Silent reflux (laryngopharyngeal reflux)

Laryngopharyngeal reflux happens when some of the stomach contents rise up the oesophagus to the throat and voice box. It is also called silent reflux because many people have no heartburn. It can cause throat clearing, cough, mucus and hoarseness, and it often improves with changes in habits.

What is laryngopharyngeal reflux?

There is a valve between the stomach and the oesophagus, the lower oesophageal sphincter. If it does not close well, some stomach contents come up. When they reach the throat (pharynx) and the voice box (larynx), which are more sensitive than the oesophagus, even a small amount can irritate them.

It is not the same as classic acid reflux, which causes heartburn. Here the symptoms are in the throat, although you can have both together.

What are the symptoms?

• Constant throat clearing.
• A persistent dry cough, especially in the morning or after meals.
• Mucus in the throat that does not go away.
• A feeling of a lump or something stuck.
• Hoarseness or a tired voice.
• Throat discomfort or pain on swallowing, and a sour or bitter taste.

You may or may not have heartburn. Many people with laryngopharyngeal reflux do not.

Why does it happen?

• Large or late meals and lying down soon afterwards.
• Being overweight: it increases pressure in the abdomen.
• Smoking and alcohol.
• Certain foods and drinks, such as coffee, chocolate, fatty meals or fizzy drinks.
• A hiatus hernia or other oesophagus problems.
• Stress, which can make symptoms worse.

How is it diagnosed?

There is no single test. Diagnosis is based on:

1. Your symptoms and habits.
2. Flexible nasendoscopy: a thin tube passed through the nose lets us see the voice box. It is mainly used to rule out other causes of hoarseness or cough.
3. Digestive tests (gastroscopy or acid monitoring). If you have frequent heartburn, warning signs or do not improve with treatment, we refer you to a gastroenterologist, who decides whether they are needed and carries them out.

A trial of treatment with changes in habits and, sometimes, medication also helps confirm the diagnosis.

How is it treated?

Habits and diet

This is the foundation of treatment. It includes eating slowly and in moderation, not lying down straight after eating, raising the head of the bed, losing weight if you are overweight and stopping smoking. There is a temporary diet in which certain foods are removed for a few weeks and then reintroduced. Everything is in reflux: diet and lifestyle tips.

Medication

Sometimes a medicine that reduces stomach acid is used for a limited time. Its benefit in reflux affecting the throat is modest: some reviews find it no better than a placebo. We therefore prescribe it only when there is a reason and review how you respond.

A reflux medicine should not be taken for hoarseness alone before we have looked at your voice box.

When it does not improve

If you do not improve, or you have frequent heartburn or warning signs, you may need to be assessed by the digestive team.

Advice

• Eat slowly and in moderate portions.
• Do not lie down until 2-3 hours after dinner.
• Raise the head of your bed.
• Do not smoke and limit alcohol.
• Lose weight if you are overweight.
• Do not take reflux medicine on your own for months.
• Avoid constant throat clearing: take a sip of water instead.

When should I seek urgent help?

Call 112 (in Spain) or your local emergency number, or go to A&E, if you have:

• Tight chest pain, especially with sweating, breathlessness or pain spreading to the arm.
• You vomit blood or have black stools.
• You choke and cannot breathe or swallow.

Book an appointment soon if you have:

• Progressive difficulty swallowing or food that feels stuck.
• Unexplained weight loss or frequent vomiting.
• Hoarseness lasting more than 4 weeks.
• Anaemia or pain on swallowing that does not settle.

Frequently asked questions

Can I have reflux without heartburn? Yes. That is what we call silent reflux. The symptoms are in the throat.

Is it dangerous? Generally not, but it is very annoying. If there are warning signs, it needs investigating.

Do I need tablets for life? Usually not. Changes in habits are the foundation, and medication, when used, is for a limited time.

Is it the cause of my hoarseness? It may contribute, but not always. Before blaming reflux, the voice box needs to be examined.

Can it cause a chronic cough? Yes, although cough has many causes. Others should be ruled out.

Are coffee and chocolate to blame? For some people, yes. That is why we suggest removing them for a few weeks to see what disagrees with you.

What about children? Symptoms and treatment can be different. Talk to your paediatrician.

References

1. Katz PO, Dunbar KB, Schnoll-Sussman FH, et al. ACG clinical guideline for the diagnosis and management of gastroesophageal reflux disease. Am J Gastroenterol. 2022;117(1):27-56.
2. Stachler RJ, Francis DO, Schwartz SR, et al. Clinical practice guideline: hoarseness (dysphonia) (update). Otolaryngol Head Neck Surg. 2018;158(1 Suppl):S1-S42.
3. Spantideas N, Drosou E, Bougea A, AlAbdulwahed R. Proton pump inhibitors for the treatment of laryngopharyngeal reflux. A systematic review. J Voice. 2019;34(6):918-929.
4. Zalvan CH, Hu S, Greenberg B, Geliebter J. A comparison of alkaline water and Mediterranean diet vs proton pump inhibition for treatment of laryngopharyngeal reflux. JAMA Otolaryngol Head Neck Surg. 2017;143(10):1023-1029.

For general information only. It does not replace a medical consultation and cannot be used for diagnosis. In an emergency in Spain, call 112.

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