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Article in Archives of Oto-Rhino-Laryngology · August 2009

DOI: 10.1007/s00405-009-1044-2 · Source: PubMed

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Eur Arch Otorhinolaryngol (2010) 267:571–574
DOI 10.1007/s00405-009-1044-2
H E A D & N E CK
Laryngopharyngeal reXux might play a role on chronic
nonspeciWc pharyngitis
Zahide Mine Yazici · Ãbrahim Sayin ·
Fatma Tulin Kayhan · Sultan Biskin
Received: 5 March 2009 / Accepted: 30 June 2009 / Published online: 21 July 2009
© Springer-Verlag 2009
Abstract Chronic nonspeciWc pharyngitis is one of the
most common reasons for visits to otorhinolaryngology
physicians. The underlying conditions are still unknown.
The aim of this study was to investigate the role of laryngo-
pharyngeal reXux in chronic nonspeciWc pharyngitis
patients based on the patient’s history and clinical examina-
tion. Fifty consecutive patients with symptoms of chronic
nonspeciWc pharyngitis and control group of 30 healthy
persons were evaluated prospectively. 14C-urea breath test
was used to exclude Helicobacter pylori infection of gastric
mucosa. All the patients and the controls were assessed by
blinded same laryngologist with the use of the reXux Wnd-
ing score (RFS) and reXux symptoms index (RSI). Also
chronic nonspeciWc pharyngitis patients with laryngopha-
ryngeal reXux (LPR) were evaluated prospectively before
and 6 months after b.i.d treatment with proton pump inhibi-
tors. The RSI of the nonspeciWc pharyngitis group was
found signiWcantly higher than the control group
(P < 0.01). The RFS of nonspeciWc pharyngitis was found
signiWcantly higher than the control group (P < 0.01). The
reXux Wnding score ¸7 has been accepted as LPR; the
reXux incidence was signiWcantly higher in the nonspeciWc
pharyngitis group than the control group (P < 0.01). Post-
treatment RSI of nonspeciWc pharyngitis patients group
Z. M. Yazici · Ã. Sayin · F. T. Kayhan · S. Biskin
BakÂrköy Education and Training Hospital,
Clinic of Otorhinolaryngology,
Head and Neck Surgery, Istanbul, Turkey
Z. M. Yazici (&)
Bakirköy Efitim ve AraotÂrma Hastanesi,
Kulak Burun Bogaz ABD, TevWk Saflam cad.,
No 13, Zuhuratbaba, 34147 Istanbul, Turkey
e-mail: minealmaz@yahoo.com
revealed a statistically signiWcant decrease when compared
with the pretreatment RSI (P < 0.01). Posttreatment RFS of
nonspeciWc pharyngitis patients also revealed a signiWcant
decrease when compared with the pretreatment RFS
(P < 0.01). We suggest that LPR may be related to the path-
ogenesis of chronic nonspeciWc pharyngitis.
Keywords Pharyngitis · Laryngopharygeal reXux ·
ReXux symptom index · ReXux Wnding score
Introduction
Pharyngitis is an inXammation of the mucosal and submu-
cosal structures of the throat. Infection may or may not be a
component of the disease [1]. The clinician usually can
determine most causes of pharyngitis with proper histories
and careful physical examination (cultures and biopsies
included). However, some people referred to us with pha-
ryngeal pain without an obvious explanation which is
named as chronic nonspeciWc pharyngitis.
Laryngopharyngeal reXux (LPR) is deWned as the retro-
grade movement of gastric contents into the larynx, phar-
ynx, and upper aerodigestive tract [2]. LPR may play a role
in chronic nonspeciWc pharyngitis patients’ etiologies. The
most accurate diagnostic test is 24-h esophageal pH moni-
toring with both proximal and distal sensors, but this test is
expensive, invasive and also is not easy to use in clinics; so
there is a need for a simple method for scanning suspicious
patients. Recently, Belafsky et al. [2] reported that reXux
Wnding score (RFS) and reXux symptoms index (RSI) were
used to document the physical Wndings and the severity of
LPR simply economically as well as noninvasively. For
these reasons, we tried to investigate LPR in adult patients
with chronic nonspeciWc pharyngitis by using RFS and RSI.
123
572 Eur Arch Otorhinolaryngol (2010) 267:571–574

The aim of the present study was to perform indirect lar-
yngoscopy by series of consecutive patients referred for
suspected chronic nonspeciWc pharyngitis by using RSI and
RFS.
Materials and methods
Fifty patients (38 females and 12 males; age range 18–72
years; mean age 44.7 years) who visited our out-patient
department for suspected chronic nonspeciWc pharyngitis
were involved. Thirty healthy adults (21 females and 9
males; age range 28–56 years; mean age 37 years) were
selected as control group. The chronic nonspeciWc pharyn-
gitis symptoms included were sore throat, chronic throat
irritation, chronic cough, globus sensation, cervical dyspha-
gia, and intermittent hoarseness. Symptoms should have
continued more than 3 months. All patients who were
included in the study had persistent symptoms of chronic
nonspeciWc pharyngitis for more than 3 months, without
any evidence for an acute infection. Patients who had
organic causes such as acute infection, nasal obstruction,
rhinitis, sinusitis or tumorous lesions on history taking and
physical examination were excluded. Also throat culture
was used to detect acute infection in both groups. A 14C-
urea breath test (Helicap, Noster system AB, Stockholm,
Sweden) was used to detect Helicobacter pylori infection
of gastric mucosa. Subjects with positive results in urea test
were excluded from our research. A detailed explanation of
the study and procedures was provided and written
informed consent was obtained. Also the protocol was
approved by BakÂrköy Sadi Konukoflu Education and
Research Hospital’s Human Subject Committee.
A self-administered included nine-items; RSI was com-
pleted by each subject at evaluation (Table 1). Each of the
items is related to LPR and is scored from 0 (no problem) to
5 (severe problem). The reXux Wndings score is an 8-item
clinical severity based on Wndings during laryngoscopy
(Table 2). The scale ranges from 0 (no abnormal Wndings)
to a maximum of 26 (worst score possible). A comprehen-
sive head and neck examination, including laryngoscopy
and determination of the RFS, was also performed by an
otolaryngologist. The reXux Wnding score ¸7 has been
accepted as LPR. In control group, three healthy subjects
had high RFS; so they were excluded from our study.
Chronic nonspeciWc pharyngitis patients with LPR
(RFS ¸ 7) were treated with 30 mg lansoprazole twice
daily; patients were also evaluated before and 6 months
after b.i.d treatment.
The Wndings of this study were statistically analyzed by
NCSS 2007 & PASS 2008 Statistical Software (Utah,
USA) program. The analyses according to the groups were
done by Student’s t test and Mann–Whitney U test. The
analyses in the groups were done by Paired samples t test.
The analyses due to categorically given groups were done
by Chi square test, and analyses in these groups were done

Table 1 ReXux symptom

During the last month, how did the following problems aVect you? Circle the appropriate response: 0 = no
index (RSI)
problem; 5 = severe problem

1. Hoarseness or a problem with your voice 1 2 3 4 5

2. Clearing your throat 1 2 3 4 5
3. Excess throat mucus or postnasal drip 1 2 3 4 5
4. DiYculty in swallowing food, liquids, or pills 1 2 3 4 5
5. Coughing after you ate or after lying down 1 2 3 4 5
6. Breathing diYculties or choking episodes 1 2 3 4 5
7. Troublesome or annoying cough 1 2 3 4 5
8. Sensations of something sticking or a lump in your throat 1 2 3 4 5
9. Heartburn, chest pain, indigestion, or stomach acid coming up 1 2 3 4 5

Table 2 ReXux Wnding score (RFS)

Subglottic edema 2 if present

Ventricular obliteration 2 if partial 4 if complete
Erythema/hyperemia 2 if arytenoids only 4 if complete
Vocal cord edema 1 mild 2 moderate 3 severe 4 polypoid
DiVuse laryngeal edema 1 mild 2 moderate 3 severe 4 obstructing
Posterior commissure hypertrophy 1 mild 2 moderate 3 severe 4 obstructing
Granuloma/granulation 2 if present
Thick endolaryngeal mucous 2 if present

123
Eur Arch Otorhinolaryngol (2010) 267:571–574 573

Table 3 RSI and RFS assessment according to the groups

NonspeciWc pharyngitis NonspeciWc pharyngitis Control reXux (¡) P
reXux (+) (n = 35) reXux (¡) (n = 15) (n = 27)

ReXux symptom indexa, 18.51 § 6.29 14.40 § 5.03 8.33 § 5.14 <0.001
mean § SD
ReXux Wndings scoresb, 8.68 § 2.04 (8.0) 1.73 § 1.83 (2.0) 1.03 § 1.42 (0.0) <0.001
mean § SD (median)
a
One-way anova test
b
Kruskal–Wallis test

Table 4 The pretreatment and posttreatment sixth month RSI and mean+SD
RFS assessment of nonspeciWc pharyngitis 30
pretreatment posttreatment
25
Group P
20
Pretreatment Posttreatment
(n = 35) (n = 35) 15

10
ReXux symptom index, 18.51 § 6.29 12.60 § 7.68 0.001**
mean § SD 5
ReXux Wnding score, 8.68 § 2.04 6.28 § 1.74 0.001**
0
mean § SD Reflux symptom index Reflux finding score

Paired samples t test; **P < 0.01 Fig. 1 Distribution of RSI and RFS pre and posttreatment

by Mc Nemar test. The results were evaluated by 95% con-

Wdence interval, and statistically signiWcance was P < 0.05.
Discussion

Results Pharyngitis is one of the most common conditions encoun-

There were no signiWcant diVerences in the age or sex dis-
tribution of two groups. ReXux symptom index was
between 2 and 33; mean symptom index was 14.32 § 7.18;
the reXux Wnding score was between 0 and 15; the mean
Wnding score was 4.75 § 4.07. The reXux symptom index
of the nonspeciWc pharyngitis group with reXux was found
signiWcantly higher than the control group (P < 0.01).
The reXux Wnding score of nonspeciWc pharyngitis with
reXux was found signiWcantly higher than the control group
(P < 0.01). The reXux Wnding score was classiWed accord-
ing to the 7; the reXux incidence was signiWcantly higher in
the nonspeciWc pharyngitis group than the control group
(P < 0.01) (Table 3).
Posttreatment reXux symptom index of nonspeciWc phar-
yngitis patients group revealed a statistically signiWcant
decrease when compared with the pretreatment RSI
(P < 0.01) (Table 4) Posttreatment reXux Wnding score of
nonspeciWc pharyngitis patients has also revealed a signiW-
cant decrease when compared with the pretreatment RSI
(P < 0.01) (Fig. 1). Posttreatment decrease of the reXux
rates of nonspeciWc pharyngitis was found statistically sig-
niWcant than the pretreatment rates (P < 0.01). While pre-
treatment reXux rate was 70% after the treatment, the rate
decreased to 38%.
tered by physicians [3]. In contrast, there are a limited num-
ber of studies in the literature related to chronic pharyngitis.
Yet, no published studies have assessed rehabilitation of
chronic pharyngeal complaints using antibiotic therapy [4].
Treating all patients suspected to having infection results in
unnecessary antibiotic therapy. When a patient presents
with pharyngitis symptoms, the ENT physician must con-
sider a wide range of illnesses. If patients do not have any
other signs of infection, physicians should investigate non-
infectious causes such as rhinitis, allergies, laryngopharyn-
geal reXux, and thyroiditis [3]. In the literature, there are a
lot of papers concerning extraesophageal reXux, but unfor-
tunately limited of them is related to pharyngitis.
In the past, chronic nonspeciWc pharyngitis was consid-
ered a kind of conversion or psychosomatic disorder [5];
but in recent studies, various organic or functional causes
have been reported [4]. In this study, we analyzed the rela-
tionship between chronic nonspeciWc pharyngitis and
reXux. As a result we utilized an endoscopic scoring and
Wndings to evaluate reXux among chronic nonspeciWc phar-
yngitis patients and control groups. We found a dramati-
cally higher prevalence (70%) of increased inXammatory
change (RFS ¸ 7) when compared with the control group.
The relationship between pharyngitis and reXux has
been previously evaluated by biopsy-based methods or

123
574
hematologic analysis [3, 6]. Aladaf et al. demonstrated that
H. pylori seropositivity rates were found signiWcantly
higher in chronic nonspeciWc pharyngitis patients than
controls. They used serum H. pylori immunoglobulin G
antibody titers to assess reXux.
Helicobacter pylori infections in the pharynx of the peo-
ple in the control group and the patients suVering from
chronic pharyngitis were examined by biopsy. Template-
directed dye terminator incorporated with Xuorescence
polarization detection and modiWed Giemsa stain were used
to examine pharynx mucous membrane tissue for H. pylori
colonization. H. pylori was detected in the pharynx of
chronic pharyngitis patients. However, it is diYcult to take
oropharyngeal biopsies in the out-patient department.
Although 24-h double-probe pH monitoring is the gold
standard method for the diagnosis of LPR, it is diYcult to
put into practice this method in the out-patient department.
For this reason, we tried to Wnd easy, cost-eVective, and
reproducible method for scanning reXux among pharyngitis
patients. Other tools such as RFS and RSI are not invasive,
and have high validity have been used to evaluate LPR in
some clinics [2]. These tests take only about 1 min each and
are simple, economical, and noninvasive [7].
Further investigations and large number of patients are
needed to explain the potential mechanisms of interaction
of LPR and chronic nonspeciWc pharyngitis. LPR may be
one of the causative factors in the progression of chronic
nonspeciWc pharyngitis.
123
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Eur Arch Otorhinolaryngol (2010) 267:571–574
Conclusion
This study revealed a high rate of RSI and RFS in patients
with chronic nonspeciWc pharyngitis. Pharmacotherapy with
proton pump inhibitors may be an acceptable treatment
modality for suitable chronic nonspeciWc pharyngitis patients.
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