The Importance of GERD on Our Voices

This might come as a surprise, but gastroesophageal reflux (GERD) can affect the quality and character of your voice. This can cause reflux laryngitis, which is an irritation of the back of the throat caused by acid reflux from your esophagus or stomach. It can happen any time of day, but typically it occurs when you’re sleeping.

Other terms for this condition are laryngopharyngeal reflux (LPR), acid reflux, and chronic laryngitis. For the purposes of this article, we will use the term LPR.

LPR can cause a variety of symptoms including hoarseness, a sour or bitter taste, burning sensation in the throat, cough, throat clearing, and a sensation that something is stuck in the back of the throat (globus sensation). In general, LPR is treated by conservative measures, including lifestyle changes.

What are the signs and symptoms?

Often, the diagnosis is made by exclusion. Various symptoms along with functional and structural abnormalities of your voicebox must be thoroughly evaluated. These structures include those that are near your esophagus or within the esophagus itself.

Who makes the diagnosis?

Ear nose and throat doctors (otolaryngologists) are usually the ones who diagnose and treat LPR and other voice disorders. In fact, in many cases a large number of patients in an ENT doctor’s practice have LPR or associated symptoms.

Some patients have difficulty swallowing, painful swallowing, bad breath (halitosis), chronic sinusitis, and other problems with the voicebox, such as malignant lesions. By far, the most common complaint is a feeling that something is stuck high in the chest or in the back of the throat.

LPR represents complications above the esophagus due to the reflux of acid content and it involves the esophagus, pharynx, larynx (voicebox), and respiratory system. It used to be that doctors thought of LPR as only a different form of GERD, but today it is treated as a separate entity.

How is LPR diagnosed?

Like many other throat issues, the gold standard for ENT doctors is indirect laryngoscopy.

This is performed either with a dental mirror and bright light or using the newer technology called flexible fiberoptic nasopharyngoscopy.

During this, a thin tube is placed down into the patient’s nose and throat under local anesthesia to visualize the vocal cords and surrounding structures.

The ENT doctor looks for the following signs:

• Redness.
• Swelling.
• Presence of a commissure bar posteriorly, behind the vocal cords themselves (this is a whitish area or evidence of scarring).
• Cobblestone appearance.
• Pseudosulcus vocalis (a groove in the lining at the free edge of the vocal cord due to swelling below the vocal cords).
• Ulcers.
• Vocal cord nodules or polyps.
• Leukoplakia (whitish plaques).

Pseudosulcus vocalis can be a good indicator of LPR. It is seen in as many as 90% of patients with LPR.

A specific bacterium associated with GERD, known as Helicobacter pylori, can be found in some patients in their nose, sinuses, or throat. These patients can develop infections involving their nose, sinuses, ears, pharynx and voicebox.

Additional signs can include:

• Recurrent or chronic sinusitis.
• Dental erosion.
• Sandifer syndrome (a unique neck posture in infants and young children. Presumably, this posture is an anatomic defense mechanism against repetitive acid reflux in children).

Aside from laryngoscopy or looking at the voicebox, there are other procedures that can offer information. These include:

• Endoscopic examination of the esophagus. Unfortunately, the presence of irritation of the esophagus (esophagitis) is not a constant finding. Some patients have used antacids, which have been effective in healing the esophagus or stomach lining, but ineffective in solving problems in the throat.
• Ambulatory 24-hour pharyngoesophageal pH monitoring. This method is more effective at diagnosing GERD than LPR, but it may offer important clues. It involves using a distal pH probe. The readings are recorded for24 hours while the patient indicates onset and end of meals, sleep, and whenever the patient experiences symptoms.
• Some ENT doctors perform videostroboscopy with testing of the vocal cords for laryngeal reflex. This is a very specialized procedure done in the office without discomfort and it has the potential to aid in both diagnosis and monitoring of patients with LPR.

What is the treatment for LPR?

As you might expect, the diagnosis is often made with some reservations because of the lack of specific and definite signs. Most ENT doctors, however, still opt for a trial of empiric therapy and close follow-up.

The four categories of drugs to be used include:

• Proton pump inhibitors (PPIs). These are the mainstay of treatment in most cases. These include Omeprazole and Lansoprazole, and others.
• H2 receptor blockers. Examples include cimetidine, famotidine and nizatidine.
• Prokinetic agents.
  • Cisapride.
  • Gimoti.
  • Metoclopramide.
  • Metoclopramide intranasal.
  • Metozolv odt.
  • Motegrity.
  • Propulsid.
  • Prucalopride.
  • Mucosal cryoprotectants.

In cases of unsuccessful medical therapy, the patient’s symptoms and physical examination are carefully reviewed. In some patients, the length of medication therapy and higher dosage are crucial factors in treatment.

Surgical care is necessary in some patients. The patient undergoes a procedure to correct the antireflux barrier. This surgery prevents the reflux of most stomach contents so that the back of the throat and voicebox are protected.

Candidates for this surgery are often patients who require continuous or exceedingly high dose medications without complete relief. Also, young, and noncompliant patients opt for the surgery to maintain a healthy lifestyle.

In some patients, the financial constraints of continually needing to purchase antireflux medications can be a motivating factor in having the surgery, which is called fundoplication.

Fundoplication is now minimally invasive and done with a lighted endoscope (laparoscopy). The surgery is done by general surgery. It is recommended that the surgery be used as a last resort for any of these patients.

Many patients with LPR have dramatic improvement with either medication or dietary changes. Dietary recommendations include:

• Decrease the size of portions at mealtimes.
• Meals should be eaten two to three hours before lying down.
• Avoid food and beverages that affect the muscle action of the lower esophagus (e.g., fried or fatty foods, chocolate, peppermint, alcohol, coffee, carbonated beverages, citrus fruits or juices, tomato sauce, ketchup, mustard, vinegar).
• Eat at a slower pace to reduce aerophagy (getting air in the esophagus or stomach).
• Patients with concurrent problems with swallowing benefit from specifically targeted interventions (eg, swallowing therapy by a speech-language pathologist).