Introduction

Your voice is a very important part of your identity and livelihood, helping to express yourself and communicate and connect with other people. Vocal health is crucial for many people, especially professional vocal users, such as teachers, lawyers, actors, radio personalities, singers and public speakers. You have to maintain a high level of control over the quality of your voice for performances and events, and so taking care of your vocal health is crucial to maintaining this control. Acid reflux refers to when the acidic contents of your stomach come back up through the oesophagus (i.e., food pipe), sometimes also reaching the throat, and is one factor that can negatively impact your vocal health.¹ Continue reading to find out how acid reflux impacts the quality of your voice, and what the treatments and prevention strategies are to maintain your singing and speaking voice.

Anatomy of the voice and vocal mechanism

The larynx (i.e., voice box) is found between the base of your tongue and the top of your windpipe (i.e., Trachea). There are three main sections of the larynx, including the supraglottis, glottis and subglottis. The glottis is the part of the larynx and is made up of four vocal cords, or vocal folds, and they are responsible for producing sound. There are two superior “fake” vocal cords that have no muscle element and have more of a protective role rather than a sound-producing role. The two inferior “true” vocal cords have a muscle element and are responsible for sound production.²

As we breathe, the vocal folds stay apart to create an open space for air to pass through the windpipe. When we swallow, the vocal folds approach each other to close the space, to help prevent any food/saliva from entering the windpipe and direct it through the food pipe instead. When we are about to speak, the vocal folds quickly approach each other and vibrate as the air from the lungs passes through them. The vibrations produce sound waves, which travel through resonating chambers such as the throat (i.e., the pharynx), mouth, nose and other surrounding tissues to influence sound amplification and quality.³

Many factors cause vocal problems, such as upper respiratory infections, trauma and injury from misuse or overuse of vocal cords, growth and cancer of the larynx, but one important factor that we will focus on is inflammation caused by acid reflux.³

The impact of acid reflux on vocal performance 

Understanding acid reflux and laryngopharyngeal reflux (LPR)

Acid reflux, or gastroesophageal reflux (GER), refers to when the contents of your stomach, especially stomach acid, come back up through the esophagus. Between the food pipe and the stomach, there is a ring of muscle called the lower oesophageal sphincter. This muscle acts as a stopper to prevent the acidic contents of the stomach from flowing back up the food pipe. When this muscle weakens, it can no longer carry out its function effectively and the acidic contents escape back up the food pipe. This is known as acid reflux and is problematic because even though the stomach is made to withstand the strong acid, other places like the food pipe cannot withstand the acid.¹ Acid reflux can be caused by various factors, including your diet, your lifestyle, including smoking and alcohol intake, being overweight, taking certain medications and other physical conditions such as pregnancy. 

The main symptoms include heartburn, which is a burning feeling in the middle of your chest, and a burning stomach pain known as indigestion. Other symptoms may include a sour, unpleasant taste in your mouth, coughing and feeling nauseous. You may even feel these symptoms are worse after eating (when acid production is increased), when bending over or when lying down (especially on your right side). Chronic acid reflux is called gastroesophageal reflux disease (GERD) and is characterised by the regular appearance of these symptoms.⁴ Laryngopharyngeal reflux (LPR) is a form of acid reflux where the acidic contents reach up through the food pipe to irritate the throat and voice box (larynx) instead.¹ Compared to GERD, LPR is associated with changes to the upper sphincter as well as the lower.⁵ It is also known as “silent reflux” as people who have LPR may not present the same symptoms as acid reflux/GERD, such as indigestion and heartburn, and so this is often overlooked. 

How does acid reflux affect your voice?

Irritation and inflammation of the vocal box (i.e., larynx) and vocal cords due to acid reflux, particularly LPR, can affect the ability of your vocal cords to vibrate freely to produce sound. Therefore, this can cause a change to the quality of your voice; It can cause a weaker, raspier, hoarse voice. You may not be able to hit the high notes or longer notes effortlessly like usual or stay in tune as you sing. You may take advantage of this type of voice, but it is not advised to do this, as this may increase the damage to your vocal cords. Constant inflammation can result in growths and vocal nodules forming, which cause semi-permanent changes and damage to your vocal cords, and therefore require medical treatment or surgery.⁶

This irritation can result in excessive coughing and throat clearing, which also affects the quality of your voice. The muscles in your throat may squeeze together to protect the vocal cords, causing high muscle tension, affecting your ability to swallow, causing a feeling of a lump in your throat and making your voice sound strained. Therefore, these symptoms are very harmful for you as public speakers, singers and other professional vocal users since you use your vocal cords constantly and need precise control over them. 

Psychological and professional consequences

Short-term reflux consequences can include increased vocal effort, a short-term loss of control over your vocal cords, and a temporary raspy voice.⁷ This may make you feel that you need to warm up your voice for a longer time than usual. This may also induce performance anxiety since you know that your voice is not cooperating with you. Long-term reflux consequences may include a constant degradation of your vocal quality over time, eventually limiting your ability to sing or speak as you did before. Professionally, this may impact your career, the opportunities that you may want/have wanted or even your reputation and therefore may impact your mental health and affect your confidence in future performances or events.

Diagnosing the problem: Challenges and tools

Symptom assessment during a visit to the doctor is normal for any disease or condition. Physical examinations and specialised tests may also help to confirm the diagnosis of GERD or LPR. Considering LPR is a “silent” disease and doesn’t typically present the obvious symptoms of acid reflux, such as heartburn, this may be overlooked by the person who has it. However, they may present with other symptoms as mentioned previously, and so this can help with differentiating between GERD and LPR during diagnosis.⁵ Some symptoms may be common for both GERD and LPR, therefore making it difficult to diagnose and potentially increasing the chance of misdiagnosis. In this case, diagnostic tests may also be used alongside symptom assessment and physical examination to determine if it is GERD or LPR.⁸ Diagnosis tests such as pH monitoring to detect any acid reflux over 24 hours,⁵ and endoscopy, which uses a small, thin tube-like camera to inspect the inside of your food pipe or larynx region.⁴ Treatment and Prevention Strategies.

Treatments can include medications that you get “over the counter” to neutralise any acid outside of your stomach, often known as antacids. Medication that is prescribed by a doctor includes proton pump inhibitors (PPIs), which help to reduce the amount of acid your stomach produces.^4,5 If your vocal cords are inflamed because of acid reflux, reduced singing and speaking may be advised, with potential vocal therapy afterwards, to prevent further damage.

Prevention strategies include changing your diet and lifestyle. You may have to cut down on specific foods such as spicy, fatty or sour foods, as well as caffeine and alcohol. Sitting upright when eating and eating slower, in smaller portions, more regularly, can also help. Losing weight or wearing looser clothing can reduce the pressure around your stomach, helping to reduce occurrences of acid reflux.^4,5 

Adele, a famous British singer, has mentioned that her singing voice was affected by acid reflux. She determined it was specific foods in her diet that were inducing her acid reflux. Cooked tomatoes were causing her acid reflux, and so she limited her intake of foods such as pizza. Bill Clinton, a former U.S. president and famous public speaker, was also said to have a long-term hoarse voice during his campaign and presidency, and his doctors said the cause was LPR. He had various factors that affected the risk of LPR, including allergies and being overweight. 

Summary

Acid reflux manifests in different forms, mainly including gastroesophageal reflux (GER), gastroesophageal reflux disease (GERD) and laryngopharyngeal reflux (LPR). GER is the basic term for the acidic contents of your stomach reaching the oesophagus, causing symptoms such as heartburn. GERD is the long-term, chronic version of GER, and LPR is acid reflux that reaches your larynx or voice box/vocal cords, causing symptoms such as a sore throat, coughing and, importantly, impacting the quality of your voice. Your voice may become raspy, weaker and strained, requiring increased vocal effort and potentially losing control of your voice during performances and events, which may impact your confidence and mental health. If you experience the same symptoms, speaking to a medical professional can help, as they can advise you further on specific, important dietary and lifestyle changes, or medications, to treat and prevent acid reflux occurrences.