Validation of the Brazilian Portuguese Version of the Reflux Finding Score

  • Claudia Alessandra Eckley
    Address correspondence and reprint requests to Claudia Alessandra Eckley, Av. Vereador José Diniz 3457, cj 501, Campo Belo Medical Center, São Paulo, SP, Brazil CEP: 04603-003.
    Head of the Otolaryngology Division of Fleury Medicina e Saúde Diagnostic Laboratories, São Paulo, SP, Brazil
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  • Rodrigo Tangerina
    Attending Physician Otolaryngology Division, Fleury Medicina e Saúde Diagnostic Laboratories, São Paulo, SP, Brazil
    Search for articles by this author
Published:February 10, 2020DOI:



      Laryngopharyngeal reflux (LPR) poses a diagnostic challenge. Clinical diagnosis, based on suggestive symptoms and laryngoscopic signs of inflammation, should be acceptable, as long as diligent differential diagnosis is sought. In order to minimize subjectivity, a number of diagnostic instruments have been proposed, being the most common the Reflux Symptom Index and the Reflux Finding Score (RFS). The latter has been translated into several languages including Portuguese, but it still has not been properly validated in this language.


      To validate the Brazilian Portuguese version of the RFS.

      Material and Method

      For validity and internal consistency, 172 adults were studied (106 with LPR and 66 healthy controls). Flexible transnasal laryngoscopy images were randomly examined twice by each of the two experienced otolaryngologists with a 72-hour interval. Strict exclusion criteria were applied to avoid other possible known causes of chronic laryngitis. For assessment of reproducibility and temporal stability, a random sample of 108 subjects (53 patients and 55 controls) were tested and retested.


      A statistically significant difference was observed in the mean RFS between patients with LPR (10.26 ± 3.58) and controls (5.52 ± 1.34) (P < 0.001). The interclass correlation coefficient comparing test and retest for both raters was high (R1 = 0.956; R2 =  0.948).


      The Brazilian Portuguese version of the RFS proved to be a reliable and reproducible instrument for the diagnosis of LPR with a sensitivity of 82.08%, a specificity of 93.94%, a positive predictive value of 95.60%, and a negative predictive value was 76.54%.

      Key Words

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        • Koufman JA
        • Aviv JE
        • Casiano RR
        • Shaw G.Y.
        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; 127: 32-35
        • Lechien JR
        • Akst LM
        • Hamdan AL
        • Schindler A
        • Karkos PD
        • Barillari M.R.
        • et al.
        Evaluation and management of laryngopharyngeal reflux disease: state of the art review.
        Otolaryngol Head Neck Surg. 2019; 160: 762-782
        • Asaoka D
        • Nagahara A
        • Matsumoto K
        • Hojo M.
        • Watanabe S.
        Current perspectives on reflux laryngitis.
        Clin J Gastroenterol. 2014; 7: 471-475
        • Martinucci I
        • Albano E
        • Marchi S
        • Blandizi C.
        Extra-esophageal presentation of gastroesophageal reflux disease: new understanding in a new era.
        Minerva Gastroenterol Dietol. 2017; 63: 221-234
        • Hom C
        • Vaezi MF
        Extra-esophageal manifestations of gastroesophageal reflux disease: diagnosis and treatment.
        Drugs. 2013; 73: 1281-1295
        • Lechien JR
        • Bobin F
        • Muls V
        • Eisendrath p
        • Horoi M
        • Thill MP
        • et al.
        Gastroesophageal reflux in laryngopharyngeal reflux patients: clinical features and therapeutic response.
        Laryngoscope. 2019; ([Epub ahead of print])
        • Hicks DM
        • Ours TM
        • Abelson TI
        • Vaezi MF
        • Richter JE
        The prevalence of hypopharynx findings associated with gastroesophageal reflux in normal volunteers.
        J Voice. 2002; 16: 564-579
        • Jamieson JR
        • Stein HJ
        • DeMeester TR
        • Bonavina L
        • Schwizer W
        • Hinder RA
        • et al.
        Ambulatory 24-h esophageal pH monitoring: normal values, optimal thresholds, specificity, sensitivity, and reproducibility.
        Am J Gastroenterol. 1992; 87: 1102
        • Lee B
        • Kim G
        • Ryu D
        • Kim DU
        • Cheong JH
        • Lee D.G.
        • et al.
        Combined dual channel impedance/pH-metry in patients with suspected laryngopharyngeal reflux.
        J Neurogastroenterol Motil. 2010; 16: 157-165
        • Carroll TL
        • Werner A
        • Nahikian K
        Rethinking the laryngopharyngeal reflux treatment algorithm: evaluating an alternate empiric dosing regimen and considering up-front, pH-impedance, and manometry testing to minimize cost in treating suspect laryngopharyngeal reflux disease.
        Laryngoscope. 2017; 127: S1-S13
        • Suzuki T
        • Seki Y
        • Okamoto Y
        • Hoppo T
        Hypopharyngeal multichannel intraluminal impedance leads to the promising outcome of antireflux surgery in Japanese population with laryngopharyngeal reflux symptoms.
        Surg Endosc. 2018; 32: 2409-2419
        • Eckley CA
        • Tangerina PR
        Sensitivity, specificity and reproducibility of the Brazilian Portuguese version of the Reflux Symptom Index.
        J Voice. 2019; (pii: S0892-1997(19)30290-5. 10.1016/j.jvoice.2019.08.012. [Epub ahead of print]. In press)
        • Belafsky PC
        • Postma GN
        • Koufman JA
        The validity and reliability of the reflux finding score (RFS).
        Laryngoscope. 2001; 111: 1313-1317
        • Belafsky PC
        • Postma GN
        • Koufman JA
        Validity and reliability of the reflux symptom index (RSI).
        Laryngoscope. 2002; 16: 274-277
        • Carrau R L
        • Khidr A
        • Crawley JA
        • Hillson EM
        • Davis JK
        • Pashos CL
        The impact of laryngopharyngeal reflux on patient-reported quality of life.
        Laryngoscope. 2004; 114: 670-674
        • Carrau RL
        • Khidr A
        • Gold KF
        Validation of a quality-of-life instrument for laryngopharyngeal reflux.
        Arch Otolaryngol Head Neck Surg. 2005; 131: 315-320
        • Simons JP
        • Rosen CA
        • Casselbrant CA
        • Chi DH
        • Schaitkin BM
        • Rubinstein EN
        • et al.
        Comparison of pediatric voice outcome survey, reflux symptom index, reflux finding score, and esophageal biopsy results.
        Arch Otolaryngol Head Neck Surg. 2008; 134: 837-841
        • Vardar R
        • Varis A
        • Bayrakci B
        • Akyildiz S
        • Kirazli T
        • Bor S
        Relationship between history, laryngoscopy and esophagogastroduodenoscopy for diagnosis of laryngopharyngeal reflux in patients with typical GERD.
        Eur Arch Otorhinolaryngol. 2012; 269: 187-191
        • Vadivelu S
        • Ma ZF
        • Ong EW
        • Hassan N.
        • Nik Hassan NFH
        • Syed Abdul Aziz SH
        • et al.
        Clinical validity and reliability of the Malay language translations of gastroesophageal reflux disease questionnaire and quality of life in reflux and dyspepsia questionnaire in a primary care setting.
        Dig Dis. 2019; 37: 100-107
        • Kulich KR
        • Piqué JM
        • Vegazo O
        • Jiménez J
        • Zapardiel J
        • Carlsson J
        • et al.
        Psychometric validation of translation to Spanish of the gastrointestinal symptoms rating scale (GSRS) and quality of life in reflux and dyspepsia (QOLRAD) in patients with gastroesophageal reflux disease.
        Rev Clin Esp. 2005; 205: 588-594
        • Kulich KR
        • Malfertheiner P
        • Madisch A
        • Labenz J
        • Bayerdörffer E
        • Miehlke S
        • et al.
        Psychometric validation of the German translation of the Gastrointestinal Symptom Rating Scale (GSRS) and Quality of Life in Reflux and Dyspepsia (QOLRAD) questionnaire in patients with reflux disease.
        Health Qual Life Outcomes. 2003; 28: 62
        • Andersson O
        • Ryden A
        • Ruth M
        • Ylitalo Moller R
        • Finizia C
        • et al.
        Validation of the Swedish translation of LPR-HRQL.
        Med Sci Monit. 2010; 16: CR480-CR487
        • Francis DO
        • Patel DA
        • Sharda R
        • Hovis K
        • Sathe N
        • Penson D.F.
        • et al.
        Patient-reported outcome measures related to laryngopharyngeal reflux: a systematic review of instrument development and validation.
        Otolaryngol Head Neck Surg. 2016; 155: 923-935
        • Lechien JR
        • Schindler A
        • De Marrez LG
        • Hamdan A.
        • Karkos P.D.
        • Harmegnies B.
        • et al.
        Instruments evaluating the clinical findings of laryngopharyngeal reflux: a systematic review.
        Laryngoscope. 2019; 129: 720-736
        • Musser J
        • Kelchner L
        • Neils-Strunjas J
        • Montrose M.
        A comparison of rating scales used in the diagnosis of extraesophageal reflux.
        J Voice. 2011; 25: 293-300
        • Habermann W
        • Schmid C
        • Neumann K
        • Devaney T
        • Hammer HF
        Reflux symptom index and reflux finding score in otolaryngologic practice.
        J Voice. 2012; 26: e123-e127
        • Włodarczyk E
        • Miaśkiewicz B
        • Szkiełkowska A
        • Skarzyński P
        • Skarżyński H
        The use of RSI and RFS questionnaires in the Polish language version.
        Otolaryngol Pol. 2018; 73: 1-5
        • Watson NA
        • Kwame I
        • Oakeshott P
        • Reid F
        • Rubin JS
        Comparing the diagnosis of laryngopharyngeal reflux between the reflux symptom index, clinical consultation and reflux finding score in a group of patients presenting to an ENT clinic with an interest in voice disorders: a pilot study in thirty five patients.
        Clin Otolaryngol. 2013; 38: 329-333
        • Mesallam T
        • Stemple J
        • Sobeih T
        • Elluru RG
        Reflux symptom index versus reflux finding score.
        Ann Otol Rhinol Laryngol. 2007; 116: 436-440
        • Belafsky PC
        • Postma GN
        • Koufman JA
        Laryngopharyngeal reflux symptoms improve before changes in physical findings.
        Laryngoscope. 2001; 111979981
        • Almeida AGDP
        • Saliture TBS
        • Silva ASD
        • Eckley C.A.
        Translation and cultural adaptation of the Reflux Finding Score into Brazilian Portuguese.
        Braz J Otorhinolaryngol. 2013; 79: 47-53
        • Oyer SL
        • Anderson LC
        • Halum SL
        Influence of anxiety and depression on the predictive value of the reflux symptom index.
        Ann Otol Rhinol Laryngol. 2009; 118: 687
        • Cherry J
        • Margulies SI
        Contact ulcer of the larynx.
        Laryngoscope. 1968; 78: 1937-1940
        • Sousa VD
        • Rojjanasrira W
        Translation, adaptation and validation of instruments or scales for use in cross-cultural health care research: a clear and user friendly guideline.
        J Eval Clin Pract. 2011; 17: 268-274