Ear pain is not usually associated with reflux, though, which makes the diagnosis difficult. Doctors don’t usually think of reflux as a possible cause.
What is LPR?
The term reflux describes the rise of stomach contents into the esophagus. Gastric juice irritates the esophagus and causes symptoms such as heartburn.
LPR is a gaseous kind of reflux that rises beyond the esophagus: Into the throat and airways. LPR is also known as silent reflux because it causes unspecific symptoms such as hoarseness, sore throat, or ear pain. Many patients don’t realize that their symptoms are caused by LPR. It can take many years to receive a correct diagnosis.
How LPR causes ear pain
Together with the acidic aerosols, an enzyme from the stomach called pepsin, is carried into the throat and airways.
Pepsin plays an essential role in digestion because it breaks down proteins. The activity of pepsin depends on the pH, and for this reason, it is usually not active outside the stomach. However, the low (acidic) pH of reflux acid can activate pepsin in the throat and airways. In addition, acidic foods can reactivate pepsin.
Outside the stomach, in the throat and airways, activated pepsin continues to digest proteins. Unfortunately, the cells of the mucous membranes mainly consist of proteins. Consequently, pepsin can cause a lot of damage and resulting inflammation.
Pepsin reaches the ears through a connection between the nasal cavity and the ear, the Eustachian tube. The Eustachian tubes regulate the pressure between the ear and the nasopharyngeal zone. If you’ve ever “popped your ears” on an airplane, you’ve been equalizing pressure by forcing open the Eustachian tubes.
If pepsin reaches the ears, it causes inflammation, like in the airways. It is more difficult for pepsin to reach the ears than the airways, so ear symptoms are one of the least common LPR symptoms. Children are especially susceptible to ear pain from LPR because their Eustachian tubes are not fully developed yet and pepsin can pass through easier.
How to treat ear pain caused by LPR
To get ear pain under control, the cause (i.e., the silent reflux) has to be minimized as far as possible.
In many cases, LPR quickly improves through dietary changes. My online course on the treatment of silent reflux covers in detail how to improve LPR symptoms through nutritional adaptations.
 Megale SR, Scanavini ABA, Andrade EC, Fernandes MIM, Anselmo-Lima WT. Gastroesophageal reflux disease: Its importance in ear, nose, and throat practice. Int J Pediatr Otorhinolaryngol. 2006;70(1):81-88.
 Johnston N, Dettmar PW, Bishwokarma B, Lively MO, Koufman JA. Activity/stability of human pepsin: Implications for reflux attributed laryngeal disease. Laryngoscope 2007;117(6):1036-9.