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Table of Contents
ORIGINAL ARTICLE
Year : 2017  |  Volume : 7  |  Issue : 1  |  Page : 1-6

Gastroesophageal reflux disorder: Lifestyle, symptomatology, and voice profile


1 Wall Street Audiology, Expert Hearing Solutions, Saskatoon, Saskatchewan, Canada
2 Department of Speech Language and Hearing Sciences, Sri Ramachandra University, Chennai, Tamil Nadu, India
3 Department of Otorhinolaryngology and Head and Neck Surgery, Sri Ramachandra University, Chennai, Tamil Nadu, India

Date of Web Publication14-May-2018

Correspondence Address:
Dr. Prakash Boominathan
Department of Speech Language and Hearing Sciences, Sri Ramachandra University, Porur, Chennai - 600 116, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jlv.JLV_3_17

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   Abstract 


Background: “Lifestyle changes and gastroesophageal reflux disorder [GERD]” is an increasingly emerging concept in voice practice (ENT and speech-language pathologist [SLP]) in India. The treatment protocol in vogue is initially a change in lifestyle with or without medical therapy. Materials and Methods: This study profiled lifestyle patterns and acoustic analysis findings of voice in 30 participants who were clinically diagnosed (symptoms and laryngoscopy findings) with GERD, and compared them with 30 participants without symptoms of GERD. Results: In this study, the highest frequency of occurrence of GERD was found in the fourth decade of life. More than 70% of the participants were nonvegetarians, coffee “lovers,” and consumed high-fat laden food rich with Indian spices. Eating habits, stress levels, voice use, and sleep habits were dependent on occupation. Majority (94%) of the participants were in sedentary, “high-stress” jobs, that induce such habits. Common symptoms reported were retrosternal burning sensation, water brash, throat irritation and pain, dry cough, and voice change. Perceptual analysis revealed low-pitched phonation, hoarseness, and breathiness (moderate to severe) as the most deviant parameters. Acoustic analysis showed deviant frequency and perturbation measures compared to participants without GERD symptoms (P < 0.05). Conclusion: The possible causes and factors contributing to voice changes with GERD that pertains to this geographical location, culture, food habits, and ethnic group are explained in this article.

Keywords: Gastroesophageal reflux, life style changes, voice analysis


How to cite this article:
Ganesan P, Boominathan P, Arunachalam R, Mahalingam S, Vijayakumar DS. Gastroesophageal reflux disorder: Lifestyle, symptomatology, and voice profile. J Laryngol Voice 2017;7:1-6

How to cite this URL:
Ganesan P, Boominathan P, Arunachalam R, Mahalingam S, Vijayakumar DS. Gastroesophageal reflux disorder: Lifestyle, symptomatology, and voice profile. J Laryngol Voice [serial online] 2017 [cited 2018 Sep 24];7:1-6. Available from: http://www.laryngologyandvoice.org/text.asp?2017/7/1/1/232354




   Introduction Top


Gastroesophageal reflux disorders (GERD) is a multifactorial disease associated with incompetent lower esophageal sphincter leading to acid regurgitation and mucosal layer irritation. Laryngeal symptoms in participants with GERD include hoarseness, a sensation of fullness in the throat, brash, repetitive throat clearing, chronic cough, and laryngeal spasm.[1],[2] The prevalence of GERD and findings along with laryngeal pathologies are reportedly high.[3],[4],[5],[6] Reflux laryngitis leads to deterioration in voice quality. These can be documented through subjective and objective evaluation of voice. Altered phonation pattern and voice-related problems due to GERD lead to negative impact on everyday life.[5] Documenting GERD-associated extraesophageal pathology is necessary, especially in this subcontinent, which is known for its spicy and rich variety of food, with varied dietary habits. Further, it may not be an overstatement to relate the effects of globalization on Indians who are adapting to Western food habits. This study aims to profile the perceptual and acoustic variations in voice, and vocal and nonvocal symptoms in participants diagnosed to have GERD.


   Materials and Methods Top


A total of Sixty participants (clinical group-30 and control group-30) in the age range of 21 and 60 years participated in the study. Clinical group included 10 males and 20 females who were diagnosed with GERD in a tertiary care center. Thirty participants (Males-10; Females-20) who did not have any symptoms of GERD served as the control. Participants were recruited based on the following criteria.

Inclusion criteria for clinical group (participants with gastroesophageal reflux disorder)

  • Complaints of frequent heartburn, hoarseness, irritation in the throat, cough, and foreign body sensation in the throat
  • Clinically diagnosed to have GERD through videolaryngoscopic examinations.


Exclusion criteria for clinical group

  • Identifiable mass lesion in the vocal folds (conditions such as vocal nodule, polyp, and growth in the laryngeal structure giving rise to change in voice)
  • Upper respiratory tract infections in the last 1 month
  • History of surgeries in the larynx and gastrointestinal tract
  • Exposure to toxic gases and chemicals
  • Pregnant women.


Inclusion criteria for control group (participants without gastroesophageal reflux disorder)

  • Normal voice quality through self-report and expert percept
  • Vocally healthy lifestyle habits (2–2½ L of water/day; regular dietary habits; Intake of traditional Indian meal).


Exclusion criteria for control group

  • History or complaint of voice-related problems
  • Complaint of obvious reported symptoms of heartburn/acid regurgitation
  • Upper respiratory tract infections in the last 1 month
  • History of surgeries in the larynx and gastrointestinal tract
  • Exposure to toxic gases and chemicals
  • Pregnant women.


Laryngeal examination

Rigid endoscope (Storz® 8706 CJ, 30°) connected to video monitor was used for the visualization of the larynx. Local anesthetic spray (10% Lignocaine) was applied to the throat. Videoendoscopic evaluation of thirty participants (clinical group) was evaluated separately by an ENT surgeon (Judge 1) and a speech language pathologist [SLP] (Judge 2). Both documented observable changes in the larynx due to GERD. [Figure 1] and [Figure 2] show videolaryngoscopic findings of normal larynx and larynx with associated GERD respectively. [Table 1] provides results of videolaryngoscopy. Posterior pharyngeal wall erythema, arytenoids/interarytenoid edema, and granular pharyngitis were the most common signs documented by both the judges in these participants. Inter-rater reliability (kappa correlation) revealed moderate agreement between judge 1 and judge 2 (k = 0.482).
Figure 1: Videolaryngoscopy image of normal larynx

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Figure 2: Videolaryngoscopic image of gastroesophageal reflux disorder features of the larynx

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Table 1: Frequency of laryngeal findings identified in participants with gastro esophageal reflux disorder (both males and females) by judge 1 and judge 2

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Procedure

Profiling the lifestyle

Participants in the clinical group completed a structured questionnaire on lifestyle habits. It was divided into three sections. The first section included the participant identification details, religion, height, weight, body mass index, information regarding diagnosis of GERD, and details of previous investigations/treatment for the same. The second section focused on lifestyle habits of the participants, which included questions related to the nature of the job, clothing preference, social lifestyle, food, and sleep patterns. The third section collected information on vocal and nonvocal symptoms experienced by the participants [Table 2].
Table 2: Common diet preferences of participants with gastroesophageal reflux disorder (males and females) participated in this study

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Voice recording and acoustic analysis

Computerized speech lab model 4150, Kay Pentax., NJ, USA, was used for voice recording at a sampling rate of 44,000 Hz. The participants were seated in an upright posture and were asked to phonate the vowel/ a/ at a comfortable pitch and loudness. Later, they were instructed to speak for a minute on a topic of their choice. The phonation and conversation tasks were recorded using a condenser microphone (SM 48) kept at a distance of 10 cm from the lips, at an angle of 45°. Recording was done in the voice laboratory of Sri Ramachandra University.

Steady state phonation sample was used for acoustic analysis. The initial 0.25 s of the phonation sample was cut off, and measurements were made for subsequent 2.0 s of the sample. The remaining parts of the sustained vowel/ a/ were discarded, which ensured that the beginning and the end of voicing did not influence the final result. Frequency measures, perturbation measures, and noise-related parameters extracted from the multidimensional voice program [MDVP] analysis were noted and independent t-test was used to report significant differences between participants with GERD and participants without GERD.

Perceptual analysis

Conversational voice sample of participants with GERD was presented to two experienced SLPs who work in the area of clinical voice pathology, for perceptual analysis using GRBAS scale.[7] A 4-point rating scale was adopted for perceptual judgment of each parameter. Inter-judge reliability was calculated using Spearman's coefficient of correlation.


   Results and Discussion Top


Lifestyle habits of participants with gastroesophageal reflux disorder

In this study, the highest frequency of occurrence (43%) of GERD was found in the participants in their fourth decade of life. However, no particular age of highest incidences of GERD can be concluded from this study. [Table 2] shows the common diet preferences of participants with GERD (males and females) in this study [Table 2].

Out of 30 participants, 21 participants took at least two liters of water, and 20 participants (67%) preferred consuming coffee and tea frequently (i. e., More than 2–3 cups per day). Approximately 70% preferred taking a non-vegetarian meal at least twice a week, 90% of the participants admitted to consuming oily/spicy food, and 65% of them consumed “sour food” (e.g., Items made predominantly with tamarind, tomatoes, lemon, etc.) twice a week. Twenty participants (70%) reported consuming food in haste (without adequate chewing or just gulped the food). Consumption of sweets once a week was reported in 33.3% rarely. Only 20% of the participants admitted to skipping a meal. Caffeine and high-fat dairy products affect the voice by thickening mucous secretions and decreasing the efficiency of vocal fold vibration.[8] Irregular meal timings led to symptoms of GERD.[9],[10]

Sleep habits

Most of the participants reported seven to 8 h of sleep per day. 20% of the men and 50% of the women in this study reported the habit of taking a nap in the day time for at least 30–60 min after mid-day meals. All the males and most of the females (95%) had the habit of going to sleep within an hour of taking their meals. Around 40% of the males and 30% of the females reported snoring during sleep. Irregular sleep habits and dinner just before bedtime correlate positively to the presence of GERD.[11]

Social habits

On analyzing their social habits, 20% of the participants have the habit of partying at night occasionally. Seventy percent of the males have the habit of consuming alcohol occasionally, whereas 20% of males were chronic smokers. None of the males reported addiction to drugs or the habit of chewing tobacco, betel nut, as opposed to 5% of the females had the habit of chewing betel nut. Smoking and consuming alcohol are known risk factors for GERD.[11] Smoking has been found to have a deleterious effect on the mucosa of the larynx which leads to decreased vibratory efficiency.[8]

Clothing preferences/exercise

Wearing tight clothes, especially around the waist is one of the factors responsible for the development of GERD which was not reported in any of the test participants. All of them preferred to wear loose fitting clothes; hence this was non-contributory to GERD in these participants. Only 30% of males and 20% of females had the habit of practicing some form of physical exercises such as morning walks, yoga, and meditation. The time spent for morning walks was reported to be 30 min on an average.

Perceptual analysis of voice

The perceptual evaluation of conversational speech was done by two SLPs using GRBAS scale. Percentage of GRBAS scale ratings by judges 1 and 2 in conversation task of the clinical group are graphically depicted in [Figure 3] and [Figure 4], revealing grade and breathiness as the most deviant parameters (moderate to severe), followed by roughness, asthenia, and strain, which were rated as mild-to-moderate deviancies. Spearman's coefficient of correlation showed a moderate correlation (r = 0.44) between the ratings made by the two judges for conversation samples. There is a significant increase in perceptual rating of hoarseness in participants with reflux laryngitis.[12] Voice in participants with GERD was rated as mildly deviant in parameters such as hoarseness and breathiness.[7] Hoarseness is one of the atypical manifestations of GERD.[13],[14] The findings in the present study are consistent with those reported in literature.
Figure 3: GRBAS scale ratings (in percentage) of conversation samples by judge 1 in participants with gastroesophageal reflux disorder

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Figure 4: GRBAS scale ratings (in percentage) of conversation samples by judge 2 in participants with gastroesophageal reflux disorder

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Acoustic analysis

[Table 3] represents the comparison of parameters of acoustic analysis of participants of GERD and participants without GERD [Table 3].
Table 3: Mean, standard deviation, P values of MDVP parameters for participants with gastroesophageal reflux disorder and participants without gastroesophageal reflux disorder

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Frequency-related measures

Average fundamental frequency (F0) (P: 0.00), highest fundamental frequency (Fhi) (P: 0.02), and lowest fundamental frequency (Fl0) (P: 0.00) in females was found to be significantly decreased when compared to vocally healthy participants. Standard deviation of the fundamental frequency (STD F0) in females showed significant increase (P = 0.02). Decreased fundamental frequency could possibly be related to vocal fold thickening/edema. In this study, majority of participants with GERD were found to have vocal fold thickening and ventricular band edema.[15] Contradictory findings of no significant change in F0 have been reported in literature.[16] However, no significant change was observed in frequency related measures in males.

Perturbation-related measures

Female participants with GERD showed significant increase in measures such as Jita (Jitter-%; P: 0.01), relative average perturbation-%; P: 0.00, pitch perturbation quotient (PPQ)-%; P: 0.00, smoothed PPQ-%; P: 0.00, variation in fundamental frequency (vF0)-%; P: 0.02, and variation in Amplitude (vAm)-%; P: 0.00. In males with GERD, vF0(P = 0.00) and vAm (P: 0.00) showed a significant increase. Increased perturbation measures in participants with GERD could be attributed to the subtle structural changes of vocal fold potentially caused by enzymatic irritants. This is also supported by VLS findings of vocal fold thickening and erythema in these participants.[9],[16] Amplitude-related perturbation measures except vAm did not show any significant change between the two groups in both males and females. Findings from this study are in par with the previous study done by Oguz et al.[16]

Noise-related measures

Noise-related parameters such as VTI (Voice Turbulence Index-%; P: 0.00) showed significant decrease and SPI (Soft Phonation Index-%; P = 0.00) and NHR (Noise-to-Harmonic Ratio; P: 0.00) showed significant increase in participants with GERD (males and females) when compared to participants without GERD symptoms. Edema of the posterior larynx and vocal fold thickening/edema disturbs the abduction of the vocal folds, thus explaining the increased glottal noise in participants with GERD.[9],[16]


   Conclusion Top


This study documents the impact of lifestyle patterns on the development of GERD and its effects on the larynx, along with perceptual and acoustic voice changes in these individuals. Findings from this study provide clinician with leads in counseling a patient with GERD from this part of the subcontinent. There is a need for further studies focusing on the correlation of severity of GERD with the development of laryngeal symptoms, and the effect of lifestyle modification on voice to understand this pathology better to improve the treatment modalities.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Zalesska-Krecicka M, Krecicki T, Iwanczak B, Blitek A, Horobiowska M. Laryngeal manifestations of gastroesophageal reflux disease in children. Acta Otolaryngol 2002;122:306-10.  Back to cited text no. 1
    
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Book DT, Rhee JS, Toohill RJ, Smith TL. Perspectives in laryngopharyngeal reflux: An international survey. Laryngoscope 2002;112:1399-406.  Back to cited text no. 2
    
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Rouev P, Chakarski I, Doskov D, Dimov G, Staykova E. Laryngopharyngeal symptoms and gastroesophageal reflux disease. J Voice 2005;19:476-80.  Back to cited text no. 3
    
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Koufman JA, Amin MR, Panetti M. Prevalence of reflux in 113 consecutive patients with laryngeal and voice disorders. Otolaryngol Head Neck Surg 2000;123:385-8.  Back to cited text no. 4
    
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Tauber S, Gross M, Issing WJ. Association of laryngopharyngeal symptoms with gastroesophageal reflux disease. Laryngoscope 2002;112:879-86.  Back to cited text no. 5
    
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Makhadoom N, Abouloyoun A, Bokhary HA, Dhafar KO, Gazzaz ZJ, Azab BA, et al. Prevalence of gastroesophageal reflux disease in patients with laryngeal and voice disorders. Saudi Med J 2007;28:1068-71.  Back to cited text no. 6
    
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Hopkins C, Yousaf U, Pedersen M. Acid reflux treatment for hoarseness. Cochrane Database Syst Rev 2006;1:CD005054.  Back to cited text no. 7
    
8.
Sairam VV, Manjula R. Vocal features in subjects with gastro esophageal reflux disorder (GERD). In: Basavaraj V, Geetha YV, editors. Students Research at A.I.I.S.H. Mysore: A.I.I.S.H; 2008. p. 197-213.  Back to cited text no. 8
    
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Pribuisiene R, Uloza V, Kupcinskas L, Jonaitis L. Perceptual and acoustic characteristics of voice changes in reflux laryngitis patients. J Voice 2006;20:128-36.  Back to cited text no. 9
    
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Boominathan P, Nagarajan R, Neelakantan S, Krishnan S. A profile of vocal & non-vocal habits of carnatic singers. J ITC Sangeeth Res Acad 2004;18:77-88.  Back to cited text no. 10
    
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Sataloff RT, Castell DO, Sataloff DM, Spiegel JR, Hawkshow M. Reflux and other gastroenterologic conditions that may affect the voice. In: Sataloff RT, editor. Professional Voice. The Science and Art of Clinical Care. 2nd ed. San Diego, London: Singular Publishing Group; 1991. p. 319-30.  Back to cited text no. 11
    
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Kuhn J, Toohill RJ, Ulualp SO, Kulpa J, Hofmann C, Arndorfer R, et al. Pharyngeal acid reflux events in patients with vocal cord nodules. Laryngoscope 1998;108:1146-9.  Back to cited text no. 12
    
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Hirano M. Clinical Examination of the Voice. New York: Springer Verlag; 1981.  Back to cited text no. 13
    
14.
Postma GN, Courey MS, Ossoff RH. The professional voice. In: Cummings C, Flint P, Harker LA, Haughey BH, Richardson MA, Robbins KT, et al., editors. Otolaryngology Head and Neck Surgery. 4th ed. Philadelphia: Elsevier Mosby; 2005. p. 2128-49.  Back to cited text no. 14
    
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Colton RH, Casper J, Leonard R. Understanding Voice Problems: A Physiologicalperspective for Diagnosis and Treatment. 3rd ed. Philadelphia, PA: Lippincott Williams &Wilkins; 2006.  Back to cited text no. 15
    
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Oguz H, Tarhan E, Korkmaz M, Yilmaz U, Safak MA, Demirci M, et al. Acoustic analysis findings in objective laryngopharyngeal reflux patients. J Voice 2007;21:203-10.  Back to cited text no. 16
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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