When we think of reflux, symptoms like heartburn, burping, and indigestion might come to mind. These are common symptoms of gastroesophageal reflux disorder, or GERD. However, there is another similar condition that often goes unnoticed: LPR. Also called “silent reflux,” LPR symptoms like throat irritation, coughing, and difficulty swallowing may be less easily connected to reflux.
LPR, or laryngopharyngeal reflux disease, is a reflux disorder that we still don’t fully understand, even among experts. There are not yet well-established LPR tests, criteria for diagnosis, or enough research studies, and symptoms can present in a variety of different ways for different patients .
Still, this doesn’t mean that LPR can’t be healed. The lack of clarity on how to approach this condition simply means that each patient should have an individualized treatment plan and take it one step at a time.
Laryngopharyngeal reflux (LPR) vs. GERD
What’s the difference between LPR and the more well-known GERD?
With GERD, stomach contents come back up into the esophagus (the tube that connects the stomach to the throat) and create acid reflux symptoms, like heartburn.
In the case of LPR, the contents of the stomach travel past the esophagus and into the larynx or voice box, and the pharynx (the throat). This leads to different symptoms from GERD, like sore throat and hoarseness, making LPR harder to diagnose or even identify.
Symptoms of LPR vary but may include any of the following :
- Frequent throat clearing
- Sore throat or throat irritation, sometimes with a burning sensation
- Acid reflux
- Chronic cough
- Globus pharyngeus (persistent feeling of a lump in the throat)
- Dysphagia (difficulty swallowing)
- Postnasal drip
LPR symptoms are uncomfortable but usually aren’t severe or dangerous for most people. However, if left untreated, LPR can damage the vocal cords or lead to vocal injury . LPR symptoms may also indicate something else in the digestive system, like infection or candida overgrowth, that should be investigated.
The LPR, GERD, and IBS Connection
While research has not illuminated the exact relationship between LPR, GERD, and IBS, the overlap between symptoms of these conditions is worth investigating.
For example, IBS is often caused by small intestinal bacterial overgrowth (SIBO), and many patients with IBS have reflux or LPR as well [3, 4, 5]. Therefore, gut health imbalances or conditions like SIBO should be considered in cases of laryngopharyngeal reflux.
There are two theories behind the causes of LPR. The main theory, “reflux theory,” is that stomach contents, including stomach acid and pepsin (a digestive enzyme), travel up the esophagus and into the larynx (voice box).
A muscular valve called the lower esophageal sphincter (LES) should keep stomach contents from moving back up into the throat. But if the LES is dysfunctional, it can allow reflux to pass through, leading to symptoms .
A secondary explanation for LPR is referred to as “reflex theory.” This states that reflux and acid in the lower esophagus (GERD) can cause laryngeal symptoms without directly reaching the larynx through a reflex involving the vagus nerve .
- Reflux theory: Stomach contents move through the throat and voice box and cause LPR symptoms.
- Reflex theory: Stomach contents backup in the lower esophagus (GERD) to trigger a nerve response that causes LPR symptoms.
Causes and contributing factors for LPR may include:
- GERD 
- High levels of pepsin (a stomach enzyme) 
- Irritable bowel syndrome (IBS) [3, 9]
- Weak esophageal motility (esophageal contractions that should move food towards the stomach are weak) 
- Hiatal hernia (when part of the stomach pushes up into the chest) 
- H. pylori infection  (although some research suggests that H. pylori may actually be protective when it comes to reflux )
- Eating certain foods, including acidic foods, high-fiber diets, alcohol, caffeine (although some research refutes this ), sugary beverages, fermented foods, and gluten [15, 16, 17, 18]
- Sleep apnea .
Several different diagnostic tools may help to diagnose LPR. These include:
- Endoscopy or specialized endoscopic procedures
- pH probe or pH monitoring
- Mucosal integrity tests
- Manometry (measures the strength and coordination of the esophagus).
There isn’t a universal testing method or standard diagnostic criteria when it comes to LPR. Gastroenterologists may also use different diagnostic techniques than otolaryngologists (ear, nose, and throat specialists).
Step-by-Step LPR Treatment
Laryngopharyngeal reflux treatments may include specialized diets, reducing microbial intruders in the gut, rebalancing the microbiome, taking natural or pharmaceutical compounds to adjust stomach acid levels, and, in some cases, surgery.
Research on LPR treatment is limited. For conditions like LPR where people respond very differently to treatments due to underlying causes and other contributing factors, I generally recommend following a hierarchical, step-by-step approach.
In many cases, finding the best therapeutic diet for you is enough to resolve your symptoms. But if your symptoms continue, you can move on to supporting the gut with probiotics, and investigating and treating any underlying gut imbalances like SIBO. It’s important to take treatment one step at a time and monitor your response to any new treatments or modifications.
Modify Your Diet
Finding your ideal diet should be the first step when it comes to LPR treatment since — good news! — the right diet alone is often sufficient to resolve LPR symptoms.
But even if diet alone is not enough, it still helps to create a healthier foundation from which to approach other treatments, such as a gut protocol.
As one example, a 2020 systematic review found following a low-acid diet helped reduce LPR symptoms .
One observational study also found that a whole foods, plant-based Mediterranean diet was better than proton pump inhibitors (PPIs) for reducing LPR symptoms . While not everyone with LPR needs to follow this specific type of diet, it does show that a therapeutic diet can be highly effective for this condition.
There is no one diet that works for all LPR patients. But trying an elimination diet can help you find out which foods aggravate your symptoms.
Use an Elimination Diet to Identify Symptom-Triggering Foods
Underlying food sensitivities can contribute to digestive issues and many other chronic symptoms, even if you eat a generally healthy diet. This is where an elimination diet can be a useful tool: Through a process of elimination and one-by-one reintroduction, you can determine which foods lead to symptoms and which help you to feel at your best.
An elimination diet based on the Paleo diet is a good place to start. The Paleo diet removes many common food allergies and sensitivities, including gluten and dairy.
Consider whether there are any foods that you already know aggravate your symptoms, and eliminate these right away. This may feel difficult at first, but remember that you are taking control of your health and you have the power over your diet, not the other way around.
Once you have taken out foods that you know are causing LPR symptoms, begin a 3-4 week elimination period in which you avoid common LPR trigger foods. This may be based on a Paleo or Autoimmune Paleo diet framework.
Certain foods and beverages have been associated with LPR symptoms, so they should be generally avoided as when doing your elimination diet. These include:
- Acidic foods (i.e. citrus, tomatoes) 
- Spicy foods 
- Oily foods 
- Fermented foods 
- Alcohol 
- Coffee 
If this helps to resolve symptoms after 3-4 weeks, begin the reintroduction period. Add one eliminated item back into your diet at a time and monitor your symptoms. This will help you to find out which foods are better left out of your diet and which ones you can tolerate. Either way, stay away from processed or sugary foods, which are not healthy for anyone.
If the elimination period doesn’t help to resolve symptoms, consider a trial of a more specialized diet, such as a low FODMAP or low histamine diet (see below).
Low Histamine Diet
A low histamine diet may help those diagnosed with LPR and can be started if a standard elimination diet doesn’t relieve symptoms.
Histamine promotes acid production in the stomach, which can aggravate LPR symptoms (this is why histamine (H2) blockers are often recommended for acid reflux). A low histamine diet reduces histamine in two ways: by reducing histamine-containing foods and lowering the body’s histamine production.
Although the low histamine diet has not been studied for LPR specifically, many individual foods that have been associated with LPR contain high levels of histamine or cause histamine production in the body. These include the foods we listed earlier: fermented and spicy foods, citrus, tomatoes, chocolate, and alcohol.
Low FODMAP Diet
The low FODMAP diet is often recommended for SIBO and IBS and has been shown to significantly improve their symptoms [23, 24, 25, 26]. A low FODMAP diet may also be effective for LPR, since this condition and reflux disorders like GERD and LPS often overlap. This diet gets rid of fermentable carbohydrates that feed certain gut bacteria.
Although the low FODMAP diet has not been studied for LPR specifically, studies have shown that low FODMAP diets can help to reduce reflux symptoms, like heartburn, for those with GERD .
Studies on the low FODMAP diet have also shown that it can significantly reduce levels of inflammatory histamine in the gut flora .
Other Dietary and Lifestyle Strategies
Other dietary and lifestyle strategies that have been shown to improve LPR symptoms include:
- Drinking alkaline water (made at home by using a special filter)
- Consuming a diet rich in fiber
- Not consuming food and drinks for 2-3 hours before sleep
- Moderate physical activity 
Modifying your diet and lifestyle will often improve gut health. However, if a therapeutic diet alone doesn’t provide symptom relief, the next step is to look into potential gut health imbalances.
In some cases, H. pylori infections may contribute to LPR and can be tested for .
Another possible culprit is small intestinal bacterial overgrowth. Although research hasn’t yet found a connection between SIBO and LPR, the increased gas pressure associated with SIBO may help push stomach contents back up through the LES.
Bacterial overgrowth can also cause increased histamine production, raising stomach acid levels. Addressing SIBO as an underlying cause may help relieve symptoms of LPR and other chronic issues.
Taking probiotics to rebalance the gut flora and increase beneficial bacteria may also be useful. Although research hasn’t determined the effects of probiotics for LPR specifically, a connection has been made to improving GERD symptoms with probiotic use .
Assess Stomach Acid Levels
Although reflux disorders are traditionally associated with excess stomach acid, the opposite (low stomach acid or hypochloridia) can also be problematic. The symptoms of too much stomach acid and not enough stomach acid are also similar, which can make things confusing.
Here are a few common signs and risk factors to help you determine whether you’re more likely to have low or high stomach acid levels.
Low stomach acid:
- Age (over 65)
- Anemia or autoimmune disease
- Chronic use of painkillers or excessive coffee consumption
High stomach acid:
- Age (younger than 65)
- “Gnawing” stomach pain
- Family or personal history of gastritis or ulcers
If low stomach acid is suspected, a trial of supplemental HCl (hydrochloric acid) may be recommended. The best way to do this is to try HCl for 2-3 weeks while monitoring your symptoms without making any other changes to your treatment or diet. Start with a low dose to see how you react. This way, you’ll know for sure whether it’s improving or worsening your symptoms. If burning in the throat or any other symptoms occur, discontinue immediately.
Naturally Reduce Stomach Acid
Many natural supplements or compounds can reduce stomach acid and help relieve symptoms. Supplements can be used with a healthy diet to reduce symptoms as other underlying causes are systematically addressed.
Supplements that have been shown to help with reflux symptoms in LPR, GERD, or both include:
- Melatonin [30, 31]
- L-tryptophan (in combination with melatonin) 
- Sodium alginate 
- Prokinetic (gastrointestinal motility strengthening) herbal blends [20, 33]
Conventional LPR Treatments
Proton Pump Inhibitors (PPIs)
Proton pump inhibitors are medications used to lower stomach acid that are often prescribed to treat LPR, GERD, and ulcers. A few common PPIs are omeprazole, esomeprazole, and rabeprazole.
However, PPIs have not been definitively proven to relieve LPR symptoms. Two systematic reviews have concluded that PPIs are only slightly more effective than placebos at treating LPR, when combined with diet and lifestyle changes [34, 35]. Another study revealed that there was no difference between PPIs and placebo treatment for LPR .
PPIs might be a possible treatment option for LPR, but diet and lifestyle modifications should come first in most cases.
Similar to PPIs, H2 blockers may be a treatment consideration for temporarily reducing symptoms once diet and lifestyle foundations are in place and gut imbalances are being addressed.
Fundoplication surgery is sometimes recommended for patients with LPR or GERD. The procedure involves wrapping part of the stomach around part of the esophagus to keep acid and other stomach contents from flowing to (or past) the esophagus.
Evidence for the effectiveness of this procedure for LPR is inconclusive, according to a 2019 systematic review of 34 observational studies .
Ideally, modifying your diet, healing your gut, and addressing underlying imbalances using a step-by-step approach is enough to improve your LPR symptoms so that this type of procedure is not necessary.
Controversy Around PPIs
PPIs are often dismissed as a treatment option in the functional medicine world based on research showing an increased risk of cardiovascular disease and complications like heart attacks, intestinal infections like C. difficile, SIBO, and pneumonia [40, 41, 42, 43].
These are serious concerns, to be sure. But these side effects are connected to long-term PPI use. Short-term use, while addressing diet and other underlying factors, can help temporarily relieve symptoms.
For example, if you have a stomach ulcer and LPR symptoms, short-term use of PPIs can help allow your ulcer to heal as you address diet, lifestyle, and any gut health imbalances that may be contributing to excess acid production and other symptoms.
With a multi-step, hierarchical treatment approach, healing LPR and regaining better digestion is possible.
Reach out to our clinic today to get started with an experienced practitioner who can help you address your symptoms and reclaim your health.