Pre-nodules, Acid Reflux and Vocal Care, Part 2

A number of years ago, I wrote an article on vocal polyps, hemorrhages, nodules, and reflux. Since then, I’ve received many great emails, particularly about acid reflux. Here are my answers to your questions, as well as seven tips to help you deal with and heal this all too common problem.

For starters, when it comes to any persistent vocal issue, your best first step is to visit an Otolaryngologist, or ENT (ear, nose and throat doctor). Beyond discussing your symptoms, he or she will be able to use a strobe– or small camera– to view your vocal cords and ascertain exactly what is going on. In the case of reflux, what your doctor is looking for is redness and irritation in the larynx and on the vocal folds.

While acid reflux presents with real physical symptoms, in my experience, stress– and our inability to manage it effectively– is the number one cause of reflux and GERD (gastroesophageal reflux disease). Food and drink, genetic and physiological issues, tight clothing, intensive exercise, poor sleep habits, and other factors can certainly create problems, and can sometimes even be sole culprits. Yet I find that these issues tend to exacerbate symptoms rather than trigger the reflux itself.

One little known such biological cause of reflux is birth control pills, the hormones in which cause the loosening of the esophageal sphincter, and as a result, allow stomach acids to regurgitate into the larynx. An overabundance of yeast– often resulting from a course of antibiotics or a high sugar, refined carbohydrate diet– can also trigger reflux, which probiotics can help to manage. Determining whether these issues are present is my first step when a client comes in with a GERD diagnosis. If they are, my advice– when possible– is to stop the medication and dietary triggers for a few weeks, and see whether symptoms subside.

I also inquire about what may have changed in your life or lifestyle recently, particularly when reflux seems to come out of the blue. Have you moved? Taken on a new personal, professional, or performance opportunity? Even a seemingly small transition in your life– music related or otherwise– can have an impact. These questions also pertain to the development of pre-nodules; while they tend to be more voice-use related, stress and reflux can certainly help to exacerbate, and even cause, irritation and lesions on the cords.

It also doesn’t have to be a real, ‘in the world’ change for the body to react. Our thoughts and emotions can be­ just as powerful in creating reflux as travel, issues in our personal lives, and impending performances. While we may be aware of the difference between thoughts and reality, our bodies aren’t. 

Tip #1:

It’s therefore critical to recognize and deal with whatever stress you may be under. A healthy, balanced schedule, plenty of sleep and rest, time in the sun and nature, nutritious food, clean water, and nourishing relationships are all imperative. If your schedule is particularly hectic, you’re grappling with challenging personal or professional issues, or you tend toward the stressed out, learning to find peace through acceptance, responsibility, and forgiveness will help you relate to your circumstances and yourself more powerfully. Click on the links above if you’d like to read articles that might help you in these areas.

Tip #2:  If you have reflux, and even if you don’t, it’s important to drink a good amount of room temperature water. Water not only helps to keep your organs hydrated, flushed, and more healthy and efficient, it helps to thin and drain the mucous in your nose and throat, which becomes particularly thick after the onset of reflux. The thinner the mucous, the less inclined we are to clear our throats and cough– two habits that are a good idea to break, as they often cause irritation and additional vocal cord swelling.

Tip #3: When it comes to singing with reflux, my favorite expression is: No Compensating! Your voice may feel thick, slow, and rigid, but resist all temptation to push through and ‘fix’ these sensations.

Imagine you have a knot in your shoulder. Banging on it won’t help matters; slow, repeated massage will help to loosen its grip. The same is true when dealing with reflux. Be gentle, and be patient. Begin to speak and gently use your singing voice as soon as you wake up, and plan for a much longer warm up prior to a performance, rehearsal, or training session.

While your throat is indeed red and irritated where the acid has come back up through the vocal tract, save for few exceptions, it is safe to sing with reflux so long as you don’t push. It’s akin to being a bit tight after a particularly hard workout the day before; you just need to take extra care stretching and easing into the next workout to prevent injury. If you’re patient and hydrated, your voice will come around and you should be able to sing– and sound– as you usually do.

Tip #4:  On a similar note, when you have reflux it’s also critical to stop focusing on how you sound. This can be a challenge indeed, but the only way to get your voice to sound normal is to stop fixating on trying to make it so. Just as when your voice is healthy, first focusing on the sensations of engagement will allow you to understand and master the physicality of how your body produces sound, as well as how to rely on that physicality in any sonic situation.

When warming up, it’s therefore a good idea to initially avoid ‘singing-sounding’ and vocally challenging exercises (runs, riffs, and normally tight and tricky areas of the voice), which will help to reduce the intellectual and ego temptation to push in order to sound good. Lots of easy slides through your range and registers will help to get your voice moving and healthily warmed up, at which point you can bring your attention back to sound and performance specifics. Also, consider hopping into the shower; not only will the steam further help to loosen things up and get the juices flowing, you’ll likely find it easier to ignore that initial mucous rattle.

Tip #5: Whether or not we sing, everyone has opinion about what we should and shouldn’t eat. Obviously food is a personal choice and you need to find what works for you. That said, when it comes to treating and preventing reflux, I recommend limiting or cutting out sugar, wheat, pasta, and other processed carbs (fruits, veggies, and sprouted or ancient grains like quinoa are OK), which tend to quickly raise blood sugar levels and increase inflammation, as well as generate yeast. Many people find that removing dairy and caffeine help too, though I’ve consumed both without issue.

It’s also a good idea to limit your liquid intake right around and during mealtimes, so that the stomach acids can process the food more effectively, without dilution. The same goes for just before performances; the powerful engagement of your support can often encourage a full belly– of water or food– to reflux. Consider giving up carbonated beverages as well, and if you smoke, please stop. In general, moderation is a great tool, yet I’ve only ever seen these two cause problems.

Finally, try eating smaller meals more frequently, and when you do, eat slowly and chew your food. Mindfulness– in eating and in all areas of life– helps to calm down our thinking as well as our bodies.  I’ve seen this tip alone halt reflux after years of suffering in a number of my singers.

Tip #6: Use medications sparingly. I know they can help, and sometimes they’re necessary to prevent damage. But in the long run, you have to find and deal with the cause of the reflux, not just treat the symptoms. This is critical because reliance on reflux medications will eventually backfire; in time, they all stop working as the body finds ways to create the potent acid it needs to digest the food you eat. I'm reminded of what Benjamin Franklin once said: "he is the best physician that knows the worthlessness of most medicines."

Another important point is that the diagnosis of reflux has become so common, that it is almost a default starting point when a singer comes presenting with issues. Often a course of reflux medication will be prescribed as a trial, just to see if indeed reflux is the problem, before actually doing a thorough analysis and physical exam of the patient. Not only does this mean you may be taking medications your body doesn't need, but that the real cause of your vocal irritation– environmental or seasonal allergies, a virus, or whatever– is not being properly explored.

Tip #7: Also, beware of surgeries purporting to solve the reflux problem. In my early 20s, after having used every reflux medication on the market, I had surgery to tighten my lower esophageal sphincter to prevent acid from refluxing into my throat and damaging my vocal folds. Physiologically, the surgery was successful, but wouldn’t you know, six months later as I prepared to return to my singing engagements, the reflux was back!

When you’re stressed out, medication– and even surgery– won’t stop the body from reacting. Sure enough, once I learned to manage my stress, the reflux subsided, never to return again. Therefore, no matter what vocal challenges you may be dealing with, and particularly when reflux is diagnosed or suspected, be sure to take a holistic look at issues in your singing and personal life. Many of the clues to resolving the former can be found in the latter.

I hope you find these tips helpful. If you have more questions about reflux and other issues regarding vocal health, please send them in and we’ll continue the conversation!

JENNIFER HAMADY is a voice coach and board-certified therapist specializing in technical and emotional issues that interfere with self-expression. Her new book, The Art of Singing Onstage and in the Studio explores the technology and relationships in performing and recording. Her first book The Art of Singing: Discovering and Developing Your True Voice has been heralded as a breakthrough in the psychology of musical and personal performance and remains a top seller in the field. www.FindingYourVoice.com