A Surprising Sign You May Have Acid Reflux

Are you having mysterious respiratory or digestive symptoms?

Is your voice hoarse in the morning?. Stockbyte/Getty Images

If you're regularly getting any one of a variety of unexplained symptoms like coughing, post-nasal drip, or a chronic sore throat, it may have nothing to do with a cold or seasonal allergies. Surprisingly, many of these respiratory complaints can actually originate in your stomach.

It's all part of acid reflux disease, a more common problem among older adults which occurs when acid rises out of the stomach into the esophagus or food pipe.

  While the hallmark sign of reflux is the burning sensation in the chest many know (and dread) with classic heartburn, more than half of people with proven reflux get no heartburn at all.  They're stuck instead with diverse discomforts like hoarseness and a persistent cough, sometimes wrongly attributed to asthma.

How reflux is diagnosed:  Doctors do not yet have a completely definitive and accurate diagnostic test for gastroesophageal reflux, but there are other tests - such as an upper endoscopy and upper GI series of X-rays - which give evidence of the damage caused by reflux on the esophagus, stomach and duodenum (upper part of the small intestine).

Other involved procedures such as esophageal manometry can measure the pressure of muscle contractions in the esophagus, to determine whether a weak sphincter muscle between the esophagus and stomach is to blame.  The most accurate test to date is called esophageal pH monitoring, which involves having a tube inserted through the mouth or the nose into the stomach for a period of 24 hours.

  A probe measures how much acid enters the esophagus from the stomach.

  • Read more about diagnosing reflux from our Heartburn Expert

Quicker and easier - judge how you sound in the morning:   Though this is by no means a conclusive test, morning hoarseness can be a "pretty good clue" of acid reflux, according to ear, nose and throat specialist (otolaryngologist) Clark Rosen.

  As director of the University of Pittsburgh's Voice Center and chair of the American Academy of Otolaryngology Head and Neck Society's voice committee, Rosen sees his share of patients with reflux-related voice problems.

"Using the pH probe to measure acid within different areas of the esophagus is the best diagnostic test we have, but it's very involved and uncomfortable for the patient," he explains.  "We usually take a complete history instead, use our best judgement and examine the larynx or voice box.  If you're in good voice when you go to sleep, but wake up with a bad, hoarse voice - very few voice conditions other than reflux will cause that."

Rosen warns that morning hoarseness is not always due to reflux, and reflux doesn't always result in a hoarse voice upon waking.

"We have to take the patient's whole history into account, since it's not a 1:1 sure correlation in 100% of cases.  Still, it's a very good sign that reflux may be to blame."

Why morning hoarseness with reflux?  If acid is backwashing from the stomach onto the sensitive larynx, irritation and inflammation can result. This is called laryngeopharyngeal reflux disease or LPR. 

"The physiology behind this is that when you lay down, your larynx and stomach are on the same level," Rosen explains.  "If the valve between the esophagus and the stomach isn't working properly or you have a leak, then stomach contents which are often acidic can irritate the throat throughout the night.  Once you get up, gravity works in your favor to keep acid in the stomach where it belongs, and the body starts making mucus which heals the irritation over the course of the day so you sound better in the evening."

Manage the reflux, help your voice and the rest of your body too:  Depending on the severity of acid reflux, medications and even surgery can help manage your symptoms.  Simple lifestyle changes - like staying away from spicy or fatty foods, not eating within 3 or 4 hours before bedtime, eating smaller meals and not smoking - can be very effective at reducing discomfort.  If these measures help rid you of reflux symptoms, that's another sign that you may suffer from this difficult condition.


Clark Rosen. Director, University of Pittsburgh Voice Center and Professor of Otolaryngology, University of Pittsburgh. Interview conducted by phone June 9, 2014.

Gastroesophageal Reflux Disease. US National Institutes of Health Public Information Sheet. Accessed June 9, 2014.

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