Vol. 14 Issue 21
GERD/LPRD and Voice Management
A survey of voice clinicians
Gastroesophageal reflux disease (GERD) and laryngopharyngeal reflux disease (LPRD) have been well documented in the medical literature. The literature in speech pathology contains only a few references to these disorders, presenting information primarily with regard to their effects on swallowing function and only secondarily with regard to their effects on the voice.
Otolaryngologists, gastroenterologists and speech-language pathologists, particularly voice therapists, are aware that these conditions can have a negative effect on the health of the vocal folds and, subsequently, the quality of the voice. While speech therapists indicate they treat patients who manifest voice disorders and a percentage of these patients have been diagnosed with GERD or LPRD, they hesitate to report they treat the vocal symptoms specifically associated with these conditions.
This paper presents the results of a survey of speech-language pathologists who were members of the Voice and Voice Disorders Special Interest Division (SID 3) of the American Speech-Language-Hearing Association.
GERD, a relatively common disorder of the gastrointestinal system, affects an estimated 25 percent to 35 percent of the population in the United States.1 It refers to the backflow of stomach contents into the esophagus.2
The symptoms of GERD include heartburn, stomach pain, dysphagia, persistent laryngitis/hoarseness, persistent sore throat, chronic cough, globus sensation, and inflammation of the vocal cords.3 Symptoms of GERD or LPRD that may be treated by the voice clinician include hoarseness and oral/pharyngeal phase dysphagia.
LPRD refers to a backflow of stomach contents into the throat (laryngopharynx).2 Patients who have LPRD do not usually complain of heartburn, as do patients with GERD. The most commonly reported symptoms of patients diagnosed with LPRD are dysphonia, vocal fatigue and voice breaks.4 Any of the vocal symptoms of LPRD may come to the attention of the voice clinician.
The literature in speech pathology contains only few references to these disorders, presenting information primarily with regard to their .....effects on swallowing function and only secondarily with regard to their effects on the voice.5-8 Physicians, primarily gastroenterologists and otolaryngologists, diagnose and treat GERD and LPRD. Treatment typically consists of the use of over-the-counter (OTC) or prescription medications. Anti-reflux surgery is reserved for patients with severe or intolerable symptoms.
The goals of treatment are to relieve symptoms, heal damaged esophageal mucosa, and prevent further erosion of the esophagus and laryngopharynx.9 Since vocal abuse and laryngeal tension also may occur with these conditions, voice therapy may be recommended as part of the treatment regimen.10-12 Up to 50 percent of patients with LPRD also have voice disorders, data from recent research indicate.13,14
The purpose of this investigation was to assess current applications, if any, of voice therapy in cases of GERD/LPRD and, specifically, the number of voice clinicians who treat patients with these conditions.
A five-item survey was developed and posted on the professional Web site of one of the authors. The purpose of the survey was given in the request for responses, which was posted on the ASHA Listserv for SID-3. A link was provided to the Web site where the questionnaire could be found. Results from the questionnaire, questions and additional comments were forwarded to an e-mail address.
The survey items posted on the Web site were as follows:
1. Do you currently or have you seen patients for voice disorders in the past year? Responses: yes or no.
2. What percentage of your caseload consists of voice patients? Responses (in percent): 0-20, 21-40, 41-60, 61-80, or 81-100.
3. Of the patients you see for voice therapy, what percentage have been diagnosed with GERD or LPRD? Responses (in percent): 0-20, 21-40, 41-60, 61-80, or 81-100.
4. Of the voice therapy patients diagnosed with GERD or LPRD, what percentage is taking medication prescribed for this condition? Responses (in percent): 0-20, 21-40, 41-60, 61-80, or 81-100.
5. Of these patients, what percentage are you actively treating for the vocal symptoms of GERD or LPRD? Responses (in percent): 0-20, 21-40, 41-60, 61-80, or 81-100.
The total membership of the SID 3 Listserv was 830 at the time the invitation for responses was posted, according to the administrator. The total number of responses received was 121, which constituted a 14.57 percent response rate.
Figures 1-5 illustrate the responses to the survey questions. As seen in Figure 1, the vast majority of the respondents (98 percent) indicated they currently see patients with voice disorders or have seen them in the past year. Caseload percentages given in Figure 2 indicate that more than one-third (38 percent) of therapists responding to the survey reported a large portion (81 percent to 100 percent) of their caseload consists of voice patients.
In Figure 3 the survey data show 30 percent of respondents indicated 61 percent to 80 percent of their voice therapy patients have been diagnosed with GERD or LPRD. The data in Figure 4 show 41 percent of respondents report 81 percent to 100 percent of their voice patients diagnosed with GERD or LPRD take medication prescribed for the condition.
Among the voice therapy patients diagnosed with GERD or LPRD, zero to 20 percent of them are treated for the vocal symptoms of these conditions, indicated slightly more than one-fourth (28 percent) of the survey respondents. (See Figure 5). This percentage was closely followed by 24 percent of the therapists who indicated they treat 21 percent to 40 percent of the voice patients on their caseload for the vocal symptoms of GERD or LPRD.
Based on the results of this survey, voice patients seem to constitute a significant portion of the caseload for the vast majority of respondents. More than a third (38 percent) of respondents reported 61 percent to 80 percent of their voice therapy patients have been diagnosed with GERD/LPRD. Most of these patients are taking medication prescribed for the conditions.
In contrast, more than a half of survey respondents indicated they are treating 40 percent or less of the patient diagnosed with GERD or LPRD for the vocal symptoms precipitated by these conditions.
The preponderance of comments received regarding the survey items was focused on the wording of question 5: "Of these patients, what percentage are you actively treating for the vocal symptoms of GERD or LPRD?" Therapists were quick to point out that voice therapists neither diagnose nor treat GERD or LPRD or any of their symptoms. The comments stressed that only a physician can diagnose and treat these medical conditions.
In addition to the actual survey responses, unsolicited communication via e-mail was received. Therapists questioned if treating voice problems experienced by patients with GERD/LPRD is equivalent to treating the vocal symptoms of these conditions. The fact that this was a major concern for therapists who responded to the survey indicates a significant number of voice therapists treating patients diagnosed with GERD or LPRD perceive a dichotomy between treating symptoms of voice disorders and treating the vocal symptoms of GERD/LPRD. To our knowledge, no such dichotomy exists. The comments and questions received in addition to survey responses indicate that voice therapists are hesitant to report that they treat vocal symptoms, which are purely medically based.
In conclusion, the vocal symptoms associated with the relatively common conditions of GERD and LPRD are well documented in the medical literature, but there are relatively few references to these conditions in the speech-language pathology literature.5-8 Many people who seek voice therapy also have GERD or LPRD. Data from the medical literature support this observation.
Speech-language pathologists readily report they treat voice patients, many of whom have been diagnosed with GERD or LPRD; but they are hesitant to report they treat the vocal symptoms of these conditions. The speech-language pathologists who responded to the survey seem to want to differentiate between treating a voice disorder and treating a voice disorder that is associated with a purely medically-based condition.
The following crucial questions need to be answered:
• Precisely why are speech-language pathologists reluctant to report that they treat voice disorders resulting from GERD or LPRD?
• Should these voice problems be treated in conjunction with medical treatment or only after medical intervention has run its course?
• Should only patients who have developed potentially damaging compensatory behaviors be treated by speech-language pathologists?
Continued vigorous discussion among speech-language pathologists who treat voice disorders will be beneficial in moving toward a more unified view of voice therapy for patients with GERD or LPRD.
1. Scott, M., Gelhot, A.R. (1999). Gastroesophageal reflux disease: Diagnosis and management. American Family Physician, 59: 1161-69.
2. Koufman, J.A. (2002). Laryngopharyngeal reflux 2002: A new paradigm of airway disease. ENT-Ear, Nose & Throat Journal, 81: 2-6.
3. Bain, W.M., Harrington, J.W., Thomas, L.E., Schaefer, S.D. (1983). Head and neck manifestations of gastroesophageal reflux. Laryngoscope, 93: 175-79.
4. Belafsky, P.C., Postma, G.N., Amin, M.R., Koufman, J.A. (2002). Symptoms and findings of laryngopharyngeal reflux. ENT-Ear, Nose & Throat Journal, 81: 10-13.
5. Koufman, J.A., Sataloff, R.T., Toohill, R. (1996). Laryngopharyngeal reflux: Consensus report. Journal of Voice, 10: 215-16.
6. Morrison, M.D., Nichol, H., Rammage, L.A. (1988). Diagnostic criteria in functional dysphonia. Laryngoscope, 94: 1-8.
7. Mendell, D.A., Logemann, J.A. (2002). A retrospective analysis of the pharyngeal swallow in patients with a clinical diagnosis of GERD compared with normal controls: A pilot study. Dysphagia, 17: 220-26.
8. Rayhorn, N., Argel, N., Demchak, K. (2003). Understanding gastroesophageal reflux disease. Nursing, 33: 36-42.
9. Holmes, S.L. (2003). Gastroesophageal reflux disease: Pathophysiology and management. ADVANCE for Speech-Language Pathologists & Audiologists, 13 (6), 26-27.
10. Diamant, E.S. (2002). A Primer: Reflux disorder. Treatment can be beneficial, but compliance varies. ADVANCE for Speech-Language Pathologists & Audiologists, 12 (45): 36-37.
11. Koufman, J.A., Amin, M.R., Panetti, M. (2000). Prevalence of reflux in 113 consecutive patients with laryngeal and voice disorders. Otolaryngology-Head Neck Surgery, 123: 385-88.
12. Loughlin, C.J., Koufman, J.A. (1996). Paroxysmal laryngospasm secondary to gastroesophageal reflux. Laryngoscope, 106: 1506-09.
13. Kuhn, J., Toohill, R.J., Ulualp, S.O. (1998). Pharyngeal acid reflux events in patients with vocal cord nodules. Laryngoscope, 108: 1146-49.
14. Belafsky, P.C., Postma, G.M., Koufman, J.A. (2002). Validity and reliability of the reflux symptom index (RSI). Journal of Voice, 16: 274-77.
Peter Mueller, PhD, is director of the School of Speech Pathology and Audiology at Kent State University, in Kent, OH; and Barbara Prakup is a doctoral student and part-time instructor at the school. They gratefully acknowledge Andrew Angell for Web site coordination and the members of the ASHA SID 3 who took the time to respond to the survey. For more information, contact Prakup at firstname.lastname@example.org.