Is acid reflux really that much more frequent than in the past? It has certainly become the go-to diagnosis for many doctors treating singers. Whether this reflects greater prevalence or just a higher degree of suspicion is not clear, but I see many singers who carry this diagnosis to explain common and persistent symptoms. And often they’re not getting better, despite what appears to be appropriate anti-GERD therapy.
The basic explanation of GERD (gastroesophageal reflux disease) is simple enough: hydrochloric acid, which normally should stay in the stomach, travels up to irritate not only the esophagus but also the pharynx and larynx. It can cause a variety of symptoms, beginning with discomfort in the esophagus behind the breastbone (hence the name “heartburn”), up to the pharynx, producing a sore throat and excess mucus with constant throat clearing and hoarseness. As the acid continues north, it can even reach the nasopharynx, causing such unexpected effects as earache and even sinusitis.
But once again, the reality is much more complicated, and the real purpose of this column is to share with you some of the controversies in this area so you don’t get caught up in the whirlwind of endless reflux therapy with no real benefit.
First, everyone has reflux. There are normally situations where acid will travel back up the esophagus. Such intermittent acid reflux is not harmful and may not even be symptomatic. It can happen when you strain or burp, and the acidic fluid may even reach your throat, causing a sour taste. Old medical books talk about “waterbrash,” a phenomenon where saliva suddenly fills your mouth, in response to this acid.
But if occasional reflux is normal in the general population, what makes some reflux pathological? Many articles have been devoted to this, looking at two main parameters: how often (per day) does it happen and how high up the esophagus does the acid travel? These two questions can be answered with the use of a pH probe, a thin flexible tube that is inserted through the nose into the esophagus and left there for 24 hours. The probe measures the acidity (pH) in the esophagus over the course of a day and night. The device can be fitted with multiple probes located along the length of the tube. These can then answer the second question as to how high up the acid travels.
Once we have established that there are episodes of reflux, we now need to put some numbers in: how often, how high up, and how much of a pH drop would constitute a significant reflux event? As you may imagine, there is disagreement, since the definition is just that—an arbitrary set of criteria that are defined as pathologic reflux.
A few years ago, Dr. Jamie Koufman, a pioneer in this field, advanced the idea that the real culprit in gastric reflux is not the acid but all the other stuff in the refluxate, primarily enzymes such as pepsin. These enzymes digest food, such as meat, and can equally damage the “meat” that is the esophagus. So perhaps we should be assaying not for acid but for pepsin to identify the real cause of GERD related symptoms.
And the complexity grows even more, since for pepsin to digest tissue (whether your hamburger or your esophagus), it must be activated by a low pH. So it now seems that the real “perfect storm” is neither acid or pepsin, but the appropriate combination of both. Pepsin assays are now being developed, and I suspect the best diagnostic probe will combine multiple sensors, for both pH and enzymes. We will, of course, still need to put a number on what amount of acid-enzyme exposure is significant enough to damage the esophagus, since there are situations where the reflux can cause symptoms but no structural damage to the esophagus. Everything has a name, and this condition carries the acronym NERD (non-erosive reflux disease).
There are two more issues you should be aware of in the world of GERD. First, many singers actively reflux and have no vocal tract issues—they sing well and consistently. This would imply that either some throats are less sensitive to acid or something else is going on in vulnerable patients that renders them more at risk with gastric reflux.
Another issue is this: many of the symptoms attributed to acid reflux in the pharynx (called laryngo-pharyngeal reflux, LPR, or silent reflux) are very common and can have multiple other causes. Mucus in the hypopharynx? Sure, it could be reflux, but it could also be many other things—inadequate hydration, allergy, low grade yeast infection, medications, among others. Similarly, hoarseness can be reflux related, but can be many other things as well. Not every case of unexplainable reflux need be thrown, willy-nilly, into the garbage can of “it must be reflux.” Singers with reflux often sing well, hoarse singers often don’t have reflux and, most significantly, not every hoarse singer with reflux is hoarse from the reflux.
Laryngeal examination in patients with reflux may demonstrate specific changes, usually red hypopharynx and arytenoids and thickened tissue in the back between the arytenoids. But what is “red”? That depends on that patient’s baseline mucosal appearance, the amount and kind of lighting used to examine the area . . . well, you get the idea. My commonest finding in cases of reflux is actually not laryngoscopic. Rather, these patients often have an elevated larynx (narrowed space between the thyroid cartilage and hyoid bone) and experience difficulties in the primo passaggio.
And, finally, management. There are many ways to prevent acid from reaching the esophagus and pharynx. You can change your diet—what, how much, and when you eat. You can use medication that prevents acid formation (proton pump inhibitors) and blocks histamine receptors on acid forming cells (H2 blockers). You can neutralize the acid already formed and prevent it from refluxing up the esophagus.
But these trials of treatment need to be reasonable. If something doesn’t work (after an adequate trial period), consider what else may be going on rather than mindlessly increasing the same medications. Most drugs have side effects, and this is certainly the case with anti-GERD medications.
I hope I have not left you confused with all of this. If you truly have symptomatic reflux and have improved on diet modification and drugs, you are on the right track. I wanted to share some of the dilemmas in managing GERD so you become better informed and, perhaps, just a bit more critical the next time you are given that diagnosis.
