Laryngopharyngeal Reflux (LPR)

Laryngopharyngeal reflux (LPR) occurs when stomach contents — acid, pepsin, and bile — travel up the oesophagus and reach the back of the throat, voice box, and nasal passages. Unlike classic gastro-oesophageal reflux disease (GERD), LPR often occurs without heartburn. This is because the larynx and pharynx are far more sensitive to even small amounts of reflux than the oesophagus — a single reflux event reaching the throat can cause significant irritation and symptoms. Many patients with LPR have no awareness of reflux occurring, which is why it is also called silent reflux.

The most common symptoms are persistent throat clearing, a sensation of mucus or a lump in the throat (globus), chronic dry cough — particularly after meals or when lying down — hoarseness or voice change especially in the morning, mild sore throat or throat discomfort, and a feeling of post-nasal drip. Less commonly, LPR can cause difficulty swallowing, excess saliva, or worsening asthma. Importantly, fewer than half of patients with confirmed LPR experience heartburn — the absence of heartburn does not exclude the diagnosis.

LPR causes irritation and inflammation of the back of the throat and the area behind the nasal passages. This produces a sensation of phlegm or mucus that feels identical to post-nasal drip from the nose — but originates from throat irritation rather than nasal mucus production. Patients often describe it as mucus they cannot clear no matter how much they throat-clear or swallow. The throat clearing itself can become a habit that perpetuates irritation even after the reflux is controlled. This distinction matters because nasal sprays and antihistamines — the correct treatment for true post-nasal drip — are not effective for LPR.

Diagnosis of LPR is challenging because no symptom or sign is highly specific to the condition. The 2024 IFOS Consensus — the most current international guideline — acknowledges that many LPR symptoms overlap with allergic laryngopathies, chronic rhinosinusitis, and muscle tension dysphonia. At consultation, a nasendoscopy allows direct visualisation of the larynx and the back of the throat to look for characteristic signs of reflux-related inflammation. The gold standard diagnostic test is hypopharyngeal multichannel intraluminal impedance-pH monitoring, which measures both acid and non-acid reflux events reaching the throat. In practice, an empirical treatment trial is often the starting point, with formal testing reserved for patients who do not respond.

Not necessarily — and this is an important recent development in LPR management. Unlike GERD, which is predominantly driven by acid reflux, LPR often involves weakly acidic or non-acidic reflux events that are not fully suppressed by proton pump inhibitors. The 2024 IFOS Consensus and recent evidence suggest that for mild-to-moderate LPR without typical GERD symptoms, alginates and magaldrate — mucosal protective agents that form a physical barrier — are preferred as first-line empirical treatment over PPIs. PPIs combined with alginates are reserved for more severe cases or where typical heartburn is also present. A clinical trial found that a Mediterranean-style diet with alkaline water achieved equivalent symptom improvement to PPIs alone.

Diet is one of the most effective and evidence-supported treatments for LPR. The following measures are consistently recommended: avoid trigger foods and drinks including coffee, tea, alcohol, chocolate, carbonated drinks, fatty foods, spicy foods, citrus, and tomato-based foods; eat smaller meals more frequently rather than large meals; do not eat within two to three hours of lying down; drink plain or alkaline water as the primary beverage. A Mediterranean-style, plant-based, low-fat diet has been shown in studies to reduce LPR symptoms as effectively as proton pump inhibitors. Keeping a food diary for two to four weeks helps identify individual triggers, which vary between patients.

Beyond diet, the following lifestyle measures consistently reduce LPR symptoms: elevate the head of the bed by 15 to 20 centimetres — using bed risers rather than extra pillows, which can worsen reflux by flexing the neck; avoid tight clothing around the abdomen; lose weight if overweight, as excess abdominal pressure worsens reflux; avoid lying down for at least two to three hours after eating; stop smoking; manage stress, as stress increases stomach acid production and slows gastric emptying; avoid vigorous exercise immediately after meals.

LPR typically responds more slowly than GERD. The larynx and pharynx are slow to heal once inflamed, and symptom improvement usually takes eight to twelve weeks of consistent dietary change and medication if prescribed. Many patients notice improvement in cough and throat clearing before hoarseness resolves. Throat clearing as a habit can persist even after the underlying reflux is controlled, because the movement itself continues to irritate the throat. Voice therapy with a speech pathologist can help break this cycle if throat clearing persists despite adequate reflux control.

Chronic untreated LPR can cause persistent inflammation of the larynx, contribute to the development of vocal cord granulomas, and may worsen conditions such as subglottic stenosis in susceptible individuals. There is an association between chronic laryngeal acid exposure and laryngeal carcinoma, though the causative relationship is not firmly established and the absolute risk for an individual patient is low. More commonly, the practical consequence of untreated LPR is ongoing voice deterioration, persistent cough, and significantly impaired quality of life.

See an ENT specialist if your symptoms have not improved after eight to twelve weeks of dietary modification and GP-managed treatment, if you have voice changes lasting more than three weeks, if you have difficulty swallowing, if you notice blood in saliva or phlegm, or if a lump in the neck accompanies throat symptoms. A nasendoscopy at ENT consultation allows direct assessment of the larynx and throat that cannot be performed in a GP setting.

Yes — LPR occurs in children at all ages, though the clinical presentation differs significantly from adults. Infants with LPR often present with feeding difficulties, regurgitation, and respiratory symptoms. Older children more commonly present with chronic cough, recurrent croup, throat clearing, and voice change. Paediatric LPR is managed with dietary and positional measures as the first approach, with medication used selectively under specialist guidance.

Individual surgeons within My-ENT may approach assessment and management differently based on their subspecialty training and clinical experience. Your surgeon will discuss the most appropriate pathway for your specific situation at your consultation.