‘Silent Reflux’: A Different Kind of Acid Reflux

If you have a chronic cough, difficulty swallowing, or other persistent symptoms that seem to arise from your throat, your problem may be related to acid reflux—even if you’re not a classic heartburn sufferer. It might be laryngopharyngeal reflux (LPR), often called “silent reflux.” LPR shares some similarities with gastroesophageal reflux disease (GERD), which causes heartburn. But unlike GERD sufferers, people with LPR usually don’t experience a burning sensation in the chest—rather, there may be a bitter taste or burning sensation in the back of the throat.

Besides coughing and swallowing problems, the most common symptoms of LPR are excessive throat clearing, hoarseness, and a feeling of having a lump in the throat. Asthma and chronic sinusitis, especially when first appearing in adulthood, may be from LPR; dental enamel erosion is another possible consequence. In some cases, people with LPR develop chest tightness or wheezing. Some even experience an occasional spasm in the voice box, leaving them briefly unable to breathe.

Though silent reflux may be only mildly annoying for many people, in other cases, it can greatly impact quality of life. If you are experiencing symptoms of LPR, it’s important to have them evaluated since some can be quite serious, or they may be due to other conditions that can be treated.

Bad “valves”

LPR and GERD are both caused by weak sphincters. Sphincters are specialized parts of the upper and lower ends of the esophageal muscular wall that act like valves. GERD occurs when the sphincter that allows food to pass from the bottom of the tube-like esophagus into the stomach weakens or opens at the wrong time. That allows acid and enzymes (pepsin) from the stomach, and sometimes bile, to reflux, or flow upwards and splash up onto the lining of the esophagus, which can produce that burning sensation in the chest.

However, you also have a sphincter at the upper end of the esophagus that separates the esophagus and the pharynx (throat). If both these sphincters malfunction, LPR can result as caustic acid and enzymes wash up past the upper sphincter and onto the pharynx and larynx (voice box); sometimes microparticles refluxed from the stomach enter the lungs, which, over time, can produce enough inflammation and bronchospasm to cause asthma and a chronic cough and eventually may even cause chronic obstructive pulmonary disease (COPD). Unrecognized or uncontrolled acid reflux can also damage the upper sphincter and cause LPR.

It’s unclear why many people with LPR don’t also experience heartburn, but one idea is that if the acidic stomach content passes quickly through the esophagus it may not cause GERD, but if it pools in the throat around the larynx it can cause those more-sensitive tissues to become irritated.

From Dx to Tx

Doctors typically diagnose LPR by ruling out other potential causes of the symptoms, such as certain cancers, unless heartburn is present as a concurrent symptom. Initial assessments can be done by your primary care physician, who may refer you to an ear, nose, and throat specialist (ENT) or to a lung specialist (pulmonologist) for further evaluation. Tests that may help in diagnosing LPR include an endoscopy and assessing esophageal motility. Most useful is a measurement of intraesophageal pH (acidity) using a 24-hour pH monitor.

If LPR is suspected, medications called proton pump inhibitors (PPIs) may be recommended—at higher doses than required for treating ordinary GERD. Such drugs, which include esomeprazole magnesium (Nexium), lansoprazole (Prevacid), and omeprazole (Prilosec), work by reducing the amount of acid your stomach produces. Some studies have found that PPIs can ease symptoms related to LPR, but they may not always be effective. They should be tried for a minimum of three months (taken 30 to 60 minutes before breakfast and dinner) to see if they work. If so, you have to continue taking the medication to maintain the benefit, but a lower dose may be possible. Although LPR is rarely associated with severe esophagitis, a drug approved by the FDA in 2023 called vonoprazan (Voquezna) has been found to be more effective in healing this condition than PPIs. Studies are needed to determine if it is also useful in treating LPR.

Other acid-reducing medications called H2 blockers (such as famotidine, brand name Pepcid), also used for GERD, may be useful when taken before bed if PPIs don’t help enough, since H2 blockers reduce acid secretion better on an empty stomach. Antacids containing calcium, magnesium, or aluminum may help, too, particularly after consuming highly acidic foods and beverages (such as tomato sauce or coffee) and when taken a half hour before you exercise or go to sleep.

While you can get these medicines without a prescription, it’s important not to self-medicate symptoms of LPR without consulting your doctor. After all, the problem you’re treating may not be related to LPR, and these drugs aren’t necessarily benign. Some research suggests that long-term use of PPIs may increase the risk of bone fractures, heart problems, kidney disease, and other health concerns, though most of the studies are observational and don’t prove cause and effect. When PPIs are found to be effective in controlling LPR, the benefits outweigh the potential risks. By the way, if you’re wondering what happened to the H2 blocker ranitidine (Zantac and generics), it was pulled off the market in 2020 due to concerns that it contained a probable carcinogen.

Self-care steps

Making some lifestyle changes can also ease symptoms of LPR, just as they help GERD. Adding such measures to drug therapy may allow you to taper off the medication or at least reduce the dose.

• Avoid large meals. This may reduce reflux by preventing the stomach from becoming distended, which allows its contents to spill out and upward if the sphincters are weak. You may also want to make lunch your bigger meal of the day rather than dinner.
• If you smoke, here’s another reason to quit: The nicotine in tobacco weakens the lower esophageal sphincter.
• Lose weight if you are overweight or have recently gained weight unintentionally.
• Wait a few hours after eating to exercise. It’s okay to drink fluids before and during exercise as needed, but avoid consuming large amounts that could distend (or bloat) your stomach.
• Avoid food and drink for three hours before going to bed. Raising the head of your bed 6 to 8 inches may help, too; use blocks or a foam wedge, not pillows, for elevation.
• As with GERD, some people with severe LPR symptoms may benefit from surgical treatment to strengthen the lower esophageal sphincter (the upper sphincter is not amenable to surgical repair).