Information About Gastroenterological Conditions that can affect the Voice

 

Two tracts


There are two major tracts in our necks: the trachea, for the passage of air to and from the lungs, and the oesophagus for the passage of food, usually to, but sometimes, when all is not well, from the stomach. The two passages run along-side each other in the neck and chest.

At the top of the trachea (windpipe), close to the top of the oesophagus (food pipe), is the larynx (voice-box), within which are the delicate vocal cords.

The vocal cords are the source of our voices.


The Respiratory/Vocal Tract


In fit, healthy people of any age, the entire respiratory/vocal tract, including the nose, mouth, trachea (windpipe) and larynx, has a smooth, moist, well-lubricated lining of mucous membrane cells.

The mucous membrane should secrete just enough mucus to keep the system wet, from the tip of the nose to the point where the trachea divides (at the tracheal bifurcation) and enters the lungs.


The Digestive/Gastric Tract


The oesophagus (food pipe) is the section of the digestive tract (gastrict tract) linking the mouth to the stomach. The oesophagus is a muscular tube, also lined with mucous membrane. Within the gastric tract are special cells which produce gastric juices, hydrochloric acid, and enzymes, which aid digestion. In fit, healthy people these substances (mucus, gastric juices, acid and enzymes) are produced in just the right amounts to digest the food being consumed.

The oesophagus starts at the upper oesophageal sphincter, and ends at the lower oesophageal sphincter. The oesophageal sphincters are designed to prevent abnormal movement of food upwards from the stomach, and abnormal movement of air downwards.

To prevent reflux (i.e., food and gastric secretions travelling up) the lower sphincter (LS) must maintain a pressure higher than the pressure in the stomach. Smoking, tranquillisers, some bronchodilators, nitrates, peppermint, alcohol, chocolate and fat all decrease LS pressure. LS pressure is increased by antacids and protein (e.g., low fat milk) ingestion, and that is why they are usually advised for people troubled by reflux.


Gastro-oesophageal Reflux Laryngitis


When gastric pressure (i.e., pressure in the stomach) becomes greater than LS pressure, reflux occurs. Gastro-oesophageal Reflux Laryngitis is an extremely unpleasant, but manageable, condition which is often found in professional voice users. Indeed, reflux was found in >38% of singers in a study conducted by Sataloff and colleagues (1988).

In professional singers, reflux is characterised by a warm-up time in excess of the 10 to 30 minutes usually taken to "warm up the voice", particularly in the morning or after sleeping. It is thought by some authorities to be aggravated by highly spiced foods, and drinks containing caffeine (tea, coffee, Coca-Cola), obesity, and a stressful lifestyle. Over-conscientious, high-achieving professionals, at the peak of their careers, seem to be a particular "at risk" group.

Referring to singers and other professional voice-users, who might include: academics (especially lecturers), actors, announcers, auctioneers, barristers, business managers, clergy, media presenters, politicians teachers, retail sales people, sports coaches, and tour guides Sataloff (1991) wrote:

'Reflux is common among singers and other professional voice users for several reasons. First, their performance requires markedly increased abdominal pressure, which works against the oesophageal sphincter. Second, many voice professionals perform without eating, because a full stomach interferes with abdominal support. Consequently, singers [and other professional voice users] arrive home late at night, eat a large meal, and go directly to bed. This lifestyle combines with the stress of a performing [or business / academic / legal] career to produce a disproportionately high incidence of this condition.

The most prevalent symptoms in professional voice users are hoarseness and a low voice in the morning, prolonged warm-up time, halitosis and a bitter taste in the morning, a feeling of a lump in the throat, frequent throat clearing, chronic irritative cough, a "coated" mouth, and frequent tracheitis or tracheobronchitis. Any or all of these symptoms may be present. Classic dyspepsia is usually absent.'


The Lombard Effect


The Lombard Effect is the tendency to increase vocal intensity, even to the extent of forcing the voice, in response to background noise, and is a common cause of voice strain in its own right. It occurs when professional voice users have to present to audiences in noisy settings or in poor acoustic conditions. It also happens when we converse at noisy parties, in aeroplanes and on car-phones.


Respiratory irritants


In the presence of airborne or chemical irritation, allergy or infection, the body naturally steps up mucus production, in order to protect the tract with more lubrication. When a chronic irritant is present, this natural protective response becomes over-productive and can pose distressing problems such as post-nasal drip, throat congestion, snoring and persistent coughing.


Gastric irritants


Gastric acid irritation of the arytenoid cartilages (to which the vocal cords are attached) can lead to pain during singing or professional speaking engagements such as business/media presentations, public speaking, preaching, lecturing, teaching, or in court.

Some people find it helpful to think of professional voice use as an "athletic" activity, and it is certainly true that the fitter you are, and the better you feel, the better your voice is likely to function.


Reference


Friedman, E. N. (2006, Nov. 7). Gastroesophageal reflux disease: Serious illness potential often misunderstood. The ASHA Leader, 11(15), 6-7, 20-21.


Self-management of reflux


There are a number of steps the professional voice user can take to restore the correct balance within and between respiratory and digestive function, and thereby control reflux and improve vocal function:

1. Elevate the head of the bed to the equivalent of the height of a house-brick. This is more effective than elevating the head with pillows.

2. Take antacids as directed by a medical practitioner.

3. Avoid eating for three hours, but preferably for four hours before going to sleep.

4. Increase food intake at breakfast and lunch, and make dinner a relatively small meal.

5. Avoidance of fatty foods, alcohol and caffeine is usually beneficial.

6. Maintain optimal weight for height (but do not lose weight suddenly by crash dieting, as this often exacerbates reflux symptoms).

7. If symptoms do not subside within a matter of three or four weeks, with conscientious adherence to this regime, then a full gastroenterological evaluation is advisable.


Other Gastroenterological Problems


Digestive tract problems other than reflux can and do affect the voice. Any condition that undermines abdominal function may interfere with the voice by undermining abdominal support - diarrhoea and constipation are notorious in this regard. Some medications used to treat enteritis can have a deleterious effect on the voice. For example, Atropine relaxes the lower oesophageal sphincter (LS) and may aggravate reflux. Any abdominal pain which causes the professional voice user to limit abdominal muscle contraction (e.g., as in diarrhoea) can cause voice dysfunction.


General Guidelines for Voice-Care


  • Maintain good health.
  • Recognise and manage intolerable levels of stress.
  • Eat a healthy diet.
  • Take regular, enjoyable exercise.
  • Monitor your posture and levels of muscular tension.
  • Drink sufficient water (at least 1 litre per day).
  • Drink alcohol in moderation.
  • Don't smoke.
  • Avoid polluted, dry and stuffy atmospheres.
  • Take fresh-air breaks as often as you can.
  • Nose-breathe on planes.
  • Avoid drying medications.

References


Sataloff, R.T. (1991). Reflux and other gastroenterologic conditions that may affect the voice. In Robert T. Sataloff (Ed.) Professional voice: The science and art of clinical care. New York: Raven Press Ltd.

Sataloff, R.T., Spiegel, J.R., Carroll, L.M. (1988). Strobovideolaryngoscopy in professional voice users: Results and clinical value. J. Voice: 1, 2 (2): 78-89.