April 8, 2019
Acid reflux is often overdiagnosed and many voice disorders are generalized to or misdiagnosed for acid reflux. That being said, if and when reflux is truly present, it most certainly can have a negative impact on the voice. As an occupational voice user, it is important to educate yourself on reflux, its effects, and how you can avoid them.
Gastroesophageal reflux disease (GERD) occurs when stomach acid frequently flows back into the esophagus (food tube). The backflow of material (acid reflux) can irritate the lining of the esophagus. GERD is considered mild acid reflux that occurs at least twice per week or moderate-severe acid reflux that occurs at least once per week (Mayo Clinic). Common symptoms include: heartburn usually after eating that can be worse at night, indigestion, chest pain, difficulty swallowing (dysphagia), a sensation of a lump in the throat (called globus sensation), chronic cough, coughing in the middle of the night, changes in voice/hoarseness (dysphonia), and/or regurgitation of food or bitter taste in the mouth in general.
Laryngopharyngeal reflux (LPR) is a condition in which acid travels up the esophagus and reaches the throat (Cleveland Clinic). This is commonly termed “silent reflux” because there may be no obvious symptoms to alert you it is occurring, especially when compared to the notorious symptoms of GERD. LPR signs and symptoms include: sore throat, an irritated/swollen/red larynx (voicebox), a change in voice/hoarseness (dysphonia), consistent need to clear throat and/or increased throat clearing in general, globus sensation, worse voice in the mornings, sensation of mucus in the throat and/or feelings of post-nasal drip, dysphagia, and/or chronic cough.
The lower esophageal sphincter (LES) is a circular band of muscle around the bottom of your esophagus/at the top of your stomach that should relax when you swallow to allow food and liquid to flow into the stomach…and then it should close again. If this sphincter is weak or it abnormally relaxes, stomach contents (food, liquid, and/or acid) can flow back up into the esophagus (GERD) or even throat (LPR). Acid is supposed to be in the stomach, but not other places in our bodies. Acid is very damaging and can cause harm to the lining of the esophagus and delicate tissues of the pharynx (throat) and larynx (voicebox). The irritation causes inflammation, redness, and swelling and has many negative effects on the esophagus, pharynx, and larynx.
Reflux can be instigated by eating late at night, smoking, stress, eating/drinking certain foods or liquids (spicy, tomato-based, acidic, fatty/fried, caffeine, alcohol), eating large amounts at one time in general, being overweight, wearing tight clothes especially around the waist/stomach, singing or speaking on a full stomach, working out after eating, and/or being pregnant. Unmanaged reflux can lead to dysphonia, vocal pathologies (granulomas), narrowing of the esophagus (esophageal stricture), an open sore in the esophagus (ulcer), and even esophageal cancer.
As an occupational voice user, it is essential to prevent reflux (and the negative effects it can have on your voice) by upholding a healthy low-acid diet, avoiding reflux triggers, reducing acid intake in general, and reading up on the common signs/symptoms of reflux and recommended lifestyle modifications you can make that will prevent their occurrence. Some of these include: elevating the head of bed while sleeping, stopping intake of food/liquid at least two hours prior to bedtime, reducing the size of meals (full stomach=more pressure on the LES), adjusting to a low-acid diet, losing weight in the abdomen area (if present), reducing stress, avoiding processed foods, reducing the tightness of pants/belt, staying upright at least thirty minutes after eating, and/or considering the use of alkaline water (hydration and alkalinity is a win-win!). Even if you have no diagnosis or symptoms of reflux, it’s always a good idea to adopt some of these preventative lifestyle modifications, as their use will protect your instrument and inhibit the possibility of an “acid bath” to the voicebox.
It is also incredibly important to be aware that although you may be diagnosed with reflux almost immediately upon someone viewing your vocal folds/larynx with a scope, there may be much more to the story as to why you are experiencing dysphonia/hoarseness.
Recommended reflux-related books are Dropping Acid by Dr. Jamie Koufman and Killing Me Softly from Inside by Dr. Jonathan Aviv. See an ear, nose, and throat doctor (ENT) or gastrointestinal (GI) doctor for further evaluation if you find yourself taking medication for heartburn consistently and/or you experience any of the above symptoms.