Reliability of Speech-Language Pathologist and Otolaryngologist Ratings of Laryngeal Signs of Reflux in an Asymptomatic Population Using the Reflux Finding Score
Introduction
The term “laryngopharyngeal reflux” (LPR) refers to a backward flow of stomach contents to the pharynx and is differentiated from gastroesophageal reflux disease (GERD) by its complexity of symptoms, presumed pathophysiology, and physical sequelae.1 The position statement of the American Academy of Otolaryngology-Head and Neck Surgery1 reviewed primary literature on this topic. The Committee found that the most common clinical manifestation of LPR is reflux laryngitis, with or without granuloma formation. Additional laryngeal conditions frequently associated with acid irritation include posterior commissure hypertrophy, subglottic stenosis, laryngeal carcinoma, polypoid degeneration, laryngospasm, paradoxical vocal fold movement, globus pharyngeus, and vocal nodules.
Most patients with LPR deny classic symptoms of GERD, particularly heartburn.2, 3 Patients with LPR may describe symptoms such as hoarseness, vocal fatigue, chronic cough, dysphagia, globus sensation, halitosis, excessive mucus, postnasal drip, and throat clearing.1, 4, 5 Although the exact mechanisms for LPR have not been conclusively described, it has been associated with the upright position and a possible dysfunction of the upper esophageal sphincter, whereas GERD tends to occur in the supine position and involves a dysfunction of the lower esophageal sphincter. Additionally, patients with GERD have longer periods of acid exposure and dysmotility.1 Differentiating the exact mechanisms of each condition is difficult as LPR and GERD may co-occur.
Definitive diagnosis of LPR is difficult to determine. Double-probe pH monitoring has been considered the gold standard,1, 2, 6, 7 but patient resistance, expense, and difficulty quantifying intermittent episodes have led many otolaryngologists to base initial diagnosis on physical findings during endoscopic examination. Unfortunately, there is disagreement among otolaryngologists regarding the laryngeal findings that constitute this diagnosis.8 Evidence of tissue irritation, particularly near the upper esophageal sphincter, may include edema and erythema of the arytenoid joints, vocal folds and posterior larynx, posterior commissure hypertrophy, and ulcerations or granulomatous masses, including cobblestoning around the esophageal inlet.4, 9, 10 However, some of these signs have been reported in the asymptomatic, non-treatment-seeking population.9, 11, 12
An additional factor confounding the accurate diagnosis of LPR is disagreement among otolaryngologists regarding the presence and severity of laryngeal signs. Many studies provide ratings made by an otolaryngologist alone or in consensus with a speech-language pathologist. However, Branski et al13 had five otolaryngologists rate 122 videotaped laryngeal examinations of patients with dysphonia on a five-point scale of classic signs of LPR (edema and erythema at the anterior commissure, along the musculomembranous vocal folds, and on the artyenoids/interarytenoid space, and interarytenoid pachydermia). The severity of LPR findings and likelihood that it is a component of the patient's dysphonia were also rated. Interrater agreement was poor, and intrarater reliability was highly variable. The authors concluded that accurate assessment of LPR based on laryngeal findings could not be made dependably.
The difficulties inherent in subjective ratings are well known, but they become unacceptable if they lead to false diagnoses. We questioned interjudge agreement in rating signs of LPR would improve if “ideal” conditions were created. That is, would interrater agreement improve if the raters had many years of experience working together in a practice devoted exclusively to voice-disordered patients, if raters were trained in the items on a standardized scale developed to represent laryngeal signs of reflux,14, 15 if raters included both speech-language pathologists and otolaryngologists affiliated with the practice, and if they rated only asymptomatic participants? The current investigation was designed to answer the components of this question. Given the reduced range of physical findings or variations thereof anticipated in an asymptomatic population, strong inter- and intrarater agreement was expected.
Section snippets
Participants
Participants were 30 nonsmoking male and female adults (15 men, 15 women), ages 35–55 years old. They were recruited from the general, non-treatment-seeking population. Prerequisites included not more than two alcoholic drinks per day, no history of swallowing, voice or pulmonary disorders, and self-described overall health quality of good or better. Each participant had no more than rare-to-intermittent use of ibuprofen, antihistamines, and steroids. There was no history of using prescription
Total RFS
Each rater made a total of 240 ratings (30 participants × 8 items). The means, standard deviations, and ranges of the total RFS scores provided by the two speech-language pathologists and two otolaryngologists are provided in Table 1.14 The frequency of rating a participant with a total RFS score greater than 7 is also provided. The mean values were within normal limits, as defined by Belafsky et al.14 However, 43% of the participants (13 of 30) were assigned a total score >7, indicative of
Discussion
Findings from the current study underscore key issues that persist in the clinical identification and diagnosis of LPR from physical findings in persons who otherwise do not report symptoms of reflux disease. These issues include interrater reliability or consensus among professionals who make provisional diagnoses of LPR based on physical findings, lack of characterization of normal variations of the physical appearance of the larynx, and over/under-diagnosis of LPR in asymptomatic patients.
Conclusions
In the current study, healthy, asymptomatic, non–treatment-seeking persons with low RFS scores received videoendscoboscopic examination. Experienced otolaryngologists and speech pathologists rated the physical appearance of those videoendoscopic images using the RFS scoring system. Results revealed that even under ideal practice conditions where close, ongoing collaboration is standard care, variability of interpretation of presence, degree, or absence of physical findings exists. The extent of
References (19)
- et al.
Laryngopharyngeal reflux: position statement of the Committee on Speech, Voice, and Swallowing Disorders of the American Academy of Otolaryngology-Head and Neck Surgery
Otolaryngol Head Neck Surg
(2002) - et al.
Laryngopharyngeal reflux: consensus report
J Voice
(1996) - et al.
Role of refluxed acid in pathogenesis of laryngeal disorders
Am J Med
(1997) - et al.
Laryngopharyngeal reflux: state of the art diagnosis and treatment
Otolaryngol Clin North Am
(2000) - et al.
Validity and reliability of the reflux symptom index (RSI)
J Voice
(2002) - et al.
The prevalence of hypopharynx findings associated with gastroesophageal reflux in normal volunteers
J Voice
(2002) - et al.
Incidence of abnormal laryngeal findings in asymptomatic singing students
Otolaryngol Head Neck Surg
(1999) - et al.
Subjective, laryngoscopic, and acoustic measurements of laryngeal reflux before and after treatment with omeprazole
J Voice
(1996) 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)
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Laryngopharyngeal Reflux and Atypical Gastroesophageal Reflux Disease
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2017, Journal of VoiceThe Reliability of the Reflux Finding Score Among General Otolaryngologists
2015, Journal of VoiceCitation Excerpt :In contrast, Kelchner et al16 found high inter-rater agreement between two speech-language pathologists and one laryngologist for total RFSs. However, the second otolaryngologist in their study had poor agreement with the other three.16 In studies examining signs of laryngeal irritation,8,9 the inter-rater reliability is poor indicating that there is lack of consensus with the respect to endoscopic laryngeal findings.
Comparison of voice quality in patients with GERD-related dysphonia or chronic cough
2014, Otolaryngologia PolskaCitation Excerpt :Breathiness is reflected in the shimmer value [36]. Hoarseness results in increased jitter, shimmer, and HNR [28, 29]. Elevated levels of jitter and shimmer might be a result of reduced control of laryngeal phonation and degenerative tissue changes [36, 37].