Laryngopharyngeal Reflux Scoring Systems

Laryngopharyngeal reflux (LPR) can be defined as chronic irritation of larynx caused by the abnormal backflow of gastric contents into the upper airway, mostly due to upper esophageal sphincter dysfunction.

Studies have found that up to 50% of laryngeal complaints that present in the otolaryngeal clinics are associated with LPR.

LPR is suspected in cases of hoarseness (voice change), dysphagia (swallowing difficulty), chronic irritative cough, globus (“lump in the throat sensation”), excessive mucus, throat pain, chronic throat clearing, and laryngospasm (choking). Hoarseness is generally a fluctuating symptom that occurs in the morning and improves during the day.

LPR has also been shown to be associated with subglottic stenosis, laryngospasm, obstructive sleep apnea, bronchiectasis, and rhinitis or chronic rhinosinusitis.

24-hour ambulatory dual-probe pH monitoring is currently considered as the gold standard for the objective diagnosis of laryngopharyngeal reflux. However, it is a time-consuming, relatively invasive, and expensive technique.

Newer diagnostic techniques like triple-probe pH monitoring, combined pH and impedance measurement, and pepsin immunoassay detection are currently inappropriate for routine clinical practice.

Hence in common clinical practice, diagnosis of LPR is based on two laryngopharyngeal reflux scoring systems; the clinical assessment of the patients with voice change and on recognition of associated reflux symptoms (Reflux Symptom Index) and findings through an endoscopic examination of the larynx (Reflux Finding Score).

Various studies have shown that these two laryngopharyngeal reflux scoring systems are easy to apply in routine clinics and have high reproducibility, validity, and accuracy in diagnosing LPR.

Treatment options available to LPR patients include diet and behavior modification, antacids, H2-receptor antagonists, proton-pump inhibitors, and fundoplication surgery. Treatment outcomes in patients can also be accurately followed up with these laryngopharyngeal reflux scoring systems.

Reflux Symptom Index Score (RSI)

Reflux symptom index (RSI) is a nine-item self-administered questionnaire developed by Belafsky et al for the assessment of symptoms in patients with laryngopharyngeal reflux disease.

The questionnaire is a simple one that can be completed in less than 1 minute time. The scale for each individual item ranges from 0 (no problem) to 5 (severe problem), with a maximum score of 45. An RSI score > 13 is defined as abnormal and indicates LPR.

The authors found that the questionnaire shows high reproducibility and validity because of the accuracy in documenting symptom improvement of patients with LPR.

Reflux Symptom Index (RSI)

How did the problems listed below affect you since the last month?
Please circle the appropriate answer
0 = no problem
5 = severe problem
1. Hoarseness or voice problems 0 1 2 3 4 5
2. Throat clearing 0 1 2 3 4 5
3. Excess mucus or postnasal drip (descends behind the nose to the throat) 0 1 2 3 4 5
4. Difficulty in swallowing solids, fluids or tablets 0 1 2 3 4 5
5. Coughing after eating or lying down 0 1 2 3 4 5
6. Breathing difficulties or choking episodes 0 1 2 3 4 5
7. Annoying cough 0 1 2 3 4 5
8. The sensation of a lump or foreign body in the throat 0 1 2 3 4 5
9. Burning, heartburn, chest pain, indigestion, or stomach acid coming up (reflux) 0 1 2 3 4 5

Reflux Finding Score

The laryngoscopic findings used for the diagnosis of laryngopharyngeal reflux are nonspecific signs of laryngeal irritation and inflammation. These findings include, but not limited to, edema and erythema of larynx particularly in the posterior region, granulomas, contact ulcers, and pseudosulcus (infraglottic edema), etc.

But these findings are also seen in healthy subjects, and the type of endoscope can influence the color of erythema. In addition, because the exam depends on the examiner, variations may exist that make the precise diagnosis of LPR highly subjective.

To identify the most specific laryngoscopic signs of LPR, Belafsky et al developed the Reflux Finding Score (RFS) based on the findings of fiberoptic laryngoscopy.

The reflux finding score is an 8-item clinical severity scale used to interpret the most common laryngoscopic findings related to LPR, including subglottic edema (pseudosulcus); ventricular obliteration; erythema/hyperemia; diffuse laryngeal edema; vocal fold edema; posterior commissure hypertrophy; granuloma; and excessive, thick endolaryngeal mucus. The scale ranges from 0 (no abnormal findings) to a maximum of 26 (worst score possible).

An RFS greater than 7 indicates that the patient has LPR with 95% certainty.

Reflux Finding Index

Subglottic edema (pseudosulcus) 0 = absent
2 = present
Ventricular obliteration 0 = absent
2= partial
4 = complete
Erythema/hyperemia 0 = absent
2 = only in the arytenoid
4 = diffuse
Vocal fold edema 0 = absent
1 = mild
2 = moderate
3 = severe
4 = polypoid
Diffuse laryngeal edema 0 = absent
1 = mild
2 = moderate
3 = severe
4 = obstruction
Posterior commissure hypertrophy 0 = absent
1 = mild
2 = moderate
3 = severe
4 = obstruction
Granuloma/granulation tissue 0 = absent
2 = present
Thick endolaryngeal mucus 0 = absent
2 = present

Various studies have found that the Reflux finding score is a simple scale that could easily be administered with high intra-rater and inter-rater reliability for the evaluation of LPR in patients with voice-related complaints. RSI and total RFS demonstrate a highly significant positive statistical correlation.

Comparison between Reflux Symptom Index and Reflux Finding Score

In 2016, Nunes et al did a comparison between these two laryngopharyngeal reflux scoring systems; RSI and RFS among 126 patients. In most patients, the RSI and RFS were positive. Only seven patients out of 126 had a positive score on RSI with a negative score on RFS. They concluded that RSI and RFS can easily be included in ENT routine as objective parameters, with low cost and good practicality.


  1. Belafsky PC, Postma GN, Koufman JA. Validity and reliability of the reflux symptom index (RSI). J Voice 2002; 16: 274-7.
  2. Belafsky PC, Postma GN, Koufman JA. Validity and reliability of the reflux finding score (RFS). Laryngoscope 2001; 111: 1313-7.
  3. Karakaya NE, Akbulut S, Altıntaş H, Demir MG, Demir N, Berk D. The Reflux Finding Score: Reliability and Correlation to the Reflux Symptom Index. Journal of Academic Research in Medicine. 2015 Aug 1;5(2).
  4. Mesallam TA, Stemple JC, Sobeih TM, Elluru RG. Reflux symptom index versus reflux finding score. Annals of Otology, Rhinology & Laryngology. 2007 Jun;116(6):436-40.
  5. Nunes HS, Pinto JA, Zavanela AR, Cavallini AF, Freitas GS, Garcia FE. Comparison between the reflux finding score and the reflux symptom index in the practice of otorhinolaryngology. International archives of otorhinolaryngology. 2016 Jul;20(03):218-21.

Meet the author

Dr Sanu P Moideen is an Indian-born oto-rhino-laryngologist (ENT) based in Cochin, Kerala, India. He is currently working as Post-Doctoral Fellow in Head and Neck Oncology at Regional Cancer Center, Trivandrum, Kerala.

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