Reflux Symptom Score and Quality of Life: Response to the Paper by Lechien JR et al.

Abstract

We read with great interest the article entitled "Validity and Reliability of the Reflux Symptom Score [RSS]," which developed a new questionnaire for diagnosing and monitoring laryngopharyngeal reflux (LPR) disease. 1 However, we found that some of the conclusions seemed arbitrary, and further discussion is necessary. First of all, in 2002, Belafsky et al. 2 published a nineitem "Reflux Symptoms Index (RSI)" questionnaire (maximum score of 45). The mean value of RSI for their LPR patients dropped from 21.2 AE 10.7 at baseline to 12.8 AE 10.0 after 6 months of treatment, and 12.8 AE 10.0 approached the baseline RSI value (11.6) in the healthy control group. Therefore, they defined RSI > 13 as indicating LPR. Interestingly, in the new 22-item RSS questionnaire (maximum score of 550), the authors also suggested an RSS value of >13 to indicate diagnosis of LPR. However, the baseline RSS total score of 112.49 AE 78.41 only improved to 77.19 AE 63.36 after treatment. The value of 77.19 AE 63.36 was much higher than 13, and the baseline value of 9.68 AE 17.51 in the normal control group. Therefore, an RSS value of 13 does not appear to be suitable for defining LPR. Secondly, the authors emphasized that RSS has the advantage of including some common abdominal/chest symptoms associated with LPR, which had been ignored before. 2-4 However, their data do not support this claim because there was no significant difference between baseline and 12 weeks after treatment for some items (P = .58 for odynophagia; P = .875 for tongue burning; P = .184 for halitosis). Only 77 (68%) of their 113 enrolled patients completed the study, which probably reflects that a redundant questionnaire with unrelated items may reduce the completion rate and limit its value in clinical practice. Thirdly, the authors also used the Quality of Life Impact score (QoL-RSS) simultaneously with the RSS in their study. QoL-RSS had the same 22 items as RSS but with a narrower range from 0 to 110. According to the data in Table III of the study (page E102), QoL-RSS had a higher Spearman rank-order correlation coefficient than RSS (0.950 vs. 0.921). In Tables IV (page E104) and V (page E105), QoL-RSS is also as good as RSS; however, QoL-RSS is much simpler to use because it is not necessary to multiply the severity score by the frequency score to obtain a symptoms score ranging from 0 to 25 for each of the 22 symptom items. Therefore, we think QoL-RSS is better than RSS itself.

In Response to Validity and Reliability of the Reflux Symptom Score

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We thank the authors for their comments. 1 In epidemiology, the threshold determination for a patient-reported outcome questionnaire usually aims to ensure the detection of a disease. 2 Therefore, the threshold, which is statistically determined through a cohort of healthy individuals, needs to be associated with a high sensitivity.

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