Conditions / LPR / Silent Reflux
Laryngopharyngeal Reflux
Affects an estimated 10% of ENT consultations
Overview
In LPR, acid and pepsin travel above the upper esophageal sphincter into the throat, voice box, and sometimes nasal passages. Unlike GERD, most LPR patients do NOT experience heartburn — making it "silent." This is why it's frequently misdiagnosed as allergies or sinusitis for years.
How it's diagnosed
Laryngoscopy reveals posterior laryngitis. Reflux Finding Score (RFS) >7 is diagnostic. 24-hr pH-impedance monitoring. Reflux Symptom Index (RSI) questionnaire.
Triggers
- All GERD triggers PLUS:
- Carbonated water
- ALL acidic foods (pH <5)
- Late-night eating
- Alcohol even in small amounts
- Coffee even decaf
- Pepsin is the primary damaging agent — not just acid
Symptoms
- Chronic hoarseness (especially morning)
- Persistent throat clearing
- Chronic cough not related to cold
- Throat tightness or lump feeling
- Difficulty swallowing
- Voice fatigue
- Recurring laryngitis
- Dental enamel erosion
Complications if untreated
- Vocal cord granulomas
- Subglottic stenosis (airway narrowing)
- Laryngeal carcinoma (rare, long-term)
- Chronic sinusitis
Immediate relief
- Drink pH 8.8 alkaline water (deactivates pepsin)
- Avoid loud speaking when symptomatic
- Steam inhalation
- Throat coat tea (slippery elm + marshmallow root)
Long-term management
- Stricter diet than GERD: all foods pH >5
- Twice-daily PPI (vs once-daily for GERD)
- Alginate therapy (Gaviscon Advance)
- Voice therapy with speech-language pathologist
- Head elevation essential
Diet
The "Dropping Acid" protocol: strict elimination of ALL foods with pH <5 for minimum 2 weeks. No citrus, tomatoes, vinegar, wine, carbonation. More restrictive than standard GERD because pepsin is active at higher pH levels.
When to see a doctor
See ENT and gastroenterologist together. Laryngoscopy is essential for proper diagnosis. Many cases undertreated because throat symptoms seem unrelated to reflux.
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