Reflux and the Voice

Acid reflux, GERD, LPR, heartburn… when stomach contents regurgitate/go backward, we call it by many names. Reflux is the scapegoat for many throat symptoms. Singers, in particular, are prone to misdiagnosis when inadequate exams fail to reveal the true cause of voice symptoms. In these cases, reflux becomes the convenient diagnosis because a prescription can be offered and the patient sent on their way.

While infrequent, reflux may cause of voice symptoms, making it an important entity to understand and treat.

What is acid reflux?

Acid reflux occurs when stomach acid travels back up the esophagus and possibly into the throat.

There are two broad types:

Gastroesophageal reflux disease (GERD): stomach acid refluxes into the esophagus, causing:

• classic heartburn

• belching

• chest discomfort

• indigestion

  GERD is thought to be due to lower esophageal sphincter dysfunction and occurs when recumbent, or lying down.

Laryngopharyngeal reflux (LPR): stomach acid refluxes into the esophagus and further up into the throat, causing:

• atypical symptoms such as hoarseness

• throat clearing

• chronic cough

• acid brash (the taste of acid in the mouth),

• globus (the sensation of something being stuck in the throat)

  LPR is often called silent reflux because symptoms are not classical reflux symptoms and so they may not be perceived to be reflux (1). LPR is thought to be due to upper esophageal sphincter dysfunction, occurring when upright during periods of physical exertion (4).

What does acid reflux look like?

Diagnosis of acid reflux based on scope appearance alone is not advised. There is significant overdiagnosis when a scope is used to diagnose reflux. However, when the scope is scored according to the Reflux Finding Score and combined with the Reflux Symptom Index, there is more reliability of diagnosis. Findings that are scored on stroboscopy include (2):

• swelling below the vocal folds (subglottic edema)

• swelling on the sides of the vocal folds (ventricular obliteration)

• redness of the arytenoid cartilages or entire larynx

• swelling of the vocal folds (vocal fold edema)

• diffuse redness of the larynx

• swelling in the back of the larynx (posterior commissure hypertrophy)

• granuloma

• thick mucous

Do I need to treat my acid reflux?

It’s true that the symptoms themselves may be tolerable. Others find easy treatments like antacids can control their symptoms and keep them away from the doctor.

However, it is important to understand that:

• Reflux causes more serious problems - unmanaged reflux can lead to Barrett’s esophagus, a precancerous condition of the esophagus, in around 5% of reflux patients.

• Tums and other over-the-counter antacids should not be taken daily and do not prevent complications such as Barrett’s

• Chronic uncontrolled reflux can lead to permanent vocal injury

So it’s probably best to take the prescribed medications for reflux?

Not necessarily. Numerous reviews have failed to definitively connect symptoms of LPR to a reflux diagnosis, especially when there are no esophageal symptoms. There are still no clear diagnostic criteria and there is a significant placebo effect to treatment. Treatment comes with risks as long term medication has been shown to affect bone, heart and brain health. Medications should be used cautiously and for a finite period of time (3).

What about professional voice users?

Singers, actors, voice actors, teachers and others who rely on their voice for a living are particularly vulnerable to minor vocal anomalies. Control of reflux is critical in these patients. However, because medical treatment is not curative, it is important to partner with a laryngologist to find a long-term strategy that does not require lifelong medication.

Lifestyle changes and diet modifications are extremely effective at managing acid reflux. Should these fail, medication may be helpful but should not be long-term and not indefinitely without referral to a gastroenterologist for evaluation of causes and better solutions.

References:

1. Koufman JA, Aviv JE, Casiano RR, Shaw GY. Laryngopharyngeal reflux: position statement of the committee on speech, voice, and swallowing disorders of the American Academy of Otolaryngology-Head and Neck Surgery. Otolaryngol Head Neck Surg 2002; 127:32.

2. Koufman JA. The otolaryngologic manifestations of gastroesophageal reflux disease (GERD): a clinical investigation of 225 patients using ambulatory 24-hour pH monitoring and an experimental investigation of the role of acid and pepsin in the development of laryngeal injury. Laryngoscope 1991; 101:1.

3. Deschler, Daniel G. Laryngopharyngeal reflux. UpToDate

4. Sivarao DV, Goyal RK. Functional anatomy and physiology of the upper esophageal sphincter. Am J Med 2000; 108 Suppl 4a:27S.

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