Reflux without the burn: could you have silent reflux?

If you persistently clear your throat or have a chronic cough and your GP has ruled out other causes, the problem may lie not in the throat itself, but further down the digestive tract, in the stomach.

What is silent reflux?

Most of us picture reflux as heartburn: a burning feeling behind the breastbone after a large meal or a glass of wine. That's gastro-oesophageal reflux disease (GORD), where stomach contents travel back up into the oesophagus (food pipe).

Laryngopharyngeal reflux (LPR) is different. Here, small amounts of stomach contents travel further up, reaching the throat (pharynx), the voice box (larynx) and sometimes even the back of the nose.

It's often called silent reflux because many people with LPR have little or no heartburn. Instead, symptoms show up in the throat and airways, which is why it's so easy to miss. Yet it is common: LPR is estimated to affect 10–30% of people seen in ear, nose and throat clinics [1].

Why the throat is so sensitive

Your oesophagus has some built-in protection against stomach contents. The delicate tissues of the throat and voice box don't. Research suggests it isn't only acid that causes irritation, but also pepsin, a digestive enzyme made in the stomach to break down protein.

Research has shown that pepsin can remain active across a wide range of acidity, not only in a strongly acidic environment, and it has been linked to inflammation of the delicate tissues of the throat and voice box [2]. This may help explain why even small, infrequent reflux episodes can leave the throat feeling irritated, and why what you eat and drink can make such a difference.

Signs that may point to silent reflux

Symptoms vary from person to person, but common ones include:

• frequent throat clearing, especially after meals or on waking;
• a persistent, often dry, cough;
• hoarseness, a croaky voice, or a voice that tires easily;
• a sensation of a lump in the throat (sometimes called 'globus');
• excess mucus or a feeling of postnasal drip;
• a sore throat or difficulty swallowing with no obvious cause;
• a sour or bitter taste in the mouth.

What can make silent reflux worse?

Several everyday factors may contribute:

Late meals

Lying down within two to three hours of eating gives stomach contents an easier route upwards.

Large portions

A very full stomach puts more pressure on the valve (the lower oesophageal sphincter) that normally keeps contents where they belong.

Certain drinks

Fizzy drinks, alcohol, coffee and acidic fruit juices are common triggers, and many fizzy drinks are highly acidic.

Fatty, fried or spicy foods, chocolate and mint

These may relax the lower oesophageal sphincter or irritate the throat.

Stress and eating on the go

In fight-or-flight mode, digestion slows, and we tend to swallow more air.

Tight clothing and extra weight around the middle

Both increase pressure on the stomach.

Smoking and vaping

Smoking and vaping may also irritate the throat and airways.

How diet may help

There is encouraging research on food-based approaches. In one study, 50 people with confirmed LPR followed a low-fat, low-sugar, high-protein, mostly plant-based diet, without medication, for six to twelve weeks. At six weeks, 74% reported a significant improvement in their symptoms [3].

A more recent study followed people with confirmed LPR who made diet and lifestyle changes alone for three months. Over that time, visible signs of irritation in the throat and voice box reduced significantly [4]. These studies are small, and more research is needed, particularly comparing diet with medication, but they suggest diet can be a valuable part of the picture.

Some practical starting points may include:

• Eating your evening meal earlier, ideally at least three hours before bed.
• Choosing smaller, more frequent meals rather than one large one.
• Building meals around vegetables, pulses, wholegrains and lean protein, Mediterranean style.
• Swapping acidic and fizzy drinks for still water or gentle herbal teas such as chamomile.
• Slowing down. Sit down to eat, chew thoroughly and put your fork down between mouthfuls.
• Raising the head of your bed slightly if night-time symptoms are a problem.
• Keeping a symptom diary to spot your personal triggers, which can vary a great deal between individuals.

How a nutritional therapist can help

Silent reflux rarely has a single cause. Working with a nutritional therapist means looking at the whole picture: what you eat and drink, when and how you eat, stress, sleep and your digestion as a whole.

So if a persistent cough, a croaky voice or constant throat clearing sounds familiar, it may be worth investigating further and working with a nutritional therapist to find the best approach for you.

References

1. Lechien JR. Personalized treatments based on laryngopharyngeal reflux patient profiles: a narrative review. J Pers Med. 2023;13(11):1567.
2. Li Y, Xu G, Zhou B, et al. Effects of acids, pepsin, bile acids, and trypsin on laryngopharyngeal reflux diseases: physiopathology and therapeutic targets. Eur Arch Otorhinolaryngol. 2022;279(6):2743–2752.
3. Lechien JR, et al. Is diet sufficient as laryngopharyngeal reflux treatment? A cross-over observational study. Laryngoscope. 2022;132(10):1916–1923.
4. Effectiveness of diet and lifestyle changes for the treatment of laryngopharyngeal reflux disease: a prospective study. J Voice. 2025. doi:10.1016/j.jvoice.2025.09.002