George Barnes, MS, CCC-SLP, BCS-S, is a board-certified speech-language pathologist with specialized expertise in swallowing and voice disorders. Known for his ability to break down complex clinical concepts in a clear and compassionate way, George brings a unique perspective to reflux—especially how it impacts the upper airway, voice, and swallowing.
In this post, George answers some of the most common questions about reflux through the lens of a swallowing specialist. From “silent reflux” to pepsin damage and globus sensation, he offers evidence-based insight into what’s really going on when reflux symptoms go beyond the burn—and how speech-language pathologists (SLPs) play a key role in helping patients find relief.
Whether you’re a clinician or someone navigating Laryngopharyngeal Reflux (LPR) yourself, this is a must-read.
Q: What is Laryngopharyngeal Reflux (LPR), and how is it different from GERD?
Answer: LPR is when stomach contents reflux into the larynx and pharynx, whereas GERD is reflux that only occurs up to the level of the esophagus. Unlike GERD, LPR often doesn't cause heartburn, giving it the spooky nickname you could easily mistake for a horror film, "The Silent Reflux." Common symptoms include hoarseness, throat clearing, globus sensation, and cough. As an SLP, these are the very patient symptoms doctors often come to us with.
The esophagus has some protection that the larynx lacks, making the acidic contents of the stomach more harmful when they pass the cricopharyngeal segment (AKA upper esophageal sphincter) and into the sensitive mucosal tissue of the upper airway. One of these protections is a water-based layer that protects tissue by forming an alkaline buffer against acid. It's like handling a hot sheet pan with thick oven mitts. Those mitts come off when the acid enters the laryngopharynx, which is the area that would need this protection the most.
Q: How does reflux affect my voice?
Answer: Reflux, especially pepsin, can irritate and damage the vocal folds. This damage can lead to:
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Hoarseness a
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Vocal fatigue
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Changes in vocal quality
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Inflammation (laryngitis)
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Vocal fold lesions
Remember that most standard reflux pharmaceuticals (I.e., Proton pump inhibitors) do not target reflux but the acidic environment of the stomach so that the reflux that does occur is not as damaging to the sensitive tissue above the level of the lower esophageal sphincter. While an important management component, especially in patients with severe reflux, this approach does not address the core issue.
Further, even non-acidic reflux can damage the upper airway's sensitive tissues, which are responsible for maintaining a healthy voice. For example, trypsin and pepsin are enzymes responsible for breaking down proteins and are present in gastric secretions no matter the stomach's pH level. You can think of them as tiny little starving critters that eat up whatever comes their way. When these enzymes make their way to the tissue of the upper airway where there isn't any food, they break down this sensitive tissue like they'd break down food. Ouch!
Q: Can reflux cause swallowing problems?
Answer: Yes! Reflux can contribute to dysphagia (difficulty swallowing). It can cause:
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A sensation of food getting stuck (i.e., Globus sensation)
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Throat discomfort or pain
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Increased throat clearing
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In severe cases, laryngospasm (spasms of the vocal folds or cords). Have you ever been peacefully sleeping, and then suddenly you were torn away from your dreams, coughing, choking, and having no idea why?
Further, in some cases of LPR, the damage done to the mucosal membrane of the upper airway can be so severe that it causes significant levels of swelling and edema, which disrupts the ability to safely and effectively push food and liquid through the pharynx and into the esophagus. Swallowing requires high levels of sensation and coordination to manipulate the bolus through the upper airway. Doing this with a swollen laryngopharynx is like trying to play the guitar with boxing gloves on. It doesn't get the job done in the same way.
Q: How is reflux diagnosed?
Answer: Diagnosis often involves a combination of:
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Medical history and symptom evaluation: For example, The Reflux Symptom Index (RSI) can be useful in screening patients who may or may not have pathological reflux.
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Laryngoscopy: A visual examination of the larynx to assess for damage to the laryngopharyngeal tissues.
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pH monitoring or impedance testing: Measures acid or non-acid reflux
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Pepsin detection in saliva: A sure sign that gastric secretions are reaching the upper airway.
Q: How can an SLP help with reflux-related voice and swallowing issues?
Answer: SLPs play a crucial role in managing these issues through:
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Voice therapy: To reduce vocal strain and improve vocal technique.
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Swallowing therapy: To improve swallowing safety and efficiency.
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Education: Guiding lifestyle and dietary modifications to manage reflux in collaboration with the gastroenterologist.
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Collaboration: Referring to appropriate interdisciplinary team members, like ENTs and gastroenterologists, to provide comprehensive care.
Q: What lifestyle changes can help manage reflux?
Answer: Key modifications include:
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Dietary changes: Avoid trigger foods like acidic, fatty, and spicy foods, caffeine, and carbonated beverages.
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Meal timing: Avoid large meals before lying down.
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Elevating the head of your bed: This can help reduce nighttime reflux.
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Weight management: Obesity can worsen reflux by adding extra weight to the abdomen, increasing abdominal pressure on the lower esophageal sphincter.
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Smoking cessation: Smoking weakens the upper esophageal sphincter (Among many other things!)
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Medications and natural alternatives: Medications may be used to reduce the acidity of stomach acids to control the amount of damage reflux causes to the esophagus and laryngopharynx. Natural alternatives, such as RefluxRaft, may be a good option for mild or moderate reflux to address the core issue and minimize the reflux that makes its way through the lower esophageal sphincter.
Q: What medications are used to treat reflux?
Answer: Common medications include:
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Proton pump inhibitors (PPIs): Reduce acid production.
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H2 receptor antagonists: These also reduce acid production but are not as widely used, given that PPIs have been proven more effective and last longer.
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Antacids: Provide temporary relief by neutralizing stomach acid.
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Alginates (e.g., RefluxRaft): Alginates provide a natural alternative to traditional medications for mild to moderate reflux. They work by forming a physical barrier above the lower esophageal sphincter to prevent acid from rising up to the sensitive tissues of the esophagus and laryngopharynx.
Q: Is surgery an option for reflux?
Answer: In some cases, surgery (like fundoplication) may be considered if other forms of medical management fail. However, it's important to weigh each patient's risks and benefits before moving forward with surgical options.
Reflux can significantly impact voice and swallowing, but proper diagnosis and management can provide relief. If you're experiencing these issues, consult your attending physician to see if you'd benefit from further assessment by a speech pathologist, ENT, and/or gastroenterologist.
About the Author
George Barnes, MS, CCC-SLP, BCS-S is a board-certified speech-language pathologist specializing in dysphagia management, with expertise in diagnostics for medically complex patients. As the co-founder of FEESible Swallow Solutions LLC and The Dysphagia Expert LLC, he is dedicated to improving patient access to high-quality dysphagia services. George is also an educator, mentor, and researcher committed to advancing the field of medical speech-language pathology.
For more from George, tap here.
Disclaimer
This article is for informational purposes only and does not replace professional medical advice. Always consult a qualified healthcare provider for individualized guidance on managing acid reflux or any other medical concerns.