Me: Hi, welcome to voice therapy!
Client: I think my ENT is crazy.
Me: Why is that?
Client: She says my voice problems are coming from acid reflux, which is nuts. I don’t even have heartburn!
This scene has played out in my work enough that it’s time for a post explaining the sometimes mysterious relationship between VOICE and REFLUX.
What is acid reflux anyway?
Acid reflux occurs when stomach acid backs up into the esophagus (the swallowing tube). We typically think of GERD (gastroesophageal reflux disease) when we hear this term, as that is the common variety that results in heartburn, indigestion, upset stomach and the like.
This is not the kind of reflux that affects the voice.
There is a second type of reflux, known as LPR (laryngopharyngeal reflux), often referred to as “silent reflux” because there are no obvious symptoms associated with it. Except voice problems.
How does reflux affect the voice?
For people with LPR, stomach acid backs up into the esophagus (starting out the same as GERD), but instead of staying in the esophagus, it keeps backing up, and it makes it all the way out the top valve of the esophagus.
When the acid comes out the top opening to the esophagus, it lands on the vocal cords. They are not designed to have acid spilled on them, so it can irritate them.
Symptoms may include:
Globus sensation (feeling of a lump in your throat)
Loss of vocal range
Increased vocal effort/fatigue/strain while talking or singing
Subtle changes in voice quality
Decreased vocal stamina (gets tired faster)
Difficulty projecting the voice
Sharp pain in the larynx
Bitter taste at back of throat
Voice extra slow to warm up in the morning
But I don’t feel anything, including heartburn!
Because reflux does happen in a human body, the clever esophagus is lined with protective cells that can tolerate a small amount of acid without feeling discomfort. So a small amount of reflux will not be perceived. The larynx, however, has no such protection and can get irritated.
A couple drops of stomach acid reaching the vocal cords is enough to impact the voice. That is not enough to cause heartburns or stomach symptoms.
As an example, if you put a drop of hot sauce on the back of your hand, you won’t feel a burn. But if you put in in your eyeball, you will. Different tissues have different sensitivities.
What causes acid reflux?
The short answer is that it is different for everyone. That said, things that commonly contribute are:
Coffee (even decaf)
Foods that are fatty, spicy, or acidic (including citrus or tomato)
Tight waist bands
Exercising or singing right after eating
Eating large amounts all at once
This is a bummer of a list for most people, but take heart.
How do I know if I have LPR, and what do I do about it?
If you have vocal symptoms that you can’t explain and think LPR might be the culprit, you can see an ENT (ear, nose and throat doctor) who specializes in voice. They make the diagnosis and discuss treatment options.
As I am not a physician, discussion of prescription medication is outside my scope, other than to say that it exists and can be discussed with your ENT or primary care physician.
Some people prefer to work with a nutritionist to delve deeper into their specific issues, and discuss probiotics and other non-pharmacological possibilities. Additionally, some folks choose to do an elimination diet, in which they remove everything that could possibly be causing reflux, and see if symptoms improve. Then they can add things back in one at a time to see what causes symptoms to return.
Because LPR has been linked to more serious diseases, it’s a good idea to manage it if it presents itself in your life.
In terms of voice, sometimes removing the irritant (by treating the LPR) causes the voice to return to normal.
In other cases, however, the voice has already habituated to the problem, and has developed some habits that don’t automatically revert once the stimulus is removed. These people benefit from some voice therapy.
If you have reflux-related voice changes and would like some guidance getting your voice back on track, schedule a session and I can help!