Gastroesophageal reflux disease, or GERD, is the recurring movement of stomach acid from the stomach back up into the esophagus (Gaynor, 1991). Stomach acid in the esophagus may cause heartburn or even chest pain; however, not all individuals will experience heartburn as the esophagus is capable of withstanding a certain amount of acid exposure. On the other hand, the throat and larynx (voicebox) are not meant to withstand any exposure to acid. If acid actually refluxes into the lungs, chronic cough and pulmonary conditions can result, such as pneumonia or bronchitis. View brochure.
Acid reflux into the larynx and throat is often referred to as "laryngopharyngeal reflux," or LPR. Symptoms of acid reflux into the larynx may include laryngitis, hoarseness, sensation of a lump in the throat, post-nasal drip, chronic throat clearing, excessive throat mucous, sore throat, cough, laryngospasm (spasm of the throat), and/ or throat pain (Gaynor, 2000). With particular regard to singers and professional voice users, other symptoms may include increased time necessary to achieve adequate vocal warm-up, restricted vocal tone placement, and decreased pitch range (Ross, Noordzji, & Woo, 1998).
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Understanding how acid reflux occurs is crucial in understanding how to avoid it. At the end of the esophagus is a tight muscle, known as the "lower esophageal sphincter," or LES. This muscle is intended to relax only as food passes from the esophagus into the stomach. Reflux can occur when the pressure or tightness of this muscle is decreased. Certain substances and behaviors are linked to the lowering of pressure of the LES. According to Gaynor (1991), diets high in fat and carbohydrates, alcohol consumption, and the use of tobacco products may all result in a susceptibility to reflux. Carminatives (peppermint and spearmint) may also decrease LES pressure; therefore, conservative use of mint-flavored gums and candies may be well-advised for individuals with reflux.
In the work of Wong, Hanson, Waring, & Shaw (2000), acid reflux was often found to occur with belching or when lying down after meals. To avoid this risk, individuals suffering from acid reflux should avoid carbonated beverages, which lead to belching, and should avoid eating two hours before lying down. Individuals with acid reflux may also have delayed emptying of the stomach in the lower intestinal tract, leaving increased amounts of food in the stomach. The more food there is in the stomach, the more time will be needed to allow for gastric emptying, and the higher the potential for more acid to be refluxed (Gaynor, 1991). To address this, it is often recommended that one have several small meals throughout the day rather than three large meals.
Certain behaviors also linked to lowered LES pressure include increased intra-abdominal pressure and bending over, creating an increased possibility for reflux (Gaynor, 1991). Forceful abdominal breathing during singing and strenuous workouts (which often involve bending over) can each contribute to lowered LES pressure. Since certain types of breathing and stretching both contribute to positive vocal use, singers and professional speakers suffering from GERD might discuss with their physician the merits of taking antacids prior to performances and/or physical workouts to neutralize any acid that might be refluxed.
Acid reflux into the larynx occurs when acid travels the length of the esophgus and spills over into the larynx. Any acidic irritation to the larynx may result in a hoarse voice. As the vocal folds begin to swell from acidic irritation, their normal vibration is disrupted. Even small amounts of exposure to acid may be related to significant laryngeal damage.
This disruption in the vibratory behavior of the vocal folds will often produce a change in the singing or speaking voice. When a singer or speaker encounters an undesirable vocal sound, the first impulse is to compensate by unknowingly changing the way in which one is singing or speaking. If the negative vocal results of acid reflux are addressed by a compensatory change in vocal technique, functionally abusive vocal behaviors often develop and can exacerbate the original symptoms through excessive muscular tension or even contribute to the development of vocal fold pathologies. For more detailed information on compensatory vocal behaviors, see an article by Dr. Jamie Koufman and Dr. Peter Belafsky entitled The Demise of Behavioral Voice Disorders.
Reflux of acid into the larynx can have a detrimental effect on the voice for several reasons, as mentioned above. One unusual phenomenon has been observed whereby irritation found only in the lower esophagus can stimulate abnormal muscular contractions in the larynx such as coughing or throat clearing via shared nerved impulses between the esophagus and the larynx (Gaynor, 1991; Shaw & Searl, 1997; Wong, Hanson, Waring, & Shaw, 2000). As a result, individuals with acid reflux may have a persistent cough in the absence of any direct contact between stomach acid and the larynx. Persistent coughing can lead to vocal fold lesions, which in turn will negatively affect vocal quality and performance.
Individuals reflux stomach acid as a result of several factors, including hiatus hernia (malfunction of the stomach valve), obesity (being overweight), and poor eating habits. Poor eating habits, which can make reflux worse, include night eating, overeating, and consuming food or drinks that promote stomach acid production, such as spicy, fatty, or fried foods, acidic foods (tomato sauce, orange juice), soda, coffee, tea, chocolate, mints, and alcohol. In addition, using tobacco products in any form promotes stomach acid production.
To reduce the likelihood of reflux, and to improve your condition, you may adhere to the following guidelines:
- No eating or drinking within three hours of bedtime or lying down to rest. This includes lying down anytime, such as an afternoon nap. Individuals suffering from reflux may have delayed emptying of the stomach in the lower intestinal tract, leaving increased amounts of food in the stomach. The more food there is in the stomach, the higher the potential for more acid to be refluxed (Gaynor, 1991). As a result, added time will be needed to allow for gastric emptying. If circumstances dictate that one must eat late, the lighter and lower in fat the food, the quicker the stomach will empty into the intestinal tract.
- Avoid overeating. Overfilling the stomach increases the likelihood of reflux. It is better to eat several small meals each day than to eat one or two big meals.
- Avoid intra-abdominal pressure. Avoid tight-fitting clothing, bending over, or straining after eating (especially working out and lifting weights).
- Reduce your intake of foods that increase stomach acid production. These include fatty, fried, spicy, or acidic foods, chocolate, caffeine, carbonated beverages, peppermint/ spearmint, and alcohol.
- Elevate the head of your bed. Place cinder blocks under the legs at the head of your bed. This will put the bed at an incline of at least 5 inches.
- Lose weight. You should lose weight if you are overweight; excess weight puts pressure on gastric contents.
- Stop the use of any tobacco products. Good for you all around.
- Take your medication. You may be placed on a medication to control your acid production. It is important to take these medicines as instructed; however, it has been shown that the medications most commonly prescribed for acid reflux, called proton pump inhibitors, are most effective if taken 30 - 60 minutes prior to your most substantial meal (usually dinner).
- Use over-the-counter antacids. Over-the-counter antacids may be appropriate, especially if you will be singing or eating close to bedtime. If you are advised to take antacids, chewable antacids such as Rolaids and Tums are not recommended because they do not neutralize enough stomach acid to be effective. You may add a medication called an H2 blocker to your daily routine, such as Zantac or Pepcid, before singing or exercising and before bed. You may also use liquid antacids such as Maalox, Mylanta, Geluscil, Amphogel, or Gaviscon. Take these as instructed.
- Chew your gum! New research from Great Britain shows post-meal gum chewing appeared to reduce acid in the esophagus and quell heartburn symptoms among people with chronic reflux problems. Why does it work? Gum stimulates saliva production, which theoretically works to neutralize acid remaining in the larynx and esophagus.
- Sleep on your left side. The esophagus enters the stomach on your right side. Sleeping on your left side may help to prevent any food remaining in your stomach from pressing on the opening to the esophagus, which could cause reflux.
In summary, acid reflux affects many voice users, some of whom may be unaware that the source of their vocal difficulty is medical and can be addressed with the options listed above. If you think you may suffer from acid reflux, there is no danger in following the behavioral and dietary guidelines above, but a visit to a qualified medical professional is the only means of securing an accurate diagnosis. Some physicians who do not specialize in voice disorders may be unaware of the relationship between acid reflux and hoarseness, and the symptoms of acid reflux may be easily attributed to other illnesses or poor vocal techniques. Be sure to question your medical professional to be certain that the possible diagnosis of acid reflux is not overlooked.
Gaynor E.B. (1991). Otolaryngologic manifestations of gastroesophageal reflux. American Journal of Gastroenterology, 86(7), 801-808.
Gaynor, E.B. (2000). Laryngeal complications of GERD. Journal of Clinical Gastroenterology, 30(3 Suppl), S31-34.
Ross, J.A., Noordzji, J.P., & Woo, P. (1998). Voice disorders in patients with suspected laryngo-pharyngeal reflux disease. Journal of Voice, 12(1), 84-88.
Shaw, G.Y. & Searl, J.P. (1997). Laryngeal manifestations of gastroesophageal reflux before and after treatment with omeprazole. Southern Medical Journal, 90(11), 1115-1122.
Wong, R.K., Hanson, D.G., Waring, P.J., & Shaw, G. (2000). ENT manifestations of gastroesophageal reflux.
American Journal of Gastroenterology, 95(8 Suppl), S15-22.