Nasopharyngeal Reflux (NPR): Causes, Symptoms, Treatment

Nasopharyngeal reflux (NPR) is a medical diagnosis that is seldom utilized in present day – given the fact that most experts prefer the term “laryngopharyngeal reflux” (LPR) coined by Dr. Jamie Kaufman (MD).

In fact, if you search Google for the term “nasopharyngeal reflux” it asks “did you mean laryngopharyngeal reflux?”

What is nasopharyngeal reflux (NPR)?

Nasopharyngeal reflux is a highly specific type of reflux wherein the symptoms primarily affect the nasopharynx (the upper part of the throat a.k.a. pharynx – the area behind the nose).

Nasopharyngeal reflux is defined as: the retrograde entry of saliva, food, or liquid into the nasopharynx during swallowing – usually due to palate weakness or dyscoordination. (R)

Pepsin waving hello

Some experts consider the term “nasopharyngeal reflux” to be outdated – such that it should instead be classified as “laryngopharyngeal reflux” (LPR).

Others believe that nasopharyngeal reflux (NPR) is simply a less commonly used term to describe laryngopharyngeal reflux (LPR).

Others claim that nasopharyngeal reflux (NPR) is merely a specific subtype of laryngopharyngeal reflux (LPR).

Others may suggest that nasopharyngeal reflux (NPR) and laryngopharyngeal reflux (LPR) are analogous conditions that fall under the umbrella term: “extra-esophageal reflux” (reflux that occurs and/or causes symptoms above the esophagus).

Nasopharyngeal reflux (NPR) symptoms

Listed below are some of the more common symptoms associated with nasopharyngeal reflux.

Difficulty breathing through nose: Individuals with NPR may experience “airway resistance” when breathing through the nose. Even if the nose contains zero mucus – there’s usually inflammation that interferes with efficient nasal respiration.

Discolored mucus: Some individuals will report discolored mucus (e.g. blood tinged, dark green, light green, etc.) due to the fact that the sinuses can become inflamed with subsequent impaired clearance mechanisms (making individuals more prone to sinus infections).

Stuffed nose: NPR can cause stuffed nose due to a combination of intranasal mucus membrane dysfunction, altered/increased mucus production, and/or inflammation resulting from refluxed acid within the nasopharynx.

Voice changes: Nasally sounding, crackling, raspy/dry, difficulty speaking clearly, etc. Many will notice a change in their voice with NPR due to inflammation within the nasopharynx and laryngopharynx.

Bloody nose: Some individuals will develop a bloody nose due to refluxed materials damaging mucus membranes and/or interfering with normal mucus production – such that the nasal canal dries out. Blowing the nose frequently as a result of it being plugged could also cause bleeding.

Eustachian tube dysfunction: The eustachian tubes may plug up from: refluxed materials; inflammation (in response to refluxed materials); and/or mucus production (in response to inflammation). May be associated with ear “popping” or hearing fluid moving within the ears.

Burning sensation in nasopharynx: Some may notice a significant “burning sensation” within the nasopharynx or tangential areas such as the laryngopharynx. This burning is usually a result of irritation from acid exposure.

Postnasal drip: Nasopharyngeal reflux can cause postnasal drip due to increased mucus production in response to acid-related irritation in the nasopharynx.

Globus sensation: This is the feeling that something is eternally stuck in your throat and won’t go away no matter how many times you swallow. (Some refer to globus as “foreign body sensation” in the throat).

Eye problems: Dry eyes, red eyes, watery eyes, burning sensation behind eyes, blurred vision, etc.

Ear pain: Nasopharyngeal reflux can cause ear pain via inflammation (in response to acidic refluxate reaching the inner ear), mucus production, and pressure from eustachian tube dysfunction.

Sleep disturbances: A combination of intranasal inflammation, globus sensation, and esophageal swelling can interfere with respiration/oxygenation during sleep – perhaps causing/exacerbating sleep apnea, UARS, insomnia, and/or fragmented sleep.

Coughing: Some individuals will develop a throat tickle that causes them to cough chronically. The cough will usually be non-productive (such that there won’t be significant mucus as there is during an infection).

Popping, crackling, ticking sounds: Some individuals will notice popping, crackling, or “ticking” sounds from within the nose, throat, or ears – usually due to a combination of inflammation, trapped air, drainage (mucus or refluxate).

Sinusitis & sinus pressure/pain: Sinusitis simply means inflammation of the sinuses – and it can be caused by an infection, but also other things like allergies and even nasopharyngeal reflux. Sinusitis can make it difficult to breathe through the nose and may be accompanied by pressure and/or pain in specific sinuses.

Nasopharyngeal reflux treatment

Treating nasopharyngeal reflux is a similar process to treating laryngopharyngeal reflux. First you need to identify the cause(s) of the condition – and then treat appropriately.

Doctors to consult (diagnosis)

Otolaryngologist (ENT); gastroenterologist (GI doctor); allergist/immunologist.

  • Otolaryngologist: This doctor should examine your nasopharynx with a laryngoscopy to rule out things like cancer. Additionally, this doctor may order a CT scan to rule out other conditions like rhinosinusitis.
  • Gastroenterologist: This doctor will examine your gastrointestinal tract with an endoscopy – and may perform additional testing such as 24-hour manometry; barium swallow; etc.
  • Allergist/immunologist: Should perform allergy testing and rule out allergies as the cause of nasopharyngeal reflux (including food allergies).

After you’ve consulted appropriate doctors – these professionals should help you come up with a custom treatment plan based on your current health status, health history, and presenting symptom severity.

Treatments

In some cases, nasopharyngeal reflux can be significantly improved or cured with one or more treatments below. For example, select individuals with allergies causing the condition can simply eradicate/remove the allergens and symptoms resolve relatively quickly.

Another example might be someone with a damaged/weak lower esophageal sphincter (LES) allowing reflux to reach the nasopharynx. In this case, high-dose PPI therapy may decrease the acid and enable healing of both the lower esophageal sphincter and upper esophagus – such that the condition will eventually be “cured.”

Proton-pump inhibitors: Most people with nasopharyngeal reflux have acidic stomach contents (e.g. gastric acid, pepsinogens, etc.) reaching the nasopharynx. PPIs decrease stomach acidity which should help reduce the severity of symptoms.

H2 blockers: Although less potent than PPIs, H2 blockers also reduce stomach acid and are particularly effective at night. The main drawback is that tolerance to H2 blockers builds rapidly (usually in less than ~2 weeks).

Head-of-bed elevation: Some individuals only experience NPR while lying down at night during sleep. Elevating the head of the bed (6+ inches) might reverse this condition for some people.

No eating within 4 hours of bed: Eating late at night is problematic in that food is digested less efficient at night (circadian-digestive changes) and while lying down to sleep, gravity is no longer on your side to keep the food in your lower stomach. As a result, you’ll end up with more undigested food, stomach acid, and gaseous contents back-flowing up the esophagus to reach the nasopharynx.

Low acid diet: Highly acidic foods are problematic in that they increase stomach acid and may reactivate pepsinogens within the nasopharynx during consumption.

Alginate suspension: Alginate suspension formulas like Gaviscon Advance, Reflux Gourmet, etc. can be helpful in some cases when administered after each meal. How? They form a “raft” or “barrier” to protect the nasopharynx from an onslaught of refluxate (e.g. acids, pepsin, etc.).

Magaldrate: This is an antacid containing magnesium hydroxide and aluminum – both of which help neutralize stomach acids post-meal.

Small meals: Eat a series of 6-8 small meals throughout the day – spaced by about 1.5-2 hours. Each meal should be about the size of your fist (as this is the amount of food your stomach can hold at once prior to digestion).

Chewing gum: Evidence suggests this helps reduce acidity in the laryngopharynx after meals.

Allergy treatment (if necessary): In the event that an allergist detects any significant allergy – it is recommended to avoid the allergen (if possible) or treat the allergy (e.g. with allergy medications).

Avoid certain foods (if sensitive): Obviously avoid any foods to which you’re allergic. Even if you have a food “sensitivity” – this should be avoided as well (as non-IgE-mediated allergies can cause reflux conditions).

Melatonin: Pure melatonin (no additives) may be helpful for maintaining normal lower esophageal sphincter (LES) pressure at night – such as to reduce reflux during sleep.

Neuromodulators: Amitriptyline; baclofen; gabapentin/pregabalin; etc. Many people with NPR have neuropsychiatric comorbidities that may be causing and/or exacerbating the severity of NPR.

Drink only water: Regular water is non-acidic and is beneficial for most reflux conditions. Alkaline water may provide additional benefit in some cases via neutralizing/deactivating pepsinogens.

Saline nasal rinses: Arm & Hammer sodium bicarbonate saline rinse in the nose after each meal. Some may find this practice significantly reduces the severity of symptoms.

Fluticasone: May help some individuals with excessive intranasal swelling – particularly during sleep when the swelling may impair breathing.

Zero unnecessary drugs/supplements: Various drugs/supplements can affect esophageal sphincter function; esophageal sphincter pressure; and overall stomach acidity. Unless a specific drug/supplement is considered medically-necessary – it should probably be avoided.

Treat other medical conditions: Any anxiety, depression, insomnia, binge eating disorder, sinus infections, allergies, neurological conditions, etc. – all should be properly treated. This should be obvious, but it’s possible that NPR might occur secondary (as a downstream effect) to certain conditions.

Nasopharyngeal reflux (NPR) causes (Possibilities)

The causes of nasopharyngeal reflux are highly individualized and vary among those diagnosed. For one person NPR may be caused by a combination of binge eating disorder and hiatal hernia – and for another it may be caused by a sleep apnea and an esophageal motility disorder.

Esophageal sphincter dysfunction (UES/LES): Dysfunction of the esophageal sphincters (upper esophageal sphincter & lower esophageal sphincter) can cause NPR. Esophageal sphincters may lose the ability to close (e.g. acid reflux) or open (e.g. achalasia).

Esophageal sphincter damage (UES/LES): The esophageal sphincters may end up damaged due consistent acid exposure over a prolonged duration, regularly overeating/binge eating, using certain drugs/supplements, etc.

Pyloric sphincter dysfunction: Dysfunction of the pyloric sphincter (ring of smooth muscle that connects the stomach and small intestine) may contribute to NPR in some cases.

Abnormal esophageal sphincter pressure: Abnormal pressure within esophageal sphincters (UES/LES) could contribute to NPR even if there’s no evidence of esophageal sphincter dysfunction.

Autonomic nervous system dysfunction: Severe psychological stress; neurological conditions; psychiatric conditions; immune conditions; infections; etc. – can all cause autonomic nervous system dysfunction. ANS dysfunction might alter esophageal motility and sphincter function – such as to induce NPR.

Vagal nerve dysfunction: The vagus nerve is understood to stimulate gastric acid secretion and promote gastric emptying. If the vagus nerve is dysfunctional or damaged – individuals may experience a variety of GI symptoms which could lead to NPR.

Hiatal hernia: This is a hole in the diaphragm (hiatus) through which food and liquids pass from the esophagus into the stomach. Hiatal hernia effectively interferes with the lower esophageal sphincter (LES) such that there’s no longer a tight barrier to prevent acid from refluxing up into the esophagus. The larger the hiatal hernia, the more likely a person is to have GERD, LPR, and NPR.

Things that lead to the above “causes”…

  • Abnormal body fat (%) & BMI: Having an abnormally low or high body fat/BMI could increase the risk of developing reflux. High body fat and BMI can increase intra-abdominal pressure, cause transient LES relaxation, and induce hiatal hernia. Although low body fat/BMI may not be problematic – one study found low body fat/BMI is associated with upper-esophageal reflux.
  • Diet & eating patterns: High acid foods/drinks; eating a lot of calories in a short “feeding window”; and eating too many calories at night (within 2-3 hours of bed) could cause hiatal hernia and esophageal sphincter dysfunction to induce NPR.
  • Drugs, medications, supplements: Various drugs, medications, and supplements are acidic (increase stomach acid) and alter function and/or pressure of esophageal sphincters – which could lead to NPR.
  • Environmental exposures: Smoke exposure, air pollution, etc. – can interfere with mucociliary clearance within the nasopharynx and esophagus as well as cause transient esophageal sphincter relaxation to promote NPR.
  • Gastrointestinal conditions: Esophageal motility disorders; hiatal hernia; eosinophilic esophagitis; functional GI disorders; H. Pylori; SIBO; gut microbiome dysbiosis; etc. – may all cause NPR as a secondary reaction.
  • Neurological conditions: Certain neurological conditions affect autonomic nervous system (ANS) function, vagal nerve function, and esophageal motility – which could result in NPR.
  • Posture/positioning: One’s posture, particularly after eating meals, may contribute to the pathogenesis of NPR. Individuals who frequently lay down after large meals may
  • Psychiatric conditions: Anxiety disorders, binge eating disorder, depression, etc. may affect gastric acid production as well as esophageal motility, esophageal sphincter function, and esophageal sphincter pressure.
  • Sleep disorders: There’s a strong link between NPR and sleep disorders (sleep apnea & UARS) – and some researchers think that impaired respiration during these conditions could create a “suction-like effect” within the airway to increase the frequency/severity of nocturnal reflux – which could reach the nasopharynx.

Note: There’s a difference between having NPR as a primary condition (such that no other conditions are causing it) and having NPR as a secondary complication (such as from eosinophilic esophagitis).

What are the physiological reactions that occur in NPR?

When NPR occurs due to esophageal sphincter dysfunction, esophageal dysmotility, etc. – distinct physiological reactions likely occur which create “vicious circle”-type feedback loops to sustain the NPR condition.

Refluxed stomach contents: Pepsinogens (e.g. pepsin); bile acids; gastric acid; trypsinogens (e.g. trypsin); food/drink particulates; etc. reach the nasopharynx.

Inflammation & oxidative/nitrosative stress: Occurs throughout the nasopharynx and esophagus – in response to refluxed stomach contents.

Further esophageal sphincter dysfunction/weakening: Chronic untreated NPR could further exacerbate esophageal sphincter dysfunction and/or weakening.

Esophageal & nasopharyngeal damage: If untreated for a long duration, NPR could cause damage within the esophagus and nasopharynx. Over a long-term, NPR may even cause esophageal or nasopharyngeal cancers.

Microbiota dysbiosis: Evidence suggests that reflux conditions cause microbial dysbiosis within the esophagus. It’s likely that esophageal and nasopharyngeal dysbiosis occur in response to NPR. Dysbiosis may impair endogenous recovery from NPR and may promote further NPR.

Abnormal mucus production/clearance: A combination of inflammation, oxidative/nitrosative stress, esophageal damage, and microbial dysbiosis – could alter mucus production and clearance which could exacerbate damage with each subsequent nasopharyngeal reflux event.

Risk factors for developing nasopharyngeal reflux (NPR)

Included below are hypothesized risk factors for developing NPR.

  • Abnormal BMI (low or high)
  • Abdominal fat (%)
  • Alcohol intake
  • Caffeine intake
  • Carbonated beverage intake
  • Chocolate intake
  • Chronic stress
  • Hiatal hernia
  • High acid diet
  • High fat diet
  • Illicit substance use/abuse
  • Immune dysfunction
  • Infectious diseases (e.g. upper respiratory tract infection)
  • Intermittent fasting (restricted feeding windows)
  • Late-night eating (within 3 hours of sleeping)
  • Low fiber intake
  • Lying down after eating
  • Malnutrition (nutrient deficiencies)
  • Nicotine use
  • Older age
  • Overeating (caloric surplus)
  • Poor posture
  • Psychiatric disorders: Anxiety, depression, insomnia, PTSD, sleep/wake disorders
  • Sedentary lifestyle
  • Skipping breakfast
  • Sleep disorders (e.g. sleep apnea, UARS, etc.)
  • Smoking & smoke exposure (e.g. bonfires, polluted air, etc.)
  • Stomach or right side sleeping
  • Systemic inflammation & oxidative/nitrosative stress
  • Undereating (caloric deficit)
  • Vagal nerve dysfunction

Note: This is not a definitive or comprehensive list of “risk factors” for NPR.

Nasopharyngeal reflux (NPR): Research

Included below are papers in which “nasopharyngeal reflux” as a specific term was utilized. Although nasopharyngeal reflux is considered by most as being synonymous with LPR – it’s technically slightly different in that refluxate is reaching and affecting the nasopharynx (perhaps in addition to the laryngopharynx).

NPR & Aspiration (2021): Nasopharyngeal reflux seems to be more severe when NPR precedes aspiration. (R)

NPR & Eustachian tube dysfunction (2021): There is a clear reciprocal causal relationship between NPR and ETD – meaning that NPR can cause ETD and ETD can cause NPR. (R)

NPR & Barrett’s Esophagus (2020): Referral recommendations are poor among NPR patients and incidence of Barrett’s Esophagus in this population may be higher than that generally reported among GERD patients. (R)

NPR & Eustachian tube dysfunction (2014): “Eustachian tube dysfunction was more likely to be associated with a higher number of nasopharyngeal reflux events and higher reflux finding score – and may have a role in the pathogenesis of ETD.” (R)

NPR & Head-of-Bed Elevation (2012): “6 inches of head-of-bed elevation can be an effective means of treating supine NPR.” (R)

NPR & Otitis media with effusion (2011): Higher rates of nasopharyngeal reflux were detected in patients with otitis media with effusion relative to controls – but not statistically significant. (R)

NPR & Rhinosinusitis (2005): Patients with chronic rhinosinusitis after endoscopic sinus surgery have more reflux at the nasopharynx, UES, and distal esophagus – than controls. The greatest difference is in NPR, especially pH less than 5. (R)

NPR & Neonatal apnea (1981): Nasopharyngeal reflux caused neonatal apnea. (R)

Have you experienced nasopharyngeal reflux (NPR)?

  • Were you formally diagnosed by a medical doctor? (Which specific tests were conducted?)
  • What do you think caused your nasopharyngeal reflux? (Did you have any risk factors for NPR mentioned above?)
  • Did an ENT rule out other conditions (e.g. rhinosinusitis) that overlap with NPR symptoms?
  • What specific NPR symptoms did you experience (e.g. plugged nose, rhinosinusitis, discolored mucus, globus sensation, difficulty breathing, etc.)?
  • Did you effectively fix/cure your NPR? Or are you still trying to treat it? (What treatments have you found most/least effective?)
  • Do you think the term “nasopharyngeal reflux” (NPR) should be used to describe a specific subtype of “laryngopharyngeal reflux” (LPR) – or do you prefer just using the latter term (LPR)?
5/5 - (1 vote)

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