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Laryngopharyngeal Reflux

LPR, often called "silent reflux," is a form of acid reflux that travels up the esophagus and past its upper valve to reach the throat, voice box and airways. Unlike GERD, it often causes no heartburn, so it can be missed or mistaken for other throat problems. Chronic throat clearing5, hoarseness6 and a lump-in-throat sensation are its calling cards.

Gut & Digestive Evidence-Based

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Definition

What Is LPR?

Laryngopharyngeal reflux (LPR) occurs when stomach acid and pepsin, the enzyme that digests protein, travel past the upper esophageal sphincter (UES)1 and reach the larynx (voice box), pharynx (throat) and airways. Pepsin as well as acid may contribute to the damage; how much each matters is still debated.

The larynx and throat are extraordinarily sensitive to acid and pepsin, far more so than the esophagus, which has some protective mucus lining. Much less exposure seems to cause symptoms here than in the esophagus. This is why LPR symptoms are often far more pronounced than GERD symptoms, despite less total acid exposure.

One theory is that pepsin left on laryngeal tissue can be reactivated by later acid exposure, which may help explain why symptoms persist; this has not been proven in patients.

โš ๏ธ LPR is frequently misdiagnosed as chronic sinusitis, postnasal drip, allergies, asthma, recurring laryngitis, vocal cord dysfunction or anxiety-related globus. Reaching the diagnosis is often slow: in one survey of people with LPR, most found it difficult, and the difficulty rose with the time taken and the number of doctors seen15.
A head and chest in profile with the throat, the esophagus and the stomach, and acid reflux rising up the esophagus toward the throat

๐Ÿ”ฌ LPR vs. GERD: Key Differences

GERD: Heartburn present; esophageal damage; responds to PPIs; worsens lying flat

LPR: often no heartburn2; throat and voice symptoms; response to PPIs is inconsistent; often worse after meals

The Pepsin Mechanism: Why LPR Is Different

Pepsin Deposition

With each reflux episode, pepsin is deposited on laryngeal and pharyngeal tissue. In laboratory testing, pepsin was most active at pH 2 and inactive at pH 6.5 or higher, close to the throat's usual pH of about 6.8, but it stayed stable and could be reactivated when acid returned21.

Reactivation Cycle

In the laboratory, pepsin kept at neutral pH for a day regained most of its activity when acid was added again21; whether acidic foods and drinks do this in the throat has not been shown. This is a proposed explanation for why some people do not respond to PPIs.

Mucosal Vulnerability

Laryngeal mucosa has no intrinsic acid-protective mechanisms, unlike the esophagus. It lacks the bicarbonate secretion, mucus gel layer and cellular junction proteins that give the esophagus moderate acid resistance. This explains why the larynx and throat sustain significant damage from even small amounts of refluxed material.

By the Numbers

LPR by the Numbers

50%+
of people with reflux into the throat had no heartburn, in a series of 58 confirmed by throat pH monitoring20
40%
of people with throat symptoms blamed on reflux had abnormal results on pH-impedance reflux testing27
59.9%
of 232 people with an LPR diagnosis said reaching it was difficult (patient survey)15
pH 8.8
alkaline water inactivates pepsin in the test tube; clinical benefit is unproven3
20%
of people with chronic cough were found to have LPR, in a review of 13 years of studies16
3 months
of twice-daily acid suppression is the trial an international consensus recommends when heartburn or regurgitation is also present17
Signs & Symptoms

Symptoms of LPR

LPR symptoms are located in the throat, voice and airways, not the chest. This is why it's so frequently missed or misattributed to ENT conditions, allergies or respiratory disease.

SymptomWhat happens
Voice & Throat Symptoms
Hoarseness & Voice ChangesOne of the most common LPR symptoms, though it has many other causes. Reflux reaching the vocal cords is thought to cause inflammation, swelling and surface erosions, altering vibration and producing a rough, strained or breathy voice. Worst in the morning (from nighttime reflux) and after talking for extended periods. Misdiagnosed as chronic laryngitis in many cases.
Chronic Throat ClearingThe compulsive need to clear the throat repeatedly throughout the day, from the sensation of mucus or irritation in the larynx. Throat clearing paradoxically worsens the irritation by mechanically traumatizing already-inflamed mucosa.
Globus Pharyngeus (Lump-in-Throat)A persistent sensation of a lump, tightness or something stuck in the throat, not associated with dysphagia. Globus has several causes, reflux among them.
Throat Burning & Raw SensationA burning or raw feeling at the back of the throat or base of the tongue, not the chest, particularly after eating, drinking coffee or acidic beverages, or speaking at length. Often accompanied by a sour or bitter taste.
Airway & Systemic Symptoms
Chronic Cough (LPR Cough)A dry, irritating cough that persists for weeks or months, unresponsive to antihistamines or cough suppressants. One review found LPR in about 20% of people with chronic cough, though whether it is the cause is harder to show16. The cough is triggered by laryngeal irritation from pepsin and acid reaching the subglottic space and trachea.
Postnasal Drip & Excess MucusLPR-driven inflammation triggers mucus hypersecretion as a protective response, creating the sensation of mucus draining down the back of the throat. This is often mistaken for allergies or sinus disease. Mucus sensation often eases once reflux is treated.
Dysphagia (Swallowing Difficulty)Difficulty or discomfort swallowing, particularly with dry foods, from laryngeal and esophageal mucosal inflammation, cricopharyngeal dysfunction and subglottic edema. Any progressive dysphagia requires urgent endoscopic evaluation to rule out stricture or malignancy.
Sleep DisruptionNocturnal LPR episodes, often silent, cause microaspirations that trigger coughing fits, choking sensations or laryngospasm (sudden inability to breathe for several seconds) from sleep. Severe LPR is associated with laryngospasm episodes that awaken patients in a panic, gasping for air. Sleep apnea can cause similar nighttime symptoms and should be tested for, not assumed away.
Causes

Causes of LPR

LPR happens when stomach contents reach the throat, but throat symptoms alone do not prove reflux: an international consensus found that an oversensitive larynx often contributes, with or without reflux17.

CauseHow It Contributes to LPRWhat Helps
Reflux past both esophageal valvesStomach contents reaching the throat have passed both the lower and the upper esophageal sphincter17, and the throat lining lacks the esophagus's defenses, so small amounts can cause symptoms1.Nothing but water for 3 to 4 hours before bed and a raised head of the bed (Treatment Comparison); a trial of a proton pump inhibitor when heartburn or regurgitation is also present (conventional care)
Hiatal herniaA hernia or other disruption where the esophagus meets the stomach supports a reflux cause; in one multicenter study of people with throat symptoms, up to 47% had esophageal erosions or a hiatal hernia on endoscopy17.Assessment and management with your clinician, including upper endoscopy when symptoms persist (conventional care)
Pressure on the stomachExcess weight and tight clothing around the abdomen raise the pressure inside the stomach, which favors reflux17.Weight management and meal timing (Treatment Comparison)
Lying down after meals and at nightLying down soon after eating and reflux during sleep let stomach contents travel upward17.Stay upright for 2 to 3 hours after meals, eat nothing for 3 to 4 hours before bed and raise the head of the bed 6 to 8 inches (15 to 20 cm) (Treatment Comparison)
Trigger foods and drinksFoods that provoke symptoms add to reflux17; for acidic foods the evidence comes from a non-randomized study4.A trial of cutting very acidic foods, alcohol, coffee, chocolate, mint and fatty meals, then reintroducing what you tolerate (Nutritional Strategy)
An oversensitive larynx and throat clearingAn overreactive larynx and heightened attention to throat sensations can cause the same symptoms, with or without true reflux17; throat clearing injures the vocal folds and keeps the cycle going5.A silent swallow in place of throat clearing (Treatment Comparison); voice therapy with a speech-language pathologist (conventional care)
Diagnosis

How LPR Is Diagnosed

LPR diagnosis requires a combination of symptom assessment, laryngoscopic findings and functional testing, as standard GERD tests (pH monitoring) often miss it.

TestWhat it shows
Self-Assessment Tools
Reflux Symptom Index (RSI)A validated 9-⁠item questionnaire scoring LPR symptoms (hoarseness, throat clearing, excess mucus, swallowing difficulty, coughing after meals, breathing difficulties, chronic cough, globus, heartburn). A score above 13 is considered abnormal, but the index is nonspecific. Widely used in ENT practice and available freely online. Track your score over time to monitor treatment response.
Food-Symptom DiaryLog every meal, drink and snack alongside symptom onset, severity and timing. LPR symptoms often appear 30 to 60 minutes after meals or acidic beverages. This diary rapidly identifies personal triggers (coffee, alcohol, fatty meals, chocolate, citrus) and confirms the diet-symptom relationship before formal testing.
Clinical Diagnostic Tests
Laryngoscopy (ENT Scope)Direct flexible laryngoscopy by an ENT specialist visualizes characteristic LPR findings: posterior laryngeal edema and erythema (redness), interarytenoid pachydermia (thickening), subglottic edema, vocal cord granulomas and excessive mucus. A Reflux Finding Score (RFS) above 7 is suggestive, but these signs are also found in many people without reflux. Laryngoscopy's key role is to rule out other causes.
Salivary Pepsin TestA non-invasive test that detects pepsin in saliva or sputum samples, rather than measuring acid as pH testing does; a positive result suggests reflux has reached the throat, and its accuracy is still being evaluated. In pooled studies it detected about two in three cases, and it was also positive in about one in three people without LPR22. Available as a mail-in test or through ENT practices.
Impedance-pH MonitoringThe most comprehensive reflux test: it detects both acid AND non-acid reflux events and tracks how high they travel. Standard pH monitoring misses LPR because the proximal (upper) sensors are rarely included. Full impedance-pH monitoring with proximal sensors is required to capture laryngopharyngeal reflux events. Performed by gastroenterologists in specialist centers.
Treatment Comparison

Conventional and Holistic Treatment for LPR

๐ŸŒฟ HOLISTIC
๐Ÿ’Š CONVENTIONAL
๐ŸŒฟ

Holistic / Functional Approach

Diet and meal timing, voice behavior, soothing agents, lifestyle

Primary Strategy
Reduce late meals, alcohol and very acidic foods, stop habitual throat clearing and investigate contributing conditions such as a hiatal hernia
Key Interventions
Alkaline water (pH 8.8+)4, Manuka honey, DGL licorice, slippery elm, strict dietary elimination, positional changes
Timeline
In one study of PPI treatment, symptoms improved over 2 months, while visible changes in the larynx resolved more slowly, over at least 6 months.8
Key Advantage
Low-risk dietary and behavioral measures that work alongside medical treatment; alkaline water inactivates pepsin in the test tube, but no clinical trial shows it treats LPR.3

Full Holistic Approach Includes

  • A trial of cutting very acidic foods for 6 weeks (pH โ‰ฅ5 for all foods and beverages); low risk, though evidence comes from a non-randomized study
  • Alkaline water (pH 8.8+). In laboratory testing, water at this pH irreversibly denatures pepsin in a test tube, which is the basis for the recommendation. No clinical trial has shown that drinking it treats LPR, and whether it reaches laryngeal tissue at that pH is not established. Harmless to try, not proven.3 Drink throughout the day, especially after meals
  • Manuka honey (1 tsp), a soothing option; its antibacterial activity is from laboratory studies, and evidence for LPR specifically is lacking; take between meals, not in the 3 to 4 hours before bed
  • DGL licorice chewables (400 mg before meals), which stimulate protective mucus on the throat and esophageal lining
  • Slippery elm bark powder in warm water, which creates a soothing mucilage layer directly on inflamed laryngeal and pharyngeal tissue
  • Aloe vera juice from the inner leaf, 2 oz (60 mL) before meals, tested for reflux symptoms only in a small pilot trial and not in LPR24
  • Nothing to eat or drink (except water) for 3 to 4 hours before sleep, critical; the supine position allows reflux to reach the UES
  • Head-of-bed elevation 6 to 8 inches (15 to 20 cm) (wedge pillow): gravity reduces nocturnal reflux reaching the throat
  • Look for contributing conditions: manage a hiatal hernia with your clinician, and use meal timing and weight management
  • Voice rest during acute flares: speaking strains already-inflamed vocal cords and delays mucosal healing
โš ๏ธ Critical: Avoid throat clearing: it mechanically injures already-inflamed laryngeal mucosa and perpetuates the cycle. Replace with a gentle, silent swallow. Breaking this habit is often more useful than any dietary change.
Supplement Protocol

Evidence-Based Supplements for LPR

These supplements are used to soothe throat symptoms; evidence for each is limited and noted in its row.

SupplementWhat it is forTypical rangeTimingNotes & cautions
Manuka Honey (UMF 10+)Coats the laryngeal and esophageal mucosa with a thick, viscous, antibacterial layer. Manuka honey has unique non-peroxide antibacterial activity (methylglyoxal) that inhibits biofilm formation in the laboratory. Evidence for LPR specifically is lacking.1 tspBetween meals on an empty throat, not in the 3 to 4 hours before bed; do not dilute with hot liquid (destroys active compounds)UMF (Unique Manuka Factor) or MGO rating required; standard honey lacks the therapeutic compounds. Keep at room temperature; do not add to hot beverages. Not for infants under 12 months.
DGL Licorice (Chewable)Thought to stimulate mucus production in the throat and esophageal lining, creating a protective gel layer over pepsin-damaged tissue. The chewable form is used so that it mixes with saliva before it reaches the throat. Evidence for LPR specifically is lacking.400 to 800 mg chewable, 3x/day20 minutes before meals, chew thoroughly for maximum mucosal contactDGL form (deglycyrrhizinated) does not raise blood pressure. Do not use whole licorice root for GERD/LPR; the BP-raising glycyrrhizin is unwanted here. Widely available; choose a product with third-party testing.
Slippery Elm Bark PowderCreates a thick mucilage (gel) that coats the throat lining and may protect inflamed tissue from further pepsin and acid contact. It may soothe the throat (globus, throat rawness, postnasal drip sensation). Evidence for LPR specifically is lacking.1 to 2 tsp powder in warm (not hot) water, 3x/dayBetween meals (not in the 3 to 4 hours before bed), drinking slowly to maximize mucosal coatingPowder in warm water is far more effective than capsules: the mucilage must physically contact throat tissue. Can also be made into a lozenge with honey. Take separately from other medications (mucilage may slow absorption).
Alkaline Water (pH 8.8+)Water at pH 8.8 irreversibly inactivates pepsin. A 2012 laboratory study found that pH 8.8 water inactivated pepsin in vitro and buffered acid. That is a test-tube result; no clinical trial has shown that drinking it treats LPR.About 8 to 13 cups (2 to 3 L) a day of pH 8.8+ waterSip throughout the day, especially after meals and before bedCommercial alkaline waters or home ionizers produce this pH. Do not use baking soda water as a daily drink, because it adds a lot of sodium.
Zinc CarnosineA chelated zinc carnosine compound that adheres to the gastric and lower esophageal mucosa for extended contact time, studied mainly for gastric ulcers; evidence in LPR is lacking.75 mg (standardized zinc carnosine) 2x/day30 minutes before mealsStudied in Japanese trials for gastric ulcers. Acts locally. Take it at least 2 hours apart from antibiotics, since zinc and some antibiotics reduce each other's absorption26.
Aloe Vera (Inner Leaf Juice)A small pilot randomized trial in 79 adults with reflux found aloe vera syrup reduced symptom frequency over 4 weeks and was well tolerated24; it has not been tested in LPR.2 to 4 oz (60 to 120 mL) inner leaf fillet juice before meals15 to 20 minutes before each main mealInner leaf fillet only: whole leaf contains aloin (a laxative). Choose decolorized, purified inner fillet aloe vera juice. Do not heat. Avoid it in pregnancy and while breastfeeding, stop it and see a doctor if you feel unwell, since aloe leaf extracts have been linked to cases of acute hepatitis, and check with your clinician if you take medicine for diabetes, since it may lower blood sugar25.
Digestive Enzymes (HCl-Free)Supports complete digestion of proteins and fats in the stomach, reducing the volume of undigested content available for reflux. Less fermentation in the stomach means less gas pressure pushing against the LES. For LPR specifically, choose enzyme formulas without betaine HCl while symptoms are active; added HCl increases the acid load available for laryngeal exposure. Evidence for LPR specifically is lacking.1 to 2 capsules per mealAt the start of each mealChoose HCl-free enzyme formulas (protease, lipase, amylase) while LPR symptoms are active.
Vitamin B12 (Sublingual)Worth checking in people who have taken acid-suppressing medicine long term, since less stomach acid may lower B12 absorption13. PPIs reduce the gastric acid needed to release B12 from dietary protein. Deficiency causes neuropathy, fatigue and cognitive changes. High-dose oral or sublingual B12 is absorbed without stomach acid.1,000 to 2,000 mcg/day sublingualMorning, dissolve under tongueCheck B12 if symptoms suggest deficiency.
What to Expect

What to Expect Over Time

Meal timing, diet and voice habits start at once, and any medicine is judged over months rather than days.

Treatment and supportive care, together
First Weeks

A look at the larynx by an ENT specialist rules out other causes, since its findings alone cannot confirm reflux17. Meal timing, bed raising and trigger-food changes begin. With heartburn or regurgitation too, a trial of acid suppression is reasonable; with throat symptoms alone, testing is advised instead17.

Months 1 to 3

In one small study, symptoms improved over the first 2 months of treatment, with no significant gain after that8. The consensus judges a twice-daily proton pump inhibitor after 3 months17. An alginate improved symptoms in a trial, but no more than placebo11.

Months 3 to 12

More people responded by 4 months than at 2 9, and visible changes in the larynx kept settling for at least 6 months8. If symptoms persist, endoscopy and reflux monitoring come next, and voice therapy can help an oversensitive larynx17.

Long Term

Stopping long-term acid suppression can bring temporary rebound symptoms; tapering and stopping at once are both options to discuss14.

When to Seek Care

Call 911 or go to the emergency department for noisy or difficult breathing, which can mean the airway is narrowing. See a doctor for a hoarse voice lasting more than 3 weeks18, and sooner with a neck lump, recent surgery or a breathing tube, or a smoking history, since the voice box may need a look by an ENT specialist19. Worsening difficulty or pain swallowing, unexplained weight loss or coughing blood need urgent assessment6.

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Next Steps

Managing LPR

LPR is managed with meal timing, diet changes, voice habits and, where appropriate, medication, after a doctor has confirmed the diagnosis. In one small study of people treated with proton pump inhibitors, symptoms improved over the first 2 months, while the visible changes in the throat kept settling for at least 6 months8.

Explore Hiatal Hernia โ†’ Explore GERD (Acid Reflux) →

References & Evidence Notes

Each numbered entry below is either a source you can follow or a note setting out what the evidence does and does not support. Both are numbered together so the markers in the text line up.

Last reviewed October 20, 2026. Supplement entries are cross-checked against the NIH National Center for Complementary and Integrative Health and the Linus Pauling Institute Micronutrient Information Center.7 Two honest framings. First, laryngopharyngeal reflux is genuinely different from heartburn: many people have no heartburn at all, the damage is attributed to pepsin reaching laryngeal tissue, and acid-suppressing drugs help less reliably than they do in classic reflux. That much is well described. Second, and less comfortable, LPR is difficult to diagnose objectively, the symptoms overlap heavily with allergy, postnasal drip, voice overuse, asthma and anxiety, and placebo response in trials is high. Persistent hoarseness lasting more than three weeks should be assessed by an ENT specialist with laryngoscopy, particularly in anyone who smokes or drinks, because that is also how laryngeal cancer presents. Do not spend months on diet changes for an unexamined voice.

  1. On what LPR is: reflux of gastric contents past the upper esophageal sphincter to the larynx and pharynx, producing hoarseness, throat clearing, globus sensation, chronic cough and postnasal drip. Laryngeal tissue lacks the protective mechanisms of esophageal mucosa, which is the basis for the claim that much less exposure causes symptoms than in classic reflux. ↩
  2. On diagnostic uncertainty, which is genuine. There is no accepted gold standard. The reflux symptom index and reflux finding score are widely used but nonspecific, and laryngoscopic signs attributed to reflux are also found in many people without it. Randomized trials of acid suppression for laryngeal symptoms have frequently failed to beat placebo, which may reflect either overdiagnosis or that pepsin rather than acid drives the damage. Both interpretations are live. ↩
  3. On alkaline water. The recommendation derives from a 2012 laboratory study showing that water at pH 8.8 irreversibly denatures human pepsin in vitro and buffers acid, PubMed 22844861. That is a test-tube result. No clinical trial has shown that drinking alkaline water treats LPR, and whether ingested water reaches laryngeal tissue at that pH, or for long enough to matter, has not been demonstrated. It is inexpensive and harmless, and it is reasonable to try on that basis rather than on a proven mechanism. ↩
  4. On dietary approaches: a Mediterranean-style diet with alkaline water was compared with proton pump inhibitor therapy in a non-randomized study and produced at least comparable symptom improvement. The design limits what can be concluded, and it is frequently cited as stronger evidence than it is. Reducing late meals, alcohol and very acidic foods is low risk regardless. ↩
  5. On voice and behavior: throat clearing is itself traumatic to the vocal folds and perpetuates the sensation that provokes it, so breaking that cycle, along with hydration, humidification and voice therapy where indicated, is often more useful than anything dietary. Speech and language therapy has good evidence for chronic cough and globus. ↩
  6. On red flags: hoarseness persisting beyond three weeks, difficulty or pain on swallowing, a neck lump, unexplained weight loss, coughing blood or ear pain on one side warrant urgent ENT assessment. Smoking and alcohol raise the concern substantially. Do not put these down to reflux before someone has looked at the larynx. ↩
  7. National Center for Complementary and Integrative Health (NIH), nccih.nih.gov, and the Linus Pauling Institute Micronutrient Information Center, lpi.oregonstate.edu/mic. ↩
  8. On how long LPR takes to settle: in 40 consecutive patients with LPR confirmed by pH monitoring and treated with proton pump inhibitors, symptom scores improved over the first 2 months with no further significant gain, while the visible laryngeal findings kept improving through at least 6 months, PubMed 11404607. It was a small preliminary report. ↩
  9. On twice-daily proton pump inhibitors: in an open-label cohort of 85 patients with suspected LPR, twice-daily dosing produced a symptom response in 50% at 2 months against 28% with once-daily dosing, and more patients responded by 4 months; adding a bedtime H2 blocker to twice-daily dosing made no significant difference, PubMed 15995512. The study was neither randomized nor placebo-controlled. ↩
  10. On proton pump inhibitors and H2 blockers in LPR: a 2026 review notes that proton pump inhibitors remain first-line therapy although many patients report persistent symptoms, that daily H2 blocker use is limited by tolerance, with significant loss of acid suppression within days of continuous use, and that persistent symptoms call for objective testing and alternatives including alginates, PubMed 42626405. ↩
  11. On alginates for LPR: a double-blind placebo-controlled trial in 80 patients found that 8 weeks of liquid alginate improved symptoms and reflux episodes but was no better than placebo, which had a large effect of its own, PubMed 29399800. ↩
  12. On the reported harms of long-term proton pump inhibitor use: an umbrella review of 42 systematic reviews, supported mostly by observational evidence, found associations with kidney disease and with Clostridioides difficile infection, concluded there was no association with neurological disease, and rated the certainty of the evidence very low for most outcomes, PubMed 34114655. ↩
  13. On nutrient absorption during long-term proton pump inhibitor use: a narrative review describes how the reduced stomach acid of long-term use may lead to deficiencies of vitamin B12 and vitamin C and of iron, calcium and magnesium, which need gastric acid for absorption, PubMed 32718584. It is a single-author review, not a trial. ↩
  14. On stopping proton pump inhibitors: gastroenterology guidance advises that people who stop long-term therapy may develop temporary upper gastrointestinal symptoms from rebound acid hypersecretion, and that either tapering or stopping at once can be considered, PubMed 35183361. ↩
  15. On how hard LPR is to diagnose: in an anonymous survey of 232 adults who reported an LPR diagnosis, 59.9% reported difficulty with the diagnostic process, and that difficulty was strongly correlated with the total number of physicians seen, the time from symptom onset and the time from the first physician visit, PubMed 39059171. ↩
  16. On chronic cough: a 2024 narrative review of the previous 13 years of studies found laryngopharyngeal reflux in 20% of patients with chronic cough, PubMed 38707186. ↩
  17. On how LPR is now assessed: a 2025 international consensus of 28 ear, nose and throat, gastroenterology, speech and psychology specialists found that throat symptoms do not by themselves mean reflux, that laryngoscopy rules out other causes but cannot diagnose reflux, that a trial of a twice-daily proton pump inhibitor for 3 months suits people who also have heartburn or regurgitation while throat symptoms alone call for testing, and that an oversensitive larynx often contributes and responds to voice and behavioral therapy. It lists weight management, staying upright for 2 to 3 hours after meals and raising the head of the bed among lifestyle measures, and found esophageal erosions or a hiatal hernia in up to 47% of people with throat symptoms in one multicenter study, PubMed 40197644. ↩
  18. On hoarseness that lasts: Cancer Research UK advises seeing a doctor for a hoarse voice lasting more than 3 weeks, one of the most common symptoms of laryngeal cancer, Cancer Research UK. ↩
  19. On when hoarseness needs a specialist: the 2018 US clinical practice guideline on hoarseness advises laryngoscopy when hoarseness has not resolved or improved within 4 weeks, or at any time if a serious cause is suspected, with earlier assessment after recent head, neck or chest surgery or intubation, or with a neck mass, breathing difficulty or a history of tobacco use, and advises against prescribing reflux medicines for hoarseness alone before the larynx has been examined, PubMed 29494321. ↩
  20. On heartburn in LPR: in 58 consecutive patients with laryngopharyngeal reflux confirmed by pharyngeal pH monitoring, 40% had heartburn, so about 60% did not, and only 19% had esophagitis or Barrett's metaplasia, PubMed 12352672. ↩
  21. On pepsin and pH: in laboratory testing, human pepsin was most active at pH 2 and inactive at pH 6.5 or higher, but it stayed stable up to pH 8 and regained most of its activity when acid was added again; the authors note that the throat averages about pH 6.8, so pepsin left there would be inactive until acid returns. Whether this happens in patients has not been shown, PubMed 17417109. ↩
  22. On salivary pepsin testing: the 2022 American College of Gastroenterology reflux guideline reports a pooled sensitivity of 64% and specificity of 68% for pepsin testing in LPR, and notes that control patients often had raised salivary pepsin, PubMed 34807007. ↩
  23. On trigger foods: the 2022 American College of Gastroenterology reflux guideline notes that in laboratory studies coffee, caffeine, citrus and spicy food had little or no effect on lower esophageal sphincter pressure, though some may still irritate, while alcohol, tobacco, chocolate, peppermint and high-fat foods do lower it, and that few studies show a benefit from avoiding them, PubMed 34807007. ↩
  24. On aloe vera for reflux: a 4-⁠week pilot randomized trial in 79 adults with reflux disease compared aloe vera syrup with two acid-reducing medicines and found that it reduced the frequency of all the reflux symptoms assessed and was well tolerated; it was small and short, and it did not study LPR, PubMed 26742306. ↩
  25. On aloe safety: the National Center for Complementary and Integrative Health reports that short-term oral use of aloe gel, up to 42 days, appears safe, that aloe leaf extracts taken by mouth have been linked to cases of acute hepatitis, that oral aloe may lower blood sugar in people with diabetes, and that aloe taken by mouth may be unsafe in pregnancy and while breastfeeding, NCCIH. ↩
  26. On zinc and medicines: zinc supplements taken with some antibiotics can reduce the absorption of both, and taking them at least two hours apart should prevent this, Linus Pauling Institute. ↩
  27. On reflux testing in throat symptoms: the 2022 American College of Gastroenterology reflux guideline reports that pH-impedance testing is abnormal in 40% of patients with LPR symptoms, and recommends looking for other causes before attributing throat symptoms to reflux, PubMed 34807007. ↩