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

 

 

 

 

My Past 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 (silent reflux, LPR).

Over the next month, I developed obsessive-compulsive disorder, had significant anxiety, LPR symptoms, gastritis, and 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 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 from 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 and be suffering from both conditions.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 closure.
  • 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, occur 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 feels normal because refluxed acid and pepsin are quickly swallowed downward. Reflux does not become trapped between our two esophageal sphincters (LES and UES) 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, when activated by acidic reflux, acidic aerosolization, or ingestion of acidic food, embedded pepsin 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 becomes inactivated and turns back into pepsinogen when mixed with alkaline bicarbonate. Bile is released from our liver and/or gallbladder 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 relatively 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 the safer transnasal esophagoscopy procedure, which does not require sedation to view the health of your throat and esophagus.15 16 17

An esophageal pH monitoring test is one of the best assessments used in diagnosing LPR. A flexible catheter with a pH monitor at the end is placed through our nose into our 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, our lower esophageal sphincter, is the only sphincter that does not function correctly. The non-functioning LES causes stomach chyme to become stuck 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 your throat, oral cavity, nasal cavities, and eustachian tubes from reflux.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 slight 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 temporary relief, 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 your nasal cavities, oral cavity, throat, or esophagus.
  • Nerve damage or inflammation to our 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 underactive parasympathetic nervous system, also known as adrenal fatigue).
  • Overactive sympathetic nervous system (compromised vagus nerve function).
  • Hypothyroidism
  • Mercury amalgams
  • Oral cavitations (caused mainly by root canals) and nerve damage/dysbiosis.
  • Medication usage

 

General Advice for LPR:

  • Ask a physical therapist about doing shaker neck exercises to strengthen your throat muscles and improve upper esophageal sphincter tone.23 24
  • Properly using a Backnobber or Theracane on your upper back and neck might improve UES function and health.
  • Daily light exercise is essential 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, mainly if it contains carbohydrates (to mix well with the bit of 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.
  • Properly ingest omega-3 fatty acids in your diet. Consume leaner, lower mercury fish, including cod and flounder. Supplementing with Nordic Naturals Ultimate Omega 2x, two soft gels, twice daily with meals, greatly improved my silent reflux.
  • Reduce your intake of acidic foods that can trigger silent reflux. I would limit what I ingest with a pH lower than 5.5. I also recommend following the Dropping Acid Diet.
  • 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 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 elicits a chronic cough reflex, among other actions.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 strengthen the UES and possibly help relieve reflux.26
  • Avoid singing, shouting, whispering, or talking for extended periods of time, as these activities 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 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, which 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, as 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 endogenous production is vital 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 who have made the lifestyle changes. If you live in an area where it is difficult to be exposed to sunlight or UV-B, a UV-B-producing tanning bed or supplementation might be needed. Check your 25-hydroxy and 1-25 hydroxy levels to see if your vitamin D levels are within range.
  • Low-level laser therapy (LLLT) provided by a trained chiropractor or naturopathic doctor may help reduce esophageal inflammation and pain, and alleviate silent reflux symptoms.27 28

 

Silent Reflux (LPR) Protocol

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

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 it sit for a few minutes to cool before consuming. Swish well, mixing with saliva before swallowing. Consider gargling the mixture as well if it is cool. Consume no more than three times daily.
  • Consider using D-limonene to coat and protect the esophagus and larynx. It helps immensely for some people, but others may not easily tolerate it.
  • Consider using liposomal colostrum to help invigorate your immune system and relieve inflammation.
  • Consider taking one dose of Reflux Raft before bed for two to three weeks. If your silent reflux is severe, Gaviscon Advance might be needed.

Outstanding Medical Problems That May Cause LPR:

  1. http://www.webmd.com/heartburn-gerd/guide/laryngopharyngeal-reflux-silent-reflux
  2. http://www.doctoroz.com/article/silent-reflux-epidemic
  3. http://www.voiceinstituteofnewyork.com/
  4. Beers, Mark. The Merck Manual, Merck Research Laboratories, 2006.
  5. http://www.webmd.com/heartburn-gerd/guide/laryngopharyngeal-reflux-silent-reflux
  6. http://www.doctoroz.com/article/silent-reflux-epidemic
  7. http://www.voiceinstituteofnewyork.com/
  8. Beers, Mark. The Merck Manual, Merck Research Laboratories, 2006.
  9. http://www.webmd.com/heartburn-gerd/guide/laryngopharyngeal-reflux-silent-reflux
  10. http://www.doctoroz.com/article/silent-reflux-epidemic
  11. http://www.voiceinstituteofnewyork.com/
  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.
  14. http://www.voiceinstituteofnewyork.com/
  15. http://transnasalesophagoscopy.com/
  16. http://www.ncbi.nlm.nih.gov/pubmed/22425272
  17. http://transnasalesophagoscopy.com/wp-content/uploads/2011/03/TNE-White-paper-20081.pdf
  18. http://www.gwdocs.com/assets/form/ent-ear-nose-throat-center/Laryngopharyngeal%20Reflux%20%28LPR%29.pdf
  19. https://www.refluxgate.com/ultimate-guide-to-lpr-causes-and-treatment
  20. http://www.doctoroz.com/article/silent-reflux-epidemic
  21. http://www.voiceinstituteofnewyork.com/
  22. Beers, Mark. The Merck Manual, Merck Research Laboratories, 2006.
  23. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2895999/
  24. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2593402/
  25. https://www.sciencedirect.com/science/article/pii/S1094553910001458
  26. http://evamor.com/static/pdf/koufman_1242.pdf
  27. https://www.ncbi.nlm.nih.gov/pubmed/23613090
  28. https://www.ncbi.nlm.nih.gov/pubmed/25916131