Quantifying Laryngopharyngeal Reflux in Singers: Perceptual and Objective Findings


Posted On Mar 15 2010 by

Up and coming results are available with speech therapy but these results need to be evaluated in future trials. Surgery should be indicated in select patients, in which high-volume refluxate and incompetence of LES are demonstrated with esophageal pathophysiological evaluations.

lpr acid reflux vocal

These studies seem to point towards a common pathophysiology, suggesting that laryngeal symptoms are indeed caused by acid exposure. In addition to the paucity of typical gastroesophageal reflux disease symptoms in patients with LPR, the tendency to under-diagnose LPR has been increased by three additional factors. First, the importance of various aspects of the physical examination is under-appreciated. Posterior laryngitis and interarytenoid pachydermia are frequently ignored.

Smokers have an increased incidence of reflux symptoms compared with nonsmokers [Talley et al. 1994; Watanabe et al. 2003]. Nilsson and colleagues [Nilsson et al. 2004] revealed, in a multivariate analysis, that among individuals who had smoked daily for more than 20 years, the risk of reflux was significantly increased by 70%, compared with those who had smoked daily for less than a year (OR 1.7; 95% CI 1.5-1.9). A relation has been considered between smoking cigarettes and a prolonged acid exposure, a decrease in LES pressure, and diminished salivation, which decreases the rate of esophageal acid clearance [Kahrilas and Gupta, 1989].

Gastric acid can cause significant inflammation when it falls on the vocal cords. LPR is caused by stomach acid that bubbles up into the throat. When you swallow, food passes down your throat and through your esophagus to your stomach. A muscle called the lower esophageal sphincter controls the opening between the esophagus and the stomach.

It has been argued that without the presence of GERD symptoms, improvement in laryngeal symptoms with PPI is unlikely. Behavioral changes and investigation for alternative causes, such as allergy, pulmonary causes, and sinus problems, should be instituted (Reichel et al., 2008).

Gastroesophageal reflux disease (GERD) occurs when gastric contents irritate mucosal surfaces of the upper aerodigestive tract. However, in some people, small amounts of stomach juice can spill back into the upper throat (pharynx) affecting the back of the voice box (larynx) causing irritation and hoarseness.

Furthermore, several signs of laryngeal irritation, which are generally considered to be signs of laryngopharyngeal reflux (LPR), were found to be present in a high percentage of asymptomatic individuals on laryngoscopic examination. The apparent advantage of operative therapy is that it corrects the antireflux barrier at the gastroesophageal junction and prevents the reflux of most stomach contents, thus preventing acid and nonacidic material from coming in contact with the pharyngolaryngeal mucosa. Candidates for antireflux surgery are often patients who require continuous or increasing doses of medication to maintain their response to acid suppressive therapy. On the other hand, increased awareness may lead to overdiagnosis of the condition because typical laryngopharyngeal reflux (LPR) symptoms are nonspecific and can occur in processes such as infection, vocal abuse, allergy, smoking, inhaled irritants, and alcohol abuse. Failing to recognize laryngopharyngeal reflux (LPR) is dangerous, while overdiagnosis of laryngopharyngeal reflux (LPR) can lead to unnecessary costs and missed diagnosis.

lpr acid reflux vocal

Randomized trials have shown that this practice can decrease esophageal acid exposure and lead to shorter reflux periods and a rapid esophageal clearance [Hamilton et al. 1988]. Elevating the head of the bed is important for people with nocturnal or laryngeal symptoms. Right lateral recumbent position has also been shown to cause prolonged reflux time and increased LES relaxations, thus patients with GERD or LPRD should avoid recumbence in this position [Khoury et al. 1999].

These results highlight the important fact that gastric acid can reflux through the esophagus to the larynx without causing esophageal injury in transit. Koufman’s data on patients undergoing barium esophagram revealed that only 18% of patients with LPR had esophagitis identified on barium study (Koufman, 1991), although the barium swallow study is a very insensitive test for esophagitis.

Hyperfunctional technique during speaking and especially singing is also associated with reflux laryngitis, which is probably due to the vocalist’s unconscious tendency to guard against aspiration. Voice professionals can be helped somewhat in overcoming this secondary muscular tension dysphonia through voice therapy with speech-language pathologists, singing voice specialists, and acting voice specialists, but it is difficult to overcome completely until excellent reflux control has been achieved.

We assume that, in patients nonresponsive to traditional PPI therapy (when LPR was diagnosed), alternative therapies may be considered, including VT techniques to improve vocal functions. Eherer et al.

Singing requires a high magnitude of recruitment and activation of respiratory and laryngeal structures. Tasks which emphasize coordinated contractions of the diaphragm and intercostal and abdominal muscles may place singers at an elevated risk for developing LPR due to high-magnitude changes in intrathoracic pressures that may occur during such maneuvers. During inspiration, the thoracic cavity expands and the diaphragm compresses the stomach, putting pressure against the LES, potentially causing stomach acids to reflux into the esophagus. There is a similar effect during prolonged expiration, as with singing, as the abdominal muscles are activated and exert pressure against the stomach wall as the thoracic cavity compresses. These pressures can affect lower esophageal sphincter opening and closing (LES), potentially contributing to LES dysfunction [2-4].

Antacids and medications called histamine antagonists – which also decrease stomach acid – can be used to treat laryngopharyngeal reflux, as well. Medications that increase the movements or contractions of the stomach and bowels, sometimes called pro-motility drugs, may be recommended for people with laryngopharyngeal reflux. The esophageal complications of GERD include esophagitis, esophageal webs and strictures, Barrett’s esophagus and carcinoma.18, 19 Barrett’s esophagus is defined as metaplasia of squamous epithelium to specialized columnar epithelium, occurring 2 to 3 cm above the gastroesophageal junction. However, short-segment (less than 2 cm) Barrett’s esophagus has also been described.6 Barrett’s esophagus is an endoscopic diagnosis and is associated with an increased incidence of adenocarcinoma. Heartburn, the classic symptom of GERD, is common in patients with gastrointestinal symptoms but uncommon in those with head and neck manifestations.

Lin RJ, Sridharan S, Smith LJ, Young VN, Rosen CA. Weaning of proton pump inhibitors in patients with suspected laryngopharyngeal reflux disease. Laryngoscope. 2017 Jul 21. [Medline]. Evidence suggests that in both healthy and patient populations the refluxed gastric acid may come into contact with structures as high as the pharynx.

This condition may occur at any time, but it happens more often when you are laying down. A common anatomic condition known as a hiatal hernia predisposes people to acid reflux. The most commonly recognized symptom of acid reflux is “heartburn” due to irritation of the lining of the esophagus. The diagnosis and treatment of LPR has been challenging due to the lack of a gold-standard diagnostic test and poor responsiveness to our best available medical therapy (PPIs).

lpr acid reflux vocal

Last Updated on: September 26th, 2019 at 8:03 pm, by


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