Silent Reflux, Laryngopharyngeal Reflux (LERD or LPR) – Causes, How to Diagnose It Properly, and How to Find Relief!

My Personal Struggle with Silent Reflux

I remember the day I first became chronically ill like it was yesterday. I was at my grandmother-in-law’s house eating a delicious catfish dinner. Afterward, my stomach felt on fire for the first time and ached severely. I tried to lie down, but the pain was so overwhelming after an hour that I could barely move. I went to the emergency room, and they could not find anything wrong with me. They told me I was perfectly healthy. I did not know at the time, but I was developing laryngopharyngeal reflux (LPR).

Over the next month, I developed obsessive-compulsive disorder, had significant anxiety, LPR symptoms, gastritis, stomach pain, and my resting heart rate increased by thirty beats per minute. During this stressful period, I thought I would die, or at the very least, I was concerned that I might be slipping into madness. For the first time in my life, my health was rapidly deteriorating. I visited several doctors whose tests showed nothing significant except an elevated heart rate. The only treatment my doctors offered me was a drug test in the hospital to see if I was a user. Once I passed the drug test, they wanted to admit me into the hospital and monitor my condition. My primary doctor planned to prescribe a series of medications, including some powerful heart and anti-anxiety medications to calm me down because he thought anxiety had caused all my problems. My grandfather told me to stop the ACE inhibitor and to wait a few days to see if I would improve. He said that any medicine, at any given time, might cause side effects in anyone. The next day, I discontinued my ACE inhibitor and checked my resting heart rate, which relieved me that it had returned to normal.

Unfortunately, the damage had been done. The ACE inhibitor left me with horrible side effects, and I almost fell into an adrenal crisis. It took me over a year to recover from the severe adrenal fatigue that I had developed. For years I was left with silent reflux as my main symptom, and it took me forever to discover that was my issue through many diagnostic tests. I started supplementing with zinc carnosine, and magnesium, and it became manageable, yet I still had flare-ups, and it was always there, just lessened. I thought I would forever be afflicted with silent reflux because I believe the primary cause was the abdominal surgeries I had as an adolescent and the associated scar tissue. I was wrong. However, in the back of my mind, I believed I was suffering from H. pylori dysbiosis, but mostly every test I had ever taken was negative. The final test showed I had antibodies to a toxin H. pylori produces CagA+. I received these positive test results in my seventh year of suffering from silent reflux, and I researched as much as possible about H. pylori and started a protocol. Through my research, I determined that I contracted H. pylori around the time of the catfish dinner, and the ACE inhibitor suppressed my immune system so that it could flourish. In six months, I finally achieved silent reflux remission on protocols to reduce H. pylori dysbiosis and improve my microbiome. I am lucky since silent reflux has many proposed causes; not everyone can achieve remission. I know what it is to suffer the hell that is silent reflux; you are not alone; hopefully, I can help anyone suffering from it overcome this terrible condition.

Silent Reflux (LERD or LPR), an Often Misdiagnosed Disease

Laryngopharyngeal reflux disease is a more recently known, less understood “cousin” of GERD (gastroesophageal reflux disease). LPR (laryngopharyngeal reflux disease) differs from GERD because people with LPR have symptoms above their esophagus. Most people who suffer from LPR do not have traditional heartburn, throat, chest pain, or any GERD symptoms. LPR sufferers usually have their symptoms during the day, whether they eat or not, and symptoms usually occur when sitting. GERD sufferers typically have their symptoms in the evening, after eating, and when lying down. Most LPR symptoms are instead felt when you arise out of bed in the morning and throughout the day. It is also harder for LPR to be diagnosed correctly because the symptoms are universal for most people. LPR can disguise itself as breathing, oral cavity, ear, or sinus issues. Finally, some people can have symptoms of GERD and LPR in which they have LERD, laryngopharyngeal esophageal reflux disease.1 2 3 4

The various symptoms of LPR include:5 6 7 8

  • Periods of dry mouth
  • Periods of backwash and increased saliva production.
  • Sour, sweet, or metallic taste inside your mouth.
  • Burning mouth feeling (may become burning mouth syndrome).
  • Halitosis (bad breath)
  • Salivary stones
  • Enlarged tongue
  • Geographic tongue
  • Periodontal disease
  • Adenoiditis
  • Tonsillitis
  • Tonsil stones
  • Post-nasal drip
  • Loss of sense of smell
  • Sinusitis
  • Chronic sinus infections
  • Nasal polyps
  • Tears that feel like they burn when you cry.
  • Inflammation of the eyes
  • Watery eyes
  • Dry eyes
  • Chronic ear infections
  • Hearing problems
  • Tinnitus
  • Ear fullness
  • Ears pop while swallowing (eustachian tube inflammation).
  • Hearing self-generated sounds like breathing (patulous eustachian tubes).
  • Coughing
  • Consistent throat clearing
  • Pharyngitis
  • Dysphagia (difficulty swallowing)
  • Severe throat swelling and possible closing.
  • Sore throat
  • Visceral hypersensitivity
  • Lump in the throat feeling (globus pharyngitis)
  • Hoarseness
  • Laryngitis
  • Laryngospasm
  • Tachycardia, arrhythmia, or spiked blood pressure during episodes of reflux.
  • Roemheld syndrome
  • Asthma
  • Perceived breathlessness
  • Aspiration pneumonia
  • Pulmonary fibrosis
  • Esophageal spasms
  • Frequent belching
  • Dyspepsia
  • Upper gut bloating
  • Mental disorders, including anxiety, panic attacks, and depression occurring from gastrointestinal issues.
  • Malaise
  • Trouble sleeping
  • Fatigue
  • Brain fog

Unlike GERD, our esophagus usually appears somewhat normal in people with LPR. Mild irritation within our esophagus might be seen in people with silent reflux. Our esophagus seems relatively normal because refluxed acid and pepsin are quickly swallowed downward. Reflux does not become trapped between our two esophageal sphincters (LES and UES), as it does in people suffering from GERD. Less inflammation within our esophagus generally occurs in people suffering from LPR. However, more inflammation for people suffering from LPR occurs within our upper airway, UES (upper esophageal sphincter), larynx, throat, oral cavity, sinus cavities, and our eustachian tubes because of a lack of antireflux cellular mechanisms within these areas of our body offering less protection from reflux to these tissues. For some, their reflux is aerosolized, and the irritating gas inflames and deposits an enzyme called pepsin onto their tissues. Finally, embedded pepsin, when activated by either acidic reflux, acidic aerosolization, or ingestion of acidic food, triggers inflammation and causes cellular damage by breaking down tissue over time.9 10 11 12

Pepsin is the primary enzyme produced by our stomach to digest protein. Pepsin is one of three main proteases (enzymes that metabolize protein) our body produces for digestion. Pepsin is the most efficient protease in breaking down peptide bonds between hydrophobic and aromatic amino acids, including tryptophan, phenylalanine, and tyrosine. Pepsinogen is released by the chief cells within our stomach wall and activates, becoming pepsin when it mixes with acidic gastric juice. Pepsin helps break down protein into polypeptides for proper metabolism. Pepsin later becomes inactivated turning back into pepsinogen when mixed with alkaline bicarbonate and bile released from our pancreas and gallbladder or liver into our duodenum. Neutralization of pepsin and acidic stomach chyme that enters our duodenum prevents inflammation, injury, and breakdown of tissues in the rest of our digestive system that cannot handle a low pH.13

The inactivation of pepsin by sodium bicarbonate does occur within our throat (it can be within our esophagus in moderation because of carbonic anhydrase). The baseline pH of our throat is rather neutral. However, when you swallow anything with a low pH, like vinegar, pepsin’s enzyme activity is reactivated and begins to break down your tissue, causing inflammation. I recommend gargling and rinsing with alkaline water after meals, throughout the day, and before bed to inactivate pepsin. In addition, limiting acidic foods like citrus fruits or vinegar and eating a diet containing more alkaline foods can also help relieve silent reflux symptoms by lessening the chance of reactivating pepsin within our oral cavity, throat, and esophagus.14

An endoscopy may also be performed to understand the scope of esophageal inflammation and the general function of your LES, UES, stomach, pyloric sphincter, and duodenum. During an endoscopy, a flexible wire with a camera positioned at the end of the wire is swallowed. The camera takes pictures down our esophagus and into our stomach and duodenum. Traditional endoscopies are known to have issues associated with the procedure, including potential injury or death from sedation, increased risk of aspiration, and slightly increased risk of infections from improperly sterilized (autoclaved) instruments. I recommend you talk to your doctor about performing the safer; transnasal esophagoscopy procedure, which does not require sedation to view the health of your throat and esophagus.15 16 17

One of the best assessments utilized in diagnosing LPR is an esophageal pH monitoring test. A flexible catheter with a pH monitor at the end is placed through the nose into the esophagus for at least 24 hours. A 48-hour dual-sensor pH catheter monitoring test (one pharyngeal probe and one esophageal probe) that can measure both acid and nonacid reflux events is instrumental in establishing an LPR diagnosis. In addition, ask if your provider also offers Bilitec monitoring at the same time to determine if you are also suffering from bile reflux.18

Finally, there is a noninvasive test for LPR known as the Peptest. The Peptest tests saliva, sputum, aspirate, and gastric juice for pepsin. If your saliva tests positive for elevated pepsin, it is probably the cause of your silent reflux. You can order the Peptest yourself; you do not need a doctor to order the tn most people with LPR, their upper and lower esophageal sphincters are malfunctioning. The UES, our upper esophageal sphincter, closes off our throat from our esophagus. In most people with GERD, our LES, known as our lower esophageal sphincter, is our only sphincter not functioning properly. The non-functioning LES causes stomach chyme to become stuck in between our stomach and our UES creating the sensation known as heartburn. The UES is your sphincter at the top of your esophagus that opens and closes when you swallow to protect our throat, oral cavity, nasal cavities, and eustachian tubes from aspiration.19 20 21 22

The main problem with LERD is that conventional medicine does not effectively treat it. There is no proven diagnostic cause of LERD. Proton pump inhibitors are prescribed with little effectiveness. “Data from controlled treatment trials convincingly show that PPI therapy is no more effective than placebo in producing symptom relief in patients suspected of laryngo-pharyngeal reflux disease. Furthermore, neither symptoms, nor laryngoscopic findings or abnormal findings on pH monitoring will predict response to PPI therapy. A reliable diagnostic test for LPR or one that might predict response to a PPI does not exist.” Reflux surgery may bring relief for a time, but it does not correct any of the underlying issues, and in time LPR returns.

Hypotheses of the many possible causes of LPR:

  • SIBO (small intestine bacterial overgrowth)
  • Upper gut dysbiosis causes an elevated stomach pH.
  • Dysbiosis of the nasal cavities, oral cavity, throat, or esophagus.
  • Nerve damage or inflammation to both the LES and UES (might occur after an acute viral throat infection).
  • Chronic viral reactivation (Herpesviridae, mainly Varicella zoster).
  • Magnesium deficiency
  • Zinc deficiency
  • Inefficient production of endogenous vitamin D and low blood levels of vitamin D.
  • Improper endogenous collagen production (lack of vitamin C ingestion and copper metabolism issues) and inadequate sphincter tone.
  • Ehlers-Danlos syndrome
  • Chronic stress (causing HPTAG [hypothalamus, pituitary, thyroid, adrenal, gonadal] axis issues and an under active parasympathetic nervous system also known as adrenal fatigue).
  • Overactive sympathetic nervous system (compromised vagus nerve function).
  • Hypothyroidism
  • Mercury amalgams
  • Oral cavitations (mostly caused by root canals) and nerve damage/dysbiosis.
  • Medication usage

General Advice for LPR:

  • Ask a physical therapist about using shaker neck exercises to strengthen your throat muscles and improve upper esophageal sphincter tone.23 24
  • Using a Backnobber or Theracane properly on your upper back and your upper neck might improve UES function and health.
  • Daily light exercise is important for proper digestive health. I recommend walking thirty minutes to an hour daily. Avoid overexertion and any activity that increases intraabdominal pressure, like abdominal crunches and leg presses.
  • Drink only room-temperature water during meals, and do not overeat. I would consume only up to ten ounces of water a meal. Most of your liquid consumption should be between meals and when you first wake up. Eat three meals daily and try not to snack if possible to help maintain proper motility.
  • Chew your food well while eating, especially if what you are eating contains carbohydrates (to mix well with what little salivary amylase we produce). The more you masticate your food, the less work your digestive system has to do.
  • Do not consume piping hot food or liquid that inflames our delicate upper digestive system tissue when swallowed. Let your food cool off before ingesting it.
  • Ingesting mint and chocolate can relax your esophageal sphincters and worsen reflux.
  • Ingest proper amounts of omega-3 fatty acids in your diet. Ingest leaner lower mercury fish, including cod and flounder. I found supplementing with Nordic Naturals Ultimate Omega 2x, two soft gels, twice daily with meals improved my silent reflux greatly.
  • Reduce intake of acidic foods that can trigger silent reflux. I would limit what I ingest with a pH lower than 5.5. I recommend following the Dropping Acid diet as well.
  • If you are suffering from bile reflux combined with pepsin reflux, reduce your ingestion of foods high in omega 9, known as oleic acid. Avocados, avocado oil, olives, and olive oil are foods that contain elevated amounts of oleic acid.
  • If you suffer from a chronic cough, then avoid spicy food. Capsaicin ingestion activates your TRPV1 receptors throughout the digestive tract, which among other actions, elicit a cough reflux.25
  • Improve your oral hygiene.
  • Drink two ounces of natural, alkaline water (Evamor, Icelandic Spring, and Mountain Valley Spring Water are good brands) two hours after a meal to deactivate pepsin within your oral cavity, throat, and esophagus. Swish well and gargle with the alkaline water before swallowing. In addition, drink two ounces of natural alkaline water before bed. Gargling has been found in studies to possibly strengthen the UES and help to relieve reflux.26
  • Avoid singing, shouting, whispering, or talking for extended periods of time which all strain our larynx and increase laryngeal inflammation.
  • Relieve constipation and maintain proper motility.
  • Having proper posture and not wearing tight clothing can help to prevent silent reflux from occurring.
  • Wash your nasal passages out with saline at least once a day. In addition, use saline drops within your nose daily and blow your nose afterward. The saline deactivates excess pepsin that might be in your nose from the reflux caused by the LPR. Please do not use a neti pot unless needed because it can reduce mucus that makes up the beneficial mucus barrier within our sinuses.
  • Sleep on your left side at night to prevent reflux. Sleeping on our left side or back prevents a lack of LES tone and helps maintain proper anatomical position. If you cannot tolerate sleeping on your left side, sleep on your right side, do not sleep on your stomach, it increases gastrointestinal pressure. Some people notice relief from sleeping on a wedge pillow or elevating the front of their bed. Do not eat food at least three hours before bed. Finally, practice good sleep hygiene. Melatonin production is important for proper digestive health and LES health.
  • Increased endogenous vitamin D production helps most people with silent reflux. I cannot stress the importance of this advice; it has made the most significant difference in my life and those I have coached that made the lifestyle changes. If you live in an area where it is difficult to be exposed to sunlight or UV-B, using a UV-B-producing tanning bed or supplementation might be needed. Get your 25-hydroxy and 1-25 hydroxy levels checked to see if your vitamin D levels are within range.
  • The use of low-level laser therapy (LLLT) from a trained chiropractor or naturopathic doctor may reduce esophageal inflammation and pain and help relieve silent reflux symptoms.27 28
  • The use of pulsed electromagnetic therapy from a trained chiropractor or naturopathic doctor over time may help improve your LES and UES tone and relieve reflux.29

Silent Reflux (LPR) Protocol

  • Magnesium glycinate – two hundred milligrams per fifty pounds of body weight, taken one hour before bed. Glycine has been shown to help enhance LES tone.
  • Eat organic grass-fed beef liver once weekly for a good source of retinol and ceruloplasmin-bound copper.

Coat and Repair Your Esophagus and Throat

  • Supplement with collagen daily.
  • Zinc carnosine – two capsules, twice daily with meals.
  • Recipe to help coat and relieve your throat – In one cup of hot filtered water, mix in 1/2 teaspoon of slippery elm powder and 1/8 teaspoon of DGL powder, and consume thirty minutes before a meal. Let sit for a few minutes to cool before consuming. Swish well, mixing with saliva before swallowing. Consider gargling mixture as well if it is cool. Consume no more than three times daily.
  • Consider using D-limonene to help coat and protect the esophagus and larynx. For some people, it helps immensely; for others, it may not be easily tolerated.
  • Consider using liposomal colostrum to help invigorate your immune system and relieve inflammation.
  • For two to three weeks consider taking one dose of Reflux Raft before bed. Gaviscon Advance might be needed if your silent reflux is severe.

Tackle Outstanding Medical Problems That may Cause LPR:

  4. Beers, Mark. The Merck Manual, Merck Research Laboratories, 2006.
  8. Beers, Mark. The Merck Manual, Merck Research Laboratories, 2006.
  12. Beers, Mark. The Merck Manual, Merck Research Laboratories, 2006.
  13. Patton, Kevin, Thibodeau, Gary, Douglas, Matthew. Essentials of Anatomy and Physiology, Mosby, March 16, 2011.
  22. Beers, Mark. The Merck Manual, Merck Research Laboratories, 2006.