Laryngopharyngeal reflux occurs when stomach acid travels backwards through the oesophagus and reaches the throat, voice box (larynx), and even the back of the nasal passages. Unlike gastroesophageal reflux disease (GERD), LPR typically doesn’t cause heartburn, earning it the name “silent reflux.” The throat and voice box lack the protective mechanisms present in the oesophagus, making them particularly vulnerable to acid damage even from small amounts of reflux. LPR may affect patients visiting ENT clinics, though many cases remain undiagnosed due to the subtle nature of symptoms.
Silent Reflux (LPR) Treatment in Singapore
Silent reflux, medically known as laryngopharyngeal reflux (LPR), often goes undiagnosed because its symptoms differ significantly from typical heartburn. Patients may experience chronic throat clearing, persistent cough, or voice changes without realising these symptoms stem from stomach acid reaching the throat and voice box. Understanding this condition and seeking appropriate treatment may help improve daily comfort and support the prevention of potential complications. Our ENT specialist provides comprehensive evaluation and treatment approaches tailored to each patient’s specific presentation of LPR.
*Individual results and timelines may vary.*
Dr Gan Eng Cern
MBBS
MRCS (Edin)
mmed (orl)
FAMS
What is Silent Reflux (LPR)?
Types of Silent Reflux
Daytime Reflux (Upright Reflux)
Daytime LPR occurs when patients are upright and active. This type may relate to dietary triggers, stress, or physical activities that increase abdominal pressure. Patients may experience symptoms like throat clearing and voice fatigue that can worsen throughout the day. The reflux episodes tend to be brief but frequent, potentially causing cumulative irritation to the throat tissues.
Nocturnal Reflux
Nocturnal LPR happens during sleep when lying flat, allowing stomach contents to flow more easily into the throat. Patients may wake with a sore throat, hoarse voice, or feeling like something is stuck in their throat. This type can be particularly problematic as the prolonged contact between acid and throat tissues during sleep may increase inflammation and damage risk.
Mixed Pattern Reflux
Some patients experience both daytime and nighttime symptoms, indicating a mixed pattern of LPR. This presentation may require a comprehensive treatment approach addressing both positional factors and lifestyle modifications to help achieve symptom control.
*Individual results and treatment responses may vary.*
Causes & Risk Factors
Causes
The lower oesophageal sphincter (LES) and upper oesophageal sphincter (UES) normally prevent stomach contents from flowing backwards. LPR occurs when these protective barriers malfunction, allowing acid and pepsin to reach the throat. Structural abnormalities like a hiatal hernia can mechanically compromise these sphincters. Delayed gastric emptying increases stomach pressure, forcing contents upward. Excessive acid production can overwhelm the body’s natural defences.
Risk Factors
- Dietary factors: Spicy foods, citrus fruits, tomatoes, chocolate, caffeine, and alcohol
- Lifestyle habits: Smoking, eating large meals, lying down after eating
- Body weight: Excess weight increases abdominal pressure
- Medications: Certain blood pressure medications, sedatives, and pain relievers
- Stress: Chronic stress affects digestive function and sphincter control
- Age: Sphincter function naturally weakens with ageingOccupation: Singers, teachers, and public speakers face increased risk
- Medical conditions: Asthma, sleep apnoea, and chronic sinusitis
Signs & Symptoms
Mild Symptoms
- Frequent throat clearing without mucus production
- Sensation of post-nasal drip despite clear nasal passages
- Mild hoarseness, particularly in the morning
- Occasional dry cough without other respiratory symptoms
- Subtle voice changes or vocal fatigue
- Intermittent globus sensation (feeling of lump in throat)
Moderate Symptoms
- Persistent hoarseness lasting throughout the day
- Chronic cough unresponsive to typical treatments
- Difficulty swallowing or sensation of food sticking
- Excessive throat mucus requiring constant clearing
- Sore throat without signs of infection
- Bad breath or bitter taste despite good oral hygiene
- Voice breaks or inability to hit certain notes
Severe Symptoms
- Significant voice loss or severe hoarseness
- Choking episodes or aspiration during eating
- Chronic laryngitis with visible throat inflammation
- Breathing difficulties or laryngospasm
- Recurrent respiratory infections
- Dental erosion from acid exposure
- Unintentional weight loss from swallowing difficulties
Silent reflux symptoms typically develop gradually. Patients may adapt to chronic symptoms, not recognising them as abnormal until the condition impacts their quality of life.
Experiencing these symptoms?
Consider scheduling a consultation with an ENT specialist for evaluation and management options.
When to See a Doctor
Seek immediate medical attention if you experience breathing difficulties, choking episodes, or severe voice loss lasting more than two weeks. Blood in saliva or phlegm, unexplained weight loss, or persistent chest pain also require urgent evaluation. Schedule a consultation if chronic throat symptoms persist beyond three weeks despite avoiding common triggers. Morning hoarseness lasting more than two weeks, especially in non-smokers, requires professional assessment.
During your consultation, the ENT specialist will review your symptom pattern, dietary habits, and medical history. The examination includes visualisation of your throat and voice box to assess inflammation and rule out other conditions. Timely intervention may help prevent progression to chronic laryngitis, vocal cord lesions, or other complications in some cases.
*Individual outcomes and treatment responses may vary.*
Diagnosis & Testing Methods
Laryngoscopy
Flexible laryngoscopy allows direct visualisation of the throat and voice box. The ENT specialist inserts a thin, flexible scope through the nose to examine the larynx for signs of acid damage, including redness, swelling, and thick mucus. This in-office procedure takes minutes and may provide visual confirmation of LPR-related changes.
pH Monitoring
Twenty-four-hour pH monitoring measures acid levels in the throat and oesophagus. A thin probe placed through the nose records acid exposure episodes throughout normal daily activities. This test can help distinguish LPR from other conditions and assess reflux patterns. Wireless pH capsules offer an alternative for patients unable to tolerate traditional probes.
Barium Swallow Study
This imaging test evaluates swallowing function and identifies structural abnormalities. Patients drink a barium solution while X-rays capture the liquid’s movement through the throat and oesophagus. The study may reveal hiatal hernias, strictures, or motility disorders that could contribute to reflux.
Oesophageal Manometry
Manometry measures pressure and coordination of oesophageal muscles. The test can help identify sphincter dysfunction and abnormal swallowing patterns. Results may guide treatment decisions, particularly when considering surgical options.
*Individual results and diagnostic findings may vary.*
Treatment Options Overview
Dietary Modifcations
Dietary changes form the foundation of LPR management. Eliminating trigger foods may reduce acid production and reflux episodes. Common triggers include citrus fruits, tomatoes, chocolate, mint, fatty foods, and carbonated beverages. Eating smaller, more frequent meals may reduce stomach distension and pressure on the sphincters. Finishing meals at least three hours before bedtime allows proper digestion before lying down.
Lifestyle Interventions
Elevating the head of the bed uses gravity to help prevent nighttime reflux. Weight loss in overweight patients may reduce abdominal pressure and reflux frequency. Smoking cessation can improve sphincter function and reduce acid production. Stress management through meditation, yoga, or counselling may address the stress-digestion connection. Avoiding tight clothing around the waist can prevent additional pressure on the stomach.
Proton Pump Inhibitors (PPIs)
PPIs reduce stomach acid production by blocking the enzyme system responsible for acid secretion. These medications require consistent daily use to achieve a therapeutic effect in LPR. Common options include omeprazole, esomeprazole, and lansoprazole. The ENT specialist determines appropriate dosing and duration based on symptom severity and response.
*Individual results and timelines may vary.*
H2 Receptor Blockers
H2 blockers provide moderate acid suppression and work faster than PPIs for symptom relief. These medications may suit patients with mild symptoms or those unable to tolerate PPIs. Famotidine and ranitidine alternatives offer bedtime dosing options for nocturnal symptoms. Combination therapy with PPIs may benefit select patients.
Alginate-Based Medications
Alginate-based medications create a protective barrier that may prevent acid from reaching the throat. These medications work after meals, providing symptom relief. Products containing sodium alginate offer an alternative or adjunct to acid suppression. The physical barrier mechanism may particularly benefit patients with postprandial symptoms.
Voice Therapy
Speech therapists specialising in voice disorders teach techniques to reduce throat irritation from chronic clearing. Proper voice use can prevent additional strain on inflamed vocal cords. Hydration strategies and vocal hygiene education may support healing. Breathing exercises can improve laryngeal control and reduce reflux-triggered coughing.
Surgical Intervention
Fundoplication surgery creates a new valve mechanism that may prevent reflux when medical management fails. Laparoscopic techniques can minimise recovery time and surgical risks. The LINX device, a magnetic ring placed around the oesophagus, offers a reversible surgical option. Patient selection requires careful evaluation of reflux patterns and anatomical factors.
*Individual results and timelines may vary.*
Every patient’s condition is unique.
Our ENT specialist will assess your specific situation and recommend the most suitable treatment approach for you.
Complications if Left Untreated
Untreated LPR may cause progressive changes to the throat tissues. Chronic inflammation can lead to vocal cord swelling, potentially resulting in voice changes. Subglottic stenosis (narrowing below the vocal cords) might develop from repeated acid exposure. This condition may require surgical intervention to help maintain adequate breathing.
Granulomas and contact ulcers can form on the vocal cords from acid exposure and mechanical trauma from coughing. These lesions may cause discomfort, voice changes, and sometimes breathing difficulties. Chronic laryngitis can increase susceptibility to respiratory infections and may progress to laryngeal dysplasia (a precancerous condition).
Long-term acid exposure can affect quality of life through sleep disruption, social concerns from frequent throat clearing, and professional limitations for voice users. Dental erosion, chronic sinusitis, and recurrent ear infections represent additional complications that may affect overall health.
*Individual outcomes and progression may vary. This information is provided for educational purposes and should not replace professional medical consultation.*
*Individual outcomes and progression may vary.*
Prevention
Maintaining a healthy weight through a balanced diet and regular exercise may help reduce reflux risk. Eating patterns can impact LPR development. Consider consuming smaller meals throughout the day rather than three large meals. Allow adequate time between dinner and bedtime for proper digestion.
Identify and avoid personal trigger foods through systematic elimination and reintroduction. Trigger foods vary among individuals, making personalised dietary planning important. Stress management techniques, including regular exercise, adequate sleep, and relaxation practices, can support digestive health.
Proper posture during and after meals may promote normal digestion. Remain upright for at least two hours after eating. Sleep position modifications, including left-side sleeping and appropriate pillow elevation, may help reduce nocturnal reflux risk. Regular dental check-ups can detect early acid-related erosion, prompting timely LPR evaluation.
*Individual results and responses to these approaches may vary.*
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Frequently Asked Questions (FAQ)
How does silent reflux differ from regular acid reflux or GERD?
Silent reflux (LPR) primarily affects the throat and voice box without causing typical heartburn symptoms. While GERD patients experience chest burning and regurgitation, LPR patients develop throat symptoms like hoarseness, chronic cough, and throat clearing. The acid exposure in LPR often occurs in smaller amounts but may cause symptoms because the throat tissues lack the protective mechanisms present in the oesophagus. LPR frequently occurs during the day while upright, whereas GERD symptoms often worsen when lying down.
How long does treatment for silent reflux take to show results?
Treatment response varies depending on severity and chosen approach. Dietary and lifestyle modifications may provide some relief. Proton pump inhibitors may require consistent use before achieving benefit for LPR. Patients might notice gradual improvement in symptoms like throat clearing and hoarseness over time. Healing of inflamed throat tissues may take time. The ENT specialist monitors progress and adjusts treatment based on individual response patterns.
*Individual results and timelines may vary.*
Can silent reflux be managed permanently, or is it a chronic condition?
Silent reflux management depends on underlying causes and individual factors. Some patients may achieve remission through lifestyle modifications and medication use. Others may require ongoing management strategies to help prevent symptom recurrence. Structural issues like hiatal hernias may benefit from surgical correction, which could potentially provide relief. Patients can aim to achieve symptom control and help prevent complications through appropriate treatment. The approach involves identifying triggers, maintaining preventive measures, and working closely with your ENT specialist to develop a management plan.
*Individual results and treatment outcomes may vary.*
What foods should I avoid if I have silent reflux?
Common trigger foods include citrus fruits, tomatoes and tomato-based products, chocolate, peppermint, fatty or fried foods, spicy dishes, garlic and onions, caffeinated beverages, alcohol, and carbonated drinks. Individual triggers vary, so keeping a food diary may help identify personal problem foods. Some patients might tolerate certain triggers in small amounts or at specific times. The ENT specialist or dietitian can provide personalised dietary guidance based on your symptom patterns and lifestyle.
Can silent reflux cause damage to my voice?
Chronic, untreated LPR may cause voice changes through repeated vocal cord inflammation and injury. Early treatment may allow recovery of normal voice function. Prolonged acid exposure might lead to vocal cord scarring, polyps, or granulomas requiring additional intervention. Professional voice users face particular risk and may benefit from prompt treatment. Voice therapy combined with medical management aims to optimise healing and help prevent compensatory voice behaviours that could cause additional damage.
*Individual outcomes may vary.*
Is surgery necessary for treating silent reflux?
Surgery is reserved for patients who don’t respond adequately to medical management or cannot tolerate medication. Surgical options like fundoplication may help control reflux in properly selected patients. The decision requires a comprehensive evaluation, including pH monitoring, manometry, and assessment of symptom patterns. Patients may achieve control through medication and lifestyle modifications without requiring surgery. Your ENT specialist will discuss surgical options if conservative treatment proves insufficient after adequate trial periods.
*Treatment outcomes and suitability for surgery vary by individual.*
Conclusion
Silent reflux can impact daily life through its diverse and often misunderstood symptoms. Early recognition and appropriate treatment may help prevent progression to chronic laryngitis and potential complications. The combination of dietary modifications, lifestyle adjustments, and medical therapy can help control symptoms for patients. Our ENT specialist provides a comprehensive evaluation using modern diagnostic techniques to assess LPR and rule out other conditions. Through personalised treatment planning, we address specific symptom patterns and lifestyle factors to support optimal outcomes.
*Individual results and treatment responses may vary.*
Take the First Step Towards Better Ear Health
Living with silent reflux can be challenging, but you don’t have to face it alone. Our ENT specialist has experience in diagnosing and treating LPR using current evidence-based approaches.
Dr Gan Eng Cern
MBBS
MRCS (Edin)
mmed (orl)
FAMS
With over 15 years of experience, Dr Gan specialises in the comprehensive management of a broad range of conditions related to the ear, nose and throat (ENT), and head and neck.
Dr. Gan has contributed to the academic field as a Senior Clinical Lecturer at the Yong Loo Lin School of Medicine, National University of Singapore. He is recognised for his extensive research work, with numerous contributions to reputable international ENT journals. Dr Gan is also highly sought after as a speaker and has shared his surgical knowledge as a surgical dissection teacher at various prominent ENT conferences and courses.
- 2020 – Reader’s Choice Gold Award for Best ENT Specialist (Expat Living Singapore)
- 2016 – Best Educator Award (Eastern Health Alliance)
- 2016 – “Wow” Award (Patient Compliment)
- 2014 – Eastern Health Alliance Caring Award – Silver
- 2014 – 19th Yahya Cohen Memorial Lectureship (awarded by the College of Surgeons, Academy of Medicine Singapore for best scientific surgical paper)
- 2012 – Human Manpower Development Award (Ministry of Health, Singapore)
- 2007 – Singhealth Best Doctor Award
Qualifications
- MBBS – Bachelor of Science, Bachelor of Medicine, Bachelor of Surgery (University of New South Wales, Sydney, Australia)
- MRCS (Edin) – Member of the Royal College of Surgeons Edinburgh, United Kingdom
- MMed (ORL) – Master of Medicine in ENT (National University of Singapore)
- FAMS – Fellow of the Academy of Medicine Singapore
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