Laryngopharyngeal Reflux (Silent Reflux)

Laryngopharyngeal reflux, often shortened to LPR, is a common cause of throat symptoms. It is sometimes called silent reflux because many patients do not experience typical heartburn, even though reflux is still irritating the throat and voice box.

In LPR, stomach contents travel upwards beyond the food pipe and reach the throat. In some patients this reflux is acidic, and in others it is non-acid reflux. That is important, because some people continue to have symptoms even when acid has been reduced with medication.

I have seen many patients with this problem. It can be frustrating, persistent, and worrying, but in most cases it is not due to anything serious. The key is to make the right diagnosis, understand what is driving it, and decide whether treatment or further investigation is needed.

What symptoms can LPR cause?

LPR can cause a wide range of throat symptoms, including:

These symptoms often fluctuate rather than staying the same every day. Many patients find that they are worse at certain times than others, depending on triggers such as meal timing, particular foods or drinks, alcohol, caffeine, lying down after eating, voice use, stress, or poor sleep. This fluctuation is very typical of LPR and is one of the reasons a careful history is so important.

In some patients, reflux can travel as far as the nasopharynx, which is the area at the back of the nose. When that happens, it may contribute to persistent mucus or a sensation of post-nasal drip. Not every patient with post-nasal drip has reflux, but reflux can sometimes be part of the picture.

Why does LPR happen?

LPR happens when reflux reaches the upper airway rather than staying lower down in the food pipe. The lining of the throat and voice box is much more sensitive than the stomach, so even a relatively small amount of reflux can cause irritation.

It is also important to understand that reflux is not always just acid. Reflux may contain acid, pepsin, bile, or other stomach contents. This is one reason why some patients continue to have throat symptoms despite taking acid-suppressing medication.

What is the root cause?

This is one of the commonest questions patients ask.

The problem is often not simply “too much acid”. More often, the underlying issue is that stomach contents are travelling upwards when they should not. That may relate to the valve between the food pipe and stomach not working as effectively as it should, a hiatus hernia, increased pressure within the abdomen, meal timing, large meals, weight gain, smoking, alcohol, caffeine, fizzy drinks, or lying down too soon after eating.

A hiatus hernia is when part of the stomach slips upwards through the diaphragm, the sheet of muscle under the lungs that helps with breathing, and into the chest. This happens at the point where the food pipe passes down to join the stomach. It is a common problem, particularly with age, and in some patients it can make reflux much more likely.

In some patients there is more than one factor involved. Others develop increased sensitivity in the throat, so even a small amount of reflux can trigger significant symptoms. That is why treatment needs to be tailored to the individual rather than approached in a one-size-fits-all way.

How is LPR investigated?

The first step is a careful history. I want to understand exactly what the symptoms are, whether there is heartburn or regurgitation as well, whether swallowing is affected, whether the voice has changed, and whether there are any concerning features that suggest something other than reflux.

I then examine the mouth, throat, and neck, and in most cases I perform a flexible nasendoscopy in clinic. This is a thin flexible camera passed gently through the nose so I can examine the back of the nose, throat, and voice box.

This is often the most useful first ENT investigation. It can support the diagnosis, but just as importantly it helps rule out other causes of throat symptoms.

Many patients do not need anything more than this. Further investigations are usually reserved for patients whose symptoms are persistent, atypical, not responding to treatment, or associated with red flags.

Additional investigations may include:

  • gastroscopy

  • reflux testing such as pH or impedance monitoring

  • swallow tests where swallowing symptoms are present

  • referral to gastroenterology where appropriate

When might a gastroscopy or gastroenterology referral be needed?

A gastroscopy is not required for every patient with suspected LPR.

It may be helpful if there are more typical symptoms lower down in the chest or upper abdomen, such as persistent heartburn or regurgitation, if swallowing is genuinely difficult, if there is pain on swallowing, weight loss, vomiting, bleeding, anaemia, or if symptoms are not settling as expected.

A gastroscopy examines the food pipe, stomach, and first part of the small bowel. It is useful when there is a need to assess the lower swallowing passage and stomach in more detail, but it is worth being clear that a normal gastroscopy does not rule out LPR.

Some patients also benefit from gastroenterology assessment, particularly where the diagnosis is unclear, symptoms are not improving, reflux testing is being considered, or there are significant symptoms lower down in the digestive tract.

Gastroenterology input may also be helpful where there is concern about more significant gastro-oesophageal reflux disease, Barrett’s oesophagus, ulcer disease, persistent indigestion, or whether Helicobacter pylori needs to be investigated.

What about Helicobacter pylori?

Helicobacter pylori, usually called H. pylori, is a bacterium that lives in the stomach. It is more commonly linked to gastritis, indigestion, and stomach ulcers than to isolated throat symptoms.

In other words, it is not usually the main explanation for throat clearing, hoarseness, or a lump sensation in the throat on its own. However, if a patient also has indigestion, upper abdominal discomfort, ulcer-type symptoms, or a history suggesting a stomach problem, testing for H. pylori may be appropriate.

If it is present, treatment is aimed at eradicating the infection. This is usually managed with a combination of antibiotics and acid-suppressing treatment, and in some cases gastroenterology input is useful.

What treatments help?

Treatment depends on what appears to be driving the reflux and how significant the symptoms are.

Lifestyle and behavioural measures

These are often the foundation of treatment. Depending on the patient, this may include:

  • eating smaller meals

  • avoiding late meals

  • leaving time between eating and lying down

  • reducing caffeine, alcohol, fizzy drinks, and heavy fatty meals

  • weight loss where relevant

  • stopping smoking

  • raising the head of the bed if night-time reflux is an issue

These measures can be particularly important because they address the underlying upward movement of reflux rather than simply reducing acidity.

Alginates

Alginates can be very useful in throat reflux. They work by forming a protective barrier on top of the stomach contents and can help reduce reflux reaching the upper airway. In practice, Gaviscon Advance or DoubleAction is often a good option and is commonly used for this reason.

Proton pump inhibitors

Proton pump inhibitors, often shortened to PPIs, are medicines that reduce the amount of acid produced by the stomach. Common examples include omeprazole and lansoprazole.

They can be helpful in some patients, particularly where there is a clear acid reflux component or overlap with more typical heartburn and regurgitation symptoms.

However, LPR is not always mainly an acid problem. It is not uncommon for LPR to involve weakly acidic or non-acid reflux. In those situations, stomach contents are still reaching the throat even when the acid level has been reduced.

That is why PPIs are often less helpful in patients whose symptoms are mainly driven by non-acid reflux. They reduce acid, but they do not stop the physical movement of reflux itself. If the main problem is non-acid reflux, pepsin, bile, meal timing, or throat hypersensitivity, they may only help partially or may not help very much at all.

Voice and throat care

If throat clearing, coughing, or voice strain are contributing, these behaviours can keep the irritation going. Hydration, reducing throat clearing, and in some cases speech and language therapy can all be helpful.

Treating associated problems

Some patients also have allergy, rhinitis, chronic cough, true nasal post-nasal drip, or muscle tension affecting the voice. These may need to be treated separately as part of the wider picture.

Should PPIs be used long term?

Not routinely.

Proton pump inhibitors such as omeprazole and lansoprazole are useful medicines, but they should not simply be started and then continued indefinitely without review. For many patients, the better approach is a defined trial of treatment followed by an assessment of whether they are genuinely helping.

One of the main reasons for this is that PPIs may not be treating the real issue. In LPR, the reflux is not uncommonly weakly acidic or non-acid, so acid suppression alone may not solve the problem.

In some patients, longer-term treatment is entirely appropriate, particularly where there is significant inflammation lower down in the food pipe, Barrett’s oesophagus, or another clear gastroenterology reason. But for many patients with throat reflux symptoms, the aim is to use the right treatment for the right length of time, rather than leaving someone on medication by default.

When should patients worry?

Most cases of LPR are not serious, but proper assessment is important if there is:

  • true difficulty swallowing

  • pain on swallowing

  • coughing or spitting blood

  • unexplained weight loss

  • persistent or worsening hoarseness

  • a neck lump

  • one-sided throat pain

  • breathing difficulty

These symptoms do not necessarily mean something serious is wrong, but they do need careful assessment.

How I approach this in clinic

When I assess a patient with suspected LPR, my aim is not simply to label it as reflux and prescribe tablets.

The first step is to make sure the diagnosis is correct. The second is to understand what is actually driving the symptoms. For some patients the main issue is classic acid reflux. For others it is non-acid reflux, meal timing, throat clearing, cough, voice strain, or a combination of factors.

The best results usually come from an individualised plan based on the likely cause, rather than a generic approach.

FAQ

Can you have LPR without heartburn?

Yes. Many patients with LPR do not have classic heartburn. That is why it is often called silent reflux.

Why do I still have symptoms while taking omeprazole or lansoprazole?

Omeprazole and lansoprazole are proton pump inhibitors. They reduce stomach acid, but they do not stop the physical movement of reflux. If the problem is non-acid reflux, pepsin, bile, throat sensitivity, or throat clearing, symptoms may persist despite treatment.

How long does LPR take to improve?

It varies. Some patients improve within a few weeks, while others take longer, particularly if there are several contributing factors. Improvement is often gradual rather than immediate.

Can LPR symptoms come and go?

Yes. Fluctuation is very common. Symptoms are often influenced by triggers such as meal timing, alcohol, caffeine, poor sleep, stress, and voice use.

Does LPR cause post-nasal drip?

It can contribute to a post-nasal drip sensation in some patients, particularly if reflux reaches the nasopharynx at the back of the nose. However, true post-nasal drip can also be caused by rhinitis, sinus problems, or allergy, so it is important not to assume reflux is the only explanation.

Do all patients need a gastroscopy?

No. Many patients do not need a gastroscopy. It is usually reserved for selected cases, particularly where there are swallowing problems, weight loss, bleeding, persistent indigestion, or symptoms that are not following the expected pattern.

Is Gaviscon better than omeprazole?

They work differently. Gaviscon is an alginate that forms a barrier to help reduce reflux reaching the throat. Omeprazole is a proton pump inhibitor that reduces stomach acid. Some patients do well with one, some with both, and some need a different approach depending on what is driving the symptoms.

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Disclaimer

This page is intended as general information only. It does not replace a consultation, examination, or individual medical advice.

I do not have any financial interest in Gaviscon or in any other reflux medication mentioned on this page.