Silent reflux (LPR): throat symptoms without heartburn

"Silent reflux" is the everyday name for laryngopharyngeal reflux (LPR): reflux that reaches the throat and voice box, often without the heartburn people expect. It is a real and common reason for throat symptoms, but also one of the most over-diagnosed, because many other conditions cause the same symptoms.

Typical symptoms

• hoarseness or a croaky voice, often worse in the morning
• frequent throat clearing, or a feeling of mucus in the throat
• a feeling of a lump in the throat (globus)
• a chronic cough, particularly after meals or when lying down
• a sore or irritated throat without an infection
• post-nasal drip feeling

Heartburn and regurgitation may be mild or absent.

Why it happens

The throat and voice box are far more sensitive than the oesophagus. Small amounts of refluxed acid and pepsin, a digestive enzyme, can irritate them even when the amount is too small to cause heartburn. Reflux can also trigger a cough reflex through nerves in the lower oesophagus.

Other causes to rule out

The same symptoms are commonly caused by allergies and post-nasal drip, asthma, voice strain, smoking, ACE-inhibitor blood pressure medicines (a well-known cause of dry cough) and, rarely, growths in the throat. Persistent hoarseness, especially in smokers, should always be checked by a doctor; in the UK, NICE advises that persistent, unexplained hoarseness in people aged 45 and over should be assessed urgently.

How it is diagnosed

An ear, nose and throat (ENT) specialist may look at your voice box with a small camera (laryngoscopy). Redness and swelling there are common in people with and without reflux, so guidelines advise that silent reflux should not be diagnosed from the camera test alone. If you do not also have heartburn or regurgitation, the American College of Gastroenterology recommends reflux testing before starting PPIs, rather than taking them on trust. If you do have typical reflux symptoms as well, a trial of PPI treatment for 8 to 12 weeks may be tried first.

What helps

• Lifestyle changes: not eating within three hours of bed, raising the head of the bed, sleeping on the left side, losing weight if needed, and limiting alcohol. See lifestyle changes.
• Diet: one study found a plant-based Mediterranean diet with alkaline water worked about as well as PPIs for LPR symptoms. It was not a randomised trial, but it is a low-risk approach to try. See the diet guide.
• Alginates after meals and at bedtime may help by forming a barrier.
• PPIs help some people, particularly those who also have typical reflux symptoms or proven reflux on testing. If a PPI has not helped after an adequate trial, ask your doctor whether another cause is more likely.
• Voice therapy with a speech and language therapist can help with throat clearing and voice problems.

Track whether your throat symptoms follow meals, late eating or lying down with the symptom diary.