© John Messmer 1999
When we swallow, muscles in the throat squeeze the food or liquid into our esophagus. Further movement is aided by muscles in the esophagus so that food moves into the stomach. Just prior to getting to the stomach, the food passes through the diaphragm which is a muscle that separates the chest and abdomen and moves down to allow air into the lungs. The diaphragm muscles "interlock" at the back part where the esophagus passes through. This diaphragmatic "crus" or crossing serves to close the esophagus and keep food and liquids in the stomach.
Occasionally all people will bring a small amount of food or liquid into their esophagus, such as, after a large meal or carbonated beverages or if air is swallowed. This is called "reflux," which means "flow backward." Normally, the esophagus can tolerate this and no symptoms other than eructation (burping) are noted. Sometimes stomach acid will irritate the esophagus and "heartburn" will occur.
By age 35 or so, most peoples' diaphragms begin to have some slacking of the crus, allowing more stomach fluid to reflux. If this occurs often, eventually the esophagus can get irritated so that heartburn occurs frequently. In some cases, the heartburn also provokes spasm in the esophageal muscles while it tries to squeeze the fluid back down. This esophageal spasm can mimic a heart attack in its intensity.
If the acid is allowed to burn the esophagus for a while, it can damage the esophagus and can in rare instances increase the chance of esophageal cancer, though there are many other factors involved in cancer production, such as, smoking and infection with Helicobacter pylori, a bacterium that is involved in ulcers.
Some people reflux acid and digestive enzymes all the way up the esophagus into the throat where symptoms can include sore throat, chronic cough, ear ache and ear congestion. If the acid or digestive enzymes get into the larynx, even in minute quantities, the vocal folds can be severely irritated. This can cause hoarseness, vocal pain, loss of range, vocal fatigue and long term, it can cause thickening of the folds and polyps. Nodules could occur as a result of vocal abuse that the singer performs trying to overcome the problems the reflux is causing, such as, excess tension trying to overcome the irritation of the folds.
Reflux is typically worsened by large meals, carbonated beverages, high fat meals, eating rapidly (which causes swallowed air), alcohol, mint, smoking, being overweight and being supine after a meal. (Note that many people can do all of these things with no problem at all; it depends on the person.) Some medications used for other problems can cause reflux, also.
People notice heartburn, but heartburn is not always a part of the reflux. Thus, antacids or acid blockers alone may not fix the problem. If heartburn is the only symptom, correcting any contributing factors should be attempted first. Weight loss is often the first thing to try as even a few pounds can make a difference. Antacids such as Maalox, Mylanta and Gaviscon can reduce symptoms or prevent them if taken prior to the onset of symptoms.
The class of drugs called histamine type 2 receptor blockers or H2 blockers, such as, Zantac, Pepcid, Tagamet and Axid reduce the production of acid so that heartburn is reduced. If acid reflux is the only problem, these may be sufficient. The doses available without prescription are half the prescription strength, though is some countries the higher strengths may be available without prescription.
The group of drugs called proton pump inhibitors are newer than H2 blockers and more effectively block the production of acid. When first introduced there was concern over the possibility of these drugs causing a type of low grade tumor in the digestive tract. This fear has turned out to be unfounded. Typical use is considered safe.
Since reflux is more than just acid, elevating the bed six inches off the ground at the head end can use gravity to assist in keeping the fluids in the stomach. Avoidance of food and beverages for two hours before bedtime and not reclining after meals can help also. If necessary, medication can be added. Often, one to two months of continuous medication can stop the reflux for many months without continuous treatment.
Sometimes a promotility agent is added or used alone. These medications encourage the esophagus to contract downward which tends to keep the stomach contents in the stomach. They also help the esophagus to stay tight at the lower end to reduce reflux. These medications can interact with others and can in rare cases have untoward side effects. Propulsid (cisapride) has been associated with heart rhythm disturbances in high doses and when combined with some other drugs; Reglan (metoclopramide) can cause fatigue, confusion and muscular dysfunction all of which are reversible.
If you suspect reflux and have tried some of the suggestions above, it would be best to check with your doctor. It can be difficult to diagnose even for physicians. Often the ENT does the diagnosing since reflux causes fairly characteristic changes in the throat and larynx. For most people it is manageable and the singer is almost always able to continue.
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