Acid Reflux

The backward flow (reflux) of acid from stomach up into the esophagus or, even further up, to the level of the laryngopharynx. Symptoms may be esophageal, laryngopharyngeal, or both. Esophageal symptoms include heartburn, indigestion, and acid belching. Laryngopharynx symptoms tend to include dry throat, husky (especially morning) voice, frequent morning throat clearing, excessive mucus, and mildly sore throat.

Sometimes acid reflux is diagnosed when it isn’t the real problem. The do-it-yourself trials in this downloadable article can help a person and his or her personal physician verify if acid reflux is the appropriate diagnosis: When Acid Reflux Treatment Takes You Down a Rabbit Trail

Q:  I’m told I have acid reflux, but how can that be if I don’t have heartburn?

A: It is possible to have an MI (heart attack) without any chest pain. In the same way, it is possible to have acid reflux up the esophagus without any heartburn. Beyond this, even if acid comes up into the throat at night, this may not waken you unless it is major. Think of gentle-to-moderate rain in the night as an analogy. If you do have the nighttime reflux, however, you may notice symptoms such as a dry or scratchy/sore throat, increased mucus production with throat clearing, a deep morning voice requiring more warmup if you must sing early in the day. The potential for “silent” reflux explains why physicians may suggest a treatment trial even when you have no awareness of actual acid either during the day, or at night.

See also: gastroesophageal reflux disease and laryngopharynx acid reflux disease.

1. Originally published in Classical Singer, April 2009. Posted with permission.


Endoscopic View of Esophageal (Acid) Reflux

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Liquid in the lower esophagus

Liquid in the lower esophagus (1 of 2)

After swallowing blue food-colored water, it sits momentarily in the lower esophagus waiting to enter the stomach. The saliva bubbles indicated by arrow and dotted lines are for reference with the next photo.
Acid reflux in the lower esophagus

Acid reflux in the lower esophagus (2 of 2)

A moment later, without effort or gag, the blue water refluxes (zooms upwards from the lower esophagus and stomach) towards the stationary camera chip. If this occurred with acidic stomach contents, the esophagus would suffer chemical irritation and the patient might experience “heartburn.”

Acid Reflux

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Phonation under strobe light

Acid reflux (1 of 2)

Phonation under strobe light. Mild capillary prominence.
Acid Reflux during phonation

Acid reflux (2 of 2)

As phonation proceeds, appearance of large amounts of viscous white mucus.
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Open phase of vibration

Acid reflux (1 of 2)

Open phase of vibration, strobe light, with white mucus sometimes but not always suggestive of acid reflux laryngitis.
Closed phase of vibration

Acid reflux (2 of 2)

Closed phase of vibration, strobe light, with same mucus findings.

Acid Reflux and Sicca Syndrome

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Acid reflux (1 of 4)

This man has obvious clinical symptoms of acid reflux such as heartburn, excessive morning mucus, husky morning voice. Note classic interarytenoid pachyderma, diffuse pinkness.

Prominent capillaries and mucus (2 of 4)

Here we see loss of color differential between true and false cords. Capillaries are prominent (like bloodshot eyes) on the true cords. There is also adherent mucus.

Closer view (3 of 4)

Closer view of the prominent capillaries.

Redness and inflammation (4 of 4)

Even the upper trachea shows evidence of redness and inflammation. This is not seen that often except with truly severe nocturnal acid reflux/ LPR.

Acid Reflux Laryngitis

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interarytenoid pachyderma

Acid reflux laryngitis (1 of 2)

Panoramic view, shows interarytenoid pachyderma (“elephant skin”) at upper blue arrow; arytenoid redness at green arrows; and mucus retention cyst at lower blue arrow.
interarytenoid pachyderma

Acid reflux laryngitis (2 of 2)

During phonation, interarytenoid pachyderma and mucus retention cyst are typically obscured.