Development and Validation of the Short Version of the Reflux Symptom Score: Reflux Symptom Score-12

The Dubai Definition and Diagnostic Criteria of Laryngopharyngeal Reflux: The IFOS Consensus

OBJECTIVE

The objective of this work was to gather an international consensus group to propose a global definition and diagnostic approach of laryngopharyngeal reflux (LPR) to guide primary care and specialist physicians in the management of LPR.

METHODS

Forty-eight international experts (otolaryngologists, gastroenterologists, surgeons, and physiologists) were included in a modified Delphi process to revise 48 statements about definition, clinical presentation, and diagnostic approaches to LPR. Three voting rounds determined a consensus statement to be acceptable when 80% of experts agreed with a rating of at least 8/10. Votes were anonymous and the analyses of voting rounds were performed by an independent statistician.

RESULTS

After the third round, 79.2% of statements (N = 38/48) were approved. LPR was defined as a disease of the upper aerodigestive tract resulting from the direct and/or indirect effects of gastroduodenal content reflux, inducing morphological and/or neurological changes in the upper aerodigestive tract. LPR is associated with recognized non-specific laryngeal and extra-laryngeal symptoms and signs that can be evaluated with validated patient-reported outcome questionnaires and clinical instruments. The hypopharyngeal-esophageal multichannel intraluminal impedance-pH testing can suggest the diagnosis of LPR when there is >1 acid, weakly acid or nonacid hypopharyngeal reflux event in 24 h.

CONCLUSION

A global consensus definition for LPR is presented to improve detection and diagnosis of the disease for otolaryngologists, pulmonologists, gastroenterologists, surgeons, and primary care practitioners. The approved statements are offered to improve collaborative research by adopting common and validated diagnostic approaches to LPR.

LEVEL OF EVIDENCE

5 Laryngoscope, 134:1614-1624, 2024.

Assessing the role of dryness and burning sensation in diagnosing laryngopharyngeal reflux

Laryngopharyngeal reflux disease (LPRD) is a condition characterized by the regurgitation of stomach and duodenal contents into the laryngopharynx, with variable and non-specific symptoms. Therefore, developing an accurate symptom scale for different regions is essential. Notably, the symptoms of "dryness and burning sensation in the laryngopharynx or mouth" are prevalent among the Chinese population but are often omitted from conventional symptom assessment scales, such as the Reflux Symptom Index (RSI) and Reflux Symptom Score-12 (RSS-12) scales. To address this gap, our study incorporated the symptoms into the RSI and RSS-12 scales, developing the RSI-10/RSS-13 scales. Afterward, we assessed the role of the new scale's reliability (Cronbach's α and test-retest reliability), construct validity (confirmatory factor analysis and confirmatory factor analysis), and diagnostic efficiency. Our study encompassed 479 participants (average = 39.5 ± 13.4 years, 242 female) and 91 (average = 34.01 ± 13.50 years, 44 female) completed 24 h MII-pH monitoring. The Cronbach's α values of 0.80 and 0.82 for the RSI-10 and RSS-13 scales, respectively. RSI-10 and RSS-13 exhibited strong test-retest reliability (ICCs = 0.82-0.96) and diagnostic efficacy (AUC = 0.84-0.85). Furthermore, the factor analysis identified the RSS-13 and its three sub-scales (ear-nose-throat, digestive tract, respiratory tract) exhibited good to excellent structural validity (χ2/df = 1.95, P < 0.01; CFI = 0.95, RMSEA = 0.06, SRMR = 0.05). The AUC optimal thresholds for the RSI-10 and RSS-13 in the Chinese population were 13 and 36, respectively. Besides, the inclusion of the new item significantly improved the diagnostic efficiency of the RSI scale (P = 0.04), suggesting that RSI-10 holds promise as a more effective screening tool for LPRD, and global validation is needed to demonstrate the impact of this new symptom on the diagnosis of LPRD.

Diagnostic Value of Fasting and Bedtime Saliva Pepsin Measurements in Laryngopharyngeal Reflux

BACKGROUND

The pepsin test is an emerging non-invasive diagnostic approach for laryngopharyngeal reflux (LPR). The aim of this study was to investigate the diagnostic value of multiple salivary pepsin tests for detecting LPR.

METHODS

Patients with suspected LPR and asymptomatic individuals were consecutively recruited from January 2020 to November 2022. Patients benefited from hypopharyngeal-esophageal impedance-pH monitoring (HEMII-pH) and fasting and bedtime saliva collections to measure oral pepsin. The sensitivity, specificity, and positive (PPV) and negative (NPV) predictive values were calculated considering fasting, bedtime, and the highest values of the pepsin tests at ≥16, ≥36, ≥45, and ≥100 ng/mL cutoffs.

RESULTS

The pepsin test was adequately performed in 147 LPR patients and 32 controls. The pepsin tests were 81.6%, 74.8%, and 61.5% sensitive at cutoffs of ≥16, ≥45, and ≥100 ng/mL, respectively. The PPVs were 93.0%, 94.0%, and 94.8%, respectively. The highest specificity (81.8%) was found for the fasting pepsin test at a cutoff of 100 ng/mL. The highest sensitivity (81.6%) was found by considering the highest measured pepsin test at the ≥16 ng/mL threshold. The measurement of fasting saliva pepsin was associated with the highest sensitivity and specificity value. At ≥16 ng/mL, 27 patients had negative findings, indicating that 18.4% (27/147) of the true positive cases were missed by considering the highest pepsin test. The receiver operating characteristic curve reported that a cutoff of 21.5 was 76.9% sensitive and 62.5% specific, while the PPV and NPV were 91.1% and 38.2%, respectively.

CONCLUSIONS

The consideration of the highest concentration of the fasting and bedtime saliva pepsin collections at a cutoff of 21.5 was associated with the best detection rate and sensitivity of the pepsin tests.

The Relation Between Endoscopic and Subjective Laryngopharyngeal Reflux Signs, Vocal Tract Discomfort, Voice Handicap, and Voice Disorder Type: Same Yet Different?

OBJECTIVES

This study aimed to investigate the relation between subjective voice-related symptoms and endoscopic findings in patients with different etiology of voice disorder and vocally healthy subjects with and without laryngopharyngeal reflux (LPR).

STUDY DESIGN

Retrospective cross-sectional study.

METHODS

The study involved 149 participants (106 female, 43 male) including 125 with various voice disorders (functional, structural, and neurogenic) and 24 vocally healthy individuals. For self-rating the German versions of the Voice Handicap Index (VHI), Vocal Tract Discomfort (VTD) Scale, and Reflux Symptom Index (RSI) were applied, while endoscopic evaluations utilized the Reflux Finding Score (RFS) and Reflux Sign Assessment (RSA). Statistical analyses incorporated ANOVA with Bonferroni posthoc tests to identify group variations. Correlations between VTD Scale, VHI, RSI, RFS, and RSA were evaluated using Pearson's correlation coefficient. To examine test sensitivity and specificity for the VTD Scale and RSA, we performed a receiver operating characteristics analysis. Youden's-Index was applied to determine the cut-off-value with best discriminatory abilities. The diagnosis of LPR was assumed when the criteria of RFS > 7 AND RSI > 13 was met.

RESULTS

Significant differences for all voice diagnosis groups and vocally healthy individuals for RFS and all three self-rating questionnaires were found. Moreover, there was significant correlation between VTD Scale and VHI and RSI as well as RSI and RFS, which was moderate, negative in the group of persons with LPR. However, there was no significant difference for RSA results between the vocally healthy or any diagnosis group.

CONCLUSION

Thus, the RFS may be more suitable to predict reflux and voice-related symptoms. The VTD Scale is a useful instrument in screening voice disorders but also LPR and can therefore be used as a tool for decision-making when transferring to a specialist.

Consensus for voice quality assessment in clinical practice: guidelines of the European Laryngological Society and Union of the European Phoniatricians

INTRODUCTION

To update the European guidelines for the assessment of voice quality (VQ) in clinical practice.

METHODS

Nineteen laryngologists-phoniatricians of the European Laryngological Society (ELS) and the Union of the European Phoniatricians (UEP) participated to a modified Delphi process to propose statements about subjective and objective VQ assessments. Two anonymized voting rounds determined a consensus statement to be acceptable when 80% of experts agreed with a rating of at least 3/4. The statements with ≥ 3/4 score by 60-80% of experts were improved and resubmitted to voting until they were validated or rejected.

RESULTS

Of the 90 initial statements, 51 were validated after two voting rounds. A multidimensional set of minimal VQ evaluations was proposed and included: baseline VQ anamnesis (e.g., allergy, medical and surgical history, medication, addiction, singing practice, job, and posture), videolaryngostroboscopy (mucosal wave symmetry, amplitude, morphology, and movements), patient-reported VQ assessment (30- or 10-voice handicap index), perception (Grade, Roughness, Breathiness, Asthenia, and Strain), aerodynamics (maximum phonation time), acoustics (Mean F0, Jitter, Shimmer, and noise-to-harmonic ratio), and clinical instruments associated with voice comorbidities (reflux symptom score, reflux sign assessment, eating-assessment tool-10, and dysphagia handicap index). For perception, aerodynamics and acoustics, experts provided guidelines for the methods of measurement. Some additional VQ evaluations are proposed for voice professionals or patients with some laryngeal diseases.

CONCLUSION

The ELS-UEP consensus for VQ assessment provides clinical statements for the baseline and pre- to post-treatment evaluations of VQ and to improve collaborative research by adopting common and validated VQ evaluation approach.

Association between oropharyngeal ph-monitoring, pepsin saliva concentration and degree of apnea-hypopnea index of obstructive sleep apnea

OBJECTIVE

To investigate the association between obstructive sleep apnea (OSA) and laryngopharyngeal reflux (LPR) through oropharyngeal pH-monitoring and pepsin saliva measurements.

DESIGN

Prospective uncontrolled study.

METHODS

Patients with sleep disturbances and reflux symptoms underwent polysomnography, 24-h oropharyngeal pH-monitoring and saliva pepsin collections. The prevalence of LPR was investigated in OSA patients according to oropharyngeal pH-monitoring and pepsin measurements. A correlation analysis was performed between pH-monitoring findings, pepsin saliva levels, reflux symptom score-12 (RSS-12), reflux sign assessment (RSA), Apnea-Hypopnea Index (AHI), Epworth Sleepiness Scale, Pichot and arousal findings.

RESULTS

Thirty-seven patients completed the evaluations. LPR was detected in 34/37 (92%) and 29/34 (85%) patients at the oropharyngeal-pH monitoring and pepsin test, respectively. OSA was detected in 30 patients (81%). Among them, LPR was detected in 28/30 (93%) cases. Pharyngeal reflux events mainly occurred nighttime/supine in OSA patients. Both Ryan score and supine reflux time at pH < 6.5 were significantly associated with BMI and the RSA sub- and total scores (p < 0.02). Tongue-base hypertrophy score was positively associated with the number of micro-arousals (p = 0.027); the supine percent of pH < 6.5 (p = 0.030); morning (p = 0.030) and bedtime pepsin saliva measurements (p = 0.037). The bedtime pepsin saliva level was significantly associated with Ryan Score (p = 0.047); AHI (p = 0.017) and the sleep saturation < 90% time (p = 0.040). The saliva level of the morning pepsin was associated with a shortest paradoxical sleep phase (p = 0.013).

CONCLUSION

OSA patients may have high prevalence of pharyngeal reflux events at the oropharyngeal pH-monitoring and high pepsin saliva measurements. Oropharyngeal pH-monitoring should be useful for the correlation between reflux and sleep findings in OSA patients. Future large cohort controlled studies are needed to determine the prevalence of LPR in OSA and healthy individuals.

Variability and accuracy of multiple saliva pepsin measurements in laryngopharyngeal reflux patients

OBJECTIVE

To study the variability and diagnostic value of multiple salivary pepsin measurements in the detection of laryngopharyngeal reflux (LPR).

METHODS

Patients with LPR symptoms were consecutively recruited from December 2019 to Augustus 2022. Twenty-one asymptomatic individuals completed the study. The diagnostic was confirmed with hypopharyngeal-esophageal impedance-pH monitoring (HEMII-pH). Patients collected three saliva samples during the 24-h testing period. Symptoms and findings were studied with reflux symptom score-12 and reflux sign assessment. Sensitivity, specificity, positive (PPV) and negative (NPV) predictive values of pepsin measurements were calculated considering morning, post-lunch and post-dinner samples. The consistency and relationship between HEMII-pH, pepsin measurements, and clinical features were investigated.

RESULTS

Morning, post-lunch and post-dinner saliva pepsin concentrations were measured in 42 patients. Pepsin measurements were 64.9%, 59.5%, and 59.0% sensitive for morning, post-lunch and post-dinner collections at cutoff ≥ 16 ng/mL. Considering the highest concentration of the three pepsin saliva collections, the accuracy, sensitivity, specificity and PPV were 70.5%, 73.0%; 66.7% and 78.9%, respectively. Morning pepsin measurements reported higher consistency, sensitivity, and specificity than post-dinner and post-lunch pepsin measurements.

CONCLUSION

The collection of several saliva pepsin samples improves the detection rate of LPR. In case of high clinical LPR suspicion and negative pepsin test, a HEMII-pH study could provide further diagnostic information.

Reliability and Validity of the Chinese Version of Reflux Symptom Score

OBJECTIVE

To evaluate the reliability, validity and clinical value of the Chinese version of reflux symptom score (RSS) (RSS in Chinese).

METHODS

This was a prospective study that contained 42 healthy volunteers and 135 possible laryngopharyngeal reflux disease (LPRD) patients. Reflux symptom index, reflux finding score, oropharyngeal pH monitoring (Dx-pH monitoring), and RSS of each patient were performed. RSS was performed again after 1 week. Confirmed LPRD patients were treated with proton pump inhibitor (PPI) for 8 weeks. And RSS was performed again after treatment. The reliability and validity of RSS was evaluated.

RESULTS

The Cronbach's α coefficient of the Chinese version of RSS was 0.772, which indicated good internal reliability. The results of test-retest found all P values were less than 0.05, which supported good external reliability. The comparison of the results of RSS with oropharyngeal pH monitoring discovered a diagnostic coincidence rate of 83.70% and a positive predictive value of 84.96%, which showed good criterion validity. After 8 weeks treatment of PPI, RSS decreased significantly (pretreatment 84.79 ± 42.50，post-treatment 20.11 ± 22.82, P < 0.001), indicating good responsiveness to change of RSS. The score of quality of life impact of suspected LPRD patients was obviously higher than that of healthy volunteers (t = 7.153, P < 0.001). All patients and volunteers agreed that RSS in Chinese can evaluate their symptoms well.

CONCLUSION

RSS in Chinese had good internal and external reliability, good criterion validity and good responsiveness to change. The content and method of evaluation of RSS in Chinese was better and more comprehensive. RSS in Chinese could be a new instrument to evaluate LPRD in China.

Laryngopharyngeal Reflux Patient Changes during the COVID-19 Quarantine

Background and Objective: To examine the effects of the lockdown on diet adherence and stress levels in patients with laryngopharyngeal reflux (LPR). Materials and Methods: Patients with a positive LPR diagnosis at the hypopharyngeal-esophageal impedance-pH monitoring were treated from a pre- to lockdown period with a 3-month high-protein, low-fat, alkaline, plant-based diet, with behavioral changes, and an association of pantoprazole (20 MG/d) and alginate (Gaviscon 3/d). The following patient-reported outcomes questionnaire and findings instrument were used: Reflux Symptom Score-12 (RSS-12) and Reflux Sign Assessment (RSA). At the posttreatment time, patients were invited to evaluate the impact of lockdown on diet adherence and stress management with a predefined grid of foods and beverages and the perceived stress scale (PSS), respectively. Results: Thirty-two patients completed the evaluations. RSS-12 and RSA significantly improved from baseline to 3-month posttreatment. Most patients experienced mild-to-severe stress levels at the end of the lockdown. The level of stress substantially increased in 11 patients (34%) due to the lockdown, while it did not change in 11 patients (44%). In 11 cases (34%), patients reported that the adherence to the anti-reflux diet was better than initially presumed thanks to the lockdown period, while 44% (N = 14) reported that the lockdown did not impact the adherence to a diet. PSS and RSS-12 were significantly correlated at the end of the pandemic (rs = 0.681; p < 0.001). The increase in stress level was positively associated with the lack of adherence to diet (rs = 0.367; p = 0.039). Conclusions: During the lockdown, the diet habits of LPR patients were improved in one-third and unchanged in 44% of cases. The stress level was increased in one-third of patients, which was associated with an increase in symptom scores.

The Reflux Symptom Score-12: Cross-cultural Adaptation and Validation for European Portuguese Speakers With Laryngopharyngeal Reflux

OBJECTIVES

To translate and cross-culturally adapt the 12-item reflux symptom score (RSS-12) to European Portuguese (EP) and determine its clinimetric properties for symptomatic individuals with laryngopharyngeal reflux (LPR).

STUDY DESIGN

Multinational cross-sectional cohort study.

METHODS

The English RSS-12 was cross-culturally adapted according to the recommendations of the international guidelines. The validation study included the completion of the RSS-12, reflux symptom index, and voice handicap index by symptomatic and asymptomatic subjects with LPR. The RSS-12 was completed a second time by symptomatic subjects. Nine clinimetric properties were analyzed according to the international guidelines for validation of patient-reported outcome measures.

RESULTS

The EP RSS-12 is equivalent to the English version (content, depth, and scoring). A total of 155 adults (84 with LPR symptoms) aged 21-78 years participated in the validation study. Statistical analyses revealed high internal consistency (Cronbach alpha >0.90), high test-retest reliability (intraclass correlation coefficient > 0.70, P < 0.001), low measurement error (Standard measure error of 5.21 for RSS and 1.59 for quality of life), good content validity (omission data <1% and item-total correlations > 0.652), good construct validity (61.9% of the total item variance with moderate item loadings), strong concurrent validity with reflux symptom index (r_p = 0.772, P < 0.001) and moderate validity with voice handicap index (r_p = 0.531, P < 0.001), and significantly known-groups validity (P < 0.001). The EP RSS-12 showed cross-cultural validity with French and Persian versions and high predictive validity with a cut-off value >8 for a sensitivity of 91.7% and a specificity of 91.5%.

CONCLUSIONS

The EP RSS-12 retained the features of the English version and is a reliable and valid patient-reported outcome measure for EP individuals with LPR in the study.

Translation and Validation of the Arabic Version of the Reflux Symptom Score, Short Version 12 (RSS-12)

BACKGROUND

The Reflux Symptom Score (RSS) is a patient-related outcomes measure (PROM) that was developed to diagnose Laryngopharyngeal reflux (LPR), by assessing the severity and frequency of specific symptoms and their respective impact on quality of life (QoL).

OBJECTIVE

To develop the Arabic version of RSS-12 (Ar-RSS-12), and to assess its validity and reliability.

METHOD

The RSS-12 was translated from French into Arabic using the forward-backward translation method, and the translated version underwent transcultural validation. A case-control study was conducted at the otolaryngology clinics of a referral hospital, during the period November to December 2022. It included 61 patients with LPR-related symptoms and a Reflux Symptom Index (RSI) score >13, and 61 control without LPR-related symptoms and negative RSI scores ≤13. The internal consistency, internal and external validity, and Test-Retest reliability of Ar-RSS-12 were analyzed.

RESULT

Patients had significantly higher scores than controls in all 12 items and total Ar-RSS and QoL impact scores, with high Z score values. Item scores showed variable correlation levels with total Ar-RSS score, with ear-nose-throat items showing the strongest correlation (Spearman's rho 0.592-0.866). The QoL scores were more strongly correlated to the symptoms' severity than frequency. The internal consistency was high, with Cronbach's alpha = 0.878. Regarding external validity, correlations with RSI score showed high Spearman's rho values for total Ar-RSS (0.905) and QoL total score (0.903). No statistically significant difference was observed between Test and Retest results in any of the 12 items' score or the total score and QoL, indicating the reproducibility of the test.

CONCLUSION

The Ar-RSS is a valid and reproducible tool for the screening, assessment, and monitoring of LPR in Arabic speaking patients. The inclusion of symptoms severity and frequency, as well as their individual effects on patient's QoL, support the superior clinical applications of RSS compared to other existing PROMs.

Saliva pepsin measurements in the detection of gastroesophageal reflux disease in laryngopharyngeal reflux patients: a cohort study

OBJECTIVE

To study the diagnostic value of salivary pepsin measurement (Peptest) for detecting gastroesophageal reflux disease (GERD) in laryngopharyngeal reflux (LPR) patients.

METHODS

Patients with reflux symptoms were consecutively recruited from January 2020 to November 2022. Patients benefited from hypopharyngeal-esophageal impedance-pH monitoring (HEMII-pH), fasting and bedtime saliva collections to measure pepsin. Sensitivity, specificity, positive (PPV) and negative (NPV) predictive values were evaluated for GERD and LPR patients considering the highest values of pepsin tests at ≥ 16, ≥ 75, and ≥ 216 ng/mL cutoffs. The relationship between HEMII-pH, endoscopic and clinical findings, and pepsin measurements was studied.

RESULTS

Saliva was collected in 109 LPR patients and 30 individuals with both LPR and GERD. The total number of pharyngeal reflux events was significantly higher in GERD-LPR patients compared with LPR patients (p = 0.008). The mean fasting and bedtime pepsin saliva concentrations were similar between groups. The sensitivity of Peptest in LPR patients was 30.5%, 70.2%, and 84.0% at cutoffs ≥ 16, ≥ 75 and ≥ 216 ng/mL. In GERD-LPR group, Peptest was 80.0%, 70.0%, and 30.0% sensitive. At cutoff 16 ng/mL, Peptest reported PPV of 20.7% and 94.8% in LPR-GERD and LPR groups, respectively. NPV were 73.9% and 8.7% in GERD-LPR and LPR groups, respectively. The consistency analysis between Peptest and HEMII-pH was not significant. Peptest was significantly associated with the number of acid pharyngeal reflux events (r_s = 0.182; p = 0.032).

CONCLUSION

Pepsin saliva measurements appear to be not a reliable diagnostic tool for the detection of GERD in LPR patients. Future studies are needed to determine the place of Peptest in laryngopharyngeal reflux and gastroesophageal reflux diseases.

Voice Hoarseness with Reflux as a Suspected Etiology: Incidence, Evaluation, Treatment, and Symptom Outcomes

PURPOSE

To describe the clinical evaluation course, treatments, and outcomes of patients with a primary complaint of hoarseness due to suspected laryngopharyngeal reflux (LPR).

METHODS

A retrospective chart review was conducted of patients with a primary complaint of hoarseness with acid reflux as the suspected cause at a single institution between October 2011 and March 2020 who underwent clinical evaluation, treatment, and follow-up. Data collected included diagnostic procedures and treatments received, subjective symptom outcomes, and final diagnosis as determined by the treating physician.

RESULTS

A total of 134 patients met the inclusion criteria. Videostroboscopy was the most performed procedure (n = 59, 44%) followed by endoscopy (n = 38, 28%) and pH monitoring (n = 28, 21%). Three patients were removed for statistical analysis of treatment differences and outcomes due to variant treatment plans. Most patients received sole medical management (n = 86, 66%), 7 patients received only voice therapy (5%), and 10 patients underwent surgical management (8%). Several patients received combined medical management and voice therapy (n = 21, 16%). Final diagnoses included gastroesophageal reflux disease (GERD) (25%), followed by multifactorial causes (17%) and dysphonia with unclear etiology (13%). Among all patients, 82 (61%) reported symptom improvement. Twenty-eight patients were diagnosed with LPR or LPR with GERD (21%), and 22 reported symptom improvement (79%). There was a statistically significant relationship between a final diagnosis with a reflux component and symptom improvement (p = .038). There was no statistically significant difference between treatment types and symptom outcomes both within the total patient population (p = .051) and patients diagnosed with a reflux condition (p = .572).

CONCLUSION

LPR remains a difficult diagnosis to establish and represents a minority of patients with voice complaints. Despite varying evaluation and treatment modalities, most patients with LPR improved during their treatment and evaluation period without a clear association with any specific type of treatment. Further studies should explore diagnostic criteria for LPR, the necessary and efficient clinical evaluation to establish a diagnosis, and possible beneficial treatments.

There is a Good Consistency Between Reflux Symptom Score-12 and Reflux Symptom Index in Chinese Population

OBJECTIVE

To investigate the consistency between the Reflux Symptom Score-12 (RSS-12) and Reflux Symptom Index (RSI) in Chinese people.

METHODS

Patients with symptoms of LPR from the outpatient otorhinolaryngology-head and neck surgery clinic were included. All included patients completed the RSS-12 and RSI. The patient with RSS-12>11 or RSI>13 suggested possible LPR. For the patients with RSI >13 or RSS-12>11, they were treated using diet recommendations and were prescribed a twice-daily pantoprazole for 12 weeks. The consistency between the RSS-12 and RSI was compared with the weighted Cohen's kappa statistic.

RESULTS

A total of 258 patients were included. The mean scores for RSS-12 and RSI were 13.21±17.31 and 12.86±6.15, respectively. The positive rate of LPR was 17.44% based on the RSI, and 24.42% based on the RSS-12. The kappa value between the RSS-12 and RSI was 0.736 (P < 0.001). Following 12 weeks of treatment, there was a significant reduction in both RSI and RSS-12. Based on the RSI, 73% of patients had a good treatment response, whereas according to the RSS-12, 85% of patients had a good treatment response.

CONCLUSION

There is a good consistency between RSS-12 and RSI, meaning that the RSS-12 is a feasible LPR initial screening tool. The RSS-12 provides a more comprehensive evaluation of reflux symptoms and treatment effect than RSI in patients with LPR.

Investigation of Reflux Characteristics in Outpatients of Otorhinolaryngology-Head and Neck Surgery by Age and Gender in the Chinese Population

OBJECTIVE

To investigate the characteristics of patients with reflux diseases in the otorhinolaryngology-head and neck surgery clinics through the Reflux Symptom Scale-12 (RSS-12) and the Gastroesophageal Reflux Disease Questionnaire (GERD-Q).

METHODS

All included patients completed the RSS-12 and GERD-Q scales and were considered to have LPR with an RSS-12 score >11 and GERD with a GERD-Q score >7. Data were analyzed according to genders (male and female) and age (18-40, 41-60, and >60 years).

RESULTS

A total of 977 patients were included. the mean RSS-12 and GERD-Q score were 11.32±21.34 and 6.31±1.21, and the positive rate of LPR and GERD were 28.76% and 8.90%, respectively. Males had a higher positive rate of LPR and GERD than females, and there were more males with LPR who also had GERD. Among those with both LPR and GERD, males had significantly higher ear-nose-throat (ENT) symptom scores such as hoarseness and excess throat mucus than females. However, females had significantly higher scores of gastrointestinal (GI) symptoms, mainly indigestion and abdominal pain, and elder patients (>60 years) had higher scores of ENT, GI, respiratory symptoms, as well as the impact of symptoms on quality of life than the young patients (18-40, and 41-60 years).

CONCLUSION

Patients in the otorhinolaryngology-head and neck surgery clinics have different reflux characteristics by gender and age in the Chinese population. Males had more severe ENT-related symptoms of distress, while females had more complaints of GI symptoms. Older patients had higher scores for ENT, GI and respiratory symptoms.

Translation and cultural adaptation of the Short Version of the Reflux Symptom Score: Reflux Symptom Score-12 into Brazilian Portuguese

OBJECTIVE

To describe the process of translation into Brazilian Portuguese and cross-cultural adaptation of the French Reflux Symptom Score-12 questionnaire used for the diagnosis of laryngopharyngeal reflux.

METHODS

This was a cross-cultural translation and adaptation study of a health instrument, with a cross-sectional design. It was carried out in eight stages: translation from French into Brazilian Portuguese, cultural adaptation by a panel of experts, application of the first version (pilot test 1), adaptation by a panel of experts, application of the second version (pilot test 2), back translation, reviewing by a committee in conjunction with the author of the original instrument and, application of the final version. The Brazilian Portuguese versions of the questionnaire were applied to individuals with symptoms and signs of laryngopharyngeal reflux who underwent pHmetry and esophageal manometry at the study site.

RESULTS

In pilot test 1, the first version of the RSS-12 in Brazilian Portuguese was applied to 30 patients. The patients had no difficulty to understand any of the 12 symptom items, but 15 patients (50%) had difficulty interpreting the symptom frequency score. After adapting the format of the frequency score, a version 2 of the RSS-12 in Brazilian Portuguese was applied to another 23 patients, who completed the questionnaire in full without any difficulty. Along with the review committee, the author of the original RSS-12 considered the version 2 to be adequate and did not propose any changes, so it was approved as the final version of the Brazilian Portuguese RSS-12.

CONCLUSION

The Brazilian Portuguese version of the instrument, called Reflux Symptom Score-12 PT-BR, shows good understanding and linguistic, conceptual and content equivalence, in relation to the original Reflux Symptom Score-12.

Readability of Commonly Used Patient-Reported Outcome Measures in Laryngology

OBJECTIVES

Patient-reported outcome measures (PROMs) are used to evaluate patients' symptoms and clinical improvement after an intervention. Advocacy efforts and increased provider awareness regarding health literacy have helped to improve the readability of PROMs. Recent studies in otolaryngology in rhinology, pediatric otolaryngology, and head and neck reported PROM readability scores above the sixth-grade level. However, there is limited data regarding the readability of laryngology PROMs. Thus, this study aims to report the readability levels of PROMs in laryngology by assessing different readability indices and describing the relationship of readability levels to equitable healthcare.

METHODS

This is a bibliometric study that received approval from institutional review board (IRB) review as a nonhuman subject research study. Recent and widely utilized laryngology PROMs were selected from a publicly available literature search by reviewing laryngology systematic reviews, PubMed, and Google Scholar. Laryngology PROMs were selected from voice, dysphagia, airway, and other PROMs including voice questionnaires administered to patients seeking gender affirming voice care from systematic reviews and expert opinion. There were 37 PROMs included in this study. PROMs were analyzed via Gunning Fog, Simple Measure of Gobbledygook (SMOG), FORCAST, and Flesch Reading Ease Score.

RESULTS

All laryngology PROMs had readabilities above the recommended sixth-grade level. The mean and standard deviation (SD) of Gunning Fog was 7.30 (2.59), SMOG was 8.70 (1.51), FORCAST was 10.05 (1.51), and Flesch Reading Ease Score was 8.08 (2.76).

CONCLUSION

Laryngology PROMs are above the recommended middle school reading level. To further promote health equity, readability should be considered when developing future PROMs.

LEVEL OF EVIDENCE

N/A Laryngoscope, 2021.

Laryngopharyngeal Reflux Disease is More Severe in Obese Patients: A Prospective Multicenter Study

OBJECTIVES/HYPOTHESIS

To investigate whether there is an impact of obesity and overweight on the clinical findings and therapeutic responses of patients with laryngopharyngeal reflux (LPR).

STUDY DESIGN

Prospective uncontrolled.

METHODS

Patients with LPR-related symptoms and positive LPR diagnosis at the hypopharyngeal-esophageal multichannel intraluminal impedance pH-monitoring (HEMII-pH) were recruited from December 2017 to December 2020. Patients were treated with a combination of diet, proton pump inhibitors, and alginate for 3 to 6 months. The following outcomes were studied according to the weight of patients: HEMII-pH, gastrointestinal endoscopy features, symptoms, findings, and therapeutic response.

RESULTS

A total of 262 patients completed the study, accounting for 134, 85, and 43 patients with normal weight (body mass index [BMI] <25), overweight (BMI = 25-29.99), and obesity (BMI >30). Obese patients reported significant higher prevalence of gastroesophageal reflux disease (GERD), acid LPR, and a more severe LPR disease regarding the number of pharyngeal reflux events, reflux symptom score (RSS), and reflux sign assessment (RSA). RSS and RSA scores significantly improved from baseline to 3-month posttreatment irrespective of the patient weight group. Symptoms and signs continued to improve from 3 to 6-month posttreatment only in patients with a normal weight.

CONCLUSION

Obesity is associated with a more severe LPR disease and a higher proportion of GERD and acid LPR. Obese LPR patients may require more frequently PPI-therapy regarding the higher prevalence of GERD.

LEVEL OF EVIDENCE

3 Laryngoscope, 2021.

Prevalence and Features of Laryngopharyngeal Reflux in Patients with Primary Burning Mouth Syndrome

OBJECTIVES/HYPOTHESIS

To investigate the prevalence and features of laryngopharyngeal reflux (LPR) in patients with primary burning mouth syndrome (BMS).

STUDY DESIGN

Prospective uncontrolled study.

METHODS

Patients who visited our Departments of Otolaryngology-Head and Neck and Maxillofacial surgery with BMS were prospectively recruited from September 2018 to September 2020. Patients benefited from dental, maxillofacial, otolaryngological examinations, and hypopharyngeal-esophageal impedance pH-monitoring (HEMII-pH). Oral, pharyngeal, and laryngeal findings and symptoms were rated with Reflux Sign Assessment (RSA) and Reflux Symptom Score-12 (RSS-12). Patients were treated with a combination of diet, pantoprazole, and alginate.

RESULTS

From the 81 included patients, 76 reported >1 pharyngeal reflux events (93.8%), accounting for 35 (46.1%), 24 (31.6%), and 17 (22.3%) acid, mixed, and nonacid LPR, respectively. Thirty-two patients had both LPR and gastroesophageal reflux disease (GERD). Thirty-eight patients benefited from pepsin saliva measurement, which was positive in 86.8% of cases. The mean scores of mouth/tongue burning, RSS-12, and RSA significantly improved from pre- to post-treatment (P < .004). At 3-month post-treatment, 62.5% of patients reported an improvement of mouth/tongue burning score. Patients with both GERD and LPR reported higher baseline RSS-12 and RSA scores.

CONCLUSION

Acid, weakly acid, and nonacid LPR may be involved in the development of BMS. The use of an appropriate treatment considering the reflux features is associated with an improvement of symptoms and findings.

LEVEL OF EVIDENCE

4 Laryngoscope, 2021.

Laryngopharyngeal Reflux: A State-of-the-Art Algorithm Management for Primary Care Physicians

Laryngopharyngeal reflux (LPR) is a common disease in the general population with acute or chronic symptoms. LPR is often misdiagnosed in primary care because of the lack of typical gastroesophageal reflux disease (GERD) symptoms and findings on endoscopy. Depending on the physician's specialty and experience, LPR may be over- or under-diagnosed. Management of LPR is potentially entirely feasible in primary care as long as General Practitioners (GPs) are aware of certain "red flags" that will prompt referral to a Gastroenterologist or an Otolaryngologist. The use of patient-reported outcome questionnaires and the consideration of some easy ways to diagnose LPR without special instrumentation oropharyngeal findings may help the GP to diagnose and often manage LPR. In this review, we provide a practical algorithm for LPR management for GPs and other specialists that cannot perform fiberoptic examination. In this algorithm, physicians have to exclude some confounding conditions such as allergy or other causes of pharyngolaryngitis and "red flags". They may prescribe an empirical treatment based on diet and behavioral changes with or without medication, depending on the symptom severity. Proton pump inhibitors and alginates remain a popular choice in order to protect the upper aerodigestive tract mucosa from acid, weakly acid and alkaline pharyngeal reflux events.