A Comparison of Rating Scales Used in the Diagnosis of Extraesophageal Reflux
Introduction
Extraesophageal reflux (EER), also referred to as laryngopharyngeal reflux, pharyngeal reflux, or supraesophageal reflux, is the backflow of stomach contents into the larynx and pharynx. EER has been implicated in complaints, such as hoarseness, chronic cough, or throat clearing, a “lump in the throat” sensation, and difficulty swallowing,1 as well as laryngoscopic findings of contact ulcers and granulomas, laryngeal carcinoma, and subglottic stenosis.2 However, its diagnosis can be elusive, because symptoms are nonspecific and the physical findings are not always associated with the severity of those symptoms.2, 3, 4 A visual examination of the throat may not provide conclusive physical findings to explain the symptoms.2 To date, 24-hour dual pH probe monitoring remains the “gold standard” for the diagnosis of EER, as declared by the American Academy of Otolaryngology,5 but may not be in full agreement with other clinical tools. A diagnosis of EER may not be valid unless a reliable means to diagnosis it exists.
Several instruments have been designed to aid in the diagnosis of EER. The reflux symptom index (RSI) is a self-administered nine-item outcome scale that assesses symptoms of EER in patients and has been used to accurately document symptom improvement of patients with EER. Based on a scoring range of 0–45, an RSI greater than 13 is considered indicative of EER.6 The reflux finding score (RFS) is an eight-item clinical severity scale applied by clinicians to assess physical findings of EER during fiberoptic laryngoscopy. Ranging in scores from 0 (no abnormal findings) to 26 (greatest possible score), the eight items encompass the most common laryngeal findings, such as vocal fold edema, postcommissure hypertrophy, and erythema. RFS scores greater than 7 are indicative of EER.7 However, several studies have demonstrated poor inter- and intrarater agreement with the RFS, which is a confounding factor in the accurate diagnosis of EER.8, 9
Data obtained from a pH probe study include the frequency, duration, and acidity levels of acid reflux events. The reflux area index (RAI) is a composite score of this information that has been “time corrected” for the total study length and is another proposed parameter to evaluate EER. RAI cutpoint scores were derived from studies10, 11 involving normal participants, in which mathematical calculations of the area under each pH level were computed. As the RAI4 represents more severe proximal reflux, the resulting cutpoint of 6.3 is lower as compared with 72.6 for RAI5. Although the parameter of pH 4 is widely used, some authors note that peptic injury to laryngeal and pharyngeal epithelium can occur at pH levels of 512 or even as high as 7.11 A recent gastroenterology consensus report stated that the sensitivity of pH measurements could be improved by increasing the pH threshold from 4 to 5, almost doubling the number of reflux events detected.13 Furthermore, it has been suggested that these thresholds may explain the discordance between EER events, otolaryngologic symptoms, acid exposure levels, and laryngeal findings.14 This change may be reflected in traditional gastroesophageal reflux disease (GERD) studies, but its effects are largely unknown in the EER population.
The present investigation is designed to evaluate three areas: the level of agreement between the RSI, RFS, and pH probe monitoring results; inter- and intrarater reliability of the RFS; and the use of pH 5 as a new criterion for EER diagnosis.
Section snippets
Participant selection
The protocol for this study was approved by the Institutional Review Board of the University of Cincinnati, and informed consent was obtained from all participants. Participants were enrolled from a private Midwest otolaryngology practice. Participants were referred for pH evaluation by their otolaryngologist (ORL) based on symptoms suggestive of EER (hoarseness, chronic cough or throat clearing, a “lump in the throat” sensation, and difficulty swallowing) and, subsequently, were eligible for
Results
Means and SDs of the three instruments (RSI, RFS, and RAI) by group are summarized in Table 1, Table 2. Abnormal RSI scores were seen in 86% of the experimental participants; control group participants were selected based on normal RSI scores. A final RFS was calculated for each case (n = 36) by taking the arithmetic average of the three raters' scores. Half (50%) of the control group participants and 92% of experimental group participants received an abnormal RFS. Abnormal RAI4 results were seen
Discussion
Findings from the current study indicate discordance among the different diagnostic tools frequently used in clinical practice to diagnose EER. Moreover, with the exception of the RSI, none of the clinical tools successfully differentiated control and experimental participants. Although some amount of varied agreement is expected between diagnostic tools that range from purely subjective (RSI), to the clinical interpretation of physical findings (RFS), to the more objective 24-hour pH probe
Conclusion
The results of this study highlight agreement issues among the current available diagnostic tools for EER. Collectively, these tools failed to differentiate patient from control groups. Despite a broader pH-testing criterion, pH 5, physical findings and pH-testing results failed to agree with each other. Raters were not in agreement regarding the presence and severity of physical findings of EER. Results support the need for greater consensus among the clinical tools used in the diagnosis of
Acknowledgments
The authors would like to thank the physicians, especially Mohan Rao, MD, at Ear, Nose, & Throat Associates, P.C., Fort Wayne, IN, for the use of all equipment, their referral of participants to the above study, and their support of this research.
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2023, Brazilian Journal of OtorhinolaryngologyCitation Excerpt :Positive scores, especially when combined, have warranted clinical treatment of LPR in the lack of objective diagnostic tests.1–3,12,17 However, over the years it has been observed that these instruments are widely non-specific and should be used with caution.1,12,17 The objective of the current study was to try to establish if the Reflux Symptom Index and the Reflux finding score can help establish the differential diagnosis in patients with distinct causes of chronic laryngopharyngitis.
Linguistic Adaptation, Reliability, and Validation of the Turkish Version of the Reflux Symptom Index
2022, Journal of VoiceCitation Excerpt :Although it is prevalent and related to a wide variety of otolaryngology conditions, LPR remains controversial. LPR diagnosis can be elusive because symptoms and physical signs are often non-specific and diagnostic tools or criteria of diagnosis remain to be established.6,7 Two methods are commonly used to diagnose LPR in clinical practice, and each method has positive and negative aspects.
Review of management of laryngopharyngeal reflux disease
2021, Annales Francaises d'Oto-Rhino-Laryngologie et de Pathologie Cervico-FacialeReview of management of laryngopharyngeal reflux disease
2021, European Annals of Otorhinolaryngology, Head and Neck DiseasesCitation Excerpt :Moreover, its analogic assessment of reflux signs makes severity assessment highly subjective in some cases [17]. Various studies reported poor intra-observer reliability [46–48],48 vitiating comparison across studies [1,17]. These weaknesses of the RSI and RFS cast doubt on their content and presentation, and new more complete clinical instruments were developed, taking account of symptoms severity and frequency and precisely defining degrees of severity of reflux signs [1,45].
Validation of the Brazilian Portuguese Version of the Reflux Finding Score
2021, Journal of VoiceCitation Excerpt :Clinical diagnosis, based on suggestive symptoms and laryngoscopic signs of inflammation, continues to be widely used in practice, and should be acceptable, as long as diligent differential diagnosis is sought.2,11,12 In order to minimize subjectivity, a number of scoring systems have been proposed for both symptoms and signs associated to LPR.6,13–25 The most widely accepted are the Reflux Symptom Index (RSI)14 and the Reflux Finding Score (RFS).13
The development of new clinical instruments in laryngopharyngeal reflux disease: The international project of young otolaryngologists of the International Federation of Oto-rhino-laryngological Societies
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This research work received no financial or material support.