My friend Kate, a professional singer for a decade, had a rude awakening about 3 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.
She chronicles her journey back to vocal health in her book “Just One Voice”, but one of the underlying causes of her injury was reflux.
This is the stuff singer’s nightmares are made of. 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.
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.
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.
What does this mean to 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:
Chronic cough and throat clearing
Feeling of a lump in the throat
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.
What can you do?
I’ve already laid out some basics in Acid Reflux and the Singer: What Every Singer Needs to Know. Paying attention to what you eat does matter. There is now evidence that a plant-based diet together with alkaline water is as effective as proton-pump inhibitor (PPI) therapy.
Why is the alkaline water important? Remember earlier I mentioned that the pepsin is active in acid (that's a pH of 2 – 6.9) and can be reactivated by coming into contact with more acid? Well, it turns out that pepsin is permanently deactivated in an alkaline environment.
An alkaline pH of 8 – 10 is most effective to deactivate pepsin.
You can buy alkaline water, or you can buy expensive machines that can mineralize your water to make it alkaline. It’s also possible to make your own by adding baking soda to water, however, this has a high sodium content, which is not recommended for your health. Buying bottled alkaline water may be the best way to go if can’t spring for a machine. If you are on a tight budget, then instead of drinking the baking soda water, try gargling after a meal.
These are the dietary steps Kate took to help with her reflux: An anti-inflammatory plant-based approach, avoiding triggers like soda, caffeine, chocolate, citrus, tomatoes and strong spices and alkaline water. Her folds are now pristine.
If you suspect you have reflux, get checked by and ENT, and if you want to get back on track vocally, you may be interested in The Fit Singer’s 14 Day Vocal Reset, which includes a reflux friendly meal plan.
Doucet, Kate J, Just One Voice A Book on Vocal Sustainability and Injury Prevention, 2018, Outskirts Press, Inc.