Acid Reflux Without Heartburn

Quite often I hear my patients say that they don’t understand how I can tell them they have acid reflux disease because they don't have a complaint of heartburn. In fact, many of my patients initially simply do not believe they have acid reflux disease at all. The symptoms they do have when they come in to see me are some combination of cough (“I’ve been hacking for weeks”), hoarseness (“I sound raspy”), frequent throat clearing (“every morning I wake up trying to clear my throat”), excess phlegm in their throat (“I have this thick stuff in my throat and it wont come out, here, I saved some in this cup for you to look at”), post nasal drip (“ I have a drip”) and/or difficulty swallowing (“I feel a lump in my throat almost all the time”). In other words, their symptoms are not about heartburn, rather they are about "throat burn."

Posted on | Jonathan E. Aviv, MD, FACS | Comments ()

Quite often I hear my patients say that they don’t understand how I can tell them they have acid reflux disease because they don't have a complaint of heartburn. In fact, many of my patients initially simply do not believe they have acid reflux disease at all. The symptoms they do have when they come in to see me are some combination of cough (“I’ve been hacking for weeks”), hoarseness (“I sound raspy”), frequent throat clearing (“every morning I wake up trying to clear my throat”), excess phlegm in their throat  (“I have this thick stuff in my throat and it wont come out, here, I saved some in this cup for you to look at”), post nasal drip (“ I have a drip”) and/or difficulty swallowing (“I feel a lump in my throat almost all the time”). In other words, their symptoms are not about heartburn, rather they are about "throat burn."


What is even more confusing to my patients is that these throat symptoms are usually treated with antacid medications that are the same as traditional heartburn medications like Nexium, Prilosec, Prevacid, Aciphex, Protonix, Kapidex or Zegerid. Or another class of antacid medications such as Zantac or Pepcid.  


So what's going on here? What’s going on is that there are 2 related diseases taking place here, GastroEsophageal Reflux Disease (GERD) and LaryngoPharyngeal Reflux Disease (LPRD). In both diseases, acid from the stomach is refluxing (or going the wrong way) back up into either the esophagus, attached to the stomach from above, or all the way back into the throat, which sits on top of the esophagus.


Conceptually, the easiest way to think about the relationship between the stomach and the throat is that the stomach is "connected" to the throat. However, that is it not anatomically true as the esophagus is what literally connects the stomach to the throat. In many situations, stomach acid travels all the way back up into the throat. When that happens, throat tissues can be injured by acid causing a burn that swells the tissue. When tissues in the throat start to swell, one can start coughing, get hoarse, feel lumps in the throat and mucus can start sticking to the swollen tissues.  


The fact is we normally reflux 50 times per day from our stomach into our esophagus. The esophagus, since it sits right next to the stomach is built to handle acid exposure from the stomach. On the other hand our throat, and specifically the vocal cords (aka the larynx) are located much further away from the stomach than the esophagus is. Also, the vocal cords are especially sensitive to acid exposure. Studies have shown that even a single episode of acid exposure starts to cause the vocal cords to swell.


How do we treat this acid induced swelling of the throat? The treatment consists of being careful with the intake of 4 of your favorite food groups: caffeine, chocolate, alcohol and mint. In addition, antacid medications are often used as well. 


So when your doctor is giving you a “stomach” pill for your throat symptoms, remember, the stomach is connected to the throat. For more information, please visit www.voiceandswallowing.com.

Blog written by Jonathan E. Aviv, MD, FACS
Author of over 60 scientific papers in peer-reviewed journals and Flexible Endoscopic Evaluation of Swallowing with Sensory...