Laryngopharyngeal Reflux Disease in War-torn Syria and its Association with Smoking and other Risks.

doi:10.21203/rs.3.rs-29417/v1

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Research Article

Laryngopharyngeal Reflux Disease in War-torn Syria and its Association with Smoking and other Risks.

https://doi.org/10.21203/rs.3.rs-29417/v1

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Journal Publication

published 26 Nov, 2020

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Version 1

posted 20 May, 2020

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Backgrounds: Syria has entered its ninth year of conflict and as its medical sector facing major hurdles, laryngopharyngeal reflux (LPR) is often overlooked although it has an association with worsening quality of life and affecting many aspects as it is chronic and left untreated although it can lead to many complications such as dysphonia. This study is to evaluate LPR prevalence and its association with different aspects such as cigarette, and shisha smoking, and the effect of war on LPR.

Methods: Cross-sectional study by using online questionnaires that included demographics, smoking, war related questions and reflux symptom index (RSI) were used online in many cities around Syria.

Findings: This research included 734 responders with 75.5% being female and the mean age being 23.97 years. 31.9% of subjects had symptoms suggestive of LPR. Participants were Syrians and we included every responder who agreed and did not neglect any question. We only found that being distressed from war noises was associated with positive LPR symptoms [P=0.009 (OR, 1.562; 95% CI 1.117-2.183)], but losing someone or changing place of living due to war were not associated with LPR. LPR was associated with cigarette smoking (P<0.05). Finally, having asthma, and male gender in the younger population were associated with LPR (P<0.05). No clear association with age, or shisha and no significant associations were found with consanguinity, marital status, educational level and SES.

Interpretations: About one third had LPR symptoms. War distress from war noise, cigarette smoking, asthma, and allergic were significantly correlated with LPR.

Otorhinolaryngology

General Practice

laryngopharyngeal reflux

reflux symptom index

war

stress

prevalence

GORD

Laryngopharyngeal reflux (LPR) is when this retrograde flow reaches the laryngopharynx and interacts with the tissue in the upper aerodigestive tract. LPR is one of the most common extra-oesophageal complications of Gastro-oesophageal reflux medical condition (GORD) (1). Data has shown 60% of GORD patients have LPR symptoms (2). Furthermore, it is still debatable whether to consider LPR as an atypical presentation of GORD or to consider LPR as an independent medical condition (3). Symptoms in patients with posterior laryngitis and pharyngeal reflux, and dual sensor pH probe could not predict the severity of symptoms (4). Nevertheless, patients’ visits to the otolaryngologist were increased by 500% due to LPR (5). Dysphonia can also be found in around half of patients with LPR.

Many laryngeal medical conditions are speculated to be caused by LPR, such as laryngitis and laryngeal carcinoma, subglottic stenosis, granulomas, contact ulcers and vocal cord nodules in the larynges. Although LPR is common, the diagnosis was widely debated as no definitive inclusion and diagnosis criteria is available. Much of the data about diagnosis and treatment is still controversial. From the otolaryngologists’ perspective, LPR is diagnosed when proton pump inhibitors (PPIs) result in symptoms resolution (6). While others use scoring systems to evaluate the possibility of LPR (6), such as reflux symptom index (RSI) which is a useful tool that uses a scoring system for LPR. It is used to assess the possibility of having LPR (7, 8). A score greater than 13 is suggestive for an empirical therapeutic trial which includes a change in diet and lifestyle and implementing high doses of PPI (6).

Syria has entered its ninth year at the time of survey with over 80% living under poverty line and a deteriorating economic status that imposed a challenge to the healthcare sector which suffered from lack of adequate staff and equipment. Living in Syria may expose its residents to unusual substances chronically either from smoking shisha which is quite common, drinking mate, the unique environment, and war exposure as it exposes to different substances (9, 10). Allergic rhinitis prevalence was found to compose around half of the population (11) with a high prevalence of distress from war (12). LPR has a wide variety of symptoms of laryngeal irritation such as coughing having a sore throat, hoarseness, dysphonia and even globus pharyngeus (13). Patients with LPR might suffer for a long time if the diagnosis is not promptly made as most symptoms and signs are unspecific and can be speculated as other aetiologies such as from voice abuse, irritants such as smoking and alcohol and many others which raise the importance of studying LPR. LPR is not well-studied in developing countries although it has a very high prevalence which shows the importance of conducting this study in our developing region. We aim to estimate LPR prevalence and its association with different factors.

Our cross-sectional study was based on online surveys to collect the data in the period between 26/03/2019 and 26/04/2019 and it covered all cities in Syria.

Every responder aged 16 and more was enrolled provided that he/she replied to each question and was Syrian. Informed consent was taken for participating in the research, and for using and publishing of the data.

We asked basic demographic questions such as gender, age, educational level, province of current living and having consanguineous parents. Socioeconomic status (SES) was assessed by using three questions; the education of the person or the working family member, monthly family income and the profession. As a result, SES was divided into 5 different categories: lower, upper-lower, lower-middle, upper-middle, and upper.

We used a form of RSI which was validated in Arabic (14). RSI is a self-administered questionnaire that relies on a scoring system for symptoms that evaluate the possibility of LPR (7, 8). These symptoms include hoarseness, throat clearing, and mucus in the throat, difficulty of swallowing, coughing after lying down or eating, difficulties of breathing, annoying cough, globus pharyngeus and heartburn. The scale ranges from 0 when answering “no problem” to 5 when answering “severe problem” for each item. The total score ranges from 0 to 45. The cut-off point was 13 or more to suggest the possibility of LPR (8).

Possible confounders were having common symptoms with other medical conditions, and that most of the subjects had to do the questionnaire online which limits the population. Another confounder was that most of the sample was from major cities rather than being homogenously from all across Syria. We asked a few questions, directly and indirectly about war, including change of place of living due to war, losing someone close, and being distressed of war noises. Respiratory diseases in this study were defined as chronic bronchitis, and chronic obstructive pulmonary medical condition (COPD). Education in the medical field included medicine, dentistry, and pharmacy. Social science included faculties of law, education, economy, literature and arts. We defined low educational level as having a high school degree or lower.

Allergy reactions are defined as having food or skin-related allergy. Specialist is defined as having a degree and working such as a doctor, and engineer. Technician is a worker with an institute degree. Labourer is a worker without a degree such as a builder and porter. We asked the patient to declare having any medical condition or using medication. We asked two simple questions about smoking “do you regularly smoke cigarettes” and another question “do you regularly smoke shisha”.

There were 816 responders, 734 of which were enrolled. Data was processed using IBM SPSS software version 26 for Windows (SPSS Inc, IL, USA). Chi-square and one-way ANOVA tests were performed to determine statistical significance between the groups. Pearson correlation was also used. We calculated odds ratios (ORs) and the 95% confidence intervals for the groups using Mantel–Haenszel test by using the same software. Values of less than 0.05 for the two-tailed P values were considered statistically significant. Any responder with missing data in the RSI or basic demographic questions was excluded. However, in other questions, responders with missing data were removed when comparing variables.

Although 776 responded to the survey, the sample had 734 subjects as some replied had invalid responses or left essential questions unanswered with 94.6% response rate. The sample comprised of 24.5% being male and 75.5% being female. The mean age was 23.97 ± 6.589 years. Age group of (18-30) constituted 88.3% of the subjects. Characteristics of the subjects are demonstrated in Table 1. Also, 31.9% of subjects had a possible LPR using RSI questionnaire. Other characteristics of the war, current medical conditions and medication, and reflux symptoms index for the subjects are demonstrated in Table 2. LPR prevalence was 31.9% (CI 95%: 28.2-35.4). In patients with LPR, males comprised of 20.5% (CI 95%: 15.4-26.1), females comprised of 79.5% (CI 95%: 73.9-84.6), cigarette smoking comprised of 21.4% (CI 95%: 16.2-26.9) shisha smoking comprised of 33.3% (CI 95%: 27.4-39.7), subjects with asthma comprised of 4.3% (CI 95%: 2.1-7.3), and subjects with allergic reactions comprised of 8.1% (CI 95%: 4.7-12).

Comparisons between subjects of negative and positive RSI are demonstrated in Table 3. Females had LPR more frequently than males, but with no statistical significance P=0.084 (OR, 1.390; 95% CI 0.956-2.021). However, age group younger than 30 years had lower rates of LPR P=0.012 (OR, 0.534; 95% CI 0.325-0.877) than subjects in the age group of older than 30 years. Subjects who reported they were distressed from war noises had LPR more frequently P=0.009 (OR, 1.562; 95% CI 1.117-2.183). Subjects who reported having LPR also reported having other medical conditions more frequently P=0.003 (OR, 1.843; 95% CI 1.223-2.780), such as asthma P>0.0001 (OR, 13.750; 95% CI 2.969-63.690), allergic reactions P=0.001 (OR, 3.074; 95% CI 1.545-6.115) and pulmonary medical conditions P=0.029 (OR, 5.500; 95% CI 0.994-30.428). Furthermore, regularly smoking cigarettes was correlated with having LPR P=0.002 (OR, 1.920; 95% CI 1.273-2.894). This was the case with shisha smoking but the result was insignificant P=0.126 (OR, 1.299; 95% CI 0.929-1.815). However, regularly smoking shisha and cigarette together was correlated with LPR more frequently when compared to all other subjects P=0.001 (OR, 2.323; 95% CI 1.395-3.869). Furthermore, a statistically significant difference was found when comparing RSI score and smoking cigarettes P<0.0001, smoking shisha P=0.035, and smoking them both P<0.0001 as smoking had higher RSI scores suggesting more symptoms of LPR. Nevertheless, no statistically significant difference was found when comparing having LPR or not with current place of living, consanguinity, marital status, education level, SES, being employed, type of work, losing someone close, or changing place of living due to war P>0.05. There was a weak negative correlation found when comparing RSI score and SES (r = - 0.075). However, no correlation was found when comparing RSI score with age and number of times changing living due to war P>0.05 and when one-way ANOVA test was used, SES classification did not correlate with RSI scores P>0.05.

Comparing the subjects, aging (18- 30) years with having LPR or not is demonstrated in Table 4. In this age group, females had more LPR (P=0.044) than males. Subjects who were involved in the medical field had LPR less frequently (P=0.033). In addition, being distressed from war noises was correlated with LPR more frequently (P=0.007). Smoking was correlated with having LPR for either cigarette smoking P<0.0001 (OR, 2.410; 95% CI 1.545-3.759), shisha smoking P=0.022 (OR, 1.504; 95% CI 1.058-2.137) or smoking both P=0.0001 (OR, 2.803; 95% CI 1.632-4.815). In addition, higher RSI scores were associated with smoking cigarettes P<0.0001, smoking shisha P=0.007, and smoking both P<0.0001. However, in this age group of (18-30) years, education level, marital status, SES, being employed, type of work, losing someone close and changing place of living due to war were not correlated with LPR.

The mean score of RSI of all subjects was 10.50 ± 9.022 (CI 95%: 8.467-9.584). The mean score of reflux symptoms index of subjects aging (18-30) years was 10.21 ± 8.114 (CI 95%: 9.55-10.86). The mean score of reflux symptoms index in subjects with positive LPR was 21.34 ± 7.533 (CI 95%: 20.38-22.34). The mean score of each question of the index in subjects with positive LPR is demonstrated in Table 5. The mean score of RSI in shisha smoking subjects was 11.43 ± 9.666 (CI 95%: 10.14-12.74), and the mean score of RSI of shisha smoking subjects aging (18-30) years was 11.36 ± 9.364 (CI 95%: 10.04-12.83). The mean RSI score in each province with gender prevalence is shown in Figure 1.

When using forward linear regression on RSI score with smoking cigarettes or not, smoking shisha or not, being distressed from war noises, gender, age, having asthma and\or allergic reaction or not, (P<0.001) for asthma and allergic reaction (R²=3.4%), for cigarette smoking (R²==3.1%), and for being distressed from war noises (R²=2.2%). When applying the same model but with using any chronic condition instead of asthma, (P<0.001) for chronic medical condition (R²=3.3%), for cigarette smoking (R²=3.1%) and for being distressed from war noises (R²=2.1%). When excluding age variable and applying the same regression on subjects aged (18-30) years, (P<0.001) for cigarette smoking (R²=4.9%), for being distressed from war noises (R²=2.6%), and for having asthma and/or allergic reaction (R²=2%).

When applying the same model (forward linear regression on RSI score with smoking cigarettes or not, smoking shisha or not, being distressed from war noises, gender, age, having asthma and\or allergic reaction or not) but with one variable for smoking (smoking shisha, cigarette, both and none), (P<0.001) and (R²=2%) for smoking, and when excluding age variable and applying the previous model on subjects aging (18-30) years, (P<0.001) for smoking shisha, cigarette, both, or none (R²=3%), for being distressed from war noises (R²=2.4%), and for having asthma and/or allergic reactions (R²=2%).

However, females were shown to be more affected by reflux symptoms such as heartburn (15) which is not similar to our findings as no significant different was found in females having LPR. Meanwhile, there are conflicting reports on the effect of smoking (16). Although smoking might not be a dominant risk factor, it was suggested that smoking cessation with appropriate pharmacological therapy might be beneficial in curing severe GORD (17) and it is evident that smoking cessation should be recommended for GORD patients (18). In our study, smoking cigarettes was correlated with higher RSI scores suggesting more LPR symptoms with the result that cigarette smoking itself can be speculated as a causal factor for these upper aerodigestive tract symptoms. This correlation did not exist with shisha in our study. Moreover, GORD was found to be correlated with respiratory diseases and asthma (19) which is similar to our findings for LPR.

In one study, a large number of patients with LPR were suggested to be struggling from higher rates of depression which should be considered when managing LPR (20) and they had a lower health-related quality of life. In addition, the yearly income is shown to be a risk factor for GORD and it was observed that the quality of life in those with GORD symptoms is lower when compared to the general population (21). Most importantly, psychological factors are linked to the deterioration of the symptoms of GORD (22). It was also found that quality of life declined depending on the severity of LPR regardless of marital status and household income (23). The high prevalence of smoking may be a factor of the high prevalence of LPR in Syria (9), mainly that there are no strong regulations to prevent smoking, causing a high exposure to second-hand smoking which could not be measured in our study. Another theory is that as allergic rhinitis is very common in Syria (11), and that allergic rhinitis and LPR may be correlated (24) which could explain this finding. We also speculate that the high psychological stress that Syrians face with high prevalence of severe mental disorder from war (12), this could cause dyspepsia and exaggerating of GORD symptoms which can mimic LPR. Similarly, we found in our study that being distressed from war noises was correlated with a higher frequency for LPR, suggesting that quality of life and psychological factors could also have contributed to our findings. The rest of war-related factors and marital status were not significantly correlated with LPR. LPR had a higher frequency among subjects who had a job but the result was not statistically significant. Type of work was not significantly correlated with LPR, suggesting that working environment had no direct effect on LPR incidence in our study.

Furthermore, other studies found that GORD symptoms increased with low income and educational level (25). These observations can be explained that people from a lower SES tend to have a lifestyle that encourages GORD. Despite adjusting for BMI and smoking, low or middle SES doubled the risk for severe symptoms of GORD (26). Lower SES and educational level in our study were more frequent among LPR subjects but there was not statistically significant.

When LPR is not treated, it may lead to scarring of the true vocal folds especially with chronic vocal abuse. LPR is also correlated with untreated GORD and Barret oesophagitis which is cancerous (27). GORD symptoms precede the diagnosis of cancer in about 60% of patients with oesophageal adenocarcinoma. In the same study, the odds ratio for oesophageal adenocarcinoma was 43.5 in individuals with long-standing and severe symptoms of reflux (28). As there is a dramatic increase in the incidence of carcinoma of the distal, there is an urgent need for early recognition and treatment of GORD and the medical conditions associated with it.

We found a significant decrease in RSI scores in subjects in the medical field, suggesting that these symptoms tend to be less frequent in this group possibly due to prior awareness of such symptoms. The rest of the educational fields were not significantly correlated with LPR. Subjects aging 30 years and more had higher RSI scores than the younger subjects. However, it is suggested that elderly people might have a higher baseline RSI (29) but another study found that patients in the older groups had significantly lower RSI (30). However, we did not find a clear association with LPR and age.

In conclusion, diagnosing LPR raises a challenge that makes it usually overlooked as it has a wide range of unspecific symptoms which further increases the challenge for diagnosis as we need a proper diagnostic approach to ameliorate patient care and prevent LPR and its complications especially in high-risk environments. War exposure, mainly distress, may increases the symptoms of LPR by a variety of ways which need further studies to be identified.

We could not eliminate many of the biases and confounders due to scarce resources. However, if these factors were taken into account, the LPR prevalence would probably be even higher. Nevertheless, there are no many reliable tools to estimate LPR. This study despite its simplicity reflects a problem that causes a lot of distress in huge populations which add even more to the suffering of war. Furthermore, LPR should be further studied worldwide, especially at distress times as it can be an undetected problem that rises in such events. We could not include the severity of allergic reaction or asthma in this study and we could not follow with medical diagnosis. The sampling was made online which made it hard to determine the sample. However, this method was the most convenient due to the financial hurdles and this method ensure accessibility and anonymity for participants which is a big issue in Syria, mainly when asking questions regarding war.

Ethics approval and consent to participate:
Online informed consent was taken before proceeding with the survey for participating in the research, and for using and publishing the data. We assured to maintain confidentiality and asked no questions that might reveal the person’s identity. No subjects were under age of 14. For subjects under age of 18 years, an online informed consent was taken that the guardian agreed that the subjects can participate in the survey as this method was agreed in the study protocol.

Our study protocol and ethical aspects were reviewed and approved by Damascus University deanship, Damascus, Syria.

Consent for publication:
Online consent for using and publishing the data were taken before participating in the research.

Availability of data and materials:
The data can be made available upon reasonable request.

Competing interests:
We have no conflict of interest to declare.

Funding:
We received no funding in any form.

Author contribution: Ameer Kakaje MD: Conceptualization; Data curation; Formal analysis; Investigation; Methodology; Project administration; Supervision; Validation; original draft; Writing - review & editing. Mohammad Alhalabi MD: Data curation; Formal analysis; Software; original draft; Writing - review & editing. Ayham Alyousbashi MD: Software; Methodology; Conceptualization; Validation; Writing editing; investigation. Aya Hamid MD: Conceptualization; original draft; Writing – review. Yousef Mahmoud MD: Project administration; Writing editing; investigation. We did not receive any support in forms of grants, equipment or drugs. The study design was a cross-sectional study with an online questionnaire that asked demographic questions and used a validated tool (reflux symptom index) to assess for laryngopharyngeal reflux disease and its associated factors with some questions related to shisha and cigarette smoking and war-related questions.

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TABLE 1

Characteristics of the subjects

Characteristic

Frequency (n=734)

Percentage%

Age

0 – 17

18 - 30

31 – 45

46+

648

2.0

88.3

7.8

1.9

Gender

Male

Female

180

554

24.5

75.5

Place of living

Damascus, Rif-Dimashq, and Aleppo

Homs and Hama

Al-Jazira region

Southern Syria

Syrian coast

Idlib

474

102

70.0

15.1

0.4

2.7

11.2

0.5

Educational level

Primary School

High School

College or higher institute certificate

Masters or PhD

575

114

0.1

5.7

78.6

15.6

Smoking Cigarettes

Yes regularly

622
112

84.7

15.3

Smoking Shisha

No
Yes regularly

517

217

70.4

29.6

SES Level

Lower

Upper Lower

Lower Middle

Upper Middle

Upper

151

177

372

1.9

20.6

24.1

50.7

2.7

Employment

Unemployed

Employed

474

258

648

35.2

Social Status

Single

In a relationship

Engaged

Married

Divorced

Widowed

598

82.0

0.7

4.8

11.8

0.4

0.3

TABLE 2

Other characteristics of war, current medical conditions and medications, and reflux symptoms index results for the subjects

Characteristic

Frequency

Percentage%

Changing area of living

Yes, but not due to the war

Yes

362

140

223

49.9

19.3

30.8

A relative being endangered by the war

Yes

228

502

31.2

68.8

Losing someone due to the war

Yes

417

312

57.2

42.8

Being distressed from the war noises

Yes

263

468

36.0

64.0

Medical conditions

Pulmonary

Cardiac

Endocrine

Urinary

Neurological

Skeletal

Asthma

Allergic reaction

435

72.4

1.0

2.0

8.8

1.2

3.3

2.0

6.0

Drugs

Yes, some supplements

Yes, over the counter drugs

Yes, prescribed drugs

394

163

59.3

5.6

10.5

24.5

Possibility for LPR

Yes

500

234

68.1

31.9

TABLE 3

Comparisons between Subjects with Negative and Positive Reflux Symptoms Index.

Characteristic

Positive Reflux

Symptoms

Percentage (CI 95%)

Negative Reflux

Symptoms

Percentage (CI 95%)

P value

Gender

Male
Female

48
186

20.5
79.5

132
368

26.4
73.6

0.084

Consanguinity

Negative
Positive

176
40

81.5
18.5

374
81

82.2
17.8

Marital status

Single
Non-single

184
49

79.0
21.0

414
82

83.5
16.5

Educational level

Low
High

19
214

8.2
91.8

24
475

4.8
95.2

Cigarette smoking

No
Yes daily

184
50

78.6
21.4

438
62

87.6
12.4

0.002

Shisha smoking

No
Yes regularly

156
78

66.7
33.3

361
139

72.2
27.8

Smoking both shisha and cigarettes

No
Yes regularly

201
33

85.9
14.1

467
33

93.4
6.6

0.001

SES

Low
Medium
High

57
172
3

24.6
74.1
1.3

104
377
17

20.9
75.7
3.4

0.286
0.120

Age groups

0-17
18-30
31-45
46+

9
193
25
7

3.8
82.5
10.7
3.0

6
455
32
7

1.2
91.0
6.4
1.4

0.005*

Working

Unemployed

Employed

138
95

59.2
40.8

336
163

67.3
32.7

0.087

Type of work

Labourer
Clerk or in a restaurant
Technician
Specialist
Employee

8
10
31
76
6

6.1
7.6
23.7
58.0
4.6

11
11
51
35
5

9.7
9.7

45.1
31.0
4.4

Medical conditions except gastro

Negative

Respiratory
Cardiac
Endocrine
Urinary
Neurological
Skeletal
Asthma
Allergic reaction

115
4
4
11
3
10
10
10
19

61.8
2.2
2.2
5.9
0.3
5.4
5.4
5.4
10.2

319
2
8
42
4
10
10
2
16

77.2
0.5
1.9
10.2
1.0
2.4
2.4
0.5
3.9

<0.0001^#

Losing someone close due to war

No
Yes a loved one or a close friend
Yes a relative

68
2
98

40.5
1.2
58.3

149
3
187

44.0
0.9
55.2

Distressed from war noises

Negative
Positive

68
165

29.2
70.8

195
303

39.2
60.8

0.009

Changing place of living due to war

Negative
Positive

116
115

50.2
49.8

246
248

49.8
50.2

NS: Not significant

* This P value is among all age groups. However, P= 0.012 when comparing age groups (0-30) years with older than 30 years and P=0.008 when comparing age group (18-30) years with older than 30 years.

# P value when comparing having other diseases or not was P=0.003.

TABLE 4

Comparing subjects aging 18 – 30 with positive or negative LPR

Characteristic

Positive Reflux

Symptoms

Percentage (CI 95%)

Negative Reflux

Symptoms

Percentage (CI 95%)

P value

Gender

Male
Female

37
156

19.2
80.8

121
334

26.6
73.4

0.044

Educational Level

Low
High

8
185

4.1
95.9

14
440

3.1
96.9

Marital status

Single
non-single

161
31

83.9
16.1

396
56

87.6
12.4

Cigarette smoking

No
Yes daily

157
45

77.2
22.3

412
49

89.4
10.6

<0.0001

Shisha smoking

No
Yes regularly

128
74

63.4
36.6

333
128

72.2
27.8

0.022

Smoking both shisha and cigarettes

No
Yes regularly

171
31

84.7
15.3

433
28

93.9
6.1

0.0001

SES

Low
Medium
High

38
149
3

20
78.4
1.6

88
346
16

19.6
76.9
3.6

Employment

Unemployed

Employed

123
69

64.1
35.9

318
136

70.0
30.0

Type of Work

Labourer
Clerk or in a restaurant
Technician
Specialist
Employee

4
8
21
29
3

6.2
12.3
32.3
44.6
4.6

8
10
44
64
3

6.2
7.8
34.1
49.6
2.3

Field of education

Medical
Non-medical

90
86

51.1
48.9

261
170

60.6
39.4

0.033

Social science
Non-social science

50
126

28.4
71.6

96
335

22.3
77.7

Losing someone close due to war

No
Yes a loved one or close friend
Yes a relative

111
1
80

57.8
0.5
41.7

282
1
169

62.4
0.2
37.4

Distressed from war noises

Negative
Positive

54
136

28.4
71.6

178
270

39.7
60.3

0.007

Changing place of living due to war

Negative
Positive

137
53

72.1
27.9

307
143

68.2
31.8

CI: Confidence interval. NS: Not significant.

TABLE 5 Mean scores of each reflux symptom index question in patients with positive LPR.
Characteristic	Mean ± SD	CI (95%)
Sore Throat	1.75 ± 1.510	1.376 – 1.631
Sputum Production	2.60 ± 1.468	1.358 – 1.569
Excessive Secretions	2.54 ± 1.581	1.467 – 1.671
Dysphagia	1.84 ± 1.649	1.532 – 1.754
Coughing after Eating, Sleeping or Laying Down	2.74 ± 1.626	1.518 – 1.721
Breathing Difficulties	2.26 ± 1.659	1.548 – 1.765
Extreme Coughing Episodes	2.69 ± 1.692	1.580 – 1.787
A Sense of a Foreign Body in Throat	2.50 ± 1.667	1.562 – 1.756
Epigastric Burning Sense, Chest Pain, Indigestion, GORD	2.64 ± 1.824	1.728 – 1.910

CI = confidence interval.

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Laryngopharyngeal Reflux Disease in War-torn Syria and its Association with Smoking and other Risks.

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