Laryngopharyngeal reflux (LPR), otherwise known as silent reflux, is a form of acid reflux. The esophagus (food tube) has special rings of muscle (sphincters) at the top and the bottom. If the esophageal sphincters don’t close properly, acid can flow up the esophagus and into the throat and voice box.
LPR symptoms can differ from those of gastroesophageal reflux disease (GERD) because they tend to affect the voice and the sinuses. These symptoms don’t usually seem to directly affect the esophagus, which is why LPR can be “silent” and challenging to diagnose.
Treatment usually involves acid-reducing medications as well as lifestyle and dietary changes.
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Symptoms
Some of the symptoms that might make a healthcare provider suspect LPR are:
- A bothersome cough or a cough after lying down or eating
- Globus sensation (feeling like something is in the throat)
- Heartburn
- Hoarseness (dysphonia)
- Postnasal drip or sticky mucus in the throat
- Stomach acid or food coming back up into the esophagus (regurgitation)
- Trouble swallowing (dysphagia)
- Throat pain
- Throat clearing
Getting a Silent Reflux Diagnosis
LPR can be challenging to diagnose because people may not know that they have it. However, when LPR is suspected, a healthcare provider will first take a history, asking questions about any symptoms and other health conditions.
There will also be a physical exam, usually by looking inside the throat in the office. The throat exam might show inflammation or other damage to the tissues. This may be enough information to diagnose LPR and start treatment to see if symptoms improve.
In some cases, tests may be necessary to diagnose LPR or understand the extent of any damage or inflammation in the throat.
For more testing, a physician specializing in conditions of the ear, nose, and throat (formally known as an otolaryngologist or commonly called an ENT) may be necessary. Another type of specialist who may diagnose LPR is a gastroenterologist, a physician specializing in digestive system diseases and conditions.
Some of the tests that might diagnose silent reflux include:
Laryngoscopy: Though guidelines don’t recommend laryngoscopy for diagnosing LPR, some healthcare providers might use it to try to determine the cause of symptoms.
This test involves inserting a scope into the throat to examine the larynx (voice box), throat, and vocal cords. This may take place in a healthcare provider’s office, and a numbing spray makes the procedure more comfortable.
Esophageal 24-hour pH/impedance reflux monitoring: Guidelines recommend this test as helpful in the decision-making process for LPR management. In this test, a catheter is inserted into the nose. While the person takes sips of water, their throat muscles move it down into the throat.
The catheter is worn for 24 hours while a monitor records measurements. This test records the acid levels in the throat to look for problems with reflux.
Esophageal manometry: This test determines how well the esophagus muscles are working. A tube passes through the mouth and into the esophagus and stomach. The tube measures pressure in the esophagus while the person swallows water. It can help diagnose LPR or other swallowing problems.
Transnasal esophagoscopy: This test might work as an alternative to endoscopy. It is also taken in the office and can be done quickly (in 10 minutes or so).
A thin tube with a light and a camera passes through the nose and down into the esophagus. In addition to seeing inside the throat, it might also help to administer some treatments, like widening a narrowed part of the esophagus.
Upper gastrointestinal (GI) endoscopy: This is an endoscopic procedure by which a thin tube with a light and a camera on the end of it passes into the mouth and down into the esophagus. It usually happens under anesthetic. It can see any problems like inflammation or other abnormalities.
This test is more likely to happen when symptoms continue despite other treatments. Biopsies (small pieces of tissue) may also be taken during this test to see if cells have changed.
Triggers
The overall cause of LPR is when the two sphincters located at the top (upper esophageal sphincter) and the bottom (lower esophageal sphincter) of the esophagus are not working as well as they should.
The lower esophageal sphincter may become too open, allowing acid to rise from the stomach and into the esophagus. The upper esophageal sphincter may also become weakened, allowing acid to rise into the throat.
Risk factors for developing LPR include obesity, smoking cigarettes, and having primary esophageal dysmotility (which is when the muscles in the esophagus don’t work well).
Foods and beverages that might trigger silent reflux symptoms include:
- Acidic foods
- Alcohol
- Foods with mint
- High-fat foods
- Salty foods
- Sugary foods
Stress and Anxiety
Research on stress as it relates to LPR is lacking. However, multiple research studies mention it in passing because stress may influence LPR. The symptoms of LPR itself could lead to stress and anxiety.
As more is understood about the brain-gut connection, strategies are being developed to help people manage their digestive conditions through mindfulness and stress reduction techniques.
GERD has been increasingly connected to anxiety disorders, which may lead to the development of more treatments. In the meantime, looking into meditation and mindfulness on one’s own and seeking a healthcare provider who can help in managing stress and anxiety or other mental health conditions is an option.
Prescribed Medication
Treatment or management options are available after a diagnosis or a suspected diagnosis of LPR. A trial of medication might be taken to see if it helps symptoms. If an initial trial works, that may help confirm the diagnosis. If medications don’t improve symptoms, more testing or other management may be necessary.
It’s often recommended that a proton pump inhibitor (PPI), a drug that reduces stomach acid, be used. Some healthcare providers may also add other types of antacids. The PPI might be tried for about three months to see if the symptoms change.
Other medications that might be tried if a PPI doesn’t help include muscle relaxants and selective serotonin reuptake inhibitors (SSRIs). Why these medications might work is not well understood, but they might help prevent the esophageal sphincters from relaxing inappropriately.
Managing Silent Reflux During Treatment
Medications aren’t the only methods for managing LPR. People who smoke should pursue a plan to quit. It may also be recommended that people avoid eating late in the day and look for ways to reduce stress levels.
Food and Eating Habits
Diet is another major part of treating LPR. Reducing foods that may lead to weakening the esophageal sphincters and thereby causing symptoms is another part of management. A recommended change in diet will include limiting:
- Alcohol
- Carbonated drinks
- Coffee
- Fatty foods
- Low protein diets
- Spices
- Tea
The authors of one study recommend the Mediterranean diet to manage symptoms. This diet includes a focus on plant protein, cooked vegetables, and low levels of animal fats.
For Better Sleep
In general, LPR is not a condition that affects people at night. However, LPR may relate to gastroesophageal reflux disease (GERD), which can occur at the same time. If nighttime heartburn is one of the symptoms, making changes to lifestyle is another likely recommendation.
The American College of Gastroenterology recommends sleeping on a wedge pillow to raise the head. Some people also put risers under the legs of their bed’s head. This helps keep acid down in the stomach through gravity, preventing it from coming up into the esophagus.
Avoiding eating within two to three hours of going to bed is also advisable. This is more appropriate for GERD or heartburn than LPR, but because the conditions can overlap, this practice can help.
Soothing Fussy Babies
LPR is a condition that can also affect babies. Symptoms of LPR in babies can include breathing difficulties, so it’s important to get any noisy breathing, pauses in breathing, or disordered breathing evaluated by a healthcare professional right away.
Caregivers should feed babies with LPR symptoms smaller and more frequent meals. Keeping babies in a vertical position after eating (more upright) is another possible suggestion.
If changing eating habits and keeping a baby more upright after meals doesn’t help, further testing and a trial of medications such as H2 blockers or PPIs may be necessary.
Complications
Long-term LPR can lead to certain complications, although this is not common. Treatment can reverse some complications, although oral problems and scarring might last for a long time. Some of the more common complications that can occur include:
When to Consider Surgery
Surgery for LPR is a controversial subject. Some sources mention a type of surgery called Nissen fundoplication for LPR. For this surgery, a section of the stomach is wrapped around the lower esophageal sphincter and tacked down into place.
Surgery might be considered when treatments with diet, lifestyle, and medications don’t work. This is especially true when there are other conditions involved that are leading to chronic LPR, like a hiatal hernia.
Risks of Severe Silent Reflux
Severe risks aren’t typically associated with most cases of LPR, but there are some reports of more serious conditions occurring along with LPR. Constant inflammation caused by the acid might lead to changes in the cells in the esophagus and cause irreversible problems. These could include:
- Barrett’s esophagitis (changes to the lining of the esophagus)
- Laryngeal cancer (rarely)
- Scarring in the vocal folds
- Subglottic stenosis (narrowing of the airway below the vocal cords)
- Vocal cord injury
Outlook With Diligent Management
Effective diagnosis and treatment of silent reflux are typically possible. However, some of the keys to managing LPR include lifestyle and dietary changes that can be more challenging to start and maintain.
If the initial three-month period of medication use doesn’t help with symptoms, another three months may be recommended. Half of all people with LPR don’t usually need to take medication for the long term.
Summary
LPR is a condition that may be challenging to diagnose. The symptoms are not specific and overlap with those of many other conditions, including GERD. Only in recent years have guidelines for diagnosis and treatment been published to help manage LPR.
In most cases, recommended treatments for LPR include diet and lifestyle changes along with medication; however, many people are nonadherent to the regimen. Complications and chronic LPR are uncommon but possible, and some are irreversible.
