Silent Reflux Disease
By Lauren O’Connor, MS, RDN, RYT
Vol. 24 No. 8 P. 40
Uncovering the Complexities of an Elusive Condition
Symptoms can appear without warning. They can manifest as a tickle in the throat, mild to moderate throat irritation, a cough, clearing of the throat, or what feels like a lump in the throat. Many people live with these mild symptoms daily—chalking it up to allergies. But if these symptoms persist, they can be part of a health condition called silent reflux, clinically known as laryngopharyngeal reflux (LPR).
Despite some similarities, silent reflux and gastroesophageal reflux disease (GERD) aren’t the same. Acid reflux may contribute to both conditions, but the symptoms and consequences are different.
Silent Reflux Defined
Silent reflux often includes an extraesophageal manifestation of GERD, says Walter Chan, MD, MPH, director of the Center for Gastrointestinal Motility at Brigham and Women’s Hospital and an assistant professor at Harvard Medical School. “It’s normal to have a number of acid reflux episodes daily for healthy individuals, particularly with eating. However, when the total amount of reflux goes over a certain threshold, symptoms and complications of GERD may occur. For some patients, their total amount of reflux may not be particularly high, but if a large proportion of it travels all the way up to the upper esophagus and airway, it may manifest as extraesophageal or LPR symptoms.”
According to a 2020 review in The Journal of Clinical Medicine, silent reflux may occur in as much as 30% of individuals.1 Some people may experience other symptoms, such as a hoarse throat and dysphagia, and their sinuses and lungs also may be affected.2
Because the condition alone isn’t marked by heartburn, indigestion, or other discomforts of GERD, it may go undiagnosed for a long time. Symptoms aren’t specific to silent reflux or any singular disease.1
Over time, its persistence can cause severe irritation and inflammation of the larynx and throat and neighboring passages.1 If silent reflux becomes severe and isn’t treated, it can lead to laryngeal lesions and throat cancer.3
Reflux vs GERD
GERD is suspected when symptoms of heartburn and/or regurgitation occur at least twice per week, and if not managed, it can cause esophageal damage.4
Silent reflux may have some of the same pathophysiological mechanisms as GERD, such as a weakened or dysfunctional lower esophageal sphincter, allowing stomach acids to flow up the length of the esophagus.5 The area of concern is irritation, swelling, and potential damage to the throat and vocal cords.5
Silent reflux and GERD eventually can lead to life-threatening conditions if they’re not properly treated.3,4 One of the issues with silent reflux is that there are other diseases in which laryngeal disorders are present, often making it challenging for clinicians to make an accurate diagnosis.6 The lining of the esophagus has protective mechanisms against the aggressive nature of stomach contents, including stomach acid and bile salts. Whereas the laryngeal and pharyngeal mucosa (throat and ear tissues) don’t have these protective mechanisms, leaving them vulnerable to damage.2 Thus, the presence of stomach contents may irritate and potentially erode that tissue more rapidly.
Other differentiations between silent reflux and GERD include the types of refluxed content, timing, and posture-related incidence. GERD mainly presents with acid reflux, while silent reflux involves acidic, nonacidic, and more gaseous components. GERD usually is triggered at night in the supine position, while silent reflux occurs during the day in a prone or upright position.1,5
“In general, it’s more difficult for people with LPR to follow a plan compared to people with GERD because they aren’t always in pain,” says Jenna Volpe, RDN, LD, CLT, a functional dietitian and founder of Whole-istic Living in Austin, Texas. “With silent reflux, some people can eat certain foods and not be aware of any damage happening at the cellular level.”
In silent reflux, damage to the larynx and vocal region can be caused by disruptions to normal esophageal function. Potential mechanisms include an eroded esophageal lining, dysfunction of the upper or lower esophageal sphincter, and/or issues with the motility of the esophagus.5
“A weaker esophagus (hypomotility) may impair the ability to clear the esophagus of refluxed contents,” Chan says. “On the other hand, chronic acid reflux may cause the esophagus to weaken. So, it can be a vicious cycle. But there are other mechanisms involved as well,” Chan continues. “Most commonly, abnormal reflux is caused by the lower esophageal sphincter (LES) inappropriately relaxing when an individual is not eating or swallowing. Certain foods can relax the muscles of the LES, as well as other factors such as excess body weight and increase in pressure from the stomach. These food items or risk factors may lead to an increase in reflux.”
The vagus nerve also may play a role in laryngopharyngeal complications such as throat phlegm, coughing, and swallowing issues.7 According to a 2018 article published in the Brazilian Journal of Otorhinolaryngology, a dysfunction of the vagus nerve may result in weakened muscles in the vocal folds and other sensory branches of the larynx, inducing throat tickle, sore throat, globus, and throat spasms.7
According to research, it’s unclear whether or not GERD causes silent reflux; it may occur concurrently or independently of GERD.2,6 But research suggests that patients who don’t manage GERD eventually can develop signs and symptoms of silent reflux.6
Heliobacter pylori (H. pylori), hiatal hernia, and impaired esophageal motility also have been associated factors in the development of silent reflux.6,8 Moreover, sleep apnea and irritable bowel syndrome may occur with, or contribute to, GERD and silent reflux.9-12
In light of these overlapping conditions that may be present in those with silent reflux, dietitians recommend ruling out these and GI disorders and following up with treatment when they coexist with silent reflux.
“Working with a GI doctor to rule out H. pylori is something that often gets skipped or overlooked, but if an H. pylori infection is the reason someone is experiencing acid dysregulation of any kind, that problem will continue until H. pylori is [diagnosed] and addressed,” Volpe says.
Diagnoses and Medical Treatment
Ruling out various digestive disorders to help diagnose silent reflux may be challenging, but the presence of one or more symptoms, including hoarseness, chronic cough, excess throat clearing, postnasal drip, dysphagia, and breathing difficulties, can help determine the need for further evaluation. First, individuals should complete a Reflux System Index, which is a questionnaire designed as a diagnostic measure for silent reflux.5
In addition, doctors can perform an endoscopic evaluation of a patient’s nose, throat, esophagus, or windpipe to determine a diagnosis.13 A laryngoscopy can be performed to examine the larynx. Edema under the vocal folds may be a good indicator of silent reflux.5,8 An x-ray or biopsy also may be performed. However, the gold standard for diagnosing silent reflux is single or dual probe pH testing, which determines the extent of acidity in the upper aerodigestive tract.8
To help treat silent reflux, clinicians can prescribe proton pump inhibitors (PPIs) to reduce stomach acid. These medications also are commonly prescribed to patients with GERD and can be taken up to twice daily for at least three months or as long as six months to 1 year.8,13 However, according to a 2020 systematic review, there’s little evidence to suggest PPIs are effective in the treatment of silent reflux. In the majority of systematic studies/meta-analyses reviewed, PPIs showed no benefit compared with placebo.14 Nevertheless, PPIs may be prescribed from one to six months since silent reflux is difficult to diagnose.1,7,13
Another treatment option is nissen fundoplication, a surgical procedure used to reinforce the structure of the LES for patients with severe or life-threatening silent reflux.8
Lifestyle and Dietary Interventions
Dietitians can recommend less invasive treatments that involve lifestyle and diet modifications to individuals with silent reflux and GERD since both conditions involve chronic acid reflux.
The American Academy of Otolaryngology-Head and Neck Surgery recommends individuals do the following:15
• Lose weight if needed. Several studies have suggested that excess weight or obesity is a risk factor for the development of chronic acid reflux and erosive esophagitis. The mechanism responsible may be due to increased gastric pressure on the LES.16
• Decrease or stop smoking tobacco products. Smoking has been shown to relax the LES and exacerbate symptoms of acid reflux.17 It’s known to increase inflammation of the larynx and silent reflux complications. In a 2019 study published in Ear, Nose & Throat Journal, smoking cessation resulted in reductions in vocal fold edema and laryngeal irritation.18
• Wear looser clothing around the waist. In a 2017 prospective study published in Gastroenterology, a tight waist belt was shown to increase gastric pressure following meals, an association related to excess abdominal weight and its effect on the LES.19
• Eat three to four small meals per day instead of two to three large ones. Large meals promote stomach distention, putting pressure on the LES and preventing proper closure of the LES.20
• Avoid eating and drinking within two to three hours of bedtime. Eating late in the evening increases production of stomach acids.20
• Raise the head of the bed if needed to help reduce nighttime reflux. Elevating the head may shorten the duration the esophagus is exposed to acid, potentially by way of acid clearance.21,22 According to a systematic review and study published in BMC Family Practice, elevating the head by 20 cm was effective in reducing acid reflux symptoms in five controlled trials of 228 participants with GERD.22
• Limit problem foods and drinks, such as caffeine, coffee, chocolate, peppermint, alcohol, carbonated drinks, tomatoes, citrus fruits, spicy foods, fatty and fried foods, and alcohol. According to a 2019 article in the Journal of Thoracic Disease, these foods contribute to mechanisms that can promote acid reflux. Caffeine, coffee, chocolate, peppermint, and alcohol reduce LES tone (relaxes the sphincter), allowing stomach acids and other gastric contents to travel up the esophagus. Carbonated drinks promote stomach distention, putting pressure on the LES, thereby preventing proper closure of the sphincter. Acidic foods and beverages, including tomatoes and citrus, as well as spicy foods, may contribute to direct irritation of the esophagus and throat. Fatty foods also may relax the LES. Researchers hypothesize that digesting calorically dense fats requires potential secretion of irritants, such as bile acids, into the esophagus and throat.20
The complexities of silent reflux are evident, but it’s a manageable condition, according to Chan, who reaches out to dietitians for multidisciplinary support. “Dietary education and counseling are first line interventions to help patients manage their symptoms.”
Kate Cline, RDN, CLT, a functional nutritionist, lifestyle coach, and owner of Dublin Dietitian in Dublin, Ohio, recommends a trial elimination diet. “Some people will do well with removing foods commonly thought to be triggering, such as caffeine, acidic foods, and spicy foods. In some cases, this can be enough. But in others, there can be personal triggers that are different for everyone, and these need to be tested in order to provide better symptom relief.”
E.A. Stewart, MBA, RD, a digestive health expert and blogger of gluten-free topics at The Spicy RD, prefers to treat patients with both IBS and silent reflux or GERD with a low-FODMAP elimination diet, as many have experienced symptom relief. “Although research is limited, some preliminary evidence suggests there may be a connection between the intake of fructose and fructans and relaxation of the LES, which could explain why a low-FODMAP diet may alleviate symptoms,” Stewart says.12
To individualize her clients’ needs, Stewart recommends they keep a food journal and complete a food frequency questionnaire. She provides clients with a list of foods and recipes they can enjoy during the elimination phase of the diet.
Before recommending an elimination diet, dietitians should evaluate their patient’s history and food diary to quantify the number of flare-ups and when they occur.23 Once RDs develop a food avoidance list, a patient may begin a short-term elimination diet followed by a slow, methodical reintroduction of foods. It’s important for clinicians to screen patients for eating disorders before suggesting an elimination diet, manage a protocol that ensures adequate nutrition, and above all, encourage a healthful, enjoyable relationship with food.23
However, Volpe says temporary elimination diets aren’t for everyone. “If a person has bulimia, addressing and interrupting the binge-purge behaviors may be the priority over any other dietary interventions to remove that source of esophageal damage (stomach acid erosion),” Volpe says.
For more fine-tuning of the diet, some dietitians recommend MRT® (Media Release Test), a food sensitivity blood test developed by Oxford Biomedical Technologies. MRT® detects foods that cause an inflammatory response in the body, as well as least-reactive foods that likely are best tolerated.24 The LEAP protocol, also developed by Oxford Biomedical Technologies, uses a patient’s best-tolerated foods as the basis for their temporary elimination diet, which is followed up with a multiphased dietary approach.25 However, according to the Academy of Nutrition and Dietetics, there isn’t enough evidence to support the validity of these tests for diagnosing adverse reactions to foods.26
Silent reflux is a complex condition that often goes undiagnosed due to the challenges of ruling out other GI and laryngeal disorders with overlapping symptoms. However, if left untreated, silent reflux can lead to severe irritation and inflammation of the larynx and throat and, in worse cases, laryngeal lesions and throat cancer.
While there are pharmacological interventions available to help treat the condition, there are lifestyle and dietary modifications patients can follow to alleviate symptoms and live a more healthful, productive life.
Educating and counseling patients about silent reflux and how it differs from GERD, as well as lifestyle and dietary interventions, are key. Dietitians can work with their patients’ gastroenterologists to develop optimal treatment plans that include pharmacotherapies and lifestyle and diet modifications to precipitate healing.
— Lauren O’Connor, MS, RDN, RYT, is a Los Angeles-based dietitian in private-practice, a yoga instructor, and a cookbook author. Find her on Instagram @laurenoconnor.rd, Twitter @HealingGERDrd, and at https://nutrisavvyhealth.com.
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