Dr. Spencer Payne is a board-certified otolaryngologist and RefluxRaft Co-Founder who focuses on sinus and nasal health and how it intersects with reflux. Below, he breaks down a major new 2026 research review on laryngopharyngeal reflux disease, why it’s so often missed, and what the evolving science says actually helps.
When most people hear the word reflux, they picture heartburn: that familiar burning sensation rising from the stomach into the chest.
But reflux doesn't always feel like heartburn.
For some people, the symptoms show up much higher—in the throat, voice, nose, or even potentially the eyes. You may wake up hoarse. Feel like something is constantly stuck in your throat. Clear your throat throughout the day. You may deal with stubborn mucus or a chronic cough. And you may never feel the classic “burn” you associate with acid reflux.
This is often called silent reflux, or more precisely, laryngopharyngeal reflux disease (LPRD).
A new, extensive review of the scientific literature is helping clarify why LPRD can look—and behave—very differently from traditional gastroesophageal reflux disease, or GERD.
Published in Otolaryngology–Head and Neck Surgery, the 2026 State of the Art Review was authored by an international group of reflux experts, including RefluxRaft Vice President of Education Inna A. Husain, MD. The authors reviewed research on how LPRD presents, how it can be diagnosed, and how our understanding of its treatment is evolving.
Why Silent Reflux Can Be Easy to Miss
For a long time, reflux was largely understood through the framework of traditional GERD: heartburn, regurgitation, esophageal acid exposure, and response to acid-suppressing medications.
That framework works well for classic GERD—but it doesn’t always capture laryngopharyngeal reflux disease.
LPRD can occur with little or no heartburn, and newer reflux-monitoring studies suggest that material reaching the throat is often weakly acidic, non-acidic, or alkaline rather than strongly acidic. The 2026 review also highlights that some patients with objectively documented pharyngeal reflux do not meet traditional criteria for GERD.
That helps explain why someone with chronic throat clearing, cough, hoarseness, mucus, or a persistent “lump in the throat” sensation may spend months being evaluated for allergies, sinus problems, asthma, or voice disorders before reflux enters the conversation.
The challenge is that these symptoms are also nonspecific. That’s why the newer literature emphasizes looking at the overall pattern—and, when appropriate, using objective reflux testing rather than assuming that symptoms alone prove reflux.
Reflux Doesn't Have to Feel Like Heartburn
GERD and LPRD are related, but they aren't interchangeable.
With GERD, reflux primarily causes symptoms or injury involving the esophagus. With LPRD, refluxed stomach contents travel high enough—or exert effects significant enough—to affect tissues of the upper airway and throat.
That distinction matters.
Research reviewed in the new paper increasingly suggests that many reflux events reaching the throat are weakly acidic, non-acidic, or alkaline, rather than the strongly acidic reflux most of us associate with heartburn. They may also occur in a gaseous form.
That helps explain an experience many people find confusing: “How can I have reflux if I never have heartburn?”
You can.
At the same time, “silent reflux” doesn't necessarily mean no digestive symptoms at all. The review emphasizes that digestive symptoms may occur in a substantial percentage of LPRD patients, and GERD and LPRD can coexist. The better way to think about LPRD isn't “reflux without heartburn,” but rather reflux whose most noticeable effects may occur outside the esophagus.
Could These Symptoms Be Connected?
Common symptoms of LPRD include persistent throat clearing, voice changes or hoarseness, cough, excess mucus, and the sensation of a lump or something stuck in the throat.
But the newer research suggests the pattern may extend further.
Researchers are now investigating associations between LPRD and findings involving the nose, sinuses, mouth, and eyes. The review highlights symptoms and findings including:
- Dry or irritated nasal passages
- Nasal congestion or obstruction
- Nasal crusting or sneezing
- Sticky mucus in the throat
- A coated tongue
- Dry-eye symptoms
- Chronic cough or persistent throat irritation
- Voice symptoms that are particularly noticeable after waking
Some of those associations are better established than others. The review emphasizes that these symptoms and physical findings are not diagnostic on their own. Their value is in pattern recognition: when several occur together, after other common causes have been considered, reflux becomes one possible explanation worth investigating.
That caveat is important. Allergies, chronic sinusitis, medication effects, voice disorders, environmental irritants, and many other conditions can produce very similar symptoms. The review therefore cautions against diagnosing LPRD from symptoms alone.
Why Acid Suppression May Not Be the Whole Answer
Here’s where the evolving science gets especially interesting.
For decades, reflux treatment has largely focused on acid. Proton pump inhibitors, or PPIs, reduce the stomach's acid production and can be extremely useful when acid reflux is the problem.
But reducing acid doesn't necessarily stop the physical act of reflux.
And if reflux reaching the throat is weakly acidic or alkaline, simply suppressing stomach acid may not address everything traveling upward.
Researchers have also identified digestive substances such as pepsin, bile salts, and elastase in association with LPRD. Some of these enzymes remain active outside strongly acidic conditions, and recent research has increasingly focused on their possible role in irritating the delicate tissues of the throat and upper airway.
That may help explain why PPI treatment has produced inconsistent results in people with suspected LPRD.
The new review describes growing evidence supporting alginate therapy as an alternative or adjunctive approach. Rather than simply changing stomach acidity, alginates create a physical barrier—or “raft”—on top of stomach contents, helping reduce material from traveling upward in the first place.
Importantly, the review notes that alginate-based approaches can act across acidic, weakly acidic, and alkaline reflux events, rather than targeting acidity alone.
That's a fundamentally different strategy: instead of asking only, “How do we make reflux less acidic?” the question becomes, “How do we help keep stomach contents where they belong?”
What Actually Helps With Silent Reflux?
Medication isn't necessarily the first—or only—step.
The review places considerable emphasis on diet and lifestyle as part of LPRD management. In one study the authors discuss, 74% of participants reported significant symptom improvement six weeks after dietary intervention, though the success rate was 54% at three months. Research has also linked reflux-promoting foods and beverages with worse reflux patterns during objective monitoring.
That makes lifestyle changes an important foundation. Depending on the individual, that may include paying attention to meal timing, portion size, foods that consistently trigger symptoms, alcohol intake, sleep, weight, stress, and other factors that influence reflux.
When additional treatment is needed, barrier-forming therapies such as alginates offer another option—particularly as researchers learn more about non-acid and alkaline reflux.
And acid-suppressing medication still has an important role for the right patient, particularly when testing suggests significant acid reflux or when GERD is also present.
The goal shouldn't be to declare one treatment universally “best.” It's to match the treatment to what is actually driving the reflux.
The Bigger Message: Reflux Is More Complicated Than We Used to Think
Perhaps the most important takeaway from this new review is that reflux shouldn't automatically be reduced to a single symptom—heartburn—or a single culprit—stomach acid.
LPRD can involve the throat, voice, respiratory tract, and potentially other parts of the upper aerodigestive system. Newer research increasingly describes pharyngeal reflux as predominantly gaseous and alkaline and specifically identifies alginate-based therapies as an important treatment consideration.
So if you've been dealing with persistent throat clearing, cough, voice changes, mucus, globus, or other unexplained upper-airway symptoms, reflux may be one possibility—but symptoms alone cannot tell you whether you have LPRD.
Talk with your doctor, an ENT specialist, or another clinician familiar with reflux disorders. Depending on your symptoms, further evaluation may be appropriate, especially before committing to long-term treatment.
Want to Dig Deeper?
Read the full review:
Lechien JR, Johnston N, Savarino E, et al. “Evaluation and Management of Laryngopharyngeal Reflux Disease: An Updated State of the Art Review.” Otolaryngology–Head and Neck Surgery. Published August 26, 2026. DOI: 10.1002/ohn.70413.
PubMed: https://pubmed.ncbi.nlm.nih.gov/42647076/
The paper includes RefluxRaft's VP of Education Inna A. Husain, MD, among its senior authors.
Disclaimer: This article is written by Dr. Spencer Payne, MD, RefluxRaft co-founder and a board-certified otolaryngologist, and reflects his professional perspective on the reviewed research. It is provided for general educational purposes only, is not a substitute for individualized medical advice, and should not be used to diagnose or treat any condition. Always consult your physician or an ENT specialist about your own symptoms.
