Is gastroesophageal acid reflux really on the rise? Ignoring the unintentional humor of that opener, it does seem that GERD is becoming a national epidemic. Every singer is certainly aware of the condition. Nightly, we are enjoined on TV to try “the new purple pill,” and the diagnosis is no longer given only to the obviously obese or overindulgent.
I thought it might be time to revisit the problem (my last column on this was five years ago) and talk about some recent developments.
There are two reasons why GERD is a hot topic among both patients and physicians. We are seeing an increase in gastroesophageal reflux, and there is also a greater appreciation of its prevalence. When I was in medical school over 25 years ago, GERD as an acronym didn’t exist. We talked about hiatal hernia causing acid reflux, with the stereotypical patient usually a middle-aged overweight mother, who after several pregnancies had stretched out her diaphragmatic hiatus, allowing part of the stomach to slide up into the chest (the hiatus hernia), and consequently spill acid up into the esophagus. We no longer see reflux in only such patients. While weight and child-bearing status are still factors, many of our patients are younger, single, slim, and—the point of this column—singers.
The stomach is normally in the abdomen, south of the diaphragm. It contains enzymes and hydrochloric acid (of pH 1, very irritating). The stomach contents are in fact so acidic, it is a wonder that the stomach doesn’t dissolve its own lining. An even greater, and more recent, surprise was the discovery of bacteria, called Helicobacter pylori, which actually thrive in these inhospitable regions. This bacterium is a form of “extremophilic” life—like bacteria found under the polar ice cap, in volcanoes and geysers, and at the icy cold bottom of the ocean. In the stomach, these intrepid inhabitants may contribute to the formation of ulcers.
The stomach is separated from the esophagus by several anatomic and physiologic structures, which constitute the gastroesophageal, or LOWER esophageal, sphincter. While acid in the stomach is essential to digestion, gastric contents in the esophagus are irritating and potentially harmful. In addition to an incompetent hiatus, which allows part of the stomach to slide up into the chest, the muscles of the lower esophagus may become overly relaxed from excess coffee or alcohol. Over-distention of the stomach by large meals or compression of the stomach due to increased abdominal pressure can potentially force gastric contents up into the esophagus. If there is a potential weakness or incompetence, lifting, straining, or even singing can lead to acid reflux.
All of this has been known for years. What we are becoming increasingly aware of is how high the acid can travel and how it can affect structures at the upper end of the esophagus. This phenomenon, called laryngopharyngeal reflux (LPR), occurs when acid is pushed above the UPPER esophageal sphincter, just behind the larynx, and is extremely important to singers.
We have gained a new appreciation for GERD in part because of new, and more sensitive, diagnostic methods to document its prevalence. One of these, the 24-hour pH monitor, involves inserting a thin probe into the esophagus, which can measure the pH at various levels: near the stomach, mid-esophagus, and above the upper sphincter, in the pharynx. These studies show that silent reflux, even up into the pharynx, occurs frequently but transiently, many times over the course of the day.
How does this affect singers? The acidic contents of the stomach can irritate the back of the throat. Even without directly soiling the vocal folds, the irritation can cause reflex contraction of the pharyngeal muscles and pull the larynx up in the neck. Patients with LPR often have a high larynx and consequently have difficulty opening the back of the throat. This can affect resonance and vocal clarity. Waking up in the morning with pain in the back of the throat (typically on the side you sleep on!) is another clue. If the acid actually touches the larynx, the arytenoids and the back part of the larynx may become red and swollen. A small ulcer or granuloma may develop over the arytenoids, which causes not only hoarseness, but also pain. And the rising gorge continues to invade new territories: recent medical literature is looking at the link between acid reflux and sinusitis, even a possible role in Eustachian tube dysfunction and middle ear disease.
How to stop the silent menace? Weight control is important, but it is becoming apparent that lifestyle changes are an equally significant factor. Eating frequent small meals and not eating late at night will prevent distention of the stomach and a nocturnal spill. Foods such as coffee, peppermint, alcohol, chocolate, or whatever you know gives you heartburn (like spaghetti sauce), should also be limited.
What if you have done all of the above (AND eliminated stress from your life!), without effect? You may need to consider medications. Medications for GERD work in a variety of ways. Drugs which inhibit acid secretion (such as proton pump inhibitors) limit the amount of acid formation. Conventional antacids, such as Gaviscon or Maalox, neutralize acid which has already formed. Medications such as Carafate primarily soothe and cover irritated surfaces. There are a variety of medications to choose from. If they don’t do the job, you may need to take higher doses, or combine different types for maximal effect.
If all else fails, there are a number of surgical options. Surgery may be helpful to reduce obesity, or to strengthen the gastroesophageal sphincter. Obesity surgery includes gastric bypass and stomach reduction or stapling. These are major procedures with potentially significant complications, not to be lightly undertaken. Sphincter surgery, called fundoplication, involves reinforcing the lower esophageal sphincter by wrapping a sleeve of stomach tissue around it. It can be wrapped completely or partially, depending on the technique. The beauty of this procedure is that stomach contraction, which would normally force contents up into the esophagus, actually tightens the sphincter, preventing reflux. The surgery is increasingly being done endoscopically, without creating a large incision. This is important for singers, who need to have their abdominal muscles intact for exhalation, phonation, and voice control. Such surgery may be dramatically successful if all else has failed.
Please consider that surgery, however “minor,” is—well—an operation. It may not always work. There have been instances where the procedure had to be redone, or converted to an open, rather than laparoscopic, procedure. Excessive fullness, bloating, belching and other symptoms may develop following such surgery. These symptoms are usually transient. If you truly have persistent reflux, your best bet is to get several opinions (at least one of which should be from a gastroenterologist), and before considering surgery, read or surf. While fundoplication may be a lifesaving (or at least voice-saving) miracle for some, it may be premature or unnecessary for others. And, as a final thought, not every vocally impaired singer with GERD is impaired because of the GERD.
For more information on GERD and related problems, see the excellent article at http://wellness.ucdavis.edu/medical_conditions_az/heartburn85.html.
Disclaimer: The suggestions given by Dr. Jahn in these columns are for general information only, and not to be construed as specific medical advice or advocating specific treatment, which should be obtained only following a visit and consultation with your own physician.
