October 10, 2023

Six Massive Misdiagnoses & Respiratory Reflux



  • The digestive and respiratory tracts are connected and act like one unit, and silent reflux (aka respiratory reflux or LPR) can cause serious respiratory diseases … most of them
  • How common is Silent Nocturnal Respiratory Reflux, SNoRR? I’m betting at least 100 million Americans have it; however, usually neither the sufferer nor their doctor knows the problem is reflux.
  • Just six misdiagnoses account for that 100M number. Most common are post-nasal drip and allergy Allergy is over diagnosed as allergy and reflux symptoms overlap … which can lead to misdiagnosis.
  • Post-nasal drip that is thick and hard to move, say off the vocal cords, is reflux; whereas allergy mucus is thin and almost never disturbs the voice. Post-nasal drip from either diagnosis is very common; however, reflux is more common, affecting  tens of millions, and that’s just one of the six.
  • The other massive misdiagnoses are asthma, chronic bronchitis and cough, sinusitis, snoring, and sleep apnea … at the very least reflux is causative.

Respiratory Reflux (RR) and Laryngopharyngeal Reflux (LPR) are synonyms and the terms can be used interchangeably. Going forward, I prefer the term RR and so should you; it is easier to pronounce, more intuitive, more comprehensive, and implies that RR can affect any and all parts of the respiratory system, which it does.

“It’s not that I’m smart, it’s just that I stay with problems longer.” -Albert Einstein

My professional life, my work, writings, and research have been focused on acid reflux as it affects the respiratory tract. How did that happen? I began as a laryngologist, specializing in problems of the voice and voice box; and in 1978, I acquired the forth CO2 surgical laser in the world. Wow! That laser allowed me to do precision vocal cord surgery (using a microscope) through the mouth, with no incisions … and for a variety of conditions, many of which were life-threatening; and by 1981, I had a National practice. 

That same year I noticed laryngeal inflammation, swelling, and redness in patients who had bad surgical results. Using a variety of diagnostics, I found that my patients almost never had heartburn or indigestion, the symptoms of GERD (gastroesophageal reflux disease).  My patients had silent reflux, and I proved it with pH (acidity) testing, using a thin tube that was placed in the throat to measure acid.

Long story short, by 1987 I had my own reflux testing laboratory, and by then I was certain that my patients were very different from GI patients with GERD. Since my patients had silent reflux in the throat and no heartburn, I coined the term LPR (laryngopharyngeal reflux), literally, reflux into the larynx (throat) and pharynx (throat). 

It took me another thirty years to recognize that the term LPR was not inclusive enough, because once reflux makes it into the throat, it can go anywhere, everywhere in the respiratory tract, including the ears, nose, and sinuses. So, about five years ago I coined the term respiratory reflux; and I think that it is a “pinnacle” term that will eventually replace LPR.

The fact is that my job has become helping people prevent Silent Nocturnal Respiratory Reflux (SNoRR)through diet and lifestyle modification; that’s the only cure. Why? Because we eat too much, to late, and commonly overeat as well … and that’s in addition to consuming reflux trigger foods like onions, fried food, alcohol, and chocolate.

The Big Six

I said that I believe that more than 100 million Americans have silent reflux, SNoRR. How could that be? Just add up how many people have one or more of the big six below and (rightly) assume that two-thirds of them have reflux. 

  1. Post nasal drip / Allergy

The symptom of post-nasal drip is a biggie; millions and millions of people have it. Unfortunately, many are mistakenly misdiagnosed as having allergies when the problem is reflux. And after the misdiagnosis comes mis-treatment, e.g., inappropriate shots and/or meds for allergies. However, allergies can be differentiated from reflux because an allergy is associated with thin mucus that hardly ever bothers the throat. Conversely, reflux produces thick mucus that is hard to move, especially if it gets on the vocal cords. Meanwhile, add the two diagnoses together and you have tens of millions of people.

  1. Asthma / Shortness of breath

One of the biggest misdiagnosis in America is asthma. Over the course of my career, I have seen hundreds of patients with “asthma,” and when asked, “When you have an ‘asthma attack,’ do you have more trouble breathing IN or OUT?” Four-out-of-five respond IN … and trouble breathing IN is never asthma, it’s respiratory reflux. Meanwhile, shortness of breath can be difficulty breathing with exertion, trouble moving air into the lungs because of airway obstruction, and just difficulty taking a full breath. The latter is common and only seen with reflux. (As an aside, reflux also is the most common trigger for true asthma.) How many people have asthma and shortness of breath, at least 20 million?

  1. Chronic bronchitis/ COPD

Chronic bronchitis and COPD (chronic obstructive pulmonary disease) are often caused by respiratory reflux unknown to either the patient or the doctor; see my eye-opening posts on Chronic Bronchitis and COPD.

  1. Recalcitrant chronic cough

“Non-pulmonary” chronic cough means that the lungs are okay. In that case, reflux is the number one cause of cough, which I have determined over the course of 40 years by clinical criteria and reflux testing. See Chronic Cough post and The Chronic Cough Enigma.

  1. Snoring / Sleep apnea

Probably the biggest “new” misdiagnoses are snoring and sleep apnea; both (clearly related)  seem to be rapidly increasing. In my experience, both are caused by reflux; and in my hands, I can make the diagnosis by a simple examination of the throat. It is unfortunate that the medical community does not recognize reflux as the cause of these problems. These people should eat dinner early, never snack at night, and should sleep on a high incline … perhaps purchasing a  bed that goes up and down. For more, see the Snoring & Sleep Apnea post

  1. Sinusitis symptoms / problems

Suffice it to say that in my opinion, a lot of unnecessary sinus surgeries are being performed in this country, because reflux is the cause of most sinus symptoms; see my post on this. 

Go on Google and look at the estimated prevalence of each diagnosis, I did: 

  • Allergies 22 million
  • Respiratory reflux, number unknown or diagnostic criteria unestablished
  • Asthma and shortness of breath 27 million
  • Chronic bronchitis 10 million
  • COPD (chronic obstructive pulmonary disease) 16 million
  • Snoring 37 million 
  • Sleep apnea 19 million
  • Chronic bronchitis 10 million
  • COPD 15 million
  • Sinus problems 20 million

While there may certainly be some overlap between groups; the above total is 156 million. If one assumes that about two-thirds of each group is misdiagnosed, with respiratory reflux being the cause of symptoms, then my estimate of 100 million of us with respiratory reflux is spot on. (In my experience, more than two-thirds of each group has silent respiratory reflux.) The surprising, yes shocking, problem is that physicians in all the specialties that share the airway, and take care of respiratory diseases, do not know when to suspect respiratory reflux or how to diagnose and treat it. 

75 Conditions Caused or Exacerbated by Respiratory Reflux



Bad breath




Can taste reflux

Choking episodes

Chronic cough

Chronic obstructive pulmonary disease

Chronic throat-clearing                                              

COPD (chronic obstructive lung disease)

Coughing up blood

Cystic fibrosis

Dental disease (progressive)

Difficulty swallowing

Dysphagia (difficulty swallowing)                                                

Ear pain, stuffiness, pressure,

Esophageal cancer

Eustachian tube dysfunction

Facial pressure and discomfort (sinus)

Fluid in ears

Food getting stuck in throat

Food/drink going down the wrong pipe

Food/drink going into lungs

Globus (a sensation of a lump in the throat)                          

Gum (progressive)




Idiopathic pulmonary fibrosis

Inability to breathe in

Inability to breathe out                      

Inability to take a full breath                              

Laryngeal cancer

Laryngeal webbing and stenosis (scarring)


Laryngospasm (cannot get enough air in, choking)

Loss of singing voice                         

Loss of vocal range                          

Lung cancer (especially in non-smokers)

MAC lung disease (Mycobacterium avium)

Nasal congestion

Nasal obstruction

Oral (mouth) cancer



Painful speaking

Paradoxical vocal cord movement


Post-nasal drip


Recurrent pneumonia

Ringing in the ears

Serous otitis media 

Shortness of breath                                                    

Sinus and facial pressure


Sleep apnea                            


Sour taste in the mouth

Stuffy nose                      

Subglottic stenosis (scarring)

Throat cancer



Vocal cord cancer

Vocal cord dysfunction 

Vocal cord granulomas

Vocal cord nodules

Vocal cord polyps

Vocal cord scarring

Vocal fatigue  

Voice change

Voice-use pain 

For more information about diagnosis and treatment, see my books on Amazon: Dropping Acid: The Reflux Diet Cookbook & Cure and Dr. Koufman’s Acid Reflux Diet. And if you would like to schedule a virtual consultation with me, you can book online.

Books by Dr. Koufman

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