Laryngopharyngeal reflux (LPR); Leukoplakia

Question 1

Describe what is meant by LPR and what causes it [1]

Answer 1

Laryngopharyngeal reflux (LPR) is a condition caused by gastro-oesophageal reflux resulting in inflammatory changes to the larynx/hypopharynx mucosa. It is a common diagnosis and thought to account for around 10% of ear, nose and throat referrals
- Dysfunction of the lower oesophageal sphincter (LES): Incompetence or transient relaxation of the LES allows gastric contents to reflux into the oesophagus and pharynx
- In LPR, transient relaxations or structural incompetence of the LES allow acidic and non-acidic gastric contents to ascend into the oesophagus.
- As these contents move proximally, they may traverse past an incompetent upper oesophageal sphincter (UES). The UES typically functions as a secondary barrier, protecting the laryngopharyngeal structures from exposure to refluxate. When this barrier fails, gastric contents can reach sensitive mucosal surfaces in the larynx and pharynx.

Question 2

Describe the clinical features of LPR [+]

Answer 2

around 50% of patients have the sensation of a lump in the throat ‘globus pharyngeus’
* typically felt in the midline
* typically worse when swallowing saliva rather than eating or drinking

hoarseness (70%)
chronic cough (50%)
dysphagia (35%)
heartburn (30%)
sore throat

Question 3

What examination findings would suggest LPR [2]

Answer 3

examination findings
* the external examination of the neck should be normal, with no masses
* the posterior pharynx may appear erythematous

Question 4

Dx of LPR? [1]

Answer 4

Diagnosis
* in the absence of red flags a clinical diagnosis of LPR can be made without further investigations
*

Question 5

Diagnosis
* in the absence of red flags a clinical diagnosis of LPR can be made without further investigations
* the NICE cancer referral guidelines should be reviewed for red flags, examples of which include [3]

Answer 5

the NICE cancer referral guidelines should be reviewed for red flags, examples of which include:
* persistent, unilateral throat discomfort
* dysphagia, odynophagia (i.e. with food rather than just saliva)
* persistent hoarseness

Question 6

How do you compare LPR to Eosinophilic Oesophagitis (EoE)? [1]

Answer 6

The hallmark histological finding on endoscopic biopsy is >15 eosinophils per high power field which is absent in LPR.

Question 7

It’s hard to differentiate LRP and GERD.

What might indicate difference? [1]

Answer 7

However, nocturnal symptoms are more common in LPR than in GERD due to the absence of swallowing during sleep which normally helps clear any refluxate from the oesophagus.

Question 8

Mx for LPR? [3]

Answer 8

Management
* lifestyle measures
* possible triggers include fatty foods, caffeine, chocolate and alcohol
* proton pump inhibitor
* sodium alginate liquids (e.g. Gaviscon)

Question 9

How do you manage leukoplakia? [3]

Answer 9

Risk Factor Modification:
* Smoking Cessation: Encourage patients to quit smoking through counselling, nicotine replacement therapy or pharmacological interventions.
* Alcohol Reduction: Advise patients on reducing alcohol intake within recommended limits.

Biopsies are usually performed to exclude alternative diagnoses such as squamous cell carcinoma and regular follow-up is required to exclude malignant transformation to squamous cell carcinoma, which occurs in around 1% of patients.

Question 10

Describe what is meant by Ludwig’s angina [2]

Answer 10

Ludwig’s angina is a type of progressive cellulitis that invades the floor of the mouth and soft tissues of the neck. Most cases result from odontogenic infections which spread into the submandibular space.

It is a life-threatening emergency as airway obstruction can occur rapidly as a result. Urgent medical treatment and airway assessment is required.