respiratory reflux
March 12, 2023

Three Conditions That May Require Lifelong Acid Reflux Treatment — Sjögren’s Syndrome, Radiation Treatment, and Achalasia

respiratory reflux


  • Sjögren’s syndrome is an autoimmune syndrome that attacks the salivary glands, resulting in lack of saliva and dry mouth; the medical term for dry mouth is xerostomia. And radiation therapy, often used as a primary or adjunctive treatment for cancers of the head and neck also results in xerostomia if the major salivary glands are in the radiated field.
  • There is plenty of saliva with achalasia, another autoimmune disease, but in achalasia, the nerves to the esophageal muscular layer are destroyed, leaving the esophagus paralyzed, and like a floppy tube with poor drainage.
  • People with Sjögren’s syndrome, head and neck irradiation, and achalasia all may have chronic acid reflux; and the author’s specific long-term therapeutic recommendations are presented.

Note: 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, and it implies that RR can affect any and all parts of the respiratory system, which it does.

Sjögren’s Syndrome

Sjögren’s syndrome (show’-grenz) is a relatively uncommon autoimmune disease in which antibodies attack and destroy saliva glands. Sjögren’s affects mostly women and the female to male ratio is 10:1. While it can begin at any age, most Sjögren’s patients present in middle-age. The most common symptoms of Sjögren’s are dry eyes and dry mouth; there aren’t enough (or any) tears or saliva.

The clinical diagnosis can be made by measuring eye tears (Schirmer’s test), but there are other causes for dry eyes. So, the definitive test for Sjögren’s is a lip biopsy. This is done by making a small incision inside the lip and removing a few minor salivary glands, which are examined by a pathologist under a microscope; diagnosis is confirmed by finding lymphocytes attacking saliva glands.

In summary, Sjögren’s syndrome is an autoimmune disease affecting mostly women. With this condition, the body makes antibodies that attack saliva glands, and the consequent dry mouth with little or no saliva is called xerostomia.

Head and Neck Cancer Radiation Therapy

While there are some minor salivary glands in the mouth, almost all of our saliva comes from two paired (right and left) glands, the parotids and the submandibular glands. Radiation is used to treat many head and neck cancers as a primary or adjunctive treatment.

Sometimes the salivary glands can be spared; for example, with vocal cord cancers, the irradiation port (target) can be as small as 1-2 inches. Unfortunately, for most head and neck cancers, the salivary glands in the irradiation field are effectively destroyed, resulting in severe xerostomia like that seen in Sjögren’s.


Achalasia is a rare autoimmune disorder that makes it difficult to swallow. Unlike Sjogren ’s syndrome where the trouble stems from lack of saliva, loss of nerve cells in the esophagus are the problem. It is unknown why these nerve cells die, but it leaves the esophagus paralyzed.

Patients often feel like swallowed food gets stuck on the way down to their stomach. The symptoms start slowly and increase over time. Since up to 40% of patients with achalasia have heartburn, they may be misdiagnosed with GERD. However, avoiding acidic food, such as citrus, coffee, and chocolate will help with symptoms.

Why Saliva Is Important

Saliva has many functions: (1) Saliva contains digestive enzymes that begin breaking down food. (2) Saliva helps prevent tooth decay by neutralizing acids and washing away food on and between teeth. (3) Saliva enhances your ability to taste and makes it easier to chew and swallow. And (4), although having a dry mouth, xerostomia is very troublesome for eating and for the oral cavity; it is a big problem when it comes to acid reflux.

Saliva contains bicarbonate, which is alkaline; and bicarbonate in saliva is important for the body’s anti-reflux defenses, particularly for esophageal acid clearance. Here’s how that works: Everyone has some reflux events some time, mostly after meals. And with just one swallow most of the refluxed material is pushed back into the stomach; however, there is still a coating of acid on the walls of the esophagus. That’s where saliva and salivary bicarbonate come in; saliva contains bicarbonate, which is alkaline and can neutralize the stomach acid on the esophageal lining. 

Suppose the pH in the lower esophagus remains low, say about pH 2. But we swallow about every 30 seconds and the esophageal pH increases in steps, increasing the pH with each swallow. The pH (acidity) gradually increases because of the delivery of salivary bicarbonate, and in healthy people the pH in the esophagus is back to normal in less than five minutes.

Recommendations for People with Xerostomia and Achalasia

Xerostomia, dry mouth or not enough saliva, is a prominent feature of Sjögren’s syndrome and head and neck irradiation. Remember, with no salivary bicarbonate, “esophageal acid clearance” does not happen. In a study of patients with xerostomia, all had acid reflux.

My recommendations for achalasia as well as xerostomia (Sjögren’s syndrome and head and neck cancer radiation therapy) are similar; however, high elevation of the bed is particularly helpful for patients with achalasia.

  • No eating or dinking within 3-5 hours of bed; and the evening meal should not be the big refueling meal of the day. Also no over-eating, no soft drinks or juices, no alcohol, or chocolate.
  • Sleep at 25o-45o … in my opinion, people with these conditions (if they can afford to) should consider purchasing a bed that elevates the back and feet … I am not necessarily recommending the bed linked here (and it need mattresses too), but the idea is right.
  • Consume alkaline water pH 9.5 or higher.

I believe that these recommendations are essential for the xerostomia group, and that a small early meal with high bed elevation (45o) is essential for the achalasia patients; the higher the angle, the better. I had a patient who was an elderly woman with achalasia and chronic cough. When she slept in her recliner sitting up, she would not cough the next day. So, her family installed two comfy “seat-belts” in the recliner so she could sleep sitting up without falling out of her chair. It worked well.

Summary: These Long-Term Measures Help

The rationale for treatment of xerostomia (i.e., Sjögren’s, radiation) is different from that for achalasia; however, going to sleep with an empty, quiet stomach and sleeping on a high incline are the most important of my recommendations for all three conditions.

With xerostomia, anti-reflux treatment with famotidine, Gaviscon Advance aniseed, proper diet, etc. are important: however, the single most helpful therapeutic for xerostomia is alkaline water; in a way, it replaces salivary bicarbonate and helps normalize esophageal pH. Again, I personally like the ~pH 9.5 Cerra Water pitcher.

With achalasia, the main point of uprightness is to facilitate drainage of the (possibly-full) esophagus. Finally, and in addition, all of the above recommendations apply to people who have Barrett’s esophagus.

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