Outpatient Clinical Markers for Laryngopharyngeal Reflux Disease: A Correlational Study

Laryngopharyngeal reflux disease (LPRD) is the result of retrograde flow of gastric contents to the laryngopharynx which comes in contact with tissues of the upper aerodigestive tract. Due to ill defined criteria for diagnosis & followup, LPRD patients are underdiagnosed & undertreated. Reflux Symptom Index (RSI) and the Reflux Finding Score (RFS) are two clinical methods which can be utilised especially in the outpatient setup. This study was done with the aim to assess various laryngoscopic findings in patients with LPRD diagnosed symptomatically and examine the correlation between the RSI & RFS by comparing these two indices. This prospective analytical study was conducted at a tertiary care centre in Bangalore in the Department of ENT for a period of 24 months between Dec 2020 to Dec 2022. The study included patients aged 18 to 60 years diagnosed with LPRD based on symptoms as per RSI score (> 13). RSI & RFS were assessed on diagnosis and patients were followed up for 1, 3 & 6 months for assessment. Total 96 patients were enrolled, with mean age of be 42.49 ± 11.33 years. Prevalence was found to be more in females (61.5%). The most common symptom according to RSI was frequent throat clearing & globus sensation (sensation of something sticking in throat) and most common finding according to RFS was erythema/hyperemia. The mean score of RSI and RFI was found to reduce with treatment at different intervals in follow-up visits. There was a significant strength of association between the RSI and RFS at baseline, 1st month, 3rd month and 6th month of follow-up (r = 0.568, r = 0.684, r = 0.774, r = 0.736 respectively) (p < 0.001).The RFS and RSI showed statistically significant strong relationships between total scores and sign and symptom characteristics. On follow-up, there was a significant reduction in the RSI which was also correlated with a reduction in RFS.

To Determine the Prevalence of Laryngopharyngeal Reflux in Patients of Various Throat Disorders and to Evaluate the Efficacy of Anti-reflux Therapy

To study the prevalence of Laryngopharyngeal reflux in individuals having throat complaints by applying the Reflux Symptom Index and Reflux finding score as a prognostic tool after anti reflux therapy. Materials and Methods: A Cross-sectional study of 75 patients of age 18 years and above with clinical diagnosis of Laryngopharyngeal reflux was conducted in ENT. Cases were examined with detailed history and thorough examination with indirect laryngoscopy and Hopkins 70 degree endoscope. Symptoms and findings of patients were assessed by Belafsky Reflux Symptom Index and Reflux Finding Score. Patients presenting Belafsky Reflux Symptom Index > 13 and also Reflux Finding Score > 7 were classified as having Laryngopharyngeal reflux. After 6 weeks of treatment, patients were reassessed and Reflux Symptom Index and Reflux finding score were calculated. Results: The mean age of the study subjects was 37.12 ± 12.39 years. Most common symptom reported based on RSI questionnaire was excessive throat mucus (81.33%) followed by clearing of throat (75%) and coughing on lying down and heartburn. Based on the Laryngoscopy, about 57.33% had thick endolarygeal mucus, 56% had diffuse erythema, 45.33% had granulations and 29.33% had subglottic edema. Based on the reflux symptom scores, we found 53.33% and 80% of patients based on reflux findings score to have Laryngopharyngeal Reflux. The mean Reflux Symptom Index scores were 16.25 ± 5.53 and 10.73 ± 4.40 and also the mean Reflux Finding scores were 13.81 ± 2.42 and 6.61 ± 2.16 respectively before and after the treatment which was statistically significant.

Development of a New Self-Assessment Tool for Laryngopharyngeal Reflux Screening in Singers (SVHI-12-LPR)

INTRODUCTION

The present study aimed to develop a new tool for the evaluation of singers with self-reported symptoms suggestive of laryngopharyngeal reflux (LPR) (the SVHI-12-LPR), by correlating RSI with SVHI in a population sample of 163 subjects (both professional and amateur singers), evaluated also by videolaryngostroboscopy. This study was a cross-sectional, double-observational study.

METHODS

RSI and SVHI were administered to 159 singers (amateurs, singing students, and professional singers). All subjects underwent videolaryngostroboscopy to objectively identify four subgroups: normal subjects (41.5%), subjects with organic lesions occupying the glottic space (17.6%), subjects with functional dysphonia (18.2%), and subjects presenting solely signs suggestive of LPR (22.6%). Using the validated RSI threshold, 33.9% of participants presented an RSI total score >13, suggestive of LPR.

RESULTS

Subjects with a suspected diagnosis of LPR at videolaryngostroboscopy presented a mean RSI significantly higher than other subgroups (p < 0.001). Moreover, the SVHI-36 score did not statistically differ between pathological subgroups. A significant positive relationship was observed between RSI and SVHI total score (Spearman's rank correlation coefficient [ρ] = 0.474, p < 0.001). 12 SVHI items (items 1, 2, 4, 5, 6, 7, 12, 20, 24, 25, 26, 30) showed a significant association with RSI pathology classification. Statistical analysis demonstrated for the 12 selected items (SVHI-12-LPR) acceptable specificity (0.691) and sensibility (0.833) for the suspected diagnosis of LPR with a cut-off of 15.

CONCLUSIONS

From the SVHI-36, 12 items were extracted that correlated with the specific impact that LPR has on the singer's voice (SVHI-12-LPR), as evaluated by RSI and videolaryngostroboscopy. Such questionnaire represents a new tool that could be applied to singers with symptoms suggestive of LPR to select which patients would benefit from a further phoniatric and videolaryngostroboscopic evaluation.

Laryngopharyngeal symptoms and oesophageal disorder: The role of heterotopic gastric mucosa in upper oesophagus

BACKGROUND

Heterotopic gastric mucosa in the upper oesophagus (HGMUE) was considered as geneogenous manifestation. However, its clinical characteristics may be beyond our knowledge if we focus on its extra-oesophageal presentation. So the aim of this study was to investigate the relationship between HGMUE and laryngopharyngeal symptoms.

METHOD

Eight hundred and eleven patients who had gastric endoscopy examination were enrolled in this study and the cervical oesophagus was examined for the patch during withdrawal of the endoscope. Questionnaire for gastroesophageal reflux disease (GERD-Q) and Reflux Symptom Index (RSI) were completed by all the patients. Pathology feature and therapeutic effect of HGMUE patients were evaluated.

RESULT

About 34.53% of the patients undergoing the gastroduodenoscopy had laryngopharyngeal (LP) symptoms. The relevance rate of HGMUE in LP(+) group (10.69%) was higher than that in LP(-) group (2%). The LP symptoms were related to the histological type and expression of H+-K+-ATPase in the histological sample of HGMUE patients. The positive rate of H+-K+-ATPase was 100% in LP(+) group, and that in LP(-) group was 28.6%. PPI therapy was effective for improving the LP symptoms in HGMUE patients. The RSI score in LP(+) patients decreased from 8.12 ± 1.46 at baseline to 4 ± 0.74 at the end of 8 weeks after treatment of PPI.

CONCLUSION

HGMUE was an important cause of LP symptoms in patients, especially in those who had no evidence of GERD. The mechanism of HGMUE-induced LP symptoms was due to its location and the function of acid secretion according to the endoscopic finding and histologic characteristics.

Comparison of Reflux Symptom Index (RSI) with Reflux Finding Score (RFS) and Its Effectiveness in Diagnosis of Laryngopharyngeal Reflux Disease (LPRD)

LPRD is a common condition in patients attending ENT OPDs. Although esophageal manometry and 24 h pH monitoring is considered the gold standard for diagnosis, it is an expensive and time consuming investigation. Newer clinical scales have been developed for diagnosing LPR such as RSI, RFS, Carlsson-Dent, ReQuest, GerdQ, etc. The objective of the study is to compare RSI with RFS and to establish its effectiveness in diagnosing LPRD among OPD patients. It's a descriptive cross-sectional study. ENT outpatients with features of LPRD were asked to fill RSI proforma (score ≥ 13 abnormal), after which they were subjected to indirect laryngoscopy to obtain the RFS (score ≥ 7 diagnostic of LPRD). RSI was compared with RFS. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and accuracy of RSI were noted. Of 165 patients, 53.9% were females. Mean RSI scores in males and females were 11.9 and 11.5 and mean RFS scores were 6.4 and 5.7 respectively. RSI had 79.1% sensitivity and 83.7% specificity in diagnosing LPRD with PPV 76.8%, NPV 85.4% and accuracy 81.8% (Chi square value 64.5, p ≤ 0.01). There was substantial agreement between RSI and RFS (Cohen's kappa: 0.625, p ≤ 0.0001). RSI is a simple tool to diagnose LPRD which doesn't mandate invasive procedures such as endoscopy or esophageal manometry. Hence it can be used effectively to diagnose LPRD in ENT outpatients and start the treatment at the earliest.

Assessment and Diagnostic Accuracy Evaluation of the Reflux Symptom Index (RSI) Scale: Psychometric Properties using Optimal Scaling Techniques

OBJECTIVES

To investigate the psychometric properties of the reflux symptom index (RSI) as short screening approach for the diagnostic of laryngopharyngeal reflux (LPR) in patients with confirmed diagnosed regarding the 24-hour multichannel intraluminal impedance-pH monitoring (MII-pH).

METHODS

From January 2017 to December 2018, 56 patients with LPR symptoms and 71 healthy individuals (control group) were prospectively enrolled. The LPR diagnosis was confirmed through MII-pH results. All subjects (n = 127) fulfilled RSI and the Reflux Finding Score (RFS) was performed through flexible fiberoptic endoscopy. The sensitivity and the specificity of RSI was assessed by ROC (Receiver Operating Characteristic) analysis.

RESULTS

A total of 15 LPR patients (26.8%) of the clinical group met MII-pH diagnostic criteria. Among subjects classified as positive for MII- pH diagnoses, RSI and RFS mean scores were respectively 20 (SD ± 10.5) and 7.1 (SD ± 2.5), values not significantly different compared to the negative MII-pH group. The metric analysis of the items led to the realization of a binary recoding of the score. Both versions had similar psychometric properties, α was 0.840 for RSI original version and 0.836 for RSI binary version. High and comparable area under curve (AUC) values indicate a good ability of both scales to discriminate between individuals with and without LPR pathology diagnosis. Based on balanced sensitivity and specificity, the optimal cut-off scores for LPR pathology were ≥ 5 for RSI binary version and ≥ 15 for RSI original version. Both version overestimated LPR prevalence. The original version had more sensitivity and the RSI Binary version had more specificity.

CONCLUSIONS

It would be necessary to think about modifying the original RSI in order to improve its sensitivity and specificity (RSI binary version, adding or changing some items), or to introduce new scores in order to better frame the probably affected of LPR patient.

The application of 24-hour pharyngeal pH-monitoring and Reflux Finding Score and Reflux Symptom Index questionnaires in the diagnostics of laryngopharyngeal reflux

Introduction

Twenty-four-hour oesophageal pH-monitoring is a gold standard in the diagnostics of gastroesophageal reflux (GERD); however, this examination does not always perform well in patients in whom laryngeal symptoms of reflux are observed.

Aim

To test the effectiveness of Reflux Symptom Index (RSI) and Reflux Finding Score (RFS) in confirming the occurrence of laryngopharyngeal reflux (LPR).

Material and methods

Eighty-two patients with symptoms suggesting the occurrence of LPR were studied. The mean age of the participants amounted to 48.79 ±12.02. The patients were asked to fill in the RSI. The pharynx was assessed using videolaryngostroboscopy and then the RSF was filled in. Next, 24-hour pharyngeal pH-monitoring was performed with the use of a Dx pH – Restech System device. All the statistical analyses were conducted with the use of the R computational environment.

Results

The authors attempted to determine the reference values of the RSI and RFS questionnaires for the Polish population. For a very general approximation, normality of the distributions of the results in the RSI and RFS questionnaire can be done and an approximation mean + 2 SD can be used as a reference value. Then, for RSI the recommended cut-off limit of LPR would fluctuate, depending on the study, between 8 and 17, whereas for RFS it would be between 8 and 14.

Conclusions

When used alone, RSI/RFS questionnaires do not allow an unambiguous diagnosis of LPR assessed by 24-hour pharyngeal pH-monitoring.

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

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.

Can the Reflux Finding Score and Reflux Symptom Index Be Used to Evaluate the Severity of Esophagitis in Children?

OBJECTIVES

Laryngopharyngeal reflux (LPR), a growing issue in ear, nose, and throat (ENT) and pediatric medicine, is the backflow of stomach contents into the laryngopharynx. Patients present with frequent upper and/or lower respiratory tract infections and coughs, associated with acid- and pepsin-mediated injury to the mucosae of the larynx and pharynx. LPR is associated with rhinosinusitis, laryngitis, pneumonia, and asthma. Children with LPR often fail to exhibit classic gastroesophageal reflux disease symptoms, or such symptoms may be intermittent. Only a few studies have sought correlations among symptoms, endoscopic findings, and the results of frequently used diagnostic tests.

THE AIM OF OUR STUDY

We sought associations among the Reflux Finding Score (RFS), Reflux Symptom Index (RSI), and the pathological extent of esophagitis.

METHODS

We reviewed data on children who underwent upper gastrointestinal tract endoscopy and showed LPR symptoms, as reported by the ENT department. The RSI was scored by pediatric gastroenterologists and the RFS by ENT doctors, via laryngoscopic examination. The pathological esophageal data were evaluated retrospectively.

RESULTS

We treated 52 patients (29 boys) with a mean age of 11.4 ± 4.5 years. On pathological evaluation, one patient exhibited normal esophageal findings, while 28 showed mild esophagitis, 16 esophagitis, and 8 severe esophagitis. Thirteen patients showed esophageal pseudopolypoid lesions secondary to gastroesophageal reflux disease on endoscopic examination, but were human papilloma virus-negative. There was no correlation among the RFS, RSI score, and age, but there was a significant correlation between the pathological data and the RFS (P = 0.010; r = 0.461).

CONCLUSIONS

The incidence of LPR/esophagitis in children may differ from that in adults. Therefore, ENT specialists should determine esophagitis status in children and, if necessary, consult pediatric gastroenterologists.

TOPPITS: Trial Of Proton Pump Inhibitors in Throat Symptoms. Study protocol for a randomised controlled trial

BACKGROUND

Persistent throat symptoms and Extra Oesophageal Reflux (EOR) are among the commonest reasons for attendance at a secondary care throat or voice clinic. There is a growing trend to treat throat symptom patients with proton pump inhibitors (PPIs) to suppress stomach acid, but most controlled studies fail to demonstrate a significant benefit of PPI over placebo. In addition, patient views on PPI use vary widely.

METHODS/DESIGN

A UK multi-centre, randomised, controlled trial for adults with persistent throat symptoms to compare the effectiveness of treatment with the proton pump inhibitor (PPI) lansoprazole versus placebo. The trial includes a six-month internal pilot, during which three sites will recruit 30 participants in total, to assess the practicality of the trial and assess the study procedures and willingness of the patient population to participate. If the pilot is successful, three additional sites will be opened to recruitment, and a further 302 participants recruited across the six main trial sites. Further trial sites may be opened, as necessary. The main trial will continue for a further 18 months. Participants will be followed up for 12 months from randomisation, throughout which both primary and secondary outcome data will be collected. The primary outcome is change in Reflux Symptom Index (RSI) score, the 'area standard' for this type of assessment, after 16 weeks (four months) of treatment. Secondary outcomes are RSI changes at 12 months after randomisation, Quality of Life assessment at four and 12 months, laryngeal mucosal changes, assessments of compliance and side effects, and patient-reported satisfaction.

DISCUSSION

TOPPITS is designed to evaluate the relative effectiveness of treatment with a proton pump inhibitor versus placebo in patients with persistent throat symptoms. This will provide valuable information to clinicians and GPs regarding the treatment and management of care for these patients, on changes in symptoms, and in Quality of Life, over time.

TRIAL REGISTRATION

ISRCTN38578686 . Registered 17 April 2014.

High Prevalence of Laryngopharyngeal Reflux Disease in Patients With Lumbar Kyphosis

OBJECTIVE

To evaluate the relationship between laryngopharyngeal reflux disease and presence of lumbar kyphosis.

STUDY DESIGN

A cross-sectional study.

METHODS

We included 20 patients with lumbar kyphosis and 31 control subjects. A diagnosis of laryngopharyngeal reflux disease and gastroesophageal reflux disease was made if the Reflux Symptom Index score was ≥13 and if the Frequency Scale for the Symptoms of Gastroesophageal Reflux Disease was ≥8, respectively. We compared the prevalence of the two reflux diseases, frequent reflux symptoms, and demographic factors between the two groups.

RESULTS

There was no significant difference in demographic factors between the two groups. Five (25%) of 20 patients with lumbar kyphosis had a Reflux Symptom Index ≥13 compared with one (3.2%) of 31 controls. Seven (35.0%) of 20 patients had a Frequency Scale for the Symptoms of Gastroesophageal Reflux Disease ≥8 compared with three (9.7%) of 31 controls. A comparison of the prevalence of laryngopharyngeal reflux disease and gastroesophageal reflux disease showed a significant difference between patients with kyphosis and controls (P value = 0.029 and 0.036, respectively). In Reflux Symptom Index, heartburn, hoarseness, and a swallowing problem were significantly frequent symptoms in the kyphosis group compared with the control group.

CONCLUSIONS

The prevalence of laryngopharyngeal reflux disease and gastroesophageal reflux disease was significantly higher in patients with lumbar kyphosis than in controls. Therefore, otolaryngologists and orthopedic surgeons should be aware that patients with lumbar kyphosis are likely to have gastroesophageal reflux disease and also laryngopharyngeal reflux disease.

Effects of Proton Pump Inhibitor Therapy for Laryngopharyngeal Reflux on Posttreatment Symptoms and Hypopharyngeal pH

OBJECTIVE

To determine the effect of twice-daily proton pump inhibitor (PPI) treatment on the relationship between laryngopharyngeal pH environment and symptoms in patients with laryngopharyngeal reflux (LPR).

STUDY DESIGN AND SETTING

Retrospective analysis of records from consecutive patients seen at a single clinical site between 2009 and 2012.

SUBJECTS AND METHODS

Forty-three records of patients diagnosed with LPR who underwent pre- and posttreatment pH studies were included. Prior to treatment, all had a Reflux Symptom Index (RSI) > 13 and an abnormal pH study. Patients were treated for ≥ 4 weeks with twice-daily PPIs. Following treatment, patients completed a second RSI and pH study.

RESULTS

Most patients (67.4%) had symptom normalization; however, most patients (60.5%) did not have pH normalization. For all patients whose symptoms did not normalize, pH scores also did not normalize; 32.6% of patients showed no subjective or objective treatment response. For individuals whose symptoms normalized but whose pH scores did not normalize, there was a significant decrease in upright pH score. For the entire group, pretreatment symptom and upright pH scores were strongly positively correlated. Improvements in symptom and upright pH scores following treatment were moderately positively correlated.

CONCLUSION

Laryngopharyngeal pH failed to normalize for most individuals after PPI treatment; only pH improvement was necessary for symptom normalization. Many patients had no treatment response. Laryngopharyngeal reflux patients may make up a heterogeneous group, and PPI responsivity may help explain conflicting results from previous studies. Posttreatment pH monitoring is recommended in studies investigating the efficacy of PPI therapy for LPR.