Diagnosis and treatment

Laryngopharyngeal reflux: why does reflux reach the throat without causing heartburn?

Reflux that reaches the throat often causes no heartburn at all. That is why it shows up as throat clearing, hoarseness and pharyngitis that keeps coming back, rather than as the stomach problem people expect.

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Laryngopharyngeal reflux (LPR) is the reflux that travels beyond the esophagus and reaches the pharynx and the larynx. It inflames the throat and the vocal folds, and that is why the symptoms show up where nobody expects them: throat clearing, a lump in the throat, hoarseness and recurring pharyngitis.

Most of the time it comes without heartburn, and it is that detail that makes patients take so long to get here. With no burning in the chest, nobody thinks of the stomach, and the throat goes on being treated as an infection, as an allergy or as overuse of the voice.

Silent reflux: the reflux that reaches the throat without heartburn

Silent reflux is the nickname given, in adults, to reflux that reaches the throat without producing heartburn. The name stuck because it describes what happens well: the classic stomach symptom is not there, and what is left is the throat complaining.

The absence of burning does not mean there is little reflux. It means the esophagus is coping better than the throat, and the explanation is in the lining. The esophagus has a mucosa used to receiving acid a few times a day, and it has saliva running down all the time, washing away what is left over. The pharynx and the larynx have none of that: they are built for air to come in. It is the difference between the kitchen sink, which takes hot grease every day, and the wall beside it, which stains on the first splash.

That is why the same amount of reflux that goes unnoticed in the chest produces daily throat clearing, hoarseness and cough further up. And that is why the sentence “but I don’t have heartburn” does not rule the diagnosis out.

Laryngopharyngeal reflux and gastroesophageal reflux: what is the difference

In gastroesophageal reflux disease (GERD), the stomach contents come back up into the esophagus and cause the heartburn everyone knows. When that same material rises higher and goes past the esophagus, reaching the pharynx and the larynx, it changes name and becomes laryngopharyngeal reflux.

The difference is not only how high it goes, it is also how it behaves. Reflux that stays in the esophagus tends to come in larger volumes and to show up lying down, at night, and it hurts. What reaches the throat comes in small amounts, often while the person is upright and during the day, and the contact with acid and with pepsin, the enzyme that digests protein, is brief. The problem is that the lining up there does not tolerate even that brief contact.

That is why the two conditions call for different questions in the office and do not always travel together: you can have reflux in the throat without ever having felt heartburn, and you can have classic heartburn without a single throat symptom.

Throat clearing, a lump in the throat and hoarseness: the symptoms

The symptom that brings most people in is constant throat clearing: a throat that needs clearing every few minutes without anything ever coming up. Along with it comes the sensation of a lump in the throat, which many people describe as a ball stuck there or as something that will not go down (the technical name is globus pharyngeus). The examination almost never shows anything caught there, and nothing is caught: it is the swollen lining sending the signal that there is a foreign body where there is none.

In the voice, the picture is hoarseness that comes and goes, a voice that tires after speaking for a while, loss of projection and a change in tone, almost always worse on waking. Completing the list are the dry cough that will not go away, a throat that burns or feels inflamed with no infection at all, the thick mucus that sits in the throat all day, bad breath and a sensation of choking when swallowing.

None of these symptoms belongs to reflux alone, and that is what makes the examination necessary. Allergy, sinusitis, incorrect voice use and vocal fold lesions produce a similar picture and call for different management.

Recurring pharyngitis that does not respond to antibiotics

There is a pattern that repeats itself: a sore throat that comes back several times a year, treated as an infection at every episode, with antibiotics that help little or do not help at all. Repeated exposure of the pharynx to acid and pepsin injures the lining and leaves it more likely to become inflamed again, and a good share of these episodes labeled as infection behave, in practice, like chemical inflammation.

What points that way is the worsening on waking, the throat clearing and the hoarseness alongside the pain, and the absence of fever and of patches of pus on the tonsils.

When reflux is the cause, treating it tends to space these episodes out. When it is not, the antibiotic goes on not resolving anything, and the way forward is to look for the other explanation.

Causes and risk factors

Reflux happens when the valve between the esophagus and the stomach, the lower esophageal sphincter, relaxes at the wrong moment and lets through what should stay down there, in the stomach. What makes this happen more often is well known: hiatal hernia, excess weight, large meals, eating late and lying down right after eating.

Some foods and habits irritate the lining directly or make the backflow easier: coffee, alcohol, chocolate, fried food, very fatty dishes, citrus fruits, soft drinks and cigarettes. They come into the conversation when a person notices they make things worse, and not as a forbidden list for everyone.

Stress, some medications and mouth breathing, which is what is left for anyone whose nose is blocked every day, aggravate the inflammatory picture of the upper airway and leave the throat more exposed.

ENT or gastroenterologist: who treats reflux in the throat?

The two specialties treat the same disease through different doors. The gastroenterologist looks at reflux from below, through the esophagus and the stomach. I am an otolaryngologist (ENT), and I look at it from above, at the place where it is causing symptoms: the pharynx and the larynx. Anyone who arrives with throat clearing, a lump in the throat and hoarseness, and not with heartburn, comes to the ENT first, because the complaint is a throat complaint.

What I do, in practice: I perform the flexible nasolaryngoscopy in the appointment itself, with no separate scheduling, and it is that examination that shows whether the pharynx and the larynx have signs of reflux. I correlate those findings with the history and separate reflux from other causes that produce similar symptoms, such as allergies, sinusitis, benign vocal fold lesions and incorrect voice use. From there I put the plan together and start the drug treatment, which I follow up myself.

Where my part ends, and this is what patients usually want to know: I order the upper GI endoscopy, but the more complex cases, the ones that need other tests such as pH monitoring with impedance and esophageal manometry, I refer to the gastroenterologist, who will take the case forward. I also refer the case that does not respond to treatment and the one with a significant hiatal hernia. In cases with vocal impairment I also refer for speech therapy follow-up, and always when the patient works with their voice.

The two paths cross often and are complementary. Starting with the ENT makes sense when the symptom is a throat and voice symptom; the handover to the gastroenterologist happens when the investigation or the treatment calls for what is done on that side.

How the diagnosis is made: flexible nasolaryngoscopy in the office

The assessment starts with the history: how long it has been going on, what makes it worse, what has already been treated, how the voice sounds on waking and at the end of the day, what is eaten and at what times. A good part of the diagnosis is decided right there, before any equipment.

Then comes the flexible nasolaryngoscopy, which I perform in the office. A thin, flexible endoscope goes in through one of the nostrils and down to the level of the larynx, showing the pharynx and the vocal folds in movement on a screen. What we look for are the signs reflux leaves behind: redness, swelling of the posterior commissure, thickening of the mucosa and granulomas.

These findings point in a direction and do not settle the diagnosis on their own, because they also appear in people who smoke, in people who strain the voice and in people with allergies. That is why the reading is always a combined one: what the examination shows, what the history tells and how the condition responds to treatment in the first weeks.

When it is necessary to go beyond what the office examination shows, I order the upper GI endoscopy, which assesses the esophagus and the stomach and rules out associated lesions. pH monitoring with impedance measures how much reflux happens over a whole day, and esophageal manometry measures the strength and the coordination of the esophagus; both are carried out by the gastroenterologist.

Treatment: habits, medication and speech therapy

Changes in habit matter a great deal in this follow-up: splitting meals into smaller ones, not lying down right after eating, raising the head of the bed, cutting down on alcohol and caffeine, stopping smoking and looking after weight. It is the part of the treatment that nobody can do for the patient, and it is the part that holds up everything else.

I prescribe proton pump inhibitors (PPIs), alginates, antacids and, in selected cases, prokinetics, for a defined period and with a reassessment already scheduled. The drug treatment starts with me and I follow it up: it is the course of the following weeks that shows whether the mucosa is healing and whether the plan needs to change.

People who use their voice for work all day long usually also need speech therapy, for technique and vocal economy, and in those cases I always refer.

When there is a significant hiatal hernia, or when the condition does not respond to medical treatment, the discussion of surgery belongs to the gastroenterologist and the surgeon, who will take the case forward.

When to seek evaluation

Hoarseness that does not improve within four weeks calls for examination of the larynx, and that is the timeframe in the dysphonia guideline of the American Academy of Otolaryngology. In practice this means something that usually goes unnoticed: it counts as well for the voice that has only worsened a little and that the person has already got used to.

Four weeks is the timeframe for hoarseness on its own, and not for everything. Pain on swallowing, choking episodes, blood in the saliva, unexplained weight loss, a lump in the neck or chest pain call for evaluation straight away, without counting weeks.

Away from the warning signs, the most common reason to book is much simpler: daily throat clearing, a lump in the throat, a dry cough that will not go away or pharyngitis that keeps coming back, even with no heartburn at all. It is the picture that tends to spend years being treated as something else.

If that is your case, book an evaluation. The first step is the flexible nasolaryngoscopy, performed in the appointment itself, which shows whether the pharynx and the larynx have signs of reflux.

Care in São Paulo: Itaim Bibi, Morumbi and Alphaville

Appointments take place in Itaim Bibi and Morumbi, in São Paulo, and in Alphaville, in Barueri, with the flexible nasolaryngoscopy performed in the appointment itself, with no separate scheduling. Behind it are more than two decades of otolaryngology practice.

References

Stachler RJ, Francis DO, Schwartz SR, et al. Clinical Practice Guideline: Hoarseness (Dysphonia) (Update). Otolaryngology–Head and Neck Surgery. 2018;158(1 Suppl):S1-S42. doi:10.1177/0194599817751030

Frequently asked questions about reflux in the throat

Can I have reflux in the throat even without feeling heartburn?

You can. Heartburn is a symptom of the esophagus, and reflux that reaches the throat often does not stay in the esophagus long enough to produce it. That is why a person answers that they do not have reflux when asked about heartburn, and still has reflux in the throat.

Is the sensation of a lump in the throat always reflux?

No. The lump in the throat, or globus pharyngeus, is a sensation and not a finding: it also appears in anxiety, in thyroid disorders, in allergy and in some swallowing problems. Reflux is on the list of common causes, and it is the examination that tells one from the other.

Does flexible nasolaryngoscopy hurt? How is it done?

It is an office examination: you stay seated, awake, without sedation. Beforehand, a topical anesthetic is applied in the nose. A thin, flexible endoscope goes in through one of the nostrils and down to the level of the larynx, with the image appearing on a screen, and during the examination you are asked to speak and to breathe, because it is by speaking that the vocal folds show themselves in movement. It is uncomfortable, mainly as it passes through the nose, and the discomfort ends when the examination ends. I perform the flexible nasolaryngoscopy in the appointment itself, with no separate scheduling.

Can recurring pharyngitis be reflux?

It can, and it is one of the explanations we look for when antibiotics help little and the condition comes back several times a year. The signs that point to reflux are the worsening on waking, the throat clearing and the hoarseness alongside the pain, and the absence of fever. Other causes also need to be considered, such as genuinely recurring infections, allergy, excessive voice use and irritants in the environment.

Is reflux in the throat serious?

Most of the time it is a chronic, uncomfortable condition, and not a dangerous one. What makes the examination necessary is not the reflux itself: it is that persistent hoarseness, pain on swallowing and a lump in the neck also appear in other conditions, and those conditions need to be ruled out before everything is put down to reflux.

Can laryngopharyngeal reflux (LPR) be cured?

It is a condition that is managed. With treatment and a change in habits, the throat clearing, the hoarseness and the lump in the throat tend to ease over weeks; when the habits go back to what they were, the symptoms usually come back with them, because the mechanism that produces them is still there. That is why what we follow is not the end of a box of tablets, it is the course of the condition: the follow-up examination shows whether the mucosa is healing and whether the plan needs to change. And be wary of any promise of a guaranteed cure, here or anywhere else in medicine.

Is there a home or natural treatment for reflux in the throat?

There is the habit side, and it is not an accessory: eating less at a time, not lying down after eating, raising the head of the bed, stopping smoking, cutting down on alcohol and caffeine. What does not exist is a tea, a recipe or a supplement that replaces the diagnosis. Without knowing whether what causes the symptom really is reflux, the effort goes to the wrong target and the condition carries on.

Can reflux cause bad breath and tonsil stones?

Bad breath is a frequent complaint among people with reflux in the throat, and the explanation is direct: what comes up has a smell, and inflamed mucosa produces more mucus. Tonsil stones, those little white lumps that come out of the tonsils, have a cause of their own, linked to the tonsillar crypts, and reflux comes in as one of the factors that change the pH of the mouth and favor build-up. When the two appear together, both are worth investigating: caseous tonsillitis has a page of its own on this site.