Extra-Oesophageal Reflux

Extra-Oesophageal Reflux / LaryngoPharyngeal Reflux / Silent reflux

If reflux persists, it can traverse the entire column of the oesophagus and breach the upper oesophageal sphincter, a group of muscles including the cricopharyngeus that open when swallowing to permit food to enter the oesophagus rather than the trachea (windpipe).

Reflux occurring here is correctly termed extra-oesophageal reflux but is often referred to as Laryngo-Pharyngeal Reflux (LPR for short), Respiratoty Reflux or "Silent Reflux". (The term 'silent reflux' is also often applied to lower oesophageal reflux where heartburn is not experienced.)

Even if the acid has been reduced or neutralised with acid suppressants or antacids, regurgitation of stomach contents and extra-oesophageal reflux (known as Non-Erosive Reflux Disorder, or NERD) can still cause damage.

From the top of the oesophagus it enters the respiratory system where it can aspirate into the throat, lungs, mouth and nose.

Irritating the lining of the throat and bronchi, inducing the production of excess mucous, sufferers frequently have the need to clear their throats and aspiration deeper into the lungs can result in chronic cough as the lungs attempt to expel the foreign matter.

Lungs

In the lungs, it can cause asthma like symptoms. It can even build up resulting in pneumonia or bronchiectasis.

Throat

Causing irritation to the voice box, it can result in hoarseness and sore throat.

Attempting to prevent extra-oesophageal reflux, the cricopharyngeus may tighten or spasm producing a feeling of a lump in the throat known as Globus.

At night, in attempting to prevent reflux, the cricopharyngeus may be responsible for restricting breathing causing obstructive sleep apnoea. 

Mouth

Entering the mouth, reflux produces bad taste and bad breath. It can also cause dental erosion resulting in tooth decay or sharp edges to the teeth.

Ears

From the back of the throat, refluxate can travel via the eustachian tube to the ears where it may stimulate excessive wax production. This is more common in the right ear as lying on the right side results in more reflux than lying on the left. It can also result in tinnitus and peripheral vertigo (dizziness).

This 2015 paper Associations between peripheral vertigo and gastroesophageal reflux disease postulates "Reflux material (Hydrochloric acid (HCl) and pepsin) could get into the middle ear via Eustachian tube and affect osseous structures directly. Disturbance of ossicles could cause tinnitus, which is more common for peripheral vertigo."

A 2017 paper in Ear and Hearing found "GERD symptoms are associated with higher risk of hearing loss in women, but use of PPIs and H2-RAs are not independently associated with the risk."

A 2021 paper in Medicine, Association of gastroesophageal reflux disease with increased risk of chronic otitis media with effusion in adults, concluded, "From long-term follow-up, the prevalence of chronic OME in adults was 1.84 times higher in the GERD group compared with the non-GERD group." 

Published in Nature, Scientific Reports in December 2024, Association between gastroesophageal reflux disease and tinnitus "aimed to explore the association between GERD and tinnitus, which encompasses data from 669,159 patients over 17 years. ... In this study, we observed that hearing loss, a covariate in both our primary and secondary analyses, is associated with the onset of tinnitus. Considering tinnitus and hearing loss are highly associated each other35, it is highly suggested that a potential association between GERD and hearing loss as well." and concluding, "Our data showed that GERD and tinnitus are highly associated. Nevertheless, the use of proton pump inhibitor medication in GERD patients did not show a significant decrease in the onset of tinnitus." [The latter is hardly unexpected since PPIs reduce acid not reflux.]

This paper published in Cureus in 2025, "Exploring the Role of Laryngopharyngeal Reflux in Eustachian Tube Dysfunction", "provides evidence supporting the link between LPRD and ETD and suggests that PPI therapy may alleviate ETD symptoms in a subset of patients. However, given the multifactorial nature of ETD, further studies are needed to explore alternative therapies (such as potassium channel blockers, Eustachian tube dilation, etc.) and long-term treatment outcomes."

Nose

Rising into the nasal chambers, excess mucous produced here can cause post nasal drip producing cough and result in the sufferer sniffing frequently to constrain it. This may also give rise to a poor sense of smell (hyposmia), a distortion of smell (parosmia) or even fool the senses to imagine smells that aren't there (phantosmia).

Eyes

From the nasal passages, it can pass to the eyes via the tear ducts resulting in dry eye syndrome.
This 2023 study, Ocular Surface Disease as Extraesophageal Gastroesophageal Reflux Disease Manifestation: A Specific Therapeutic Strategy, claiming "Studies showed a correlation between GERD/LPR and ocular discomfort," aimed to look at prevalence and therapeutic solutions, concluding "We report an increase in prevalence of ocular discomfort in patients with GERD/LPR. The observations of [peptides] demonstrate the potential neurogenic nature of the inflammatory state. Restoration of the ocular surface parameters suggests the potential usefulness of topical alginate therapy."

2014 prevalence poll

A 2014 poll of 100 reflux sufferers [r-i] revealed 70% reported experiencing Hoarseness, 64% constant throat clearing, 58% post nasal drip, 58% chronic cough, 53% sinusitis, 53% bad taste in mouth, 50% Globus (lump in throat), 42% Asthma-like symptoms (shortness of breath), 41% tooth decay or sharp edges to teeth, 35% Catarrhal symptoms (blocked nose), 35% Loss of voice, 35% dry or gritty eyes, 30% nocturnal ear waxing.

In other responses, the following symptoms were also highly indicated: Bad breath, Tinnitus, Hyposmia (poor sense of smell), Sore throat.

2017 Prevalence poll

Following the findings of the 2014 poll, three fresh but interrelated surveys involving over 200 participants in 2017 [r-ii] rationalised the symptoms and explored the efficacy of PPIs and Anti-Reflux surgery on the management thereof.

Survey 1 targetting refluxers who didn’t use daily pre-emptive medication but who may use occasional on-demand antacids as and when required garnered 51 responses.

Throat symptoms were most commonly identified with 63% reporting hoarseness, sore throat, loss of voice or throat clearing as a symptom. 45% reported globus, 43% post nasal drip, sinusitis of catarrh, 33% bad breath or taste in mouth, 31% dry or gritty eyes, 31% ear problems: waxing, glue ear, tinnitus or dizziness, 27% chest complaints, cough orasthma like symptoms and 22% dental problems.

Survey 2 was completed by 100 refluxers using daily medication of H2 blockers or Proton Pump Inhibitors.

As with survey 1, the most prevalent reported symptom was concerned with the throat: hoarseness, sore throat, loss of voice and throat clearing reported by 66% of relfuxers with 50% reporting globus, 49% nasal problems, 48% ear problems, 46% cough, 44% oral, 42% eyes and 26% dental problems.

It is assumed those with the most prolific symptoms are the predominant users of acid suppressants (rather than PPIs actually result in higher incidence of EOR symptoms) and dosage levels seemed to make no difference.

Survey 3 targetted recipients of anti-reflux intervention. 52 responses were amassed during the collection period.

Pre intervention, 73% reported the throat issues and 58% globus with 50% reporting cough, 50% oral, 44% nasal, 35% aural, 33% eyes and 33% dental problems.

All but 2 repondees had received Nissen fundoplication, one had had Linx successfully and one had had Stretta unsuccessfully.

Post intervention, reported throat issues had been reduced to 35% oral problems 29%, globus 25%, cough 19% nasal problems 19%, eye problems 17%, ear problems 13% and dental erosion 10%.

A cumulative score of prevalence of symptoms reduced from 47% to 20% as a result of anti-reflux intervention.

Conclusions

In the management of symptoms of extra-oesophageal reflux, acid suppressant medication did not appear to be effective whereas reflux reduction surgery was.

For those exhibiting symptoms of extra-oesophageal reflux, reflux reduction should be considered in preference to acid reduction.

A paper published in World Journal of Gastroenterology in May 2017 "Nissen fundoplication vs proton pump inhibitors for laryngopharyngeal reflux" [r-iii]  using reviews of 53 patients, also concluded: "Laparoscopic Nissen Fundoplication achieves better improvement than PPIs for LPR."

This paper published in Cureus in 2024, "A Study on the Prevalence of Laryngopharyngeal Reflux in Saudi Arabia", interestingly found, "LPR was found to be prevalent in 31.2% of the study population, with the most common associated demographics being female gender and adults aged 36-45 years." 

The graphic below shows the percentage of Reflux Symptom Index items among study participants.

A 2025 paper in Otolaryngology: Head & Neck surgery, "Association Between Gastroesophageal Reflux Disease and Laryngeal Disorders: Real-World Evidence" used data from Taiwan National Health Insurance Research Database to perform a population-based analysis to estimate the risk of laryngeal disorders in patients with GERD and those without GERD. 

It concluded, "This study is the first to use population data for identifying the association between GERD and laryngeal disorders for real-world findings. Our population-based analysis indicates that patients with GERD have an elevated risk of laryngeal disorders."

Extra-Oesophageal Aspiration

Though rarer, non gastric extra-oesophageal reflux exists when the oesophagus constricts causing dysphagia or the cricopharyngeus spasms in a similar way to globus and is probably from oesophageal pouch (aka Zenker's Diverticulum).

It differs from gastric extra-oesophageal reflux inasmuch as there will be no pepsin present which Jamie Kaoufman, who coined the term LPR, suggested may be causal.

Barrett's Alert Markers 

Surveys conducted in June 2023, looked at what symptoms people experienced prior to being diagnosed with Barrett's. This chart shows the prevalence of those symptoms and the paper may be read below.

Footnote to the above study.

In an October 2023 study, "Prevalence of Barrett's Esophagus and Adenocarcinoma With and Without Gastroesophageal Reflux: A Systematic Review and Meta-Analysis", while suggesting "gastroesophageal reflux disease (GERD) symptoms are an essential criterion for Barrett's esophagus (BE)", the authors went on to conclude, "BE prevalence in those without GERD is substantial, particularly in large high-quality population-based studies. These data are important to factor in future BE/EAC early detection guidelines."

The definition of GERD used in analysing texts required the existance of acid reflux symptoms, by "those without GERD" they were referring to those who didn't experience symptoms of acid reflux, which the above study on "Identifying Alert Markers" showed to be 48% of women and 22% of men.

To reduce reflux, follow the lifestyle modifications listed here:  Reflux Remedies

Page updated 11 May 2025