Laryngopharyngeal Reflux (Silent Reflux) Treatment in Sydney

Laryngopharyngeal reflux (LPR), often called silent reflux, occurs when stomach acid travels up past the oesophagus and reaches the throat and voice box. Unlike typical reflux, most patients with LPR do not experience heartburn: instead they have chronic throat clearing, a persistent cough, voice changes and a sensation of something stuck in the throat.

What Is Laryngopharyngeal Reflux?

LPR is a form of gastro-oesophageal reflux in which stomach contents, including acid, pepsin and bile, travel up the oesophagus and spill over the upper oesophageal sphincter to contact the throat (pharynx), voice box (larynx) and sometimes the back of the nose and sinuses. The lining of these structures is far more sensitive to acid injury than the oesophagus, which has protective mechanisms against acid exposure.

While gastro-oesophageal reflux disease (GORD) primarily causes heartburn and oesophageal symptoms, LPR produces throat and voice symptoms. Importantly, up to 50% of patients with LPR-related throat symptoms have no heartburn at all, making the diagnosis less obvious and often delayed. LPR is a very common cause of chronic throat symptoms and is diagnosed by ENT specialists.

Symptoms of LPR

LPR produces a characteristic pattern of throat and voice symptoms that are often worst in the morning (due to reflux occurring during sleep):

Chronic throat clearing: often the most bothersome symptom
Persistent dry cough, particularly after meals or when lying down
A sensation of a lump in the throat (globus pharyngeus)
Hoarseness or voice fatigue, especially in the morning
Excessive throat mucus or post-nasal drip sensation
Difficulty swallowing or a sensation of food sticking
Sore throat or burning sensation in the throat
A bitter or sour taste, particularly on waking
Bad breath
Worsening of asthma symptoms (acid can irritate the airways)

Symptoms are often chronic, persisting for months or years, and may be mistakenly attributed to allergies, post-nasal drip or recurrent throat infections.

Causes and Risk Factors

Factors that promote LPR include:

Dietary factors: acidic foods (citrus, tomatoes, vinegar), caffeine, chocolate, alcohol, spicy foods and carbonated drinks all increase reflux
Eating habits: large meals, eating close to bedtime, and eating quickly
Obesity: increased abdominal pressure promotes reflux
Smoking: weakens the lower oesophageal sphincter and increases acid production
Hiatal hernia: allows acid to more easily reflux into the oesophagus and beyond
Stress: can increase stomach acid production and alter oesophageal motility
Certain medications: some blood pressure medications, anti-inflammatory drugs and bisphosphonates can worsen reflux
Pregnancy: hormonal changes and increased abdominal pressure

Diagnosis

At Central Sydney ENT, our specialists diagnose LPR through:

Symptom assessment: The Reflux Symptom Index (RSI) is a validated questionnaire that scores the severity of LPR symptoms. A score above 13 is considered suggestive of LPR.

Flexible nasendoscopy: A thin flexible camera is passed through the nose to examine the throat and voice box. Characteristic findings include redness and swelling of the tissue behind the voice box (posterior laryngitis), swelling of the arytenoid cartilages, thickening or redness of the vocal cords, and a cobblestone appearance of the throat lining. The Reflux Finding Score (RFS) is used to grade the severity of endoscopic changes.

pH monitoring: In cases where the diagnosis is uncertain or the patient is not responding to treatment, ambulatory dual-probe pH monitoring or impedance testing can objectively measure acid exposure in the throat over a 24-hour period. This is arranged in conjunction with gastroenterology.

Exclusion of other causes: It is important to exclude other conditions that can produce similar symptoms, including vocal cord lesions, allergies, chronic sinusitis with post-nasal drip, and, rarely, throat cancer.

Treatment Options

Dietary and Lifestyle Modifications

Lifestyle changes form the foundation of LPR treatment and are often effective on their own for mild to moderate disease:

Avoid eating within 3 hours of lying down
Elevate the head of the bed by 15 to 20 centimetres (using a wedge pillow or bed risers)
Reduce or eliminate caffeine, alcohol, carbonated drinks and acidic foods
Eat smaller, more frequent meals rather than large meals
Maintain a healthy weight
Stop smoking
Avoid tight-fitting clothing around the waist
Drink alkaline water (pH greater than 8) between meals

Medical Therapy

Proton pump inhibitors (PPIs): medications such as esomeprazole or pantoprazole reduce stomach acid production. For LPR, PPIs are typically prescribed twice daily (before breakfast and before dinner) for 3 to 6 months, as LPR takes longer to respond than typical reflux
Alginate-based medications: products such as Gaviscon Advance form a physical barrier (raft) on top of stomach contents, preventing reflux. These are particularly useful taken after meals and before bed
H2 receptor antagonists: medications such as famotidine may be added at bedtime to control nocturnal acid production

Voice Therapy

When LPR has caused habitual throat clearing or voice strain, speech pathology voice therapy can help patients break the cycle of throat clearing and learn techniques to protect and rehabilitate the voice. Our surgeons, including Dr Rahuram Sivasubramaniam and Dr Jareen Ebenezer, work closely with speech pathologists experienced in voice disorders.

Anti-Reflux Surgery

For patients with severe, medically refractory LPR confirmed on objective testing, laparoscopic fundoplication (a surgical procedure to tighten the lower oesophageal sphincter) may be considered. This is arranged in collaboration with an upper gastrointestinal surgeon.

When to See an ENT Specialist

You should seek a referral to an ENT specialist if:

Chronic throat clearing or cough has persisted for more than 6 to 8 weeks
Your voice has been hoarse for more than 3 weeks
You have a persistent sensation of a lump in the throat
Throat symptoms are worsening despite treatment from your GP
You have difficulty swallowing that is not improving
You are a smoker or former smoker with persistent throat symptoms (to exclude other causes)

Related Conditions

LPR is closely related to several other conditions managed at Central Sydney ENT:

Hoarse Voice: LPR is one of the most common causes of chronic hoarseness
Vocal Cord Lesions: chronic acid irritation can contribute to the development of vocal cord nodules, polyps and granulomas
Dysphagia (Difficulty Swallowing): LPR can cause a globus sensation and mild swallowing difficulty

Common Questions

Laryngopharyngeal Reflux FAQ

What is the difference between LPR and GORD? +

Gastro-oesophageal reflux disease (GORD) causes heartburn and chest discomfort because acid irritates the oesophagus. Laryngopharyngeal reflux (LPR) occurs when acid travels further up and reaches the throat and voice box, causing throat symptoms without typical heartburn. Most LPR patients do not experience heartburn at all, which is why it is called ‘silent reflux’.

Why does LPR cause throat clearing and cough? +

The lining of the throat and voice box is much more sensitive to acid than the oesophagus. Even small amounts of refluxate reaching the larynx cause inflammation and swelling of the vocal cords and surrounding tissue. This triggers a protective response of throat clearing, coughing and excess mucus production. Over time, chronic acid exposure can cause significant voice changes and persistent throat discomfort.

How is laryngopharyngeal reflux diagnosed? +

An ENT specialist diagnoses LPR through a combination of symptom assessment, flexible nasendoscopy (a thin camera passed through the nose to examine the throat and voice box), and sometimes pH monitoring or impedance testing. Characteristic findings on endoscopy include redness and swelling of the tissue behind the voice box (posterior laryngitis), swelling of the vocal cords, and cobblestoning of the throat lining.

How long does it take for LPR treatment to work? +

LPR typically takes longer to respond to treatment than typical reflux. Dietary and lifestyle modifications should be started immediately. Proton pump inhibitor therapy, if prescribed, usually needs to be taken for 3 to 6 months before full benefit is seen, as the damaged throat and laryngeal tissue takes time to heal. Most patients notice some improvement within 6 to 8 weeks.

Does Central Sydney ENT treat laryngopharyngeal reflux? +

Yes. Central Sydney ENT surgeons diagnose and manage laryngopharyngeal reflux, including flexible nasendoscopy, medical therapy and coordination with gastroenterology when needed. We see patients across seven Sydney locations including Burwood, Campbelltown, Gregory Hills, Ultimo, Drummoyne, Hunters Hill and Miranda.