LPR: The Silent Voice Threat

My friend Kate, a professional singer for a decade, had a rude awakening about 5 years ago. In the middle of singing a song her voice snapped. She had a vocal hemorrhage. On closer inspection it turned out she also had pre-nodules and significant stiffness in her right fold.
 
This is the stuff singer’s nightmares are made of. 
 
She was told that much of this damage was caused by acid reflux.
 
The thing is many singers are not even aware of their reflux. When you feel heartburn or have a distinct backflow of acid to the back of your throat, you can be sure you are suffering from Gastroesophageal reflux (GERD), but many singers don’t feel this, yet they may still experience Laryngopharyngeal Reflux (LPR).
 
LPR occurs when stomach contents come up the throat in a gaseous form or as a mist. This allows for easy access to the larynx as the mist can be inhaled. And you won’t even know it!
 
It’s estimated that 10% of the U.S. population suffers from LPR. However, LPR occurs in as many as 50% of individuals with voice disorders.
 
Though it was previously thought that the acid was doing the damage, more current research suggests that it is actually not the acid, but inflammation due to the action of pepsin.

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What is Pepsin?

Pepsin is a digestive enzyme, specifically for the breakdown of protein. Guess what the pharyngeal and laryngeal tissue is made of? That’s right. Protein. So the pepsin is digesting your tissue! Gross!!! Right? The stomach has a special lining that prevents this from happening, but outside of the stomach all tissue is fair game for the pepsin.
 
To make matters worse, Even if pepsin stops digesting and lays dormant, it can be reactivated by acid. So that coke or orange juice you drink can be reactivating it, starting the cycle all over again.

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What does it mean for your voice?

If you have LPR you may be experiencing inflammation in the vocal folds and even a thinning of the epithelial layer of the vocal folds. This puts you at greater risk of nodules, polyps, and hemorrhages when you sing. It also increases the risk of laryngeal cancer (though this is still a very rare form of cancer at 1% incidence).
 
If you have a very active singing life, this is a disaster waiting to happen.
 
Look out for the symptoms:

• Hoarseness
• Sore-throat
• Asthma-like symptoms
• Chronic cough and throat clearing
• Feeling of a lump in the throat
• Difficulty swallowing
• Excessive belching
• Post-nasal drip
• Excessive Mucous
• Frequent infections

 
See an ENT if you have any of the above issues that are not associated with a common cold and persist for more than 2 weeks.

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What can you do for your voice?

One thing that you should avoid is taking antacids or proton pump inhibitors (PPIs). These may give temporary relief, but neither is meant for long term use and can actually exacerbate the problem.
Currently acid reflux is the third leading cause of drug prescriptions. 
In fact, though PPIs like Prosilec and Nexium are heavily advertised in the United States they come with risks. These drugs have many side effects, can create dependencies and there is little if any clinical information on use beyond a year.  These drugs are really only meant for the most severe forms of reflux after all other methods to control it have failed.
 
Though there are lots of things that you can do to alleviate reflux, in my experience working with singers it boils down to three main things you can do to prevent or reverse it:
 
Nutrition
Meal timing
Stress management


 1. Nutrition
Paying attention to what you eat really does matter. Not just trigger foods, but making sure you are overall eating a healthy diet. When we aren’t eating optimally, we can be causing nutritional insufficiencies that lead to chemical imbalances in the body that can contribute to reflux. There is now evidence that a whole food plant-based diet is as effective as PPI therapy to treat LPR and GERD.


 2. Meal timing
Timing when you eat can prevent too much pressure being placed on the stomach that can result in back pressure on the esophageal sphincter. That means allowing sufficient time before activities such as exercising, singing and sleep. One to two hours before should be sufficient to empty the stomach.

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 3. Stress management
There is some debate whether stress actually can cause acid reflux, however, when we’re stressed we’re more likely to overeat, drink alcohol, smoke and eat unhealthy food, all of which can trigger acid reflux.
 
Stress can also cause acid reflux to feel worse. Some scientists think it may be because changes in the brain cause pain receptors to be ramped up, so you are more sensitive to acid. There is also a depletion of the hormone prostaglandin in the stomach when under stress that helps protect the stomach lining from acid.
 
Increased stress can also affect the nerve function of the stomach, which can result in the inappropriate relaxation of the esophageal sphincter.
 
So having strategies in place to help with stress are crucial: 

• getting sufficient exercise - this is the number one way to break the stress cycle, 
• making sure you are having not only the correct quantity of sleep, but also quality sleep, 
• mindfulness and meditation, 
• and as I mentioned before - nutrition. 

 
All of these play a big role, not only in managing stress, but in building your capacity to handle stress.
 
 
By taking these steps, Kate was able to rehabilitate her voice without surgery. Her folds are now pristine. These are the steps that we take in the Resilient Singer Method, as well. 
 
If you suspect you have reflux get checked by an ENT, and if you want to get back on track vocally, you may be interested in a Singer’s Wellness Strategy Session to discuss your options. 
 
You can book your FREE 45 minute Singer’s Wellness Strategy Session here.

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