Dear Dr. Jahn: I am a professional American operatic baritone currently living and working in Europe. I have struggled with (what has seemed to be) laryngopharyngeal reflux (LPR) issues since I was about 19–20 years old and first went to see an ENT in Boston. That ENT noticed the “typical” visual symptoms of LPR through laryngoscope exam and started me on the common twice-a-day proton pump inhibitor (PPI) (at that time, esomeprazole). I remained on PPIs, more or less consistently, for the last nine years up until the present day.
A couple months ago, having read about the potential increase in risk of pneumonia and upper-respiratory infections related to PPI use, I decided to have an endoscopy with a gastroenterologist here in Europe to see if I had other “evidence” of a reflux disorder. When those results came back clean, I decided to go off PPIs, by weaning myself first down to one pill a day (I had been taking 40mg omeprazole a day for the last three years or so) from two. I did this for about a month, and then went off the pills altogether.
Everything seemed fine for about three weeks, until I came down with a laryngitis/pharyngitis infection that may have been bacterial or viral. I wasn’t sure. After I recovered from this, about five weeks into being off PPIs altogether, I started to begin waking up with a hoarse, dry voice. I had extreme difficulty warming up in the morning. I had some increased post-nasal drip. All the tell-tale signs of LPR, as I have read about it for many years. So, sadly, I resigned myself to needing the PPIs in my life again.
Now I’ve been back on them for two weeks. After week one, I felt great again—voice was strong and no issues singing at all. Now into the second week, I am on two pills again as I used to be for many years, and I am noticing almost the same darn symptoms as before—throat is feeling dry and raw, brittle, burning a little bit, trouble with high notes and stamina. Nothing seems to have provoked this. I have been relatively “tame” in behavior and eating and have followed acid reflux behavior changes all my life.
All of this being said, I was pleased to read Dr. Bastian’s article [“When Acid Reflux Treatment Takes You Down a Rabbit Trail,” CS, April 2009] as it reaffirmed my symptoms as relating to LPR. I am dismayed, however, that I must remain and be dependent on these drugs for as long as I have my career (20, 30, 40 years?), especially since these drugs have not always provided consistent relief for me. Although, without them, I did notice a big difference.
I was wondering if you might be able to shed some light on anything I might be overlooking. Do you work with many singers who suffer a similar situation and find themselves “dependent” on these drugs? Are you aware of any other truly effective alternative treatments?
I would be very grateful for any advice you might have, given your great experience working with professional singers’ unique vocal concerns.
Dear Reader: Your long and detailed history of problems really requires a personal examination and consultation. Having said that, I do have a few suggestions for you to consider. First, are you overweight? You need to be at, or just below, your “ideal weight,” for your height. So if that is an issue, I would go on a diet to see whether this improves your symptoms.
While your comments that things improved when you went back on a proton pump inhibitor would suggest that you may indeed be refluxing, I would suggest a 24-hour pH probe study to document nocturnal (and daytime) reflux—the number of episodes and also the level to which the acid rises (this is done with a double probe). If this test is positive, it amounts to a “smoking gun” indicator that acid reflux is indeed your problem. If you can get this done in Europe, that would be easiest.
By way of treatment, and in addition to modifying what, when, and how much you eat (and drink), I would add Gaviscon liquid, which not only neutralizes acid but prevents it from coming up the esophagus. Also look at DGL, a form of licorice which is helpful for acid reflux, is nonaddictive, and has no side effects. You can buy this online.
—Dr. Jahn
Dear Dr. Jahn: Hello again. Thank you for your response! I would really like to know if you encounter many singers who find themselves “dependent” on PPI drugs—that is, unable to find alternative treatments after having been on them long term? And if so, does this concern you from a medical perspective?
I know that there are several studies on some alarming potential side effects with PPIs, and I would love to hear your perspective on opera singers, who need optimal vocal function, being on these drugs for their entire careers and the potential complications/risks involved so that we all know if it is worth it or not, for the sake of our health. Many of us experience “rebound” acid if we try to wean off the drugs, and it’s a scary prospect taking them our whole lives! (Not to mention expensive!)
Dear Reader: In answer to your question, please consider that PPIs have only been around for a few years, so no one really knows what a lifetime of medications would result in. Two significant concerns are increased osteoporosis and achlorhydria. Osteoporosis, normally seen in post-menopausal women, occurs more frequently in men who take PPIs. The decrease in gastric acid can have consequences on vitamin B12 absorption. Neither of these issues is specific to singers, and I’m not sure they would have adverse effects specific to singing.
But I would suggest that before you commit to a lifetime on any medication, you exhaustively explore every other method of controlling your reflux, including dietary (what, when, and how much you eat), weight control, and alternative methods of controlling hyperacidity and reflux (herbal and homeopathic remedies, acupuncture, antacids, and alkaline diet).
—Dr. Jahn
Dear Dr. Jahn: After a recent dentist visit I was told that I have “moderate tori palatinus and mandibular torus.” I never heard of this condition prior to my dental visit! I also was never aware of the extra bone growth in my mouth until it was pointed out, and now I can’t stop feeling it! My dentist told me that she could remove it through surgery—yikes! As an opera singer, that is the last thing I want to do. Is surgery necessary? Could it become necessary in the future?
I have no idea what to do. I look forward to hearing your opinion.
Dear Reader: Torus is a Latin word that means “ridge.” Here, it refers to a ridge of bone that runs lengthwise along the middle of your hard palate (torus palatinus) and two bony bumps on either sides of the inner surface of your lower jaw (facing your tongue).
Torus palatinus is more common. It is simply an overgrowth of bone where the two sides of the hard palate come together during embryonic development. Consider that your hard palate is formed by two bony plates that gradually grow together to meet, and fuse, in the midline. If this process is deficient, you have a cleft palate. If it is a bit too exuberant, you develop a torus.
This condition is completely harmless, and normally there is no reason to remove it. The two situations where I have removed torus palatinus have been cases where the mucous membrane over it is diseased or eroded, or in older patients who require a full upper denture and need more room to insert this device. I am assuming neither case applies to you. I have never removed a torus mandibularis, and can’t think of a good reason to do so, unless they are so large that food is getting caught underneath.
Consider that you have lived with this common benign condition all of your life and you have had no problem speaking, chewing, swallowing, or singing. You can certainly ask the dentist why she would like to remove them—but unless there is a specific reason, my advice is to leave them alone. Be reassured that they represent a harmless variant that normally needs no treatment. If, however, you and your dentist agree that surgery is needed, there should be no long-term impact on your singing, assuming that the procedure is done without complications.
—Dr. Jahn
