Laryngopharyngeal reflux (LPR)

Laryngopharyngeal reflux (LPR) is a common condition

• accounts for approximately 10% of all “ear, nose and throat” (ENT) referrals (1)
  
  
• caused by gastric contents passing up through the oesophagus and upper oesophageal sphincter
  • causes macroscopic and microscopic inflammatory changes to the upper aerodigestive mucosa (2)
  • LPR is defined as the retrograde flow of stomach content to the larynx and pharynx whereby this material comes in contact with the upper aerodigestive
    tract
    • in contrast, gastro-oesophageal reflux disease (GORD) is the flow of stomach acids back into the oesophagus
  • cause of laryngeal damage is uncertain
    • likely to comprise a combination of acid and reflux components, particularly pepsin
      • pepsin is associated with nonacid or weakly acid reflux
        • pepsin remains stable in laryngeal tissues and is reactivated by subsequent reflux or by dietary acids
          
          
• most commonly leads to the sensation of a lump in the throat, termed globus pharyngeus
  
  • other symptoms include chronic throat clearing, excessive mucus, vocal hoarseness, and cough
  • LPR classically occurs when swallowing saliva and not when eating or drinking
• main diagnostic methods currently used are laryngoscopy and pH monitoring
  • most common laryngoscopic signs are redness and swelling of the throat
  • findings are not specific of LPR and may be related to other causes or can even be found in healthy individuals
  • role of pH monitoring in the diagnosis of LPR is controversial
  • empirical therapy with PPIs has been widely accepted as a diagnostic test and for the treatment of LPR
    
    
• LPR has been implicated in the aetiology of many laryngeal diseases such as reflux laryngitis, subglottic stenosislaryngeal carcinoma, granulomas, contact ulcers, and vocal nodules (3,4)
  
  
• Management
  • dietary changes and changes in habits such as weight loss, quitting smoking, avoiding alcohol, and not eating immediately before bedtime
    • dietary restrictions include caffeine, chocolate, gasified beverages, fat, tomato sauce, and red wine (5,6)
  • medication
    • first line treatments include proton pump inhibitors and sodium alginate liquids (2)
    • H2 antagonists are less effective at controlling LPR symptoms than PPIs or sodium alginate (2)
  • a cancer pathway referral should be considered if there are associated persisting symptoms including pain, swallowing difficulty, or change in voice (2)
  • assessing response to management:
    • if no response or worsening symptoms, check lifestyle and medication adherence, review the diagnosis, and consider referral to an ENT outpatient clinic for endoscopic examination of the throat
    • if only a partial response, discuss whether to continue with existing medication, try a different medication, or refer for an ENT assessment
    • if complete resolution of symptoms, stop PPI treatment at three months
    • if symptoms of LPR recur after a trial without PPIs
      • then consider longterm PPI therapy after discussion of the potential long term risks and alternatives such as alginates and dietary modifications

Reference:

• Koufman JA. The otolaryngologic manifestations of gastroesophageal reflux disease (GERD): a clinical investigation of 225 patients using ambulatory 24-hour pH monitoring and an experimental investigation of the role of acid and pepsin in the development of laryngeal injury. Laryngoscope 1991;101(Suppl 53):1-78. doi: 10.1002/lary.1991.101.s53.1 pmid: 1895864
• Hamilton NJI et al. 10 minute consultation - A lump in the throat: laryngopharyngeal reflux. BMJ 2020;371:m4091 http://dx.doi.org/10.1136/bmj.m4091
• Koufman JA. The otolaryngologic manifestations of gastroesophageal reflux disease (GERD): a clinical investigation of 225 patients using ambulatory 24-hour pH monitoring and an experimental investigation of the role of acid and pepsin in the development of laryngeal injury. Laryngoscope 1991; 101(4 Pt 2, Suppl 53):1–78
• Belafsky PC, Postma GN, Koufman JA. Validity and reliability of the reflux symptom index (RSI). J Voice 2002;16:274–277
• Ford CN. Evaluation and management of laryngopharyngeal reflux. JAMA 2005;294:1534–1540
• BoveMJ, Rosen C. Diagnosis and management of laryngopharyngeal reflux disease. Curr Opin Otolaryngol Head Neck Surg 2006;14:116–123