Validated Clinical Score to Predict Gastroesophageal Reflux in Patients With Chronic Laryngeal Symptoms: COuGH RefluX

Amanda J. Krause, Alexander M. Kaizer, Dustin A. Carlson, Walter W. Chan, Chien Lin Chen, C. Prakash Gyawali, Andrew Jenkins, John E. Pandolfino, Vinathi Polamraju, Ming Wun Wong, Madeline Greytak, Rena Yadlapati

Research output: Contribution to journalArticlepeer-review

1 Scopus citations


Background & Aims: Discerning whether laryngeal symptoms result from gastroesophageal reflux is clinically challenging and a reliable tool to stratify patients is needed. We aimed to develop and validate a model to predict the likelihood of gastroesophageal reflux disease (GERD) among patients with chronic laryngeal symptoms. Methods: This multicenter international study collected data from adults with chronic laryngeal symptoms who underwent objective testing (upper gastrointestinal endoscopy and/or ambulatory reflux monitoring) between March 2018 and May 2023. The training phase identified a model with optimal receiver operating characteristic curves, and β coefficients informed a weighted model. The validation phase assessed performance characteristics of the weighted model. Results: A total of 856 adults, 304 in the training cohort and 552 in the validation cohort, were included. In the training phase, the optimal predictive model (area under the curve, 0.68; 95% CI, 0.62–0.74), was the Cough, Overweight/obesity, Globus, Hiatal Hernia, Regurgitation, and male seX (COuGH RefluX) score, with a lower threshold of 2.5 and an upper threshold of 5.0 to predict proven GERD. In the validation phase, the COuGH RefluX score had an area under the curve of 0.67 (95% CI, 0.62–0.71), with 79% sensitivity and 81% specificity for proven GERD. Conclusions: The externally validated COuGH RefluX score is a clinically practical model to predict the likelihood of proven GERD. The score classifies most patients with chronic laryngeal symptoms as low/high likelihood of proven GERD, with only 38% remaining as indeterminate. Thus, the COuGH RefluX score can guide diagnostic strategies and reduce inappropriate proton pump inhibitor use or testing for patients referred for evaluation of chronic laryngeal symptoms.

Original languageEnglish
JournalClinical Gastroenterology and Hepatology
StateAccepted/In press - 2024


  • Diagnosis
  • Esophageal pH Monitoring
  • Esophagus
  • Laryngopharyngeal Reflux


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