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Approximately 75% of my voice rehabilitation clients have reflux ranging from mild to severe. It is important for singers to recognize the symptoms of reflux as well as other medical disorders that cause or exacerbate vocal problems so that they may seek prompt medical attention. Many reflux suffers are not consciously aware of the symptoms, because chronic reflux often dulls one's esophageal sensations and the symptoms do not appear to be associated with their vocal problems.

Stress is a major cause or exacerbator of reflux, -- personal stress, performance stress and physical stress. Fatigue, singer's worst enemy, is another contributing factor. Also, watch your weight, because obesity is a reflux trigger. Losing weight relieves abdominal pressure.

Singers, actors, and other professional voice users are more at risk, because the increased intra-abdominal pressure needed for performing works against the esophageal sphincter. Also, many voice professionals do not eat before performing -- and they usually sing in the evening. A full stomach interferes with abdominal support. To make matters worse, singers arrive home late at night, eat a large meal, and go directly to bed. When a singer "supports the tone," the contents of the stomach are pushed up toward the diaphragm, weakening the lower esophageal sphincter. The "GERD process" has begun!

Knowledge of the digestive process is helpful in understanding reflux. Digestion consists of process dissolving food and breaking it down into simpler chemicals which can be absorbed by the blood and used to provide energy. Foods and liquids we swallow travel through a tube, the esophagus, to the stomach, where it is mixed with gastric acid and enzymes. This process takes about an hour. The food then continues through the pyloric sphincter, the "doorway" from the stomach into the duodenum which is the first part of the small intestine. There it is mixed with digestive juices secreted by the liver and pancreas. The partially digested food is then transported down the small intestine where more enzymes break down proteins, fats, and starches into food molecules easily absorbed into the bloodstream. Undigested food and waste products are handled by the large intestine (colon). Normally, the sphincter muscle at the bottom of the esophagus prevents "refluxing," but fatty and acidic foods, chocolate, alcoholic beverages, some medications, and cigarettes relax the esophageal sphincter. If it fails to close tightly after food has passed through on its way to the stomach, the gastric acid backs up into the esophagus, causing a burning sensation or a painful "fire" in the stomach, throat and/or chest - hence the name heartburn.

The vocal process (arytenoids) is attached to the posterior "end" of the vocal folds near the uppermost opening of the esophagus. The stomach contains extremely corrosive hydrochloric acid which flows or is flushed backwards or refluxed into the esophagus. This acid irritates the mucous membrane lining of the esophagus and "eats away at" the very thin, delicate covering of the arythenoids (cartilage-like muscles). The sphincter is supposed to act as a one-way valve (not a true valve ) to keep the contents of the stomach from backing up into the esophagus. The corrosive acid can cause swelling , vocal ulcers, contact ulcers, granulomas (a sort of tumor or nodule), and erosive esophagitis (Barrett's esophagus, an inflammatory process). Erosive esophagitis, which contributes to poor motility, causes refluxed stomach acid to be trapped in the lower esophagus and may predispose patients to esophageal and laryngeal cancer. Untreated erosive esophagitis can result in a build-up of scar tissue which may require dilation (stretching) of the esophagus to allow the patient to swallow.

Otolaryngologists (ear, nose and throat physician specialists) or laryngologists (throat specialists) can usually recognize and diagnose reflux by inspecting the vocal folds. The characteristic red and swollen mucosa covering the arythenoids and the swelling and irritation of the posterior third of the vocal folds indicates probable reflux. Other, more definitive diagnostic tests used to confirm the diagnosis of reflux are: Barium swallow, 24-hour pH monitor study, and gastroesophageal endoscopy (insertion of a fiber-optic tube which lets the physician visually examine it).

If you have several of the symptoms listed below, you probably have reflux. Some of the most common symptoms are:

• 1. Bad breath (halitosis) and a bitter taste in the mouth when one awakens.
• 2. Excessive thick phlegm, particularly in the morning.
• 3. Heartburn.
• 4. Chronic throat clearing and tickle in the throat.
• 5. Chronic, irritating cough.
• 6. A scratchy, sore throat, particularly in the morning.
• 7. Chronic Hoarseness.
• 8. A "lump in the throat."
• 9. Excess mucus production.
• 10. Prolonged vocal warm-up, with low or husky voice quality.
• 11. Undependable voice -- good one day and hoarse and tired the next.
• 12. Vocal fatigue after short periods of singing and speaking.
• 13. Trouble breathing or laryngospasm (closing-off of the airway).
• 14. Regurgitation of food and liquids.
• 15. Exacerbation of asthma. Asthma is also more difficult to control when complicated by reflux.

The tickle cough, throat clearing, coughing and vocal fatigue resulting from reflux can be eased and soothed by spraying with Entertainer's Secret. Of course, be sure to drink plenty of liquids so that your throat membranes are not dry. Remember, for a beautiful sound and correct resonation of the voice, the mucus membranes of the nose and mouth must be moist. Don't "save" Entertainer's Secret for times when you are desperate, dry, or just before a performance. Use it often during the day, particularly if your mouth is dry or you have reflux and vocal fatigue.

Researchers at Thomas Jefferson Medical College in Philadelphia provoked heartburn by feeding the volunteers a meal that was high in fats. The patients were then asked to lie down on either their left or right sides and the esophageal acid levels were measured for four hours. Those patients who rested on their right sides experienced reflux for 200 minutes, while the "left siders" experienced approximately 100 minutes -- half the amount. Gastroenterologist Dr. Donald Castell said, "Lying on the right side may un-crimp the esophagus where it enters the stomach, making it easier for stomach acids to enter." These findings are valid, whether induced by fat consumption, caffeine, alcohol, spicy foods, or acid foods, so try sleeping on your left side more often.

Treatment of reflux can be relatively simple, depending on the cause and severity of your condition. Your self-discipline and adherence to the Reflux Regimen listed below can, in many cases, eliminate or reduce the symptoms of reflux. Try the regimen for a week, if not free of symptoms, consult your physician immediately. If it is indeed reflux, medications may be required.

The most common medications recommended by physicians are antacids. Four over-the-counter medications are Gaviscon [my preference], Maalox, Mylanta, and Gelusil. Diet restrictions and antacids may be sufficient to relieve symptoms of mild reflux, however, physicians may recommend taking antacids in conjunction with other medications . Some medications prescribed which suppress production of stomach acid are Zantac, (ranitidine) Tagamet (cimetidine), Pepcid (famotidine), Axid (nizatidine), and Prilosec (omeprazole) . Note: Recently researchers have advised carefully monitoring anyone taking Propulsid. It sometimes causes incontinence, particularly women.

Complete Vocal Rest For A Few Days May Be Required, depending on the severity of your symptoms. Then you must limit vocal use, particularly when speaking, until the reflux improves. When beginning to rehabilitate the voice, use easy humming exercises and lip trills. Vocalize quietly in the middle range.

Remember, medications alone may not [probably will not] solve your problems. Singers and professional voice users with even mild reflux must raise the head of their beds and follow the diet in order to gain optimal vocal improvement, with or without medications!!!

The Loeding Reflx Regimen:

• 1. ELEVATE THE HEAD OF THE BED at least 4-6 inches on wood blocks. DO NOT SUBSTITUTE MORE PILLOWS. This only aggravates the condition. Put the blocks under the legs of the bed, allowing gravity to keep the acid from reaching the vocal folds.
• 2. DO NOT LIE DOWN for at least three hours after eating. Gravity makes it easier for the liquids and foods to be refluxed.
• 3. AVOID EATING LARGE MEALS, which puts greater stress on the lower esophageal sphincter and result in increased acid production.
• 4. FOLLOW DIET RESTRICTIONS, for example:

AVOID Acid Foods - tomatoes (pizza, spaghetti, catsup, etc.) and citrus fruits, pineapples, cranberries. AVOID alcoholic beverages. AVOID Highly Spiced Foods. This eliminates many Mexican, Italian, Thai, Indian and Chinese dishes. AVOID Fats and Fried Foods. AVOID Peppermint. AVOID Caffeine and Chocolate. Caffeine causes the band of muscles separating your esophagus and stomach to relax. This allows the stomach acid to back up into the esophagus , which can irritate reflux and existing stomach ulcers by increasing stomach acid secretion [and gastrointestinal upset]. NOTE: Some caffeine-containing beverages: Jolt, Surge, Mountain Dew, Mellow Yellow (very high caffeine content), Coca Cola, Pepsi Cola, and Dr. Pepper -- Eliminate soft drinks with caffeine. Drink decaffeinated soft drinks or water - despite what you may have heard, water will not rust your pipes. Coffee , chocolate, and tea. All coffee products are acid, so you must eliminate decaffeinated coffee , too. Drink herbal or decaffeinated tea. And some over-the counter drug products have caffeine as an ingredient, e.g. stimulants like No Doz ; pain medications like Excedrin, Anacin, BC, Goody's Headache and Migrainex; and some appetite suppressants. Read the labels carefully! AVOID taking sleeping pills if at all possible. After taking a sleeping pill you may not awaken to change positions, allowing the gastric acid to stay in the esophagus longer and cause even more damage to the thin tissue lining the food pipe and the tissue covering the vocal folds.

RESTRICT items with vinegar, such as pickles, Italian dressing, and green olives.

LIMIT Milk Products (milk, ice cream, cottage cheese, sour cream cheese, etc.). Active culture yogurt improves the condition. Lactose and butter fat are responsible for exacerbating reflux. Buy 100% lactose reduced milk.

DO NOT SMOKE and Avoid Smoky Places.

NOTE: It will be very difficult to avoid everything on this list, but you should try to eliminate the worst offenders and severely limit the others. Reflux is often mistaken for heart attacks and bulimia. The chest pains caused by esophageal motility problems may mimic the symptoms of a heart attack. The vocal and esophageal symptoms of reflux are very similar to symptoms of bulimia.

If these restrictions seem to take all of the fun out of your life, you must decide what your priorities are. If you wish to fulfill your potential as a singer or speaker, you must have determination, courage and self-discipline. Your voice will not improve appreciably until you follow the reflux regimen. But, let's be positive, this diet is healthy and may help you to lose weight since it eliminates most junk foods and, again, gaining too much weight exacerbates reflux.

I will end with a quote from Izaak Walton: "Look to your health; and if you have it, praise God and value it next to a good conscience; for health is the second blessing that we mortals are capable of - a blessing that we cannot buy; therefore value it, and be thankful for it."

APPENDIX A. Digestive Process

Digestion is a process used by the body to dissolve food, break it down into simpler chemicals which can be absorbed by the blood and used to provide energy. Foods and liquids we swallow travel through the esophagus into the stomach, and are mixed with gastric acid and enzymes. This process takes about an hour. The food then continues through the pyloric sphincter into the duodenum where it is mixed with digestive juices secreted by the liver and pancreas. The partially digested food is then transported through the small intestine, where more enzymes break down proteins, fats, and starches into food molecules easily absorbed into the bloodstream. Undigested food and waste products are handled by the large intestine (colon).

APPENDIX B. Upper Esophageal Sphincter & Lower Esophageal Sphincter

Quoted from The Professional Voice by Robert T. Sataloff, Chapter 12: Gastroesophageal Reflux Laryngitis.

"The esophagus is a tubular structure made of muscle and mucosa. Its primary function is to carry food from the mouth to the stomach. It starts at the upper esophageal sphincter (UES) and ends at the lower esophageal sphincter (LES)." (p.180) "The sphincters are designed to prevent abnormal movement of food upward from the stomach or esophagus and abnormal movement of air down." (P. 180)

"In order to prevent gastroesophageal reflux, the lower esophageal sphincter must maintain a pressure higher than that in the stomach. Smoking, tranquilizers, some bronchodilators, nitrates, peppermint, alcohol, chocolate, and fat - decrease LES. LES is increased by antacids and protein ingestion. Its tone is caused by intrinsic muscle activity." ....

" . . . (LES) is decreased by drugs such as atropine and calcium channel blockers. Beta-adrenergic and dopaminergic neurotransmitters inhibit lower esophageal sphincter contraction... Various hormones alter lower esophageal sphincter pressure." (P 180-181)

APPENDIX C. Reflux and Other Serious Esophageal Diseases

Quoted from The Professional Voice by Robert T. Sataloff Chapter 12: Gastroesophageal Reflux Laryngitis (p. 179)

"... reflux is common among singers and other professional users for several reasons. First, their performance requires markedly increased abdominal pressure, which works against the esophageal sphincter. Second, many voice professionals perform without singing, because a full stomach interferes with abdominal support. In addition, they usually sing in the evening. Consequently, singers arrive home late at night, eat a large meal, and go directly to bed."

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