Boston Singers' Resource News Bulletin, November 20, 2006

By Sarah Whitten

It is nearly impossible to watch an hour of television without seeing something to do with heartburn. If you’ve been on the moon for the last year and missed Ashley Simpson’s debacle on Saturday Night Live when the drummer in her band turned on the wrong track then you don’t know that the need for the recorded track which doubled her voice, was attributed to her problems with acid reflux. Commercials for Prilosec, Prevacid, Nexium, Zantac, Pepto-Bismal, Tums and Maalox are a regular feature on television as well. Some of the prevalence of the commercials is due to the drugs moving from prescription to over-the-counter, but acid reflux is a serious problem in our society and it can have serious vocal consequences for singers. There is also a possible link between reflux and esophageal cancer but no studies have been done yet to show whether cells in lesions in the esophagus caused by reflux actually turn into cancer.

What is acid reflux?
At the top and bottom of the esophagus there are sphincter muscles that contract strongly to keep food and acid from traveling upward. When the lower esophageal sphincter (LES) relaxes, acid can flow into the esophagus (the persistent form of this is called GERD, Gastroesophageal Reflux Disease) or it can flow all the way up the esophagus and if the upper esophageal sphincter (UES) is relaxed, acid can spill over in the larynx (this is called LPR, Laryngopharyngeal Reflux). Both conditions are considered chronic and generally require long-term care even after symptoms have been brought under control.

What causes Acid Reflux?
It is important to know that everyone experiences acid reflux. Our esophagi are built to withstand a certain number of reflux episodes every day. When the number of episodes escalates, problems arise. The tissue in the larynx is easily irritated meaning it only takes a few episodes of LPR for the voice to be affected. It takes a larger number of episodes for the esophagus to be irritated (GERD). Persistent reflux can be caused by a hiatal hernia, obesity, bad eating habits and certain behaviors such as bending over or lying down immediately after eating.

Why should singers care about Acid Reflux?
As singers our lifestyles and singing habits can put us at particular risk for reflux problems. To avoid having to eat before a performance we often eat late at night, eat on the go, running from job to job or job to rehearsals. When we sing we contract the stomach muscles, putting pressure on the LES, which is why singing on a full stomach is never a good idea.
It is possible that you have LPR or GERD and you don’t know it. Many people with GERD experience the sensation of heartburn, but those with LPR are less likely too. Dr. Jamie Koufman, a pioneer in the research of LPR, indicates that up to half of those who have LPR have no symptoms. Koufman and others believe that reflux can be an underlying factor in other voice problems like nodules and polyps. (See webpage at http://www.ucdvoice.org/demise.html for more information.)

What are the symptoms of Acid Reflux?
If you are a singer wondering if you might have a reflux problem, here are some symptoms:

* Scratchy throat/ feeling of something stuck in the throat
* Bitter taste in your mouth, especially in the morning
* Bad voice quality in the morning
* Prolonged warm up time needed for the voice
* Reduced pitch range
* Chronic throat clearing
* Sinus problems – post-nasal drip
* Chronic cough and/or sore throat

What the Doctor looks for:
To be diagnosed with acid reflux you should visit your primary care physician first. If you are a singer, you will also want to see your local laryngologist who will examine your vocal cords looking for cherry red arytenoid cartilages (located in the back of the laryngeal mechanism, where the vocal cords attach – these cartilages help to open and close the cords), and possible contact ulcers on the vocal process of the arytenoids (where the cords attach to the cartilage). In cases of extreme reflux, the skin in the back of the throat can be gray and is referred to as pachydermia, because it looks like an elephant’s skin!! The doctor may also see swelling in the vocal cords. As indicated in an earlier BSR article (http://www.bostonsingersresource.org/franco.asp), doctors rely on a visual exam to see if symptoms have resolved and the singer’s indication of any change in the quality of the voice; i.e. the effort required to produce a sound is less.

What you can do:
So, you’ve received the diagnosis. Here are some steps to help you manage your reflux:

* Lose weight if needed
* Wear clothing that is looser around the waist
* Minimize heavy lifting
* Don’t sing on a full stomach
* Eat smaller, more frequent meals
* Chew your food well – saliva has enzymes to break down food, aiding in digestion.
* Avoid eating less than three hours before bed
* Don’t lie down or bend over immediately after eating
* Don’t smoke (hopefully you don’t do this because you’re a singer!)
* Avoid alcohol, chocolate, coffee, carbonated beverages and citrus foods
* Raise the head of your bed 6 inches
* Develop coping strategies for managing/reducing stress

If you read that list and feel like you are going to spend the rest of your life eating plain toast for every meal, don’t despair. Talk with your doctor about the best approach to managing your diet.

If prescribed a medication, take it exactly as the doctor directs. There are several kinds of medications – some suppress acid production triggered by H2 receptors in the stomach. These medications allow for healing of the esophagus. Some medications inhibit the proton pumps in the stomach. These medications are generally more effective at allowing the esophagus to heal and keeping reflux in control. Be sure to talk with your doctor to evaluate what medication will work best for you in the management of your reflux. You will likely have a follow-up visit after several months so the doctor can do another visual exam of the cords and talk with you about any changes you perceive in your vocal production.

If you change your eating habits and take medicines and still don’t see a change in your reflux, the final option is to have a surgical procedure called fundoplication. This involves wrapping one part of the stomach around the lower portion of the stomach to create a tight sphincter to keep acid from traveling upward into the esophagus. As with all surgeries you will want to thoroughly weigh the risks versus benefits of the procedure.

Resources:

UC Davis Center for Voice and Swallowing:
http://www.ucdvoice.org/reflux%20therapy.html

International Foundation for Functional Gastrointestinal Disorders
http://www.aboutgerd.org/index.html

Greater Baltimore Medical Center
http://www.gbmc.org/voice/refluxchanges.cfm


Benninger, Michael et al. Vocal Arts Medicine. 1994. Thieme Medical Publishers Inc.

Coates, Valerie. “Managing Acid Reflux Without Medication.” Classical Singer (2004, November.) p.48.

Franco, Ramon A. Jr,, “Laryngopharyngeal Reflux,” UpToDate, 2006.

Jahn, Anthony. “Asthma: What Singers Need to Know.” Classical Singer. (2005, November) p. 57.

Mitrano, Melanie. “Treating Acid Reflux in the Professional Singer.” Journal of Singing (2001 March/April) Vol 57, p 3.

Verdolini, Katherine. National Center for Voice and Speech’s Guide to Vocology. 1998 National Center for Voice and Speech.