Silent reflux (LPR)

The defining feature of silent reflux is what is missing. There is no heartburn. People arrive after months of clearing their throat, a voice that has gone gravelly, a cough with no cold behind it, or the sensation of something sitting in the throat — and because none of it burns, reflux is the last thing considered. Around half of people with these symptoms describe no chest burning at all. That silence is the whole reason this page exists.

The medical name is laryngopharyngeal reflux, or LPR: stomach contents travelling past the oesophagus altogether and reaching the larynx and pharynx.

The mechanism differs from ordinary heartburn in ways that matter. The oesophagus is built to cope with acid: it clears refluxed material downward with a wave of muscle contraction, it is bathed in bicarbonate-rich saliva, and its cells carry defences. A healthy oesophagus tolerates dozens of brief reflux episodes a day without complaint.

The larynx has almost none of that. The lining is thin respiratory-type tissue, unequipped to meet stomach contents, and there is no peristaltic wave to sweep anything away. Experimental work suggests a handful of episodes a week is enough to inflame it. The same volume of reflux therefore produces a burning oesophagus in one person and an inflamed larynx with a comfortable chest in another.

Pepsin appears to do much of the damage. It is the stomach's protein-digesting enzyme, and once deposited on laryngeal tissue it can be taken up into cells and reactivated whenever the pH around it drops again — including from an acidic drink hours later. This is one explanation for why suppressing acid alone helps less here than expected: the enzyme remains where it landed, and non-acid reflux still carries it upward.

The timing differs too. Classic reflux is a lying-down, night-time, liquid problem. Silent reflux is more often an upright, daytime, gaseous one — fine droplets and vapour escaping through the upper oesophageal sphincter, which relaxes with belching, straining, and prolonged or loud voice use.

One honest caveat belongs here. Whether reflux is genuinely responsible for most throat symptoms attributed to it remains contested between ENT surgeons and gastroenterologists. Silent reflux is over-diagnosed in some clinics and missed entirely in others, and holding both in mind is more useful than believing either.

ⓘThis information is educational and not a diagnosis.

The commonest complaint is throat clearing, repeated so often that family notice it before the patient does. Close behind sit a dry, tickly cough unrelated to any infection; hoarseness that is worst on waking and eases through the morning; globus, the sensation of a lump or tightness that swallowing does not shift; a feeling of mucus dripping at the back of the nose; a raw or scratchy throat; and a voice that thins and tires by evening.

The morning pattern is a useful clue: symptoms heaviest on waking that settle over a few hours fit something accumulated overnight.

What is generally absent is equally informative: no burning behind the breastbone, no sour taste, and often a completely normal endoscopy. If burning in the chest and sour regurgitation are your main problems, the oesophageal form of the disease is the more useful page, and the two are worth reading as separate conditions rather than one.

The differential diagnosis genuinely matters here, because several conditions produce an identical picture and are more common than reflux in some patients. Allergic rhinitis and post-nasal drip head the list. Asthma and cough-variant asthma follow. Cough caused by ACE-inhibitor blood pressure medicines is easily overlooked and resolves only on changing the drug. Chronic sinusitis, voice overuse in teachers, priests, call-centre staff and street vendors, an enlarged thyroid pressing on the throat, and globus arising with anxiety all belong on the list.

In India three exposures deserve naming directly. Ambient air pollution, particularly through a north Indian winter, inflames the upper airway in people with no reflux whatsoever. Chronic exposure to biomass cooking smoke does the same, and remains common in households still cooking on wood or dung. And tobacco in every form — cigarettes, bidis, gutka, khaini, betel quid — irritates the larynx directly while also loosening the sphincters above and below the oesophagus.

The features listed below overlap with head and neck cancers. That is worth saying calmly and plainly rather than hinting at, because it is the reason a persistently hoarse voice is examined promptly rather than treated by guesswork.

There is no single test that settles this, and any clinic that claims otherwise is overselling. The diagnosis is built from the pattern, from examination, and from what happens over time.

Laryngoscopy is the usual first step. An ENT surgeon passes a small flexible scope and looks for swelling of the vocal folds, redness, thickening at the back of the larynx and narrowing of the space beneath the folds, often scored formally with the Reflux Finding Score. The important caveat is that these appearances are common in people with no symptoms whatsoever — most healthy volunteers show at least one of them. A positive score raises the possibility; it does not confirm it. Its greater value is in excluding growths, nodules, palsy and other structural causes of a changed voice.

The Reflux Symptom Index is a nine-question form scoring the symptoms above. It is quick, free and reproducible, which makes it good for measuring change. As a diagnostic instrument it is weak, since its questions do not distinguish reflux from allergy or voice strain.

Reflux monitoring with a pH-impedance catheter carrying a sensor high in the pharynx comes closest to a direct measurement, capturing acid and non-acid episodes reaching the throat. Availability in India is largely confined to tertiary centres, the study is uncomfortable, and normal values for the pharyngeal sensor are still argued over. Salivary pepsin testing is a promising idea that has not yet settled into routine practice.

Upper GI endoscopy is added where swallowing is affected or oesophageal symptoms coexist, and it is normal in most people with purely laryngeal complaints — informative rather than disappointing.

Alongside all of this, the parallel assessment changes outcomes: examining the nose, considering allergy, reviewing every medicine for an ACE inhibitor, and thinking about asthma. Many people have two contributors at once.

The first thing to set is the timescale. Heartburn often improves within a week or two of acid suppression. Laryngeal tissue is slower, and a fair trial runs eight to twelve weeks before it can be judged. People told to expect a quick response conclude the treatment failed and abandon measures that were beginning to work.

Voice hygiene and the throat-clearing loop. Forceful throat clearing traumatises the vocal folds, which produces more mucus and more urge to clear, and the loop sustains itself long after any reflux has settled. Replacing it with a sip of water, a firm silent swallow or a gentle hum breaks the cycle. Steady hydration matters more than it sounds in Indian summers and in air-conditioned offices, where thick secretions are often blamed on reflux. Reducing loud, prolonged or strained voice use helps, and whispering is worth avoiding, since it loads the larynx rather than resting it.

Treating the nose. Where allergic rhinitis or post-nasal drip is present, saline irrigation and an intranasal steroid frequently do more for the throat than any acid medicine. This is not a consolation prize — it is often the actual diagnosis.

Alginate preparations. These have a specific rationale in silent reflux rather than a borrowed one. An alginate raft floats on the stomach contents and covers the pocket of unbuffered acid that sits near the junction after a meal, reducing what escapes upward, and it also traps pepsin. A randomised trial in laryngeal reflux found benefit over control, which is more than can be said for several other options here.

Meals, weight and posture. Because much of this reflux happens upright and through the day, constant grazing matters as much as the late dinner. Leaving three hours between the last meal and lying down, keeping evening meals lighter, reducing weight at the waist and raising the head of the bed remain sensible, unglamorous and free.

Smoke, dust and tobacco. Stopping tobacco in every form is the single highest-value change available in this condition, both for symptoms and for the risks discussed above. Where household smoke or seasonal air pollution is a factor, ventilation, a switch away from biomass fuel, and a well-fitted mask on high-pollution days are practical rather than theoretical.

Acid suppression. Proton pump inhibitors are widely prescribed here, frequently twice daily and for months. The evidence is weaker and more contested than for heartburn: several placebo-controlled trials have shown little separation from placebo, and pooled analyses disagree with one another. That does not make a trial unreasonable, particularly where oesophageal symptoms coexist. It does mean the trial deserves a defined endpoint, an honest review, and a plan for what happens if nothing changes. Stopping after prolonged use produces rebound acid hypersecretion for two to four weeks, which is easily misread as proof the drug was working, so any change of course is a conversation to have with your prescriber rather than a decision to take alone.

Referral. Speech and language therapy for voice care is underused in India and helps many people whose larynx has become irritable independently of any reflux. An ENT opinion is warranted for persistent hoarseness, and a gastroenterology opinion where symptoms resist a fair trial.

Silent reflux is unusual among common conditions in how much of the difficulty is diagnostic. The symptoms are real, the tests imperfect, several conditions look identical, and the most commonly prescribed treatment carries the least convincing evidence. Understanding that landscape is what stops five years of medication with nobody asking whether it helped.

The Learning Session below covers reflux in both its forms in a small group — practical voice care, how to run a fair treatment trial, and how to tell a nose problem from a throat problem.

If your voice has changed, if symptoms persist despite treatment, or if any of the features above apply, that is a conversation for a consultation rather than an article.