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Singers' Warm-up
Acid reflux & voice
Winter Cold Care
At Home in Your Range
How your Voice Works
About Voice Medicine


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Acid reflux & voice


originially published in FOLKWORKS Jan-Feb. 2003,
revised 2008.

Acid reflux, and its management, are getting a lot of attention from throat doctors (and patients) these days. The vocal cords are located at the top of the airway, and are medically classified as part of the respiratory system. Acid reflux is a condition of the digestive system. So the connection between them may not be immediately clear.

Remember, though, that the mouth and throat are common to both systems; breathing and eating start out in pretty much the same place.  In fact, the larynx (voice box) serves as the switching station, actively separating the airway from the esophagus. Just as a railroad switchman adjusts the track to send one eastbound train to Chicago and another to Baltimore, the larynx stays open for breathing but closes tightly and even moves out of the way for swallowing, as the esophagus opens.  

When this coordination breaks down—such as when someone tells a joke while you have a mouthful of food—things can get scrambled. You might swallow a bit of air, or feel something "go down the wrong way." In the latter case, the larynx aggressively protects the lungs, triggering your cough reflex to get the airway clear again.

These mechanics of everyday life show how close the larynx is to the top  muscular valve of the esophagus. In fact, only a few layers of tissue separate them. This means that even small amounts of stomach acid that sneak back up the esophagus are apt to spill into the larynx, irritating the back area of the vocal cords.

On a throat exam by a laryngologist, the resulting redness, inflammation, or other tissue changes can be recognised as reflux laryngitis. The diagnosis may be also be called GERD (gastro-esophageal reflux disease) although this term should specifically mean simply that acid has come up into the esophagus. If the acid material gets all the way to the larynx, the formal term is (laryngo-pharyngeal reflux) or LPR.

Acid-related vocal inflammation can occur without any symptoms of heartburn. While some voice patients with reflux irritation report stomach discomfort, burning sensations, acidic taste in the mouth, etc.,  most do not. Yet reflux contributes to more than half of the problems I treat as a voice therapist.

Common compaints associated with reflux laryngitis include a gradual roughening of the voice that seems independent of any lingering cold or overuse. The most common symptom, after hoarseness, is the constant feeling of a lump in the throat, a feeling of thickness or ache when swallowing.

There may be a vague sense of vocal irritation so that you clear your throat more frequently. Post-nasal drip may increase, without other signs of nasal congestion, as the throat over-lubricates to try to counteract the acidic material. Sometimes a chronic, irritable cough can develop that is clearly triggered in the throat rather than in the chest.

As with any vocal inflammation, the speaking voice may become lower in pitch. Singing high notes may become difficult. But unlike other kinds of vocal changes, acid reflux often "attacks" the midrange of the voice, with cracking or gaps where you normally shift into the head register. The voice typically sounds worst in the morning—talking as well as singing—because lying down tends to increase reflux activity.

In an unfortunate double-whammy, singers seem to be at higher risk for acid reflux than the average person, because we create more vigorous pressure changes inside the midsection of the body. Reflux irritation can also make the vocal cords more vulnerable to overuse conditions such as vocal nodules.

If significant reflux is left untreated, more serious vocal problems can show up over time, such as a benign but painful sore on one or both vocal cords (granuloma). In the most extreme cases, uncontrolled reflux can contribute to laryngeal cancer. But most of the time, it is mild and easily managed, usually with a combination of medication, diet changes, and common sense. (If you have no indication of reflux, you can still benefit from these precautions.)

  • Don't eat late at night; if you have a snack after a concert sit up for a little while before going to bed so that gravity can help keep "juices" where they belong.
  • Limit how much alcohol you drink, especially late at night.
  • Pay attention to what foods seem to trigger digestive discomfort. For some people, citrus fruits and tomatoes are the cluprit. Others react to raw onion and/or garlic.
  • Hot spices like cayenne don't seem to cause reflux, but can make it worse if the condition already exists.
  • The same goes for coffee (experts disagree about decaf, and about tea.)

Some holistic health specialists deny the problem of acid reflux.  Any condition with as much hype as GERD has generated – pushed in part by pharmaceutical companies’ business needs—naturally gets a skeptical reaction in some circles. One holistic otolaryngologist I know acknowledges the condition, but treats it with digestive enzymes and probiotics.

The latest research implies that if there is no benefit from 3-6 months of treatment with the most advanced anti-reflux medications, the problem is probably not GERD. So stay in close touch with your doctor.

Good news: paying attention to what and when you eat can make a big difference. Taking care of your voice means taking care of your lifestyle in many ways. Get into good habits early and your voce will last a long time.

(c) Joanna Cazden 2008  Creative Commons LicenseThis work is licensed under a Creative Commons Attribution-Noncommercial-No Derivative Works 3.0 United States License.


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