RSI — Reflux Symptom Index for LPR Assessment
The Reflux Symptom Index (RSI) is a 9-item self-administered questionnaire for assessing laryngopharyngeal reflux (LPR) symptom severity. Each item is scored 0-5 (0=no problem, 5=severe problem), with a total ranging from 0-45.
About
The Reflux Symptom Index (RSI) was developed by Dr. Peter C. Belafsky and colleagues at the University of California, Davis, and published in the Journal of Voice in 2002. It was designed to quantify symptom severity in patients with laryngopharyngeal reflux (LPR) and to monitor treatment response. The RSI consists of 9 items: (1) hoarseness or voice problem, (2) throat clearing, (3) excess throat mucus or post-nasal drip, (4) dysphagia (difficulty swallowing food, liquid, or pills), (5) post-nasal drip sensation, (6) globus sensation (lump in the throat), (7) chronic cough, (8) breathing difficulty or choking episodes, and (9) heartburn, chest pain, indigestion, or regurgitation. Each item is scored on a 0-5 scale where 0 = no problem and 5 = severe problem, yielding a total score of 0-45. A cutoff score of >13 is considered abnormal and suggestive of LPR. The RSI has demonstrated good test-retest reliability and responsiveness to treatment, with a minimal clinically important difference of approximately 6 points. It is the most widely used symptom index for LPR in both clinical practice and research settings.
Formula
RSI = Sum of 9 items (each 0-5). Total score 0-45. Cutoff: >13 = abnormal (suggests LPR)
Each of the 9 items is scored from 0 (no problem) to 5 (severe problem). The total RSI is the sum of all 9 individual item scores, ranging from 0 to 45. A score of 0-13 is considered normal (below the diagnostic threshold for LPR). A score of 14-45 is considered abnormal and suggestive of laryngopharyngeal reflux. The severity is graded as: 0-13 = normal, 14-25 = mild LPR symptoms, 26-35 = moderate, 36-45 = severe. The minimal clinically important difference (MCID) for the RSI is approximately 6 points, meaning a change of at least 6 points is needed to represent a true clinical change.
Score Interpretation
Laryngopharyngeal reflux (LPR) is a common condition affecting approximately 10-30% of patients presenting to ENT clinics. Unlike gastroesophageal reflux disease (GERD), LPR often presents without heartburn, making clinical diagnosis challenging. The RSI provides a standardized, validated method for quantifying symptom severity and tracking treatment response. It is recommended by the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) guidelines for LPR diagnosis and management. The RSI is often used in conjunction with the Reflux Finding Score (RFS) from laryngoscopy, together providing complementary information for diagnosis and treatment monitoring.
Normal — Below Diagnostic Threshold — 0–13
RSI ≤13: Symptoms are below the diagnostic threshold for laryngopharyngeal reflux.
Management: No specific LPR treatment indicated based on RSI alone. Reassess if symptoms worsen or persist.
Abnormal — Suggestive of LPR — 14–45
RSI >13: Abnormal, suggestive of laryngopharyngeal reflux.
Management: Consider laryngoscopy to evaluate for LPR findings. Empiric trial of PPI therapy twice daily for 8-12 weeks. Lifestyle modifications: elevate head of bed, avoid late meals, limit caffeine/alcohol/acidic foods.
Reference Ranges
| Population | Normal Range | Notes |
|---|---|---|
| Adults with suspected LPR | 0-13 (normal), 14-45 (abnormal) | Cutoff >13 is suggestive of LPR. Severity: 14-25 mild, 26-35 moderate, 36-45 severe. |
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View medical review board & editorial policy →Example Calculation
A 45-year-old female presents with chronic hoarseness (3/5), frequent throat clearing (4/5), excess throat mucus (3/5), globus sensation (4/5), and occasional heartburn (2/5). Other items scored 0. RSI = 3+4+3+0+0+4+0+0+2 = 16/45. Abnormal (>13), suggestive of LPR. Laryngoscopy is recommended with consideration of empiric PPI trial.
Related Conditions
Related Medications
Common Mistakes
Using RSI alone without laryngoscopic correlation
RSI is a symptom index, not a diagnostic test. Laryngoscopic findings (using the Reflux Finding Score) should complement RSI for a complete LPR assessment.
Attributing all throat symptoms to LPR based on high RSI
High RSI can occur in other conditions including post-nasal drip from allergic rhinitis, chronic cough from asthma, muscle tension dysphonia, and globus from anxiety. Consider alternative diagnoses.
Frequently Asked Questions
What is the difference between LPR and GERD?
How long does PPI therapy need to work for LPR?
Can RSI be used to monitor treatment?
References
- Belafsky PC, Postma GN, Koufman JA. Validity and reliability of the Reflux Symptom Index (RSI). J Voice. 2002;16(2):274-277. PubMed
- Belafsky PC, Postma GN, Koufman JA. Laryngopharyngeal reflux symptoms improve before changes in physical findings. Laryngoscope. 2001;111(6):979-981. PubMed
- Lechien JR, Saussez S, Muls V, et al. Laryngopharyngeal reflux: a state-of-the-art review. Ear Nose Throat J. 2020;99(1_suppl):3S-15S.