What Are the Symptoms of Respiratory Reflux With No Heartburn or GERD?

Respiratory Reflux (RR) is the new (2017), easier-to-pronounce, and more accurate term for LPR (laryngopharyngeal reflux) (1987). Notably, with RR, the sufferer rarely has heartburn or indigestion… it’s not GERD … it’s silent reflux.. 

The reason there are such dynamic differences between RR and GERD appears to be related to the American diet and lifestyle. The #1 RR-causing variable is the evening meal, which is usually the major refueling meal of the day and is often combined with alcoholic beverages and other reflux-trigger foods. RR is almost always SNoRR (silent nocturnal RR).  

Meanwhile, the daytime RR symptoms depend on what part(s) of the respiratory tract are involved. Here is a baker’s dozen RR symptoms, more or less in the frequency of occurrence. For example, post-nasal drip and too much mucus are the #1 symptoms of RR. 

1. Postnasal drip, too much mucus. RR-caused postnasal drip is thick mucus that gets stuck on throat surfaces, and it’s hard to move, especially off the vocal cords. Thin clear mucus, on the other hand, associated with allergies, never gets on the vocal cords.

2. Chronic throat clearing. Chronic throat clearing results from the thick mucus of RR, and again, it is particularly problematic when it gets in the larynx. It takes effort to get the sticky stuff off the vocal cords.

3. Shortness of Breath. Forty-three percent of people with RR complain of shortness of breath (SOB); of that group, 77% have SOB on exertion or with exercise, 42% have airway obstruction, e.g., asthma, laryngospasm; and 68% have difficulty or discomfort taking a full deep breath IN.  

4. Hoarseness, Laryngitis. This includes “heavy voice,” raspy voice, voice and/or pitch change, effortful speaking, and vocal fatigue. Unlike viral laryngitis, which lasts less than a week, the voice changes of RR persist for weeks, months, or even many years, sometimes with some variation; the severity of the voice consequences may vary over time. For singers, RR is a big deal.

5. A Feeling of Something In Your Throat. A lump-in-the-throat sensation, Globus, is usually the result of abnormal pressures in the UES (upper esophageal sphincter), which lies behind the larynx. The cause is RR. Here is a clinical pearl that is virtually diagnostic of RR: people with globus may complain that they have it all the time; however, when asked, “Do you notice it when you’re eating?” The answer is “No,” which is a hallmark of RR.

6. Difficulty Swallowing. There are many causes of difficulty swallowing, but dysphasia (difficulty swallowing) is most commonly due to malfunction of the UES (upper esophageal sphincter) caused by RR. The UES gets out of sync and closes in the middle of the swallow, but with successful anti-reflux treatment, the dysphagia goes away.

7. Excessive burping. A burp is an aerosolized reflux event. No one knows how much acid and pepsin comes up, but the LES opens, and air comes from the stomach. Excessive burping is associated with acid reflux.

8. Loud snoring. Snoring (and sleep apnea) are most often caused by 20 or more years of SNoRR (silent nocturnal respiratory reflux). On examination, people who snore usually have thickening of the entire upper throat, and in many cases the uvula is enlarged as well, drooping down, sometimes into the larynx. It takes only a few weeks of solid antireflux treatment for the uvula to shrink back to normal size.

9. Choking Episodes.  Excluding serious causes of choking episodes that are life-threatening, like a Cafe Coronary, the most common cause of choking is Laryngospasm, in which the vocal cord clamps shut, making it difficult to get air in during inspiration. This is frightening but never truly life-threatening.

10. Persistant, Annoying Cough. Assuming no lung disease, RR is the most common cause of chronic (>4 weeks) cough. Some patterns are characteristic of the RR cough: coughing after lying down, after meals, and bending over. In addition, the RR cough is usually “wet,” productive of mucus. See The Chronic Cough Enigma.

11. Nasal congestion. Nasal congestion occurs when a person refluxes at night into their nose. For this, I recommend alkaline water nasal drops when arising in the morning.

12. Facial pain or pressure. RR, reflux into the nose during sleep can close the openings of the sinuses, leading to feelings of sinus pressure and pain. Nose or sinus surgery is never indicated for this.

13. Heartburn.  Some people with RR also have GERD and heartburn. Recent data suggest that this group represents less than 10% of people with RR. Indeed, people with both RR and GERD respond well to treatment for RR. People with heartburn should have an endoscopy at least once, and I recommend a transnasal esophagoscopy. Treatment of RR is effective for GERD as well.

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