaryngology clinic[2],[3] and 1% of patients in primary care practice. Although the prevalence has increased, it is still considered a challenge for an otorhinolaryngologist to diagnose LPR for its vague presentation.

In 1979, Pellegrini et al.[4] were the first to report and establish a relationship between airway symptoms and reflux of gastroesophageal contents. In 1996, Koufman et al. introduced the terminology LPR.[5]

In an effort to help diagnose LPR, Belafsky et al.[6] developed a validated reflux symptom index (RSI) and reflux finding score (RFS).

This study helps us to find the relationship between RSI and RFS in patients with symptoms, suggestive of LPR.

Aim and objectives

The aim of our study was to study and establish an association between RSI and RFS in patients with LPR. To achieve the aim, our objectives were (1) to identify the symptoms of LPR disease via RSI score; (2) to clinically assess the LPR changes using 70° laryngoscope and fiberoptic laryngoscope (FOL) via RFS; and (3) to compare and find out a relationship between RSI and RFS if any in patients with laryngopharyngeal reflux disease (LPRD).


   Materials and Methods Top


It was a cross-sectional analytical study done for 9 months at Bharati Hospital, Sangli, Maharashtra. In this study, 30 patients aged between 18 and 60 years who attended ear-nose-throat outpatient department (OPD) at our hospital with symptoms, suggestive of LPR disease from June 2018 to November 2018, were enrolled. Written informed consent was obtained. Patients who had received radiotherapy in the past, with neurologic illness, who underwent surgery for laryngeal pathologies in the past, with other laryngeal pathologies, and who were unable to comply with the study protocol were excluded from the study. The study tools used were well-designed protocol with pro forma and questionnaire developed by an investigator, 70° Hopkins rigid endoscope, fiberoptic flexible laryngoscope, monitor, Storz camera, and cold light source. RSI was obtained from all the patients included in the study. RFS was evaluated with 70° Hopkins rigid endoscope and fiberoptic flexible laryngoscope. Patients with RSI score ≥13 and RFS ≥7 were considered as positive for LPR diseases and classified accordingly. The following pro forma was used in our study for determining RSI and RFS [Table 1] and [Table 2]. [Table 1] and [Table 3] The data were entered into Microsoft Excel and were analyzed. Chi-square statistical test was used wherever applicable.
Table 1: Reflux symptom index

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Table 2: Reflux finding score

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Table 3: Reflux symptom index versus reflux finding score

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   Results Top


The study was conducted on 30 patients within the age group of 18–60 years. Of 30 patients, 16 were males and 14 were females. In our study, RSI ranged from 10 to 42 with mean = 23. 83 (standard deviation [SD] =9.07) and RFS ranged from 2 to 24 with mean = 16.07 (SD = 7.31).

RSI was considered as positive when score was higher than or equal to 13 and/or RFS equal to or higher than 7. Only four patients out of 30 had a positive score on RSI with a negative score on RFS, and one patient had a positive score on RFS with a negative score on RSI.

In our study, the most common symptom presented was lump in the throat (80%) followed by clearing of throat (66.66%) and annoying cough (60%). Choking/breathing difficulties accounted the least with 6.66% [Figure 1].
Figure 1: Distribution of symptoms of laryngopharyngeal reflux (reflux symptom index) in patients

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Endoscopic findings include subglottic edema, ventricular obliteration, erythema/hyperemia, vocal fold edema, diffuse laryngeal edema, posterior commissure hypertrophy, granuloma/granulation, and thick endolaryngeal mucus [Figure 2],[Figure 3],[Figure 4],[Figure 5],[Figure 6],[Figure 7].
Figure 2: Hyperemia

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Figure 3: Posterior commissure hypertrophy

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Figure 4: Diffuse edema with ventricular obliteration

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Figure 5: Hyperemia of arytenoids

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Figure 6: Granulation with hyperemia

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Figure 7: Endolaryngeal mucus

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Hyperemia/erythema was the most common sign with 83.33%, closely followed by posterior commissure hypertrophy with 76.66%. Subglottic edema (16%) and granuloma (10%) were found least [Figure 8].
Figure 8: Distribution of endoscopic findings (RFI) in patients

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We found that there was strong positive correlation between RSI and RFS (r = 0.86) with P = 0.01. Chi-square statistical test was applied for the same [Table 3].{Table 3}


   Discussion Top


Diagnosing LPR is still one of the challenges faced by otorhinolaryngologists in today's scenario. It is a disease with many synonyms! Extraesophageal reflux disease, supraesophageal reflux disease, silent reflux, esophagopharyngeal reflux, gastropharyngeal reflux, atypical reflux disease, airway reflux, to name a few.

Pathophysiology of LPR is that in under normal circumstances (upper esophageal sphincter), pressure increases with respect to esophageal acid exposure; however, in patients with LPR, the function of this protective reflux fails to occur.[7] Tissue damage is due to peptic injury.[8] It is tissue-bound pepsin that causes tissue injury. It is reported that the peptic injury is associated with depletion of key protective proteins, including carbonic anhydrase, E-cadherin, and stress proteins.[9-12] It is noted that there is significant reduction in MUC4 and MUC5AC expression in LPRD laryngeal biopsies of vocal fold. Based on the above pathophysiology, LPR is considered as a new diagnosis.[13-15] As compared with gastroesophageal reflux disease (GERD), the pathophysiology, symptoms, and response to treatment of LPR are different. The main difference between the two was that majority of patients with LPR do not present with heartburn and esophagitis as compared with GERD. Patients LPR have reflux mainly during the day, unlike GERD which occurs at night. Furthermore, LPR does not have prolonged acid exposure in GERD.

Thus, evaluation of clinical symptom is considered to be essential in determining the accurate diagnosis of LPR. To aid that, Belafsky et al.,[6] an American physician, have developed nine most common occurrences in the form of an RSI, which is a preset questionnaire introduced by them and answered by the patient himself/herself. It also evaluates treatment efficacy, which has excellent reproducibility and criterion-based validity. FOL/70° endoscope is a most useful and effective method of evaluation and documentation of physiological and pathological conditions of the larynx. It is of great value for making accurate diagnosis and further management. An 8-item clinical severity rating scale based on findings of FOL/70° endoscope was used for RFS. RFS helps in identifying subtle changes due to reflux disease, in evaluating severity of laryngeal tissue injury, and to know treatment outcome. RFS of more than 7 indicates >95% have LPR.[8]

A study conducted by Iqbal et al.[16] showed that the mean RSI of the patients was 17 which was comparable to that found by Belafsky et al.,[17] with a mean RSI being 19.9 + 11.1. Shah and Vishwakarma[18] in their study had a mean RSI of 22.99 (SD = 7.93) which is comparable with our study of mean 23.83 (SD = 9.07). In the same study conducted by Iqbal et al.,[16] clearing of throat (97.1%) was found to be the most common symptom which was followed by lump in the throat (96.2%). However, our study showed lump in the throat as the most common symptom followed by clearing of throat. In another study conducted by Bhargava et al.,[19] the most common symptom was throat pain (71%) followed by foreign-body sensation/lump in the throat (55%) and the sign was hyperemia (72%). The mean RFS was 11.04 with SD 3.07 in the study conducted by Shah and Vishwakarma,[18] which is similar to our study, where RFS mean was 16.07 (SD = 7.31). In the same study, Shah and Vishwakarma[18] revealed a strong correlation coefficient of RSI and RFS as 0.98 which is similar to our study of 0.86 [Table 3]. Thus, RSI and RFS have a strong association and thus can be routinely used as diagnostic parameters of LPR.

Other tests used for the evaluation are Pepsin Immunoassay-Spit Test Screening for Airway Reflux Ambulatory 24 h pH-Monitoring and transnasal esophagoscopy.

Long-term treatment with proton pump inhibitors and H2-antagonists and lifestyle modifications play a key role in reversing the signs and symptoms of LPR.


   Conclusion Top


RSI and RFS are reliable, effective, and minimally invasive diagnostic tools to diagnose LPR. This helps in clearing an otolaryngologist's dilemma in diagnosing LPR in a simpler way by filling up a questionnaire and performing FOL/70° endoscopy in an OPD set up. It is a combination of both subjective and objective assessment. Our aim and objectives were met in this study as there is a significant association between RSI and RFS in patients with symptoms, suggestive of LPR.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Vakil N, van Zanten SV, Kahrilas P, Dent J, Jones R, Global Consensus Group: The montreal definition and classification of gastroesophageal reflux disease: A global evidence-based consensus. Am J Gastroenterol 2006;101:1900-20.  Back to cited text no. 1
    
2.
Rees LE, Pazmany L, Gutowska-Owsiak D, Inman CF, Phillips A, Stokes CR, et al. The mucosal immune response to laryngopharyngeal reflux. Am J Respir Crit Care Med 2008;177:1187-93.  Back to cited text no. 2
    
3.
Sen P, Georgalas C, Bhattacharyya AK. A systematic review of the role of proton pump inhibitors for symptoms of laryngopharyngeal reflux. Clin Otolaryngol 2006;31:20-4.  Back to cited text no. 3
    
4.
Pellegrini CA, DeMeester TR, Johnson LF, Skinner DB. Gastroesophageal reflux and results of surgical therapy. Surgery 1979;86:110-9.  Back to cited text no. 4
    
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Koufman J, Sataloff RT, Toohill R. Laryngopharyngeal reflux: Consensus conference report. J Voice 1996;10:215-6.  Back to cited text no. 5
    
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Belafsky PC, Postma GN, Koufman JA. The validity and reliability of the reflux finding score (RFS). Laryngoscope 2001;111:1313-7.  Back to cited text no. 6
    
7.
Koufman JA. The otolaryngologic manifestations of gastroesophageal reflux disease (GERD): A clinical investigation of 225 patients using ambulatory 24-hour pH monitoring and an experimental investigation of the role of acid and pepsin in the development of laryngeal injury. Laryngoscope 1991;101:1-78.  Back to cited text no. 7
    
8.
Koufman JA. Perspective on laryngopharyngeal reflux: From silence to omnipresence. In: Branski R, Sulica L, editors. Classics in Voice and Laryngology. San Diego: Plural Publishing; 2009. p. 179-266.  Back to cited text no. 8
    
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Axford SE, Sharp N, Ross PE, Pearson JP, Dettmar PW, Panetti M, et al. Cell biology of laryngeal epithelial defenses in health and disease: Preliminary studies. Ann Otol Rhinol Laryngol 2001;110:1099-108.  Back to cited text no. 9
    
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Johnston N, Bulmer D, Gill GA, Panetti M, Ross PE, Pearson JP, et al. Cell biology of laryngeal epithelial defenses in health and disease: Further studies. Ann Otol Rhinol Laryngol 2003;112:481-91.  Back to cited text no. 10
    
11.
Gill GA, Johnston N, Buda A, Pignatelli M, Pearson J, Dettmar PW, et al. Laryngeal epithelial defenses against laryngopharyngeal reflux: Investigations of E-cadherin, carbonic anhydrase isoenzyme III, and pepsin. Ann Otol Rhinol Laryngol 2005;114:913-21.  Back to cited text no. 11
    
12.
Johnston N, Dettmar PW, Lively MO, Postma GN, Belafsky PC, Birchall M, et al. Effect of pepsin on laryngeal stress protein (Sep70, Sep53, and Hsp70) response: Role in laryngopharyngeal reflux disease. Ann Otol Rhinol Laryngol 2006;115:47-58.  Back to cited text no. 12
    
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Dent J, El-Serag HB, Wallander MA, Johansson S. Epidemiology of gastro-oesophageal reflux disease: A systematic review. Gut 2005;54:710-7.  Back to cited text no. 13
    
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Koufman JA. Laryngopharyngeal reflu×2002: A new paradigm of airway disease. Ear Nose Throat J 2002;81:2-6.  Back to cited text no. 14
    
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Saritas Yuksel E, Vaezi MF. New developments in extraesophageal reflux disease. Gastroenterol Hepatol (N Y) 2012;8:590-9.  Back to cited text no. 15
    
16.
Iqbal I, Masoodi ZA, Chiesti LA, Kadla SA. Laryngopharyngeal reflux disease; How to evaluate. Open Sci J Clin Med 2013;1:5-11.  Back to cited text no. 16
    
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Belafsky PC, Postma GN, Koufman JA. Validity and reliability of the reflux symptom index (RSI). J Voice 2002;16:274-7.  Back to cited text no. 17
    
18.
Shah RV, Vishwakarma R. Laryngopharyngeal reflux: Is it the real culprit in patients with laryngeal complaints? Int J Phonosurg Laryngol 2017;7:6-9.  Back to cited text no. 18
    
19.
Bhargava A, Shakeel M, Srivastava A, Varshney P, Saxena S, Agarwal E. Role of reflux finding score and reflux symptom index in evaluation of treatment outcome in patients with laryngopharyngeal reflux. Int J Phonosurgery Laryngol 2017;7:39-43.  Back to cited text no. 19
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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