Acid Reflux affects about 20% of US adults according to the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK).

Silent reflux (also called laryngopharyngeal reflux or LPR) is similar to acid reflux, however, there are a few major differences. Silent Reflux is much harder to diagnose as symptoms are less characteristic, albeit often quite unpleasant.

Let’s take a closer look at silent reflux, see how it differs from acid reflux, what the most common symptoms are and how to manage this condition:

What is acid reflux?

There is a muscle between the stomach and the esophagus called the lower esophageal sphincter (LES).

This muscle acts as a one-way valve, when there is Food in the food pipe the LES relaxes so that the food can enter the stomach. Most of the time this muscle is tight to prevent digestive acids from flowing back (reflux) from the stomach into the esophagus.

For some people, the LES might relax even when it is supposed to be tight. The exact reasons are not known, but these are the common factors that make LES relaxation more likely:

• certain foods (fatty foods, citric fruits, chocolate, alcohol, caffeine, etc.)
• being obese
• hiatal hernia
• smoking
• stress

When the LES relaxes and stomach acids seep back into the food pipe. This condition is called acid reflux. they start to irritate the lining of the esophagus.

The digestive juices in the food pipe cause a burning sensation around the center of the chest. The name of this symptom is heartburn and this is the most common symptom of acid reflux.

What is silent reflux?

There is another sphincter, at the top of the food pipe, called the upper esophageal sphincter (UES).

The UES protects the throat and airways against the reflux of food from the esophagus. It also prevents air from entering the food pipe.

We talk about silent reflux when both the LES and UES malfunction and stomach contents can travel all the way up to the throat.

It is called silent reflux, because people with LPR often don’t experience heartburn, the characteristic symptom of acid reflux. This is because stomach acid flows up into the throat and doesn’t spend enough time in the esophagus to trigger heartburn.

These are the common symptoms of silent reflux:

• lump in throat
• coughing
• hoarseness
• sour taste in the mouth
• difficulty swallowing

These symptoms above can be caused by a number of conditions, doctors don’t always suspect reflux when patients are experiencing these.

What causes untreated LPR?

If silent reflux is not recognized and treated, it can cause several health issues in the long term:

• Chronic coughing after eating. The patient might also cough up mucus and digestive juices.
• Dental problems. Stomach acids entering the mouth might damage the enamel of the tooth.
• Ulcers and cancer in the throat and voice box. The tissues in these organs are not designed to withstand long-term exposure to the acidic content of the stomach.

How is LPR diagnosed?

Sometimes the medical history of a patient, the symptoms, and a physical examination of the lower throat and voice box might be enough.

If backed up by the symptoms, a swollen or red throat/voice box usually indicates silent reflux.

However, if special tests are needed, these are the ones used commonly:

• X-ray and barium: the patient swallows a special liquid that contains barium. This makes the movement of food in the esophagus visible via X-ray.
• Endoscopy: doctors might examine the throat, esophagus with a small camera, looking for signs of tissues damaged by stomach acids.
• Esophageal pH test: this device measures the acidity in the esophagus. If it’s more acidic than normal, it indicates that stomach acids are able to enter the food pipe.

How to manage silent reflux naturally?

Dietary and lifestyle changes can go a long way in managing silent reflux.

These are the most important tips to follow:

• quit smoking, tobacco might relax both the LES and UES
• avoid alcohol, coffee, soda, they might also relax the sphincters
• avoid clothes that are tight around the waist
• eat smaller amounts, more frequently
• do not eat 2-3 hours before lying down
• eat healthily, avoid “trigger foods”

This last piece of advice is a bit tricky. Most people observe that certain foods are more likely to cause silent reflux symptoms. These foods are called “trigger foods”.

However, these trigger foods vary from person to person, so certain foods might cause symptoms for some people, but not for others.

Common trigger foods are:

• fatty foods, e.g. red meat, fried foods
• cheese, eggs
• chocolate
• citric fruits
• certain vegetables, tomato, and onion are the two most common

As a rule of thumb, high fat and high sugar foods are the most likely to trigger symptoms.

Using a food diary to write down what and when you ate and whether you experienced symptoms after the meal or not can be a big help in identifying your trigger foods.

Even though changing your lifestyle and eating habits helps a lot, sometimes this is not enough.

LPR medications and surgery

When silent reflux cannot be managed with lifestyle changes, doctors prescribe medications.

These are supposed to decrease the amount of stomach acid, either by neutralizing it (antacids) or preventing gastric acid secretion (proton-pump inhibitors).

Both might be very effective, but they only treat the symptom and not the cause.

They are also not recommended for long-term use, because of their side effects.

In rare cases, neither lifestyle changes, nor medications are enough. As a last resort, surgery is recommended in these situations.

Nissen fundoplication, a laparoscopic anti-reflux surgery, is used to prevent both acid and silent refluxes. During the surgery, the top of the stomach is wrapped around the LES to reinforce it.

This is a minimally invasive procedure and most patients experience a significant decrease in both the number of reflux episodes and the severity of the  symptoms.

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