Better Hearing & Speech Month

Week 2: Silent Reflux and Laryngeal & Esophageal Cancer

Silent Epidemic

More than 50 million Americans are affected by silent reflux and only a few know it. Often misdiagnosed, silent reflux is acid reflux that does not produce heartburn or indigestion. Silent reflux can be treated but, if left unchecked, can cause cancer. To find out if you should be concerned about silent reflux, take this simple quiz.

This quiz, known as the Reflux Symptom Index (RSI), can be used as a first test to determine if you should see a specialist. Circle the appropriate number for each symptom and add up the numbers to find your RSI. If your RSI is 15 or more (and you have a zero or a one for heartburn), you should contact a doctor trained in detecting reflux (ENT or GI physician) by examining both the throat and esophagus.


LPR/Laryngopharyneal Reflux

Reflux that has progressed beyond point of esophagus and now affecting laryngeal area. Often the first, and only signs, are throat clearning, coughing and hoarse voice.

Key Medical Terms to Know:

Globus Pharyngeus- feeling of something stuck in the throat

Dysphagia- trouble swallowing

Dysphonia- abnormal voice

Larynx/Laryngeal- voice box/having to do with the voice box

Pharynx- throat

Esophagus- "tube" between throat and stomach, food passageway to stomach

ENT- Ear, Nose, Throat Physician aka Otolaryngologist

GI Doctor- Digestive Physician aka Gastroenterologist

Silent Reflux: A Hidden Epidemic

Jamie Koufman, MD, F.A.C.S.
Founder & Director, Koufman Reflux
Director, Voice Institute of New York

Modified to fit, original source:

What you don’t know can kill you. Silent reflux is acid reflux that does not produce heartburn or indigestion. You don’t know you have it, and yet it can still cause cancer.

Often overlooked and misdiagnosed, silent reflux affects over 50 million Americans. The backflow of stomach acid and digestive enzymes (pepsin) can wreak havoc on your esophagus (the food passage that goes from your throat to your stomach), as well as your ears, nose, throat, vocal cords, sinuses, mouth, and lungs. Pepsin, in the presence of acid, digests protein and damages tissue. Outside the protected stomach, pepsin, bathed in acid, digests you! And when pepsin attacks your sensitive airway and esophageal tissues, you can suffer all kinds of problems.

The most common silent reflux symptoms are hoarseness, chronic cough, throat-clearing, post-nasal drip, sinusitis, sore or burning throat, difficulty swallowing, shortness of breath, snoring, sleep apnea, bad breath, tooth decay, asthma, and COPD. Unfortunately, your doctor is probably unaware that these symptoms may be caused by silent reflux and that it could be controlled with the proper diagnosis and treatment.

Did you know that asthma is one of the most common misdiagnoses, because silent reflux mimics asthma? Here’s a big tipoff: When you have trouble breathing, do you have more difficulty getting air IN or OUT? People with reflux have trouble getting air IN during inspiration (not out during expiration). People with asthma have difficulty getting air OUT of the lungs. In truth, many people with “asthma” may not actually have it, and, consequently, asthma medication doesn’t really help much if at all. The fact is that once the correct diagnosis is made, effective anti-reflux treatment can permanently cure this asthma-like breathing problem.

How Do I Know If I Have Silent Reflux?

One of the characteristics of silent reflux is that most people who have it have several different symptoms all at the same time, but often heartburn isn’t one of them.

To find out if you may have silent reflux, take this simple quiz. (see boxes above)

Why Is Reflux Sometimes Silent?

What makes silent reflux different than heartburn is that the silent reflux sufferer may be unaware of having it, and his or her doctor may not suspect the diagnosis. A lot of reflux is needed to damage the esophagus, but very little reflux can severely damage the more sensitive throat, sinuses and lungs. Many people with silent reflux have never even once experienced classic heartburn.

How the term “silent reflux” came to be is instructive. In 1987, Walter Bo, a medical school colleague, was my patient. As a result of nighttime reflux, he had terrible morning hoarseness. This was because he had a habit of eating dinner very late and then falling asleep on the sofa. Hence, he would reflux into his throat all night.

I tried explaining the problem, but Walter repeatedly denied having reflux. As it turned out, Walter affirmed that he thought that heartburn and reflux were the same. When I was able to explain that one could have reflux without heartburn – as in this example, when it occurred during sleep – Walter rolled his eyes and said, “I see. I have the silent kind of reflux.” I declared, “Yes, Walter, that’s it! You have silent reflux!”

Why Doesn’t My Doctor Know About This?

Unfortunately, people with silent reflux symptoms, even if they ask their doctor, are usually incorrectly told they do not have reflux. The medical specialties are broken down by parts of the body, and doctors are experts in, and only test for, those parts of the body in which they specialize. The problem is that reflux does not care where your doctor trained and how it might affect the different medical specialties – the esophagus treated by gastroenterologists, the throat and sinuses treated by ear, nose and throat specialists (otolaryngologists), and the trachea and lungs treated by lung specialists (pulmonologists).

The Solution: Integrated Aerodigestive Medicine

Only a trained reflux specialist who knows what to look for in all affected areas and who has the right diagnostic tests is equipped to make an accurate diagnosis. Otherwise, a doctor may guess wrong and treat you for an illness that you don’t have. Some of the symptoms of silent reflux can sometimes be caused by other diseases, which doctors try to treat unsuccessfully, leaving you miserable, frustrated, and having wasted money on useless tests and drugs.

Instead of focusing on the patient’s diet and lifestyle – the root cause of almost all reflux disease – doctors often employ pills, usually the wrong pills, that rarely correct the problem. In truth, reflux medications are grossly misused and over-used today.

A new medical field is emerging, one devoted to the comprehensive diagnosis and treatment of reflux symptoms and all reflux-related breathing and digestive tract diseases. The name for this new field is Integrated Aerodigestive Medicine (IAM). This approach represents the leading edge of change in American healthcare. For the first time in the nation, Integrated Aerodigestive Medicine is available in New York City at The Koufman Reflux Center of New York. This groundbreaking approach is based upon my 30 years of scientific research and clinical experience.

You don’t have to be on medication for life; you can change your life, and you can be cured.

Silent Reflux Is an Epidemic

I am often asked if reflux is more common today or if we are just more aware of it? The answer is both. But make no mistake about it, reflux is now an epidemic. Esophageal and silent (airway) reflux have skyrocketed since the 1970s. The actual prevalence of reflux in America has increased from 10% in 1976 to a staggering 40% today.

What You Eat Could Be Eating You

The reflux epidemic appears to be related to too much acid in the food supply! How did this happen? Following an outbreak of food poisoning in 1973, the Food and Drug Administration (FDA) set Good Manufacturing Guidelines for all food and beverages in bottles and cans. And what did they mandate? Acid, acid, acid. By law, everything in a bottle or a can must be acidic. This kills bacteria and prolongs the shelf life of products, but it also causes reflux disease.

Pepsin, the main digestive enzyme that digests protein, needs acid to work. Every time you reflux, pepsin is washed onto your sensitive tissues. Once a pepsin molecule is bound to, say, your throat or esophagus, any dietary source of acid can reactivate it: soda, salsa, strawberries. That’s why I say what you eat may be eating you.

Reflux medication is not the answer for most people. People who have reflux should see their doctors, because medication can just cover up the underlying problem. Just the same, if you have reflux, there is a lot that you can do by changing what you eat and when you eat it.

Reflux Can Be Cured Through Healthy Eating

Healthy eating. What’s that when it comes to reflux? First, no late-night eating. If you go to bed with a full stomach, you are likely to reflux all night. Besides, reflux is the most common cause of disturbed sleep and it is even associated with snoring and sleep apnea. Second, restrict all highly acidic foods and beverages. If you have reflux, the only thing you should drink out of a bottle is water, and alkaline water is best. Alkaline water kills off pepsin; look for alkaline waters with a pH above 8.0. After over-eating, soft drinks (all of them) are the next greatest cause of reflux. Finally, your diet should be low-fat as well as low-acid. It works! Do a strict, two-week induction ("detox") low-acid diet, and then follow it up with a moderate low-acid, low-fat, pH-balanced diet for 3-6 months.

Table 1 shows the recommended reflux diet in a nutshell, and Table 2 shows the best-for-reflux food list.

Table 1: Basic Elements of Dr. Koufman's Reflux Diet

  • Nothing out of a bottle or a can except water (alkaline is best)
  • Alcohol in moderation (one drink), and no late-night eating
  • Eat lots of fish, poultry, vegetables, breads, and grains
  • Use and order all dressings, cheeses, and sauces on the side
  • Minimize fatty meats; some beef and pork, and portion control!
  • Avoid excessive consumption of acidic foods like citrus fruit
  • Avoid reflux-causing foods like mints, chocolate, and fried food

Table 2: Dr. Koufman's Short Best-For-Reflux Food List

  • Grilled/baked/broiled/boiled fish, shellfish, and poultry
  • All veggies (except onions, tomatoes, garlic, and peppers)
  • Breads, rice, grains (low-sugar cereals), oatmeal, and tofu
  • Alkaline water, low-fat cow, soy, almond, and coconut milk
  • Melons, bananas, ginger, chamomile tea, Manuka honey

Finally, if you are going to be on a low-acid diet, you must know if there is acid added to something. You have to read the ingredients on labels. What should you look for? Phosphoric acid, ascorbic acid, citric acid, and “vitamin C added or enhanced” all mean that what’s in the bottle may be as acidic as stomach acid. And if you have significant reflux symptoms, avoid it!

Try these recipes from Dr. Koufman’s cookbook, Dropping Acid, The Reflux Diet Cookbook & Cure:

Gastroesophageal Reflux Disease: Serios Illness Potential Often Misunderstood by Ellen N. Friedman

More than 60 million Americans suffer from heartburn, the most common symptom of gastroesophageal reflux disease (GERD) (Castell, 2003). Other symptoms may include dysphagia with a globus sensation (a feeling that there is a lump in one's throat) in the pharynx or burning in the esophagus while swallowing. Others experience nighttime choking episodes, or may have black, tar-like stools. The voice may become dysphonic. Asthmatic reactions may appear. These symptoms all reflect inflammatory reactions in the epithelium (skin lining) of the esophagus, pharynx, vocal folds, and sinuses, as well as the trachea, bronchi, and lungs.

The serious illness potential of GERD is widely misunderstood by the public. Individuals often delay essential medical intervention, largely because GERD affects so many people; in many cases, it is treatable and well-controlled with over-the-counter medications. Barrett's Esophagus is found in 5%-10% of people who have frequent heartburn symptoms (Rosen, 2003). In Barrett's Esophagus, the esophagus is coming into regular contact with gastric acids, creating a lining more like that of the intestinal lining, which causes damage to the lining of the esophagus and sets up a pre-cancerous environment.

(content modified, for full article, see source at bottom)


Treatment options for primary non-cancerous GERD and LPR include medication and lifestyle changes. If the patient also presents with dysphonia, a referral is made to the speech-language pathologist, who then plays a key role in monitoring the patient's hoarseness, aligning vocal bio-mechanics, and instructing the patient on behavioral reflux precautions. The SLP takes a detailed case history of diet, including types of food eaten, portions, and the time lapse between eating and reclining or engaging in rigorous activity.

Treatment options for primary non-cancerous GERD and LPR include medication and lifestyle changes. If the patient also presents with dysphonia, a referral is made to the speech-language pathologist, who then plays a key role in monitoring the patient's hoarseness, aligning vocal bio-mechanics, and instructing the patient on behavioral reflux precautions. The SLP takes a detailed case history of diet, including types of food eaten, portions, and the time lapse between eating and reclining or engaging in rigorous activity.

Equally important is knowing the patient's current medications, and whether they are taken properly (including time of day and whether or not medications need to be taken with food). The patient is guided to follow strict behavioral reflux precautions, including:

  • Eat light meals at least three hours prior to a performance, intense vocal activity, reclining or sleeping

  • Avoid ingestion of alcohol, caffeinated beverages, decaf coffee, carbonated beverages, and citrus juices

  • Eliminate fatty, fried, spicy, and acidic foods from the diet

  • Avoid acidic medications such as aspirin and vitamin C

  • Take medications as directed

  • Elevate the head of the bed by at least six inches

  • Take antacids when acute symptoms appear

  • Avoid chemically filled environments

  • Avoid mints, chocolates, or nuts

  • Eat slowly

Standard voice therapy then is utilized to align proper vocal bio-mechanics. If this is accomplished with no change in dysphonic features, the SLP can assume that further medical investigation is warranted. Judicious referral to proper medical personnel is imperative, due to the potentially quick progression of the disease.

Refer to a gastroenterologist if the current medical coverage does not appear to be alleviating gastric symptoms. Follow up with the otolaryngologist if dysphonia worsens. Schedule a modified barium swallow study if swallow function worsens beyond a globus sensation. Refer to cardiology if the patient's symptoms reflect nocturnal apneic dyspnea and/or significant and consistent inspiratory stridor at rest. Follow up with pulmonology if stridorous inhalation and exhalation appears or persists along with chronic cough.

Physicians consider various medication regimes in cases of primary GERD. For ongoing use, three types of medications include proton pump inhibitors, such as Prilosec 2-4mg/kg/day and the usual dose rate is 5-10mg po BID; or the H2 blockers QHS (once at bedtime), such as Zantac 6mg/kg QHS, syrup 15mg/1ml, or 150mg Efferdose tablets or granules (Rosen & Murry, 2003). The other treatment may include prokinetic agents, which are still considered controversial at this time.

For severe reflux in both children and adults, surgical treatment of fundoplication connects the LES with the stomach and improves the sphinteric function, and there is endoscopic repair and laryngotracheoplasty for endoscopic management of stenosis.

For patients who have had an esophagogastroendoscopy (EGD)-an examination of the entire upper gastrointestinal (GI) tract using an endoscope-and who have been found to have displasia of the esophagus, the esophagus may be scraped of abnormal cells, or pre-cancerous cells. At other times they will be given a strict medication regimen that may include a combination of H2 blockers and proton pump inhibitors. Then they will be closely monitored for signs of healing or further erosion. If a tumor is found a biopsy must be taken. If the tumor is cancerous and is determined to be the primary cancerous site with no metastatic secondary sites, the tumor is removed surgically.

GERD and LPR are common among Americans as well as people from other countries whose lifestyles and food choices affect the health of the digestive tract. This common disease can be managed and treated if behavioral and other management strategies are used to alleviate symptoms. All too often, however, people tend to ignore symptoms, or believe that medication will allow them to continue leading sedentary lifestyles, eating foods that encourage reflux, or snacking before going to bed. They often do not realize that their esophagus has possibly begun a journey of erosive esophagitis.

In holistic medicine, the triad relationship between breathing, swallowing/digestion, and the nasal sinus region is well understood. GERD is both a primary diagnosis that affects all three regions and secondary regions as well, and is also causative or symptomatic of more serious diseases, such as Barrett's Esophagus, or esophageal cancer, for example. When any symptoms point back to GERD or LPR, it is wise to be examined thoroughly, and to strictly follow the recommendations for follow-up.

Ellen N. Friedman, is a speech-language pathologist in private practice in Ohio. She also is a consultant and public speaker, and her work focuses on voice and GERD-related anomalies. Contact her at or on the Web at


American Speech-Language-Hearing Association

Friedman, E. N. (2006, November 07). Gastroesophageal Reflux Disease : Serious Illness Potential Often Misunderstood. The ASHA Leader.


Christina Rojas, M.A, CCC-SLP

Audubon Elementary's own friendly Speech Therapist :)