Laryngopharyngeal Reflux (“Silent Reflux”): The Basics

This photo shows reflux laryngitis (LPR)

Photo of voice box with reflux laryngitis (LPR)

Laryngopharyngeal Reflux (LPR) aka “Silent Reflux”

LPR Can Cause:
Chronic Cough
Trouble Swallowing
Too Much Throat Mucus
A Lump in the Throat
Post-Nasal Drip

What Is Reflux and What Is LPR?

The term REFLUX comes from a Greek word that means “backflow.” It refers to “the back flow of stomach contents.” Normally, once the things that we eat reach the stomach, digestion should begin without the contents of the stomach coming back up again, i.e., refluxing. Some people have reflux just into the esophagus (the swallowing tube that joins the throat to the stomach). If this happens frequently, a person may develop heartburn, (a painful, burning sensation in the chest). This condition is called gastroesophageal reflux disease (GERD). In some people, the backflow from the stomach goes all the way up to the throat. That is LPR.

The term LARYNGOPHARYNGEAL REFLUX (LPR) refers to the backflow of stomach contents into the larynx and pharynx (the voice box and throat). LPR can occur during the day or night, and many people who have LPR will not have heartburn; so LPR is sometimes called silent reflux.

Many People with LPR Don’t Have Heartburn, Why Is That?

Some people with LPR have a lot of heartburn, but usually, people who have LPR don’t have heartburn very often. In fact, more than half of people who have LPR never have heartburn. This is because the material that refluxes does not stay in the esophagus for very long. In other words, the acid does not have enough time to irritate the esophagus. However, if even small amounts — the refluxate comes all of the way up into the throat – throat problems can occur. This is because, compared to the esophagus, the voice box and throat are much more sensitive to injury and irritation from reflux compared to the esophagus. This is the explanation for “silent reflux.”

How Do I Know If I Have LPR?

Chronic hoarseness, throat clearing, and cough, as well as a feeling of a lump in the throat or difficulty swallowing may be signs that you have LPR. Some people have intermittent hoarseness, and others have problems with too much nose and throat drainage, that is, too much mucus or phlegm. That causes chronic throat clearing. If you have any of these symptoms, and especially if you smoke, you should ask your doctor about LPR.

The specialists who most often treat people with LPR are Laryngologists (throat/voice doctor) or Otolaryngologists (ear, nose, and throat physicians). If your doctor thinks that you could have LPR, he/she will probably perform a throat examination and look at the voice box and the lower throat. If this area is swollen and/or red, you may have LPR. At that point, your doctor may order some tests or recommend specific treatment.

What Tests Might My Doctor Order?

If your doctor orders tests, it is to be certain about your diagnosis, to help pick the best type of treatment for you, and to make sure that you don’t have any complications. The three most common tests for LPR are high-definition manometry, pH monitoring (pH-metry), and transnasal esophagoscopy (TNE). These tests each give different information, and it is common to have more than one test done. Manometry takes about 30 minutes to complete, and it evaluates the swallowing mechanism, especially function and the esophagus and stomach valves. An overnight test, pH monitoring measures acid in the esophagus and throat throughout the day and night; see below. TNE is a quick and easy way for your doctor to examine your esophagus for signs of damage from reflux and to make sure that you don’t have pre-cancer or other growths in the esophagus. This is a relatively new kind of minimally-invasive endoscopy that is done so that you can return to normal activity right after the test.

What Is It Like to Have pH-Monitoring (pH-Metry)?

Double-probe (simultaneous pharyngeal and esophageal) pH-metry is a special test that takes about 24-hours to complete. People are not admitted to the hospital for pH-metry, which is used to measure acid in your esophagus and throat. Some people say this test is annoying, but it is not painful. It is extremely useful in evaluating the severity and pattern of LPR. To do this test, you will have a small, soft, flexible tube placed through your nose and down into your throat, where it will stay over night. The tube, called a “pH probe,” is connected to a small computer (a box that you wear around your waist) that measures acid in your esophagus and in your throat. At the Voice Institute, we employ advanced diagnostic technology that is well-ahead of the state of the art, and which will provide answers. Click here to see the Voice Institute Reflux-Testing Info Sheet.

How Is LPR Treated?

Treatment for LPR should be individualized, and your doctor will suggest the best treatment for you. Generally, there are several treatments for LPR but diet is very important, and reflux treatment should be customized for each patient based upon his/her symptoms and findings. There is no one size fits all.

(1) Changing habits and diet to reduce gastric reflux
(2) Medications to reduce acid and the effects of LPR
(3) Surgery to restore the stomach valve and prevent reflux

Most people with LPR need to modify how and when they eat, as well as take some medication to get well. Sometimes, nonprescription liquid antacids, such as Gaviscon, are recommended. When used, these antacids should be taken one-half-hour after meals, before exercising, and bedtime.

Your doctor also may give you a prescription. LPR is usually treated with medicines called PPIs that reduce stomach acid. These medicines are usually taken twice-a-day, 30-60 minutes before breakfast and 30-60 minutes before the evening meal. In addition to PPIs, sometimes a second type of medication (like Zantac, ranitidine, or Pepcid) is recommended before bedtime. For people who have symptoms after meals, chewing gum can help, too. Finally, a low-acid low-fat diet helps as much as anything; there will be further posts on this soon; see also the Reflux Diet, Cookbook & Cure website.

Will I Need LPR Treatment Forever?

Most patients with LPR require some treatment most of the time, and some people need life-long medicine. But some people do recover completely or at least have LPR-free intervals of many years. Having LPR is a little like having high blood pressure in that with treatment, it doesn’t usually cause serious medical problems; but without treatment, LPR can be serious, even dangerous. For people with LPR who don’t improve with medication or who are allergic to reflux medicines, stomach surgery called lap fundoplication, that restores function of the main esophageal valve, may be recommended.  It now appears that diet is very important; see The Reflux Diet, Cookbook & Cure.

What Kind of Problems Can LPR Cause and Are They Serious?

LPR can cause serious problems: Breathing problems (such as asthma or bronchitis), choking episodes, sleep apnea, and relatively uncommonly, cancer of the esophagus, lung, throat, or voice box.  For cancer to develop as a result of LPR, it must be very severe and go untreated for many years.  People with reflux should be checked by a doctor.

27 comments to Laryngopharyngeal Reflux (“Silent Reflux”): The Basics

  • Debbie Franzen

    Great Information. What is the connection of LPR and perimenopause:?

  • Jamie A. Koufman, M.D., F.A.C.S.

    Thank you for the compliment. In regards to your question, I’m not aware of any connection.

  • Ingrid

    I have constant nausea. Is this typical for acid reflux? On day 4 of your induction diet which has relieved heartburn, but still very nauseous. Thanks!

  • RogerT

    I’ve had terrible side effects on all PPIs (dizziness, depression, muscle/joint aches pains) and seem like I am one of the unlucky ones here (nexium=>protonix). After that even H2 blockers gave me side effects (milder versions of the above).

    My question is – can diet / lifestyle management be able to control / manage LPR? Initially I had more mucous in throat but after the PPI treatment the symtoms have been milder so far (for the last 2 weeks) – throat ache, throat dryness etc. I hope so .. since my quality of life gets much worse on the PPIs than off PPIs!

  • Eddie

    I am sure that I have LPR but my primary doctor sent me to a ENT dr and he said I have reflux and was prescribed Ranitidine twice a day. It did not work that well so dr switched me to Prilosec twice a day. I always feel I have a lump in my throat, cough, clearing my throat. I live in Jacksonville, NC. Can you recommend a dr in this area? Thank-you. Liked the article.

  • Sue DeMasi

    Is the Bravo test as accurate as the 24 hour PH double probe test? Thank you.

  • Bonnie

    This is very helpful. Is difficulty breathing a symptom of LPR (assuming cardiac, pulmonary, endocrine, thyroid And other issues have been ruled out)? I have that lump in my throat, dry cough, difficulty after eating, and chest tightness at times but that feeling of air hunger is most problematic for me. It does not worsen after exertion, but rather gets worse after eating. From what I’ve read, breathing problems are mentioned briefly but aren’t such a defining symptom. Would love your thoughts on this. Many thanks.

  • Pixy

    Hi, I’m from England and have finally had some kind of diagnosis of LPR from a speech and language therapist, she gave me your name and highly recommended you and your work in this field. I am currently due to see an ENT in a month after a year of going from one doctor to another and one actually telling me I had mental health issues that these symptoms of the lump in my throat where all in my head. I just wanted to thankyou for all the information and great advice you have on your website, I actually thought I was going to cry when I watched you on utube and then came here. I have taken note of your advice and after a year of what I can only describe as sheer torture at least now I can maybe ease this horrible pain in my neck/throat area.

    Thankyou again from sunny England x

  • kay hutton

    Two people have told me this week that their persistent coughs have been nearly eliminated by going on
    prilosec. My understanding is that we need stomach acid to digest god, and indeed reflux happens as we age (poor dietary and lifestyle choices, also) so we need to supplement with HCl/food enzymes. Doesn’t prilosec neutralize stomach acid? If so, how do we digest food in our stomach properly? I appreciate this site and a chance to ask questions.

  • Evan

    Dr. Koufman,

    I was wondering if you could recommend a colleague in the Virginia area that could help me? I am a 19 year old college student and I have a severe case of LPR. Thanks.

  • Kim Bolin

    Would there have to be some sort of physical evidence in viewing the throat(i.e. redness or swelling) to have LPR?

  • Kim Bolin

    If the larnyx and throat show no signs of redness or swelling, then is further testing not completed for LPR?

  • Tom Santoro

    I visited thirteen ENT’S and gastro doctors before getting state of the art testing by Dr. Koufman and finally a diagnosis of severe LPR followed by an agressive treatment plan. After three weeks I felt 75% to 80% better!I suffered with LPR for over three years.The comments from doctors ranged from “It’s all in your head to “You just need to stop clearing your throat”Why are so many doctors missing the boat on LPR?

  • Kim Egginton

    Do you know of any doctors near Salt Lake City, Utah that are knowledgeable about chronic neurogenic cough caused by vagus nerve stimulation? You’re right, it falls through the cracks between the specialties and each specialist treats it according to his/her perspective and bias.

    I have had a really terrible, powerful chronic cough for 23 years. Although I appear to be high-functioning, it greatly disrupts my professional and social life and has caused (or complicated) stress incontinence, umbilical hernia and vaginal and rectal prolapse and several premature births. In short, my organs are being pushed out. I have had several surgeries, including bladder mesh repair (failed, mesh erosion, probably due to coughing), umbilical hernia mesh repair (starting to tear), nasal valve prolapse repair (inflammation related to LPR), sinus reduction (inflammation), and uvulapalatalplasty.

    While I am confident that the cough is partly caused by reflux and by post nasal drip, treating both concurrently DOES NOT stop my cough. Physical stimulation of the vagus nerve is a factor that my doctors continually dismiss (except one, who sent me to chiropractor who tried to help).

    -The ONLY successful treatment has been inhaled nebulized lidocaine–but I have a reaction to the vehicle in the licodaine, so I can’t use it. Menthol cough drops help some as a mild anesthetic; I can’t be without them.

    These things make me cough (often uncontrollably):
    -A chiropractor uses a vibrating instrument near the vagus nerve
    -Someone jiggles the bed when I’m on my back.
    -I sing correctly. (I am a semi-professional singer. Can’t be a professional with this cough!!)
    -I eat or drink anything, especially cold drinks
    -I get up in the morning
    -I lie down.
    -I go to bed…but once I stop coughing (usually with menthol cough drops), I’m OK until morning.
    -Breathing cold air, especially mouth breathing
    -A fan on my face
    -Perfume; fumes of any kind
    -Virtually every asthma trigger–but I test negative for asthma. Histamine isn’t much of a factor.
    -I’m pregnant
    -I bend over (reflux)
    -PPIs and NSAIDs decrease inflammation in my sinuses so INCREASE post nasal drip–some PPIs and Ranitidine give me side effect of severe sore soft palate, which worsens with continued use.

    -I have a dorsal-lumbar scoliosis which may push tissue to put pressure on vegas nerve?
    -My cough is slightly better when I’m very thin. (Reflux or scoloisis?)
    -Exam of vocal chords: normal
    -Barium swallow: normal
    -Asthma testing: borderline, but negative
    -Asthma meds don’t help but cause severe coughing when inhaled
    -Manometry: normal
    -Ambulatory 24-hr PH-monitoring–single probe?– (on PPI): normal
    -Endoscopy: slight inflammation from reflux diagnosed as GERD
    -Pulmonoscopy: slight inflammation at entrance to lungs consistent with GERD

    Any help you can give would be MOST appreciated! THANKS!

  • philip devlin

    Is it okay to gargle with a warm saltwater solution to alleviate the symptoms of a LPR inflamed throat? If so, how often?
    Thanks for writing the book.It has been of great help to me.

  • sergio camacho

    Dr. Koufman, I am a GERD patient from Mexico, I have a cholecistectomy 2 years ago,im 30 years old, 1 year ago i feel the symptons that you mentioned, lump in throat, mucus, a dry hoarness, i have taken ppi from 2 years, but know i feel that is not enough because the issue in my throat continues. Endoscopy: hiatal hernia 1 inch, Impedance: 142 if acid reflux and 40 non acid reflux, Result: pathologic acid reflux. What should i do? please help me.

  • Vikash (Mauritius Island)

    I have found that your description of LPR is very documented and highly informative to LPR and GERD sufferers like me, compared to many articles I have gone through since a few years. Congratulations for this. I think I suffer from LPR more often than I suffer from GERD. I have seen a few gastroentorologists and ENT specialists. I have been and I am still on PPI : 20 mg in the morning everyday. But my doctors do not seem to understand my problem, they say its stress which is causing my hyperacidity, nausea, sour taste in the mouth, burning sensation at the back of my tongue, ear pain…One has even prescribed me Prozac for this. In fact, it is these symptoms that are depressing me. I don’t think an anti-depression treatment will cure my LPR and GERD. I have persistent burning sensation on the left side of my throat. The papillae on the left side of my tongue have become enlarged and also my gum pains in this region, especially during the day. I don’t know what to do. I am suffering from all these symptoms since four years now and I fear this could result into cancer. Please, give me some medical advice as to how I can get rid of these problems and live a normal life.

  • Robert Cola

    I recenlty visited an Otolaryngologist. I had difficulty swollowing. He put a scope through my nose a suggested i take a PPI. He gave me Dexilant, but only 1 time per day. I belive you suggest 2x/s per day. I don’t want to second guess my doctor. It’s been about 1 week and I’m feeling better. Any thoughts. Thanks

  • Joe S

    Thanks for the helpful write-up. I noticed you mentioned twice-a-day PPIs… are Protonix, Nexium, or anything similar ever prescribed twice a day? I tried Omeprazole twice per day and it turns out that I’m allergic to it.

  • sally lannan

    Great book, recently diagnosed with silent acid reflux, went to my dr after seven yrs of on and off chronic cough episodes, seemingly activated by using my voice, coughed through all 3 pregnancies (as well as had heartburn), had never thoguht of the connection, until the cough returned after not being preganant and without any heartburn,my father was diagnosed with acid reflux (coughed for yrs), I thought perhaps even though I never have heartburn (outside of pregnancy) the cough could signify reflux, I was correct! Currently on 80 mgs of protonix, no more coughing, but after reading your book I plan to, effective immediately, attempt to manage with diet! I saw no mention of pregnancy related coughing and definitly feel that it was a huge part of figuring out this was reflux as I experienced the heartburn as well only during that time, happy to have solved this medical case for myself after 7 yrs of suffering!

  • I have had choking episodes for many years. I went to an ENT specialist who examined my vocal chords and found no irritation. He made no recommendations but did say I had larynogospasms.
    I do have constant phlegm in my throat with incessant clearing of the throat.
    What type of doctor would you recommend? I live in the Dallas, TX area.
    Thank you. Your website is the most informative of anything I have found.

  • Diana Demers

    Have had this chronic cough due to Acid Reflux (family physician had me tested and it was confirmed) but nothing seems to help. Have tried food combining (protein with no starch etc.) so now I cannot wait to get your book and hopefully that will give me relieve!

  • Rena Herson

    I’ve been dealing with the symptoms you describe for a decade, seeing gastroenterologists and taking PPIs and wondering why there was little improvement except with diet modification. The article in today’s Times indicating that it is pepsin in the throat and not necessarily acid from the stomach that causes the damage is really a revelation. How can I get an appointment?

  • Jamie A. Koufman, M.D., F.A.C.S.

    You can schedule an appointment by calling the Voice Institute of New York at 212-463-8014.

  • Jamie A. Koufman, M.D., F.A.C.S.

    You may have gastroparesis (“lazy stomach”) as part of your problem. You may need a “prokinetic” medication or possibly a touch of amytriptyline before bed. This is a medical issue for a medical doctor. Come see me in New York City if you don’t get well. Above our door, we have a sign that reads, “This is the last stop.”

  • Chloe Eichenlaub

    Believe it or not, I have suffered from a debilitating chronic cough for over 50 years. Your article on LPR in our health newsletter struck me like lightening! I immediately when on the restricted alkaline diet, and the cough has improved 90 %. Finally, a diagnosis plus a lifestyle treatment that works. I am truly grateful for your work.
    Are there ENT doctors that you can recommend in the Southern California area?

  • Jamie A. Koufman, M.D., F.A.C.S.

    You may ask you doctor to add 10 mg of amytriptyline before bed … may help, too.