Silent reflux (laryngopharyngeal reflux)

What is silent reflux?

Silent reflux, also called laryngopharyngeal reflux (LPR), happens when acid and other digestive juices travel all the way up from your stomach into your throat and voice box, rather than stopping in your food pipe. Your throat isn't built to cope with these juices the way your stomach and gullet are, so even a small amount reaching it can cause irritation, often without the heartburn or indigestion you'd expect with ordinary reflux.

What are the symptoms of silent reflux?

By far the most common signs are a hoarse voice, needing to clear your throat often, a dry cough that won't shift, and the feeling that something is stuck in your throat. Other symptoms can include:

• excess mucus or phlegm in the throat, often worse in the morning
• a bitter, sour or acidic taste in the mouth
• difficulty or discomfort swallowing
• a sore, burning or dry throat
• occasional choking or coughing episodes, particularly at night
• excessive burping during the day
• occasional breathlessness, or asthma that becomes harder to control.

Symptoms tend to flare up first thing in the day and once you've eaten, particularly anything spicy. Some people also get heartburn or indigestion alongside these throat symptoms, but many don't, which is exactly why it's called 'silent'.

What causes silent reflux, and who is at risk?

Two ring-shaped muscles, called sphincters, normally act as gatekeepers for your digestive system: one keeps stomach contents in your stomach, and a second, higher up, keeps anything that does escape out of your throat.

Silent reflux happens when this second, upper gatekeeper also relaxes when it shouldn't, letting reflux that's already made it into your food pipe travel further, into your throat and voice box.

There's rarely a single obvious cause – usually, several things weaken these muscles or make reflux more likely at once. These include:

• certain medicines, including some sedatives, blood pressure tablets, antidepressants, anti-inflammatory painkillers and asthma medication
• coffee, chocolate, alcohol, mint, garlic and onions
• reclining shortly after a meal, sleeping flat on your back, oversized portions, or tight clothing and belts
• smoking, being overweight, pregnancy, or a hiatus hernia (where part of the stomach pushes up through the diaphragm), all of which can weaken these muscles over time
• bending over, exercising, singing or burping soon after eating.

Some people have silent reflux on its own, while others have it alongside typical heartburn and indigestion (known as GORD) – it's possible to have either, or both together.

Are there different types of silent reflux?

Rather than distinct types, the main distinction is between silent reflux on its own and silent reflux occurring alongside typical heartburn and indigestion. Some people have only throat symptoms and no heartburn at all, which is why it can be easy to miss and harder to diagnose than classic reflux – others have both conditions together, needing treatment for each.

How is silent reflux diagnosed?

Your doctor will start by asking about your symptoms, including how long you've had them and what seems to trigger them, then examine your throat and abdomen.

A common next step is a flexible nasal endoscopy (sometimes called a laryngoscopy) – a thin, flexible tube with a light and camera is passed gently through your nose to give a close-up view of your throat and voice box.

Because silent reflux can be harder to confirm than typical reflux, further tests are sometimes used, including an endoscopy that looks further down into your food pipe and stomach, a 24-hour test that measures acid levels using small sensors, a test of the muscle pressure in your food pipe, or an X-ray of your food pipe.

In practice, many doctors will instead simply start treatment and see whether your symptoms improve, using that response as part of confirming the diagnosis.

How is silent reflux treated?

Treatment usually starts with lifestyle and dietary changes, moves on to medication if needed, and only rarely reaches surgery.

Non-surgical treatment

Lifestyle changes that can help include:

• sitting upright to eat, and staying upright for 3 hours afterwards rather than lying down or bending from the waist
• eating smaller, more frequent meals, and eating slowly
• raising the head of your bed by around 4 to 6 inches (10 to 15cm), and sleeping on your left side
• losing weight if you're carrying extra weight, avoiding tight clothing around your waist, and bending at the knees rather than the waist to pick things up
• stopping smoking, cutting down on alcohol, and finding ways to reduce stress.

It's also worth looking at your diet. Foods and drinks that tend to make symptoms worse include fatty, fried or spicy food, chocolate, pastry, dairy, tomatoes and citrus fruit, caffeine and fizzy drinks. A diet built around vegetables, lean protein, wholegrains and fruits like apples and bananas tends to suit people with silent reflux better.

Medication options include:

• Alginate or antacid liquid: Taking these after eating and again just before you go to sleep, forms a protective layer over your stomach contents
• Proton pump inhibitors (PPIs): These reduce how much acid your stomach makes; these are usually taken around half an hour before meals and generally need several months of continuous use before you'll notice the full effect
• H2 blockers: This is an alternative for people who can't tolerate a PPI.

It typically takes 2 to 3 months of treatment to notice a general improvement, but your voice and throat can take considerably longer, sometimes 6 months or more, to fully settle, so it's worth persevering with an initial course for around half a year before judging whether it's working.

If you're taking anti-inflammatory painkillers for another reason, mention this to your doctor, as they can sometimes contribute to symptoms and may need a PPI alongside them. Never stop a reflux medication abruptly without medical advice, since this can make symptoms worse – your doctor can guide you through gradually reducing the dose instead.

Surgical treatment

Surgery is only occasionally needed, generally when lifestyle changes and medication haven't controlled symptoms well enough, or where there's a clear structural cause such as a hiatus hernia.

The usual procedure is a keyhole operation, sometimes called fundoplication, which tightens the valve between your stomach and food pipe to stop contents escaping upwards. A similar approach can reinforce the valve higher up in the throat if that's also needed.

When should I see a doctor?

See your doctor if:

• you have ongoing hoarseness, throat clearing, cough or a lump sensation in your throat that isn't settling with simple self-help measures
• your voice hasn't improved within about 4 weeks, despite treatment – ask for a closer look at your throat (laryngoscopy), to rule out other, rarer causes of these symptoms
• you have painful or difficult swallowing, or any bleeding, since these can point to complications that need assessment
• you're already on reflux medication and want to stop – make sure you do this with your doctor's guidance rather than stopping suddenly.