What do you think of silent reflux? I've had occasional heartburn but not after every meal.
You describe one of the most common presentations to my office. You have been clearing your throat more frequently throughout the day, have a sensation of mucous or foreign body sensation in your throat, also known as globus hystericus. The mucous is more bothersome in the morning when you wake up and you may feel an occasional sensation of sore throat and dry cough. Alternatively some people complain about a tickle in the throat or an itch. You may notice you are clearing your throat more frequently after a large meal or shortly after eating fatty food, you may be coughing after spicy food or in relation to acidic foods. The heartburn is a dead giveaway although it does not necessarily need to be present.
An examination by a primary medical care physician, an allergist, a pulmonologist or other specialists may not reveal any cause despite extensive testing including stethoscope ausculatation of the lungs, blood laboratory testing, throat cultures, strep tests, allergy testing, breath testing, chest x-rays and other diagnostic means. Empirical treatments with inhalers, nasal sprays, antihistamines, steroid medications, antibiotic regimens, throat gargles and lozenges follow with little relief.
It is important to consider, in light of your symptoms, "silent reflux" or laryngopharyngeal reflux. Food or liquids that are swallowed travel through the esophagus and into the stomach where acids and enzymes help digestion. Each end of the esophagus has a sphincter, a ring of muscle, that helps keep the acidic contents of the stomach in the stomach or out of the throat. When these rings of muscle do not work properly, you may get heartburn or gastroesophageal reflux (GER). Sometimes, acidic stomach contents will reflux all the way up the esophagus, past the ring of muscle at the top (upper esophageal sphincter or UES), and into the throat. When this happens, acidic material contacts the sensitive tissue at back of the throat and even the back of the nasal airway. This is known as laryngopharyngeal reflux or LPR. LPR causes a relatively rapid ejection of the gastric contents that often does not elicit any heartburn at all. Two general consequences of contact of gastric juices with the throat may occur. The first is the direct effect of the acidic content of the stomach on the relatively unprotected mucosal lining of the throat which causes an initial irritation. This starts off a cough, throat clearing and mucous sensation and increased mucous production in the throat. The second event is the coating of the throat with an enzyme normally found inside the stomach called pepsin. This enzyme helps us to digest proteins such as meat and fish and is normally active in relatively acidic environments. The next time you ingest an acid such as tomatoes, onions, mint, caffeinated products, carbonated products, citrus, smoking or alcohol, the activation of pepsin by these acids is going to prompt digestion of protein. However, the only protein in your throat is not fish or a piece of steak but unfortunately the "meat" of your throat (its lining). Now, let's not be overly dramatic, it isn't like you are going to disappear and self digest but on a microscopic and macroscopic level there is a definite injury to the lining of the throat. This prompts a sensation of burning, more severe itching or scratchiness of the throat and occasionally the sensation of "knives" cutting the throat (often quoted patient complaint).
The diagnosis of LPR is made by an Ear Nose and Throat doctor with a small flexible camera that slides into the throat to confirm the injury by the acid to the lining of the throat. The treatment for LPR includes a diet that temporarily eliminates or greatly reduces acidic factors and treatment with medications that lower the acidity in the stomach.