Synopsis: Millions of people who think they have allergies, asthma, and sinus problems may actually have “silent reflux” which can travel up the esophagus all the way to the throat and head. An expert discusses telltale symptoms and the dietary triggers that can cause the disorder.

Host: Nancy Benson. Guest: Dr. Jamie Koufman, Director, Voice Institute of New York, Professor of Clinical Otolaryngology, New York Medical College and author, The Chronic Cough Enigma.

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Silent Reflux

Nancy Benson: Millions of Americans have had asthma, allergies, sinusitis, a chronic cough or a scratchy throat for years. Or at least those are the disorders they think they have. Maybe they’ve even been told by their doctors that they have respiratory issues… But treatment doesn’t do any good.

Koufman:  Those patients what I say is cough, bluster and wheeze. So they make a lot of noise, they’re the ones you hear when you go to a concert just when it’s quiet and you don’t want to hear someone coughing, you do. You hear these people if they work in your office they’re always clearing their throat or making a lot of noise and you hear them before you see them. This population of patient has non-pulmonary, meaning the lung’s not the cause of chronic coughing. There’s a gazillion of these people.

Benson: That’s Dr. Jamie Koufman… director of the Voice Institute of New York, professor of clinical otolaryngology at the New York Medical College, and author of The Chronic Cough Enigma. She says there are millions of Americans who’ve gone to lung specialists for symptoms like those… only to be misdiagnosed. She says specialists can do their jobs only when what’s wrong is in their specialty.

Koufman:  If you have a bad leg, bad knee you see an orthopedist. You have a bad tooth you see a dentist. But what if you have a cough that never goes away? What if you have chronic throat clearing postnasal drip? What if you have asthma that’s not asthma, that’s not responding? What if you have sinusitis that’s no better after the sinus surgery? What if you have allergies and allergy symptoms and no one seems to make any difference even after the diagnostics and all the shots. So I think there’s a massive number of people with silent reflux with these conditions that cause non-pulmonary cough that are literally being missed by their physicians because they’re not attuned to it.

Benson: Wait. Reflux can cause a cough, and symptoms like allergies and asthma?

Koufman:  Four out of five people in America with a diagnosis of asthma don’t have it. Ask yourself the question — do you have more trouble getting air in or out? If you say in, you do not have asthma. End of story. End of discussion.  

Benson: But how does reflux do that? Isn’t reflux a backup of stomach acid? Koufman says yes. But acid can go a lot farther up than most people realize, all the way up the esophagus into the throat, without causing what you probably think of as typical reflux symptoms. That’s why this kind of malady is called “silent reflux.”

Koufman:  The assumption was that reflux was heartburn and heartburn was reflux. And you know heartburn. Everyone’s seen it on TV — people bursting into flames, clutching their chest. Here’s the anatomy for it – you have the stomach that makes acid and a very corrosive enzyme called pepsin that causes a lot of tissue damage and possibly cancer as well. We have the esophagus, which has two valves; it is the tube that connects the throat and the stomach. The bottom valve is called the lower esophageal sphincter. The upper valve where the throat meets the esophagus is the upper esophageal sphincter. Then you have the throat. The throat contains both the breathing passages and the swallowing passages. There’s a very clever bunch of physiologic switches that open and close the right thing so you breathe in the right hole and swallow down the other. The problem is that reflux in the stomach comes into all those places.

Benson: And when it does, it can corrode the throat and voice box, prompting chronic coughing and throat clearing. Koufman says silent reflux has cut short the careers of many professional singers — even opera stars. And if the damage goes on long enough, it can lead to esophageal cancer, which has risen markedly in the last couple of decades. Koufman says lifestyle is to blame…starting with the acid-laden American diet.

Koufman:  It has to do with nutrition. It has to do with diet. Has to do with consumption of soft drinks, a major risk factor, and it has to do with late night eating. People will come in with stories and they’ll say, “You know, I never had heartburn, but now if I eat”…and they go whatever it is, “it’s a trigger food for me.” And by the way, the biggest foods are, and that’s not for everybody, but across the board, chocolate, coffee, white wine, nuts, especially cashews and macadamia nuts. No question. Onions, tomatoes, garlic and pepper affect at least half the population, green peppers more than red peppers. Anything can be a trigger.

Benson: But after the trigger occurs, most people don’t feel it when reflux does its worst damage — at night.

Koufman:  We work longer hours. Maybe we work out after we leave work, go to the gym, take a swim, take a jog, and then we get home, maybe we feed the kids. So what happens is Americans get home typically later. What are they? Hungry and tired. And so they eat and then they lie on the sofa or fall asleep with food in their stomach and they reflux all night. Reflux all night is the biggest enemy we face. Reflux all night goes up into the sinuses. Reflux is not a chronic disease; it’s a vicious cycle. So the more you reflux, the worse your valves work that are supposed to keep stuff from coming up. The more you reflux, the worse your esophageal function. So we see snoring narrowing of the pharynx, sleep apnea, really narrowing of the pharynx, sinusitis and asthma with inflammation in the back of the nose up in the nasal pharynx. We see these anathema-like syndromes, shortness of breath.

Benson: Koufman says almost every patient she sees has already been put on a proton pump inhibitor like Prilosec. But she says you can’t expect to just take a pill and eat whatever you want. If the problem is nutritional… the solution is, too.

Koufman:  The first thing we do is put them on a two-week detox of low acid, low-fat diet. In a nutshell it’s melons and bananas, your only fruit, poultry and fish essentially is your only meat. All the grains are pretty much fine. All the vegetables accept no onions, garlic, tomatoes or peppers. Nothing out of a bottle except water. We recommend alkaline water. Alkane water means ph8 or higher. And then finally comes the kicker – no eating within four hours of bed. No alcohol. If you want something in the evening because you are a little hungry at 10 o’clock have a little pot of chamomile tea. Two-week detox strict. Then start introducing things back slowly so you can identify which foods and problem foods you may have.

Benson: Koufman also advises that patients get their esophagus examined carefully for cancer and precancerous conditions. She admits it takes a lot of effort on the patient’s part to heal from silent reflux. But it can help people get over a lot of misery that they thought were asthma and allergies. You can find out more about Dr. Jamie Koufman’s book, The Chronic Cough Enigma, through her clinic’s website Our production director is Sean Waldron. I’m Nancy Benson.

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