Is gastroesophageal reflux (GERD) really becoming so much more prevalent? Almost every singer with hoarseness has been given this diagnosis, and not by their general doctor but an ENT. The result is a huge nationwide consumption of proton pump inhibitors (Pepcid, Nexium, etc.), with decidedly mixed clinical results. I have been treating singers for over 30 years, so I hope you will forgive me if I use this opportunity for sharing my own experience and opinions.
Consider first: What is the overall prevalence of acid reflux? We have no hard numbers on this, for several reasons. Every healthy person has, at some time in their life, experienced heartburn. At what point does “normal” heartburn become a disease? In my opinion, that would have to do with frequency and severity—but, even more important, with the clinical effect, the signs, symptoms, and the damage caused by reflux.
Historically, we know that certain patients are definitely more prone to acid reflux. The condition has been linked to obesity, certain foods, poor eating habits (eating large amounts late in the evening), and excessive intake of coffee and alcohol. Less obviously, women who have been pregnant may be more at risk because an incompetent hiatus in the diaphragm (due to the stretching that occurs during pregnancy) may cause hiatus hernia and an incompetent gastroesophageal sphincter. In the old English medical books, hiatus hernia, gall bladder disease, and diverticulosis were clumped together as “Saint’s Triad” and said to be common in patients who are “fat, fair, female, 40, and flatulent.”
But we also see reflux in slim, young males, so the stereotype (a caricature, really) doesn’t hold. Without doubt, a combination of increased incidence in such atypical patients, along with increased recognition and diagnostic testing, has raised the diagnostic suspicion of reflux disease almost to the front of the diagnosis line.
For singers, a significant advance in understanding this condition came with Dr. Jamie Koufman’s identification of laryngeal and pharyngeal reflux (LPR) as a separate clinical entity. This is different from esophageal reflux: acid travels up above the esophagus, to the pharynx and larynx. The mucous membranes of this area are more vulnerable to acid damage than the stomach and esophagus. A variety of common and rather nonspecific symptoms have been attributed to acid irritation of the pharynx and larynx, including hoarseness, chronic cough, excessive mucus, and throat clearing. Ear pain, rhinitis, and even Eustachian tube blockage have also occasionally been attributed to stomach acid being in the upper airway. More recently, Dr. Koufman has proposed that it is not the acid in stomach juices but, rather, some digestive enzymes (such as pepsin) that may be the main culprit in LPR.
A number of tests have been used to measure acidity (pH) along the upper GI tract. These pH probes, placed through the nose and left in for 24 hours, sample the acidity of fluids along the esophagus and the pharynx. When the pH drops, it suggests that acid has refluxed from the stomach upward. Acid reflux, however, is often transient and may not be clinically significant. Yet, once the pH test is positive, the physician leans even more toward the diagnosis of reflux disease. We all like to see graphs and numbers, even as the definition of what constitutes significant reflux is rather gray.
But here is the quandary—LPR symptoms are common, rather nonspecific, and have many potential causes. So, categorically attributing them to reflux may be putting all our diagnostic eggs into one basket.
The crux of the problem is this: while transient reflux may be common, and a variety of singers’ complaints (such as hoarseness, mucus, and throat clearing) are also frequent, that should not lead to the conclusion that the first invariably causes the second. Many patients with documented reflux sing well, whereas others, with no reflux, do not. And even when reflux and hoarseness coexist, it is still not clear that the one invariably causes the other. The link is not clear. Making that diagnosis fit the clinical picture is not only sometimes wrong, but leads to thousands of unnecessary prescriptions, lifestyle changes, and worry.
Unfortunately, reflux has in many cases become the “default diagnosis” when the true cause of vocal symptoms is not clear. The psychological ramifications are interesting: when hoarseness due to faulty vocal habits is (incorrectly) attributed to reflux, it exonerates the singer from dealing with technical issues. It is no longer her problem, but it is a “disease” that needs pills. It also frees the physician from looking deeper into the matter and from having to admit that, at times, we just don’t have a good answer. It is for these reasons that GERD and LPR are generally overdiagnosed as clinically significant, especially among singers.
I am not saying that laryngeal and pharyngeal problems are not due to reflux—often they are and they resolve dramatically with dietary changes and medication. But not always. And if a singer’s hoarseness has not improved after a month of Nexium twice a day, along with antacids and dietary modification, we should logically look at other possible causes rather than increase the medication to three times a day.
In my practice, if vocal problems continue after a good clinical trial of twice-daily proton pump inhibitors, dietary modification, and antacids, I reconsider the diagnosis and explore other possibilities.
Any of the common LPR-linked symptoms (hoarseness, throat clearing, mucus, lump sensation) may have other causes and now need to be considered. If we consider that acid reflux, although common and often symptomatic, is not the only diagnosis, we will have fewer cases of overmedicated singers who continue to struggle vocally despite maximum therapy and who have been told that “nothing else can be done.”
