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Reflux Symptom Index (RSI)

last modified on: Mon, 05/06/2024 - 10:08

 return to: Extraesophageal reflux disease


The Reflux Symptom Index (RSI) is in common use as a semi-quantitative tool to assess symptoms associated with laryngopharyngeal reflux (LPR) (Belafsky 2002). This tool was developed to improve upon previous questionnaires thought to be directed more to classic GERD (gastroesophageal reflux disease) - with existing questionnaires also considered by Belafsky et al as too lengthy (Locke 1994, Colwell 1999, Shaw 2001). 

Francis et al have identified that 'a sensitive and specific gold standard objective diagnostic test to consistenly identify patients afffected by LPR remains elusive" and that patient-reported outcome (RPO) measures remain the primary way to diagnose LPR and monitor treatment (Francis 2016).

Other assessment tools have been developed in an effort to address shortcomings to the RSI - including the Reflux Symptom Score (RSS) as a PRO (Patient Reported Outcome) initiated through expert opinion at a round-table discussion at a world ENT congress in 2016 (Lechien 2017). This RSS was designed to take into account symptoms attribued not only to LPR, but also to GERD and to address respiratory symptoms associated with LPR - identifying this survey was designed for both the diagnosis and follow-up of LPR patients. Lechien et al identify their questionnaire to be advantageous by including assessment of common symptoms associated with LPR that are lacking in other surveys such as odynophagia, burning tongue, nausea and halitosis. They additionally identified benefit in assessing not only the severity of symptoms, but also their frequency. They acknowledge the main weakness of the RSS to be the length of time needed to complete the questionnaire - but relate it is usually ≤ 2 minutes. 

Debate about the best tool to use assess LPR continues (Lin 2021, Lechien 2021). Through a critical systematic review of PRO measures used to diagnose LPR, Francis et al (2016) conclude that PRO measures are currently a principle method of diagnosing LRP - and that several measurement techniques have important strengths that contribute to the assessment of patients with presumed LPR, but also that  "care must be taken to understand the developmental characteristics of PRO measures before selecting, advocating for, and using them in research and clinical applications."

The Reflux Assessemnt Tool (RSI)

derived from Belafsky et al 2002

The RSI was evaluated ('validated') through study of 25 patients with larynopharyngeal reflux (LPR) before (including two separate assessments before PPI treatment) and 6 months after twice daily (b.i.d.) treatment with proton pump inhibitors (PPI's).

Results from those assessments were compared to 25 age-matched and gender-matched controls without reflux (normative data) assessed with RSI's recorded in a database.

The pre-treatment mean RSI of patients with LPR improved from 21.2 (+/- 10.7) to 12.8 (+/- 10.0) post-treatment and approached that of asymptomatic controls (11.6)

Question posed over a limited time frame: "Within the last month, how did the following problems affect you?"

Subjects instructed to circle the number that best applies to their symptoms on a range extending from 0 = No Problem to 5 = Severe Problem with a maximum score of 45

  1. Hoarseness or a problem with your voice. 
                0     1     2     3     4     5
  2. Clearing your throat. 
                0     1     2     3     4     5
  3. Excess throat mucus or postnasal drip.  
                0     1     2     3     4     5
  4. Difficulty swallowing food, liquids, or pills.  
                0     1     2     3     4     5
  5. Coughing after you ate or after lying down. 
                0     1     2     3     4     5
  6. Breathing difficulties or choking episodes. 
                0     1     2     3     4     5
  7. Troublesome or annoying cough. 
                0     1     2     3     4     5
  8. Sensations of something sticking in your throat or a lump in your throat.  
                0     1     2     3     4     5
  9. Heartburn, chest pain, indigestion, or stomach acid coming up.
                0     1     2     3     4     5


Belafsky PC, Postma GN, Koufman JA. Validity and reliability of the reflux symptom index (RSI). J Voice. 2002 Jun;16(2):274-7. doi: 10.1016/s0892-1997(02)00097-8. PMID: 12150380.

Locke GR, Talley NJ, Weaver AL, et al. A new questionnaire for gastroesophageal reflux disease. Mayo Clin Proc. 1994;69:539–547.

Colwell HH, Mathias SD, Pasta DJ, et al. Development of a health-related quality-of-life questionnaire for individuals with gastroesophageal reflux disease: a validation study. Dig Dis Sci. 1999;44:1376–1383.

Shaw MJ, Talley NJ, Beebe TJ, et al. Initial validation of a diagnostic questionnaire for gastroesophageal reflux disease. Am J Gastroenterol. 2001;96:52–57.

Lechien JR, Bobin F, Muls V, Thill MP, Horoi M, Ostermann K, Huet K, Harmegnies B, Dequanter D, Dapri G, Maréchal MT, Finck C, Rodriguez Ruiz A, Saussez S. Validity and reliability of the reflux symptom score. Laryngoscope. 2020 Mar;130(3):E98-E107. doi: 10.1002/lary.28017. Epub 2019 Apr 14. PMID: 30983002.

     cites Lechien JR, Benninger MS, Crevier-Buchman L, et al; IFOS. Laryngopharyngeal reflux and voice disorders. Presented at: World Ear, Nose, and Throat Congress; June 2017; Paris, France

Francis DO, Patel DA, Sharda R, 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.

Lin WJ, Wang CC, Chen SH, Liao JS. Reflux Symptom Score and Quality of Life: Response to the Paper by Lechien JR et al. Laryngoscope. 2021 Jan;131(1):E203. doi: 10.1002/lary.28677. Epub 2020 Apr 30. PMID: 32352168.

Lechien JR, Bobin F, Muls V, Rodriguez A, Saussez S. In Response to Validity and Reliability of the Reflux Symptom Score. Laryngoscope. 2021 Jan;131(1):E204. doi: 10.1002/lary.28679. Epub 2020 Apr 30. PMID: 32352167.