Symptoms of Silent Reflux (Laryngopharyngeal Reflux)
Silent reflux causes chronic throat and voice symptoms without typical heartburn, including hoarseness, chronic throat clearing, persistent cough, globus sensation (lump in throat), sore throat, and excess throat mucus. 1, 2, 3
Primary Laryngeal Symptoms
The hallmark feature of LPR is that up to 75% of patients have NO typical gastrointestinal symptoms like heartburn or acid regurgitation, which is why it's called "silent" reflux. 1, 4 This absence of classic GERD symptoms makes the diagnosis particularly challenging.
Specific symptoms include:
- Hoarseness/dysphonia - Present in 100% of otolaryngology patients with LPR, making it the most consistent symptom 1
- Chronic throat clearing - A reflexive response to perceived throat irritation 2, 3, 5
- Persistent cough - Can be the sole manifestation in up to 75% of cases without any heartburn 1, 4
- Globus sensation - The feeling of a lump or foreign body in the throat 3, 5
- Chronic sore throat or throat pain - Ongoing discomfort without infectious cause 2, 6
- Excess mucus production in the throat - Patients often describe needing to clear thick secretions 3, 5
- Dysphagia - Difficulty swallowing, though less common than other symptoms 2, 6
Critical Diagnostic Pitfall
The presence of these symptoms alone does NOT confirm LPR as the diagnosis. 7 The American Academy of Otolaryngology-Head and Neck Surgery explicitly states that LPR should not be diagnosed based on voice symptoms alone, and clinicians should not prescribe antireflux medications for isolated dysphonia without visualizing the larynx. 7
However, even laryngoscopic findings (such as laryngeal erythema, edema of arytenoids, or vocal fold changes) have poor specificity and can be present in asymptomatic individuals or result from non-reflux causes. 7, 8 These findings have sensitivity and specificity less than 50% for diagnosing LPR. 8
Why Silent Reflux Differs from Typical GERD
The laryngeal mucosa is significantly more sensitive to refluxate than esophageal tissue, requiring fewer reflux episodes to produce symptoms. 8 This explains why patients can have severe laryngeal symptoms without experiencing heartburn - the threshold for laryngeal injury is much lower than for esophageal injury.
Clinical Context
In contrast to typical GERD where heartburn occurs in approximately 89% of gastroenterology patients 1, only 6% of otolaryngology patients with laryngopharyngeal reflux report heartburn despite having 100% prevalence of hoarseness. 1 This dramatic difference underscores why the condition is termed "silent" - the reflux is occurring without the classic warning symptom of heartburn.
The lack of a gold standard diagnostic test means that diagnosis relies on clinical suspicion based on symptom patterns, laryngoscopy to exclude alternative diagnoses, and often a therapeutic trial of proton pump inhibitors. 7, 8, 2, 5