Sam Cansfield was at her desk, drinking coffee, when a sudden, crushing pressure began building in her chest.
The fit and healthy 54-year-old was taken aback, but because the sensation lasted only a short time, she initially dismissed it.
Over the following two weeks, however, the strange episodes kept returning. Sam also developed a tingling feeling in her throat and a runny nose, despite having no cold.
‘It was such an unusual sensation and I had no idea what was causing it,’ Sam recalls.
At times, she felt as though there was a lump in her throat and occasionally experienced the frightening sensation that she was choking.
After three weeks, Sam, who works in property, visited her doctor. Suspecting a possible heart-rhythm problem, the doctor referred her for an electrocardiogram.
Fit and healthy 54-year-old Sam Cansfield developed a tingling throat and a runny nose without having a cold
The results were clear, and no further tests were offered.
‘By then I was extremely worried because nobody seemed to know what was wrong,’ says Sam.
‘Meanwhile, the pressure in my chest, the runny nose and the strange creeping sensation in my throat continued to worsen.
‘The symptoms became more noticeable after I ate and whenever I drank coffee. But there was always some degree of them present.’
Fearful that something serious had been missed, Sam arranged an online consultation with a private doctor in November 2020. The doctor identified the condition as a type of reflux, which surprised Sam because, as she explains, ‘I didn’t have the usual reflux symptoms’.
There was an explanation: Sam was not experiencing ordinary reflux.
Reflux typically occurs when acidic stomach contents flow back into the food pipe, causing symptoms such as heartburn — a burning feeling in the chest — and nausea. Sam, however, had what is known as silent reflux.
Also known as laryngopharyngeal reflux, or LPR, the condition can affect the throat, nose and chest. Symptoms may include coughing, a sore throat, frequent throat-clearing or the sensation of a lump in the throat.
Like other forms of reflux, silent reflux begins when the valve between the stomach and the lower end of the oesophagus — the food pipe — becomes weakened. This allows stomach acid and other contents to escape upwards.
Possible risk factors include being overweight, which can place additional pressure on the stomach valve, as well as smoking, a hiatus hernia — when part of the stomach pushes into the chest — stress and anxiety.
Diet may also play a role. Coffee, tomatoes, alcohol, chocolate and fatty or spicy foods can encourage excess stomach-acid production and cause the valve to relax.
However, silent reflux can sometimes develop without any clear cause.
Experts do not yet fully understand why some people develop these less obvious symptoms, while others experience the classic burning sensation associated with heartburn.
One theory is that irritating substances escape from the stomach suspended in a spray, rather than the rush of liquid acid which is usually behind heartburn, says Nick Boyle, a consultant upper gastrointestinal surgeon and medical director of the Reflux UK, a specialist private clinic with centers across the UK.
This spray can travel up the esophagus and reach the throat, voice box, the back of the mouth – and even up to the sinuses behind the nose to create the wide range of symptoms, says Mr Boyle.
Some patients develop a husky or weak voice as the acid irritates their voice box, or some suffer sinus problems, a streaming nose and a nasty taste in their mouth.
As the stomach spray can be inhaled into the lungs, in some cases the condition can lead to persistent chest infections.
‘It is called silent reflux as it doesn’t come with heartburn, but I have always thought it is not a good name,’ says Mr Boyle.
‘A lot of people have these symptoms and it is not silent – it troubles them a lot.’
While one in five people in the US has some form of reflux, according to the American Medical Association, tracking those who suffer from silent reflux can be more difficult.
However a UK study of almost 380 randomly selected people, published in the European Archives of Oto-Rhino-Laryngology in 2012, found one in three had symptoms of silent reflux.
The problem is that, in the absence of heartburn, many people with silent reflux struggle for years without a diagnosis, says Mr Boyle.
Dr Rehan Haidry, a consultant gastroenterologist at the private Cleveland Clinic in London, says that about 10 per cent of his reflux patients have the silent form and some of those will have been told wrongly that they had asthma.
But a prompt diagnosis is important as any form of reflux raises the risk of Barrett’s esophagus, where the cells in the lining of the esophagus undergo change as a result of the constant exposure to acid.
Researchers estimate around five percent of adults in the US have Barrett’s esophagus, which can develop into cancer, according to the National Institutes of Health.
Reflux is often diagnosed simply by a doctor taking a history of symptoms, but if the diagnosis is in doubt then some may be referred for a gastroscopy, where a small camera is put down the throat to check the esophagus and stomach.
If silent reflux is suspected, then another test that may be carried out involves a small capsule being inserted into the esophagus (via a tiny tube, called a catheter), which remain in place for 24 hours to measure pH levels, which it monitors wirelessly. Low pH could be a sign of acid.
After surgery, Sam can eat anything she wants again – and even drink coffee, which once exacerbated her symptoms
Whatever the form of reflux, treatment is the same.
It starts with lifestyle changes, such as losing weight if appropriate and taking antacids, which neutralize stomach acid to stop it irritating the esophagus lining.
Another option is alginates, which come as liquid and tablets and form a protective barrier on top of the contents of the stomach to stop it rising up into the esophagus.
Patients may also be prescribed drugs called proton pump inhibitors (PPIs), which help by reducing production of stomach acid.
However, these tend to be less effective for silent reflux as in this case it’s not just the stomach acid that is causing the problem – a number of different substances found in the stomach (including bile and pepsin, a stomach enzyme) – contribute to it.
(These substances are involved in other forms of reflux too, but they seem particularly important in LPR, for reasons not fully understood.)
‘PPIs only work for about 20 percent of people with silent reflux,’ says Mr Boyle.
‘And there is a misconception among many doctors that if PPIs don’t work then it isn’t reflux.’
If people with silent reflux don’t improve on PPIs after six weeks, then they should be stopped, says Mr Boyle.
He adds that often patients are switched to higher doses, or different PPIs – however, these are unlikely to work and could actually worsen the problem, as the drugs suppress the production of acid which can lead to an overgrowth of bacteria, called small intestinal bacterial overgrowth (SIBO), which can lead to bloating and belching – and even a worsening of the reflux.
Tests showed Sam also had excessive production of stomach acid due to triggers such as coffee.
During surgery, it was also discovered that Sam had a hernia that was weakening the valve at the top of her stomach; her stomach was pushing up into her chest.
After Sam’s diagnosis in November 2020, she tried a PPI and another type of medication which reduces acid production, called a H2-blocker, but neither worked.
She cut out tea, coffee and food high in fat and tried not to eat too close to bedtime and slept sitting up, supported by pillows, to stop the reflux while she slept.
‘My symptoms, including the chest pressure and the runny nose, continued despite everything I tried, and I was living on a diet of antacids, going through bottles and bottles of Gaviscon,’ she says.
‘I was practically drinking it for months, taking it after everything I ate.’
Risk factors include being overweight, as this can put pressure on the stomach valve, or smoking, a hernia (where part of the stomach pushes up into the chest) and suffering from stress and anxiety
As the symptoms persisted, Sam decided she needed a different approach.
‘It was just a horrible experience and I wanted it sorted out properly. So, while it felt like a big step, I decided to go ahead with surgery.’
This is usually reserved for severe cases that don’t respond to other measures.
Typically this takes the form of an operation called a fundoplication, where keyhole surgery is used to wrap the top of the stomach around the bottom of the esophagus to tighten the valve to stop stomach contents escaping.
Sam had a newer procedure carried out privately by Dr Haidry, called a transoral incisionless fundoplication, which is carried out with instruments and a camera inserted through down the throat, making it less invasive.
The esophagus is pushed into the top of the stomach which is and stitched into place. Studies show this creates a new stronger valve between the stomach and the gullet, to stop acid flowing back out, although there is a small risk of side effects such as difficulty belching and swallowing and bloating.
Other newer options for surgery include using a small band of magnets around the base of esophagus just above the stomach to strengthen the valve.
It took Sam a year to fully recover from the operation in the summer of 2021, but the effects have been transformative.
‘I don’t get symptoms any more – I can drink coffee and I can eat anything I want to,’ she says.
‘I don’t worry about going to sleep or being woken by my symptoms, and I can sleep lying down again, instead of propped up on cushions.
‘It has changed my life.’
