A patient presented with a chronic cough and throat clearing but without the heartburn or regurgitation that might otherwise suggest a diagnosis of gastroesophageal reflux disease (GERD).

This scenario describes what could be silent reflux, also known as laryngopharyngeal reflux (LPR), a somewhat tricky clinical challenge, but one that can be navigated with the right tests and treatment decisions, said Michael F. Vaezi, MD, PhD, in presenting on the issue at Digestive Disease Week (DDW) 2026.

“If you’re a gastroenterologist or an advanced practice provider, these patients are very common,” said Vaezi, a professor of medicine and otolaryngology and associate chief and clinical director of the Division of Gastroenterology, Hepatology and Nutrition at Vanderbilt University Medical Center in Nashville, Tennessee.

“In addition to the cough and throat clearing, they will have no heartburn or regurgitation — that’s where the ‘silent’ part comes in,” he said.

In addition, the typical patient will have been unresponsive to therapy, he said. By the time they are referred to a specialist, they may in fact be on multiple medications, despite having no improvement in symptoms.

“The patient is perhaps on twice-per-day therapy, H2 receptor antagonists at night and [other drugs], and they’re still not better, even though all of that has been piled on,” said Vaezi.

“So the first message to physicians is — don’t pile on,” he told meeting attendees.

Appropriate Testing

Instead, start taking steps to determine whether the patient truly has reflux or not, keeping in mind that, in silent reflux, endoscopic assessments for esophageal acid exposure will likely be normal.

While such results can be perplexing to the patient and physician alike, they can be a first step in helping to rule out some of the more concerning possibilities, Vaezi said.

“Patients may have been told that if they don’t control the symptoms they may get throat cancer,” or other serious concerns, he noted.

“Endoscopy is helpful because it tells you what it isn’t,” he said. “You can reassure the patient that it’s not esophagitis and it’s not esophageal cancer.”

Other options for testing include the salivary pepsin assay, however, Vaezi noted that even among patients with severe esophagitis, the sensitivity is not impressive, at only about 55%.

Mucosal integrity testing, measuring electrical impedance along the esophagus, is “something we do at Vanderbilt, as it essentially shows you a pattern of reflux,” he said.

While longer-term pH monitoring can provide objective data on acid exposure in patients who had normal endoscopy results yet are refractory to proton pump inhibitor (PPI) therapy, the decision of whether patients should remain on or go off of therapy during testing should be determined by the pretest probability of reflux, as described in a 2018 paper, by Vaezi and colleagues.

Few Patients Improve With Surgery

Even when patients are found to have reflux, however, the question remains of whether the reflux is causing the chronic cough or extraesophageal symptoms, and surgical treatment should still be withheld, he noted.

Vaezi cited a previous randomized trial that he and his colleagues conducted, involving 72 patients with suspected GERD-related laryngeal symptoms who were not responsive to therapy and had continued laryngeal inflammation with normalized esophageal acid exposure.

All patients were offered laparoscopic Nissen fundoplication surgery. The results showed that only 1 of 10 patients who received the surgery had improvement in laryngeal symptoms at 1 year; likewise, the rate was only 1 of 15 in the control group of patients who continued only on medical therapy.

“The patients who received surgery weren’t any better, so don’t send them to surgery,” Vaezi said. “The one thing you don’t want to do is undergo surgery for reflux when reflux isn’t the cause,” he added.

Other Causes, Other Treatments

Ultimately, Vaezi suggested an algorithm for several courses of action in such patients, included in a paper he and his colleagues published on LPR and functional laryngeal disorder.

For instance, “if you have someone with extraesophageal symptoms and it’s ‘silent,’ ie, they don’t have concomitant heartburn, take them off of therapy and look for abnormality — if their pH is [normal], that’s great,” he said.

“If it’s abnormal, and they’re not responding to PPI therapy, then you should be looking for [other potential causes], such as a large hiatal hernia and mechanical defect, or esophagitis stage B, C, or D,” said Vaezi.

“Furthermore, you should be looking for regurgitation as a concomitant symptom before you even entertain the idea of any endoscopic or surgical intervention.”

If the patient continues to have coughing spells or sore throat and has resolved heartburn but continues to regurgitate, then “I would say let’s send that patient to surgery,” he added.

“But keep in mind that even in this population, the likelihood of response to surgical intervention is only 50% regarding their extraesophageal symptoms.”

Of note, “patients will sometimes ask for surgery” if they are not getting better, “but we have to be careful about giving into this since they likely will not respond,” Vaezi told Medscape Medical News.

“Sometimes neuromodulation is appropriate once all other causes are ruled out,” he added.

Vaezi’s disclosures included relationships with Phathom Pharmaceuticals, Diversatek, and Sanofi.