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Health Information | 02/05/2021

A Different Kind of Acid Reflux

By  Dr. Ralph Iannuzzi
Acid Reflux in a woman's throat
Most of us have experienced heartburn at one time or another. Maybe you ate too much at a holiday gathering, or chowed down a chili cheese dog at a ball game, or had some other “dietary indiscretion” and before you knew it, the classic burning feeling in the chest began. Heartburn is caused when the acid in your stomach, there to break down the food you ate, refluxes (flows in the wrong direction) and enters your esophagus which connects your throat to your stomach. If this happens frequently, you can develop gastroesophageal reflux disease (GERD), or chronic acid reflux.

Sometimes, refluxing acid travels all the way up the esophagus and makes contact with the tissues in your upper esophagus or throat, injuring those tissues. When this happens, it is called laryngopharyngeal reflux, LPR for short. Unlike the lower part of your esophagus, the tissues of the throat are not designed to tolerate acid at all. Think about it like this: if lemon juice is squeezed onto the skin of your hand, it's just going to feel wet. But if lemon juice is squeezed into your eye, you’re going to feel it! It’s the same difference between the tissues in your esophagus and those in your throat. Your system can tolerate many (50 or more) episodes of acid refluxing in the lower esophagus, but it only takes a few episodes – two or three in a 24-hour period – of acid making its way to your throat to hurt it.

This is why as many as 80% of people that have LPR never have the classic indigestion and heartburn symptoms of typical acid reflux; our bodies generally handle the refluxing acid in the esophagus but cannot handle it in the throat.


The most common symptoms of LPR are:
  • Coughing
  • Hoarseness
  • The sensation of a lump at the back of the throat (called a globus sensation)
  • The need to clear the throat
  • Difficulty swallowing
  • Sore throat (often a mild, scratchy, or irritated feeling)
  • Thick or extra mucus production
LPR is one of the top three diagnoses we see in the ear, nose, and throat (ENT) specialty, and estimates of how many people have LPR range from 10-15%. Because similar symptoms can be caused by many common ailments – allergies, infection, a virus – and because people often do not experience typical acid reflux symptoms, LPR can go undetected for years.

Factors that may increase your risk for LPR

The risk factors of LPR overlap with those of traditional acid reflux or GERD:
  • Age and getting older, something we cannot control, can contribute to your likelihood to develop LPR. The upper and lower esophageal sphincter muscles– one between your upper and lower esophagus and the other between your lower esophagus and your stomach – are gateway muscles and act as barriers by stopping acid from refluxing. As we get older, these muscles don't always function properly and provide the needed defense against refluxing stomach acid.
  • Lifestyle choices top the list of risk factors for LPR that we can control. These range from the types of food you eat, how much you eat, and even when you eat. Certain foods and drinks and activities like smoking either produce more acid or relax the sphincter muscles and allow acid to flow more easily back up the esophagus.


An ENT doctor can sometimes diagnose LPR based on your symptoms alone and prescribe a treatment regimen. Given the treatment focuses on your digestive system and not your throat, if the medicines work, it’s fairly easy to confirm the diagnosis of LPR. The second diagnostic path may involve a physical exam in the form of a laryngoscopy. Your ENT doctor will insert a very small fiber optic tube into your nose and down your throat to look for redness and irritation which are cardinal signs of LPR. Another test called an esophageal pH test can be done by placing and leaving a tube in the esophagus for 24 hours to measure how much acid comes up. Additionally, measuring the level of pepsin (a digestive enzyme that comes from the stomach and activates the acid in your stomach) in your saliva can indicate that acid has likely entered the throat and caused tissue damage.


Treatment involves both medications and lifestyle changes. The primary medicines used are those that you would also take for GERD as they suppress acid production in the stomach. It's not that you necessarily have too much acid, you just have acid that moves in the wrong direction. Nevertheless, it's relatively easy to suppress the amount of acid so it more likely remains where it should. There are two classes of drugs that suppress acid. The first drug class is H2, or histamine, blockers, with brand names Pepcid and Tagamet and generic drug names famotidine and cimetidine.

Then there is a newer class of drugs called proton pump inhibitors, or PPIs. PPI generic drug names all end with -zole – omeprazole, lansoprazole, rabeprazole, pantoprazole, esomeprazole and so forth – and have the brand names Prilosec, Prevacid, Aciphex, Protonix, and Nexium. While H2 blockers shut off most of the acid production, PPIs can shut off acid secretion completely. Because the throat tissues are more vulnerable and need time to heal, we typically prescribe PPIs to be used twice a day for 6-8 weeks, and then taper down to either a once a-day PPI or a PPI in the morning and then an H2 blocker at bedtime. We like to move off PPIs and onto H2 blockers if we can. While PPIs are safe drugs, compared to H2 blockers they have some potential side effects, primarily around calcium and magnesium metabolism and a higher risk of osteoporosis.

In total, the medication phase for LPR can last anywhere from a few weeks to three or four months, and then we control your LPR with lifestyle modifications. In extreme cases, there are some surgical interventions and also endoscopic procedures we do. But very, very few people should require surgical procedures for LPR, as the vast majority can be controlled with medications and lifestyle.

Lifestyle changes to manage LPR

This is the list of foods and drinks you should try to avoid altogether or consume judiciously, as they either increase acid production or relax the upper and lower sphincter muscles, allowing acid to more easily reflux:
  • Acidic foods, such as citrus juices and fruits, tomato-based foods, decaf coffee, tea, etc.
  • Fatty or fried foods
  • Spicy foods
  • Caffeinated beverages
  • Carbonated beverages
  • Alcohol
  • Chocolate
  • Peppermint
Additionally, there are other lifestyle changes you can try that can make a big difference:
  • Eat smaller, more frequent meals
  • Drink plenty of water
  • Stay upright (don’t lie down) at least two and preferably three hours after your evening meal and before bedtime. Do not eat or drink anything except water during those hours.
  • When sleeping, raise your head about 6” so you are more upright. An extra pillow usually won’t achieve the full 6 inches, but you can accomplish this by putting a wedge between the box spring and the mattress, sleeping with a wedge pillow, or placing boards or bricks under the legs of the headboard.
  • If you smoke, try to quit
I know that lifestyle changes are probably the hardest thing to do for most people. For example, if you've had an additional cup of coffee every afternoon for the last 20 years, and I say – “You know, one cup of coffee in the morning and that's it!” – you’re going to struggle with that. I also know that the list above contains many favorite foods! The good news is that not every food is a trigger for every person – what might bother one person might not bother the next. So I tell my patients to try and identify the foods that bother them the most and work to remove those.

Also, speak with your doctor about whether taking an extra, occasional dose of medication is right and safe for you if you know you’ll be in situations that might disrupt your careful routine. For example, say you're going to a wine and cheese get together with your friends at 6:00pm. You typically take your Pepcid at 11:00pm before you go to sleep. Most people can handle taking an extra dose of an H2 blocker from time to time, so take an extra Pepcid at 5:30pm in this example. Bottom line:  while LPR is a condition that you may remain susceptible to, it can be managed well with common-sense lifestyle changes you can control and advice and guidance from your clinician on how best to use medications that are safe and effective.

About The Author

Dr. Ralph Iannuzzi

Dr. Ralph Iannuzzi is an otolaryngologist (ear, nose, and throat or ENT physician) at Atrius Health. Dr. Iannuzzi received his medical degree from the University of Massachusetts Medical School and completed his surgical internship at St. Elizabeth’s Medical Center and ENT residency at the Massachusetts Eye and Ear Infirmary. Since joining Atrius Health in 2008, Dr. Iannuzzi has served as chief of the Atrius Health ENT department, chief of cosmetics, chief of allergy and associate chair for specialties. He has served on the Board of Trustees for the organization. He is an assistant professor at Harvard Medical School, Senior Surgeon at Mass Eye and Ear and was previously an assistant professor at the University of Massachusetts Medical School.

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