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Treatment Strategies for Voice Disorders Associated with Suspected
Larygopharyngeal Reflux (LPR): A Literature Review
Introduction
Larygopharyngeal Reflux and its symptoms have been the topic of controversial
debate for decades. Research literature from the fields of medicine and voice science
reveal areas of confusion from nomenclature to unreliable clinical signs for diagnosis to
vast differences in opinion about the disease across medical specialties to disagreement
about testing and treatment. According to nationally recognized laryngologists, Bransky
and Sulica, “The controversy has yielded an interesting clinical paradox: LPR may have
become at once the most underdiagnosed and the most overdiagnosed clinical entity in
laryngology (Bransky & Sulica, p.177).” Due to a lack of consistency in diagnosis and
symptomology, patients can spend years bouncing from specialist to specialist before an
adequate diagnosis is reached (Koufman, 2010). This review of the literature spanning
the past twenty years regarding this complex condition traces the evolution of the
prevalence and fundamentality of the role of LPR in the understanding of laryngeal
pathologies and their treatment. Definitions of the relevant nomenclature, exploration of
the symptoms, traditional therapies and new directions of treatment will also be
examined. The central focus will be related specifically to relevant voice disorders
associated with LPR found in the literature.
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Differentiating between Larygopharyngeal Reflux and Gastroesophageal Reflux Disease
Acid reflux is defined as the backflow of acid from the stomach up to the
esophagus (Rees & Belafsky; Koufman et al, 2002). According to Bransky and Sulica,
the most cited article on the subject was published in 1991 by J. Koufman entitled “The
Otolaryngologic Manifestations of Gastroesophageal Reflux Disease (GERD)” (Bransky
& Sulica 189). Bransky and Sulica have included the entire article from Laryngoscope
that was published in 1991, by The American Laryngological, Rhinological, and
Otological Society in their book. In her seventy-eight page thesis Koufman provides an
extensive literature review tracing the history of GERD from 1966, as well as laying the
foundation for delineation between LPR and GERD by describing “typical” and
“atypical” manifestations of GERD (Bransky and Sulica 196). In fact, it was in that same
year of 1991, that Koufman promoted the phrases “Larygopharyngeal reflux” and “silent
reflux” to “call attention to the fact that the symptoms and manifestations were laryngeal
and pharyngeal, that is not esophageal (Bransky and Sulica 179).” Several articles follow
in Dr. Koufman’s footsteps (Johnston et al; Sana et al; Monini et al; Sataloff; Spencer) by
outlining the basic differences between LPR and GERD and their importance.
Laryngopharyngeal reflux is often referred to as GERD that affects the Larynx
and Pharynx (Koufman, 2001; Johnston et al, 2003; Sataloff et al, 2006), albeit with
noticeable differences. Heartburn is a main complaint of GERD patients but not LPR
because of a difference in motor dysfunction and location (Sana et al; Sataloff, 2005).
Heartburn is caused by abnormal esophageal motor function and lower esophageal
sphincter dysfunction, while patients with LPR have normal motor function and upper
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esophageal sphincter dysfunction (Sana et al; Sataloff, 2006). Other factors that may
contribute to GERD, but not LPR are delayed gastric emptying, delayed esophageal
clearing and obesity (Sana et al; Sataloff, 2010; Saatloff et al, 2006). The onset of
symptoms in LPR often occurs when sitting or standing while in GERD symptoms occur
while lying down (Sana et al; Koufman; Altman; Sataloff). GERD is often found in
obese patients, however this is typically not the case with LPR (Koufman et al, 2002;
Halum et al, 2005). A quantitative study of nutritionists found conflicting data over
whether body mass index (BMI) was a contributing factor to symptoms of LPR (Nowak
et al).
Controversies and confusions abound when examining the problem of reflux
(Sataloff, 2010). A common complaint in regard to the difficulties in diagnosis stem
from a lack of consistency between symptoms and laryngeal findings (Sana et al;
Sataloff, 2010; Bransky & Sulica; Aronson & Bless). A plethora of imperfect studies
with conflicting conclusions proliferate the literature (Sataloff, 2010). Belafsky et al
have developed both the Reflux Finding Index (RFI) Reflux Symptom Index (RSI) for
clinicians to help in the standardization of laryngeal findings and symptoms to aid in the
diagnosis of LPR. The authors stress that the independent items are not meant to
individually indicate LPR, but just assist in diagnosis and treatment (Belafsky et al, 2001
& 2002). Other studies assert that the Reflux Finding Score (RFS) and Reflux Symptom
Index (RSI) findings are often inconclusive because the symptoms can be attributed to
any number of causes (Sana et al; Kelchner et al; Sataloff, 2010; Spencer).
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In addition to the RSI and the RFS, the standard method of diagnosis is 24 hour
ambulatory double-probe (simultaneous esophageal and pharyngeal) pH testing (Amin et
al; Belafsky et al; Sataloff, 1991; Sataloff et al, 2006; Koufman et al, 2001; Davis &
Jahn). This method is of particular value since incidence of reflux is often intermittent
(Koufman, 1991; Sataloff, 2006; Boone et al) and the double-probe determines the
location of acid exposure (Johnson et al, 2001). Information garnered in this fashion is
invaluable when correlating amount of time reflux occurs with symptoms (Koufman,
1991; Sataloff, 1991 & 2006; Boone et al). However, a negative pH probe test does not
rule out reflux (Boone et al) Experts in the field consider esophageal biopsy to be the
most effective means to rule out the disease (Boone et al; Sataloff, 2005; Koufman et al
2010).
LPR treatment is also an area of differentiation with GERD since it does not
respond as well to Proton Pump Inhibitors (PPI’s) (Aronson & Bless; Belasky & Sulica;
Sana et al; Koufman; Sataloff, 2010). Studies have shown that double doses of PPI’s and
longer periods of treatment (from four months to a year) are most often necessary for
relief of LPR symptoms (Koufman, 2011; Sataloff, 2010). According to Koufman and
colleagues, the main issue is due to acid activated pepsin and not acid alone (Koufman,
2011; Koufman & Johnson, 2012). Therefore, in LPR particularly, it is the pH levels that
must be addressed (Amin et al; Johnston et al; Koufman et al; Møller, Grøntved & West;
Davis & Jahn). Additionally, diagnosis and treatment are complicated by the fact that
while LPR and GERD are often grouped together, not all episodes of GERD have LPR
and vice versa (Hopkins et al).
4
Terminology in reference to acid reflux throughout the literature is also varied.
Before 1991, Gastroesophageal Reflux (GER) was the standard name (Bransky & Sulica;
Koufman; Sataloff, 2005). After 1991, studies were using GERD with the “D” referring
to it as a disease since occasional GER (up to 50 incidences a day) was considered
normal (Koufman, 2001; Sataloff et al 2006). For studies outside the United States,
GORD (Gastro-Oesophageal Reflux Disease) is commonly used (Behlau & Oliviera;
Usai et al; Wright). Laryngopharyngeal Reflux (LPR & LPRD), Non Erosive Reflux
Disease (NERD), and Extra Esophageal Reflux all refer to the same disorder (Aronson &
Bless; Bransky & Sulica; Koufman, 1991; Sataloff, 1991, Boone et al, Sana et al;
McGuirt). This inconsistency of terminology not only confuses the patient, but the
medical and voice specialists as well (Sataloff, 1991; Koufman, 2011). Differentiating
between LPR and GERD is extremely important for “Laryngopharyngeal Reflux is
clearly a very different disorder than Gastroesophageal Reflux (Sataloff, 2005, p. 339).”
Along with the seminal aforementioned thesis by Koufman in 1991, two very
important documents were published in the past ten years about the cellular impact of
LPR on the esophagus. “Cell Biology of Laryngeal Epithelial Defenses in Health and
Disease: Further Studies” was part of the 2nd Annual Report of International Collaborate
Research and was the first major investigation of the damaging factors and protective
mechanisms related to LPR (Johnston et al, 2003). Along with differentiating between
LPR and GERD, the paper emphasized the importance of bicarbonate ions in protecting
laryngeal epithelium. Through the study of porcine and rabbit models it was discovered
that active pepsin is what causes laryngeal mucosal damage (Johnston et al 2003). The
second important study demonstrated that pepsin was damaging because it depletes the
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Carbonic Anhydrase Isoenzyme III (CA III) (Johnston et al, 2004). CA III is a defense
against damage because it produces bicarbonate ions. CA III has been found to be absent
or in very low levels in patients with LPR (Johnston et al, 2004). This illustrates the
reason why the larynx is much more susceptible to damage (Koufman et al, 2002;
Johnston et al, 2003) for pepsin is active in a pH as high as 7.2 (Johnston et al, 2003;
Amin et al; Koufman et al, 2010; Koufman & Johnston, 2011). LPR is different in its
physiologic mechanisms, patterns of reflux symptoms, manifestations and responses to
treatment (Koufman et al, 2002; Sataloff, 2006).
Voice Specialists and Their Contribution to Understanding LPR
The literature thus far has arisen from clinicians of three different fields:
medicine, voice science, and singing. N. Welham states that “voice disorders are
inherently complex and their evaluation should reflect this (Aronson & Bless).” Several
publications in the Journal of Voice, the Journal of Singing and books on voice disorders
have emerged in the past two decades with this paradigm in mind. Clinical Voice
Disorders by Aronson and Bless, The Voice and Voice Therapy by Boone et al, Care of
the Professional Voice by Davies and Jahn, and numerous publications by Sataloff were
also reviewed and provided essential information. The advantages of reviewing this type
of literature are numerous. Sataloff in particular provides very detailed descriptions of
medications, their uses and their common side-effects that are easily understood by the
non-health professional (Sataloff, 1991; Sataloff, 2006 & Sataloff, 2010). Detailed
description of the anatomy of the esophagus highlights the function and location of the
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upper and lower esophageal sphincters (Koufman, 2001; Boone et al; Satoloff, 1991 &
2005). An entire chapter is dedicated to describing the physiological process of
swallowing and movement throughout the esophagus, including the amount of time
needed for a substance to travel between sphincters: eight to ten seconds (Sataloff et al,
2006). Understanding of the function esophagus and sphincters is integral to the health
professional knowing which treatment(s) will be the most helpful (Satoloff, 2006,
Kaufman, 2010).
Common characteristic symptoms of LPR include hoarseness, chronic throat
clearing, globus pharyngeus (lump in the throat), chronic cough, postnasal drip, and a
strange taste in the mouth (Aronson and Bless; Sataloff; Sana et al; Monini et al; Spencer;
Sandage et al; Kahn et al). The most common and problematic symptoms for voice
professionals are hoarseness, longer voice warm-up time and low voice in the morning
(Aronson & Bless; Boone et al; Karkos et al, Davis & Jahn; Sataloff; Spencer). Reflux
Laryngitis, laryngospasm, paradoxical vocal fold movement, vocal nodules, asthma,
sinusitis, otitis media (inflammation of the middle ear) also seems to have a causal
relationship with LPR (Koufman et al, 2002; Sataloff, 2006; Gainer et al, 2011; Spencer).
Consistent among most of the literature reviewed is the need for detailed patient
information intake (Boone et al; Aronson & Bless; Davis & Jahn; Sataloff; Koufman;
Belasky & Sulica; McGuirt) and comprehensive approach for treatment (Sataloff, 2006;
Sataloff, 2010; Wright et al; Behlau & Oliviera). The literature from the voice care
specialists stress developing a team of clinicians that would include Gastroenterologists,
Laryngologists, Voice Specialists, Voice Pathologists and Psychologists (Boone et al;
Aronson & Bless; Davis & Jahn; Koufman; Sataloff; Spencer).
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Standard Medical Treatment
Standard treatment for GERD falls into three categories: Behavioral
modification, Pharmaceutical treatment and surgical procedure. Diet and lifestyle
modifications, aggressive PPI treatment, antacids before and after meals and elevation of
the bed eight inches when sleeping (Koufman; Aronson & Bless; Boone et al; Davis &
Jahn; Sataloff) are the standard. Recommendation of sleeping on the left side is also
present in the literature (Sataloff et al 2006, Nowak et al).
Although studies demonstrating consistent results from the dietary changes are
lacking (Belafsky et al; Kahn et al), the standard recommendations include low fat/high
protein meals and the avoidance of chocolate, mints, onions, citrus, tomatoes, carbonated
beverages, alcoholic beverages and caffeine (Sataloff, 2006; Koufman, 2010; Nowak et
al; Kahn et al; Belafsky et al; Davis & Jahn; Spencer). Recommendations also include
having several small meals instead of large ones, the last one being at least three hours
before going to bed (Koufman et al, 2010; Sataloff et al 2006; Martin). Chewing gum
has also been cited as a means of creating a bicarbonate effect and thus raising the pH
levels in the larynx (Smoak & Koufman; Davis & Jahn; Rees & Belafsky). Lifestyle
modifications include cessation of tobacco usage, weight loss for those who were obese
and avoiding tightly fit clothes (Belafsky & Sulica; Davis & Jahn). In one study of
questionnaires sent to over 600 Australian nutritionists, data was inconclusive as to
whether it was the methods to lose weight that were beneficial or weight loss per se
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(Nowak et al). This study also raised the question of the relevance of food allergies to
LPR. Spencer’s article is particularly instructive in that it explains the effects of a
particular food or behavior on the digestive system. For example, chocolate, onions, mint
and smoking do not produce acid but effect LES function (Spencer).
Anti-reflux surgery has been recommended as the third stage of treatment,
especially for those who are resistant to PPI’s (Boone et al; Sataloff, 2006). The most
common procedure is Nissen Fundoplication which has been in practice since the mid
1950’s (Belafsky & Sulika; Boone et al; Chapman et al; Spencer; Mjönes et al). This
procedure is effective, but after 11-13 years reflux has been demonstrated to return
(Chapman et al).
Benefits and Cautions of Pharmaceutical Protocols
Medical management of LPR has several goals (Sataloff, 2005). The first goal is
symptom relief by neutralization of gastric acid through the use of antacids (Sataloff,
1991 & 2005; Boone et al; Koufman, 1991). Although symptom relief may be
instantaneous, side effects may include constipation, diarrhea, bloating, and in the singer
support mechanism effects as well as laryngeal dryness (Sataloff, 2005). Sataloff
recommends finding some that do not have aluminum.
To suppress acid secretion, Histamine Receptor Antagonists (H2 blockers) such as
Zantac and Pepcid are prescribed (Sataloff, 2005; Spencer) to regulate esophageal motor
function and work in 50% of patients (Amin et al; Sataloff, 2005). They affect acid
output, but not basal rate of acid production. Side effects include some drying effect and
9
the elevation of liver enzymes (Sataloff, 2005). Over the counter forms at smaller doses
are available (Sataloff, 2005), but with prolonged use many patients developed
intolerance (Amin et al; Spencer).
Since the 1980’s, Proton Pump Inhibitors such as Omeprazole and Prilosec
became the mainstay of treatment (Boone et al; Amin et al; Koufman et al; Sataloff et al;
Watson; Patrick; Spencer). PPI’s have been deemed superior to H2 blockers because
they act at the final pathway (Amin et al) and block the production of the gastric proton
pump enzyme (Sataloff, 2005). Although it is the first choice amongst clinicians, PPI’s
are mixed in controversy as well. Several studies have indicated that there is a 56%
failure rate for most patients after one dose (Amin et al; Koufman et al; Sataloff et al). In
a two month double blind study both improved (PPI and placebo), however not in the
case of hoarseness, laryngoscopic findings or pH (Sataloff, 2006). PPI’s taken twice a
day showed marked improvement (Sataloff, 2006; Koufman, 2010; Boone et al), however
a large percentage of the population is PPI resistant (Amin et al; Koufman, 2010 & 2011;
Hershcovici & Fass).
PPI’s appear to be more successful in the treatment of GERD than LPR (Boone et
al; Amin et al; Koufman et al; Chapman et al). Since the larynx and pharynx are more
susceptible to injury to acid and pepsin, around the clock aggressive PPI therapy is the
standard treatment (Chapman et al; Amin et al; Koufman et al; Spencer). Recent studies
have demonstrated abnormalities in vitamin and mineral absorption leading to risk factors
of osteoporosis, and fractures as well as platelet problems and infections in longtime PPI
users (Chapmen et al; Hershcovici). Additionally, longitudinal studies are now being
published that indicate the recurrence of GERD and LPR as little as three months after
10
cessation of PPI’s (Koufman et al, 2010; Dickman). Issues with patient compliance due
to the expense and misunderstanding that dietary changes are also required may moreover
be contributing factors (Sataloff, 2006; Boone et al; Amin et al).
The last two protocols are less common. Potassium-competitive acid blockers
offer quick relief, but lead to liver toxicity (Chapmen et al). Pro-kinetics showed promise
in that they helped with pain and improvement of motility (Sataloff, 2005 & Chapman et
al) but have neurological side effects in 10% of patients (Sataloff, 2006). However,
neither one of these are prescribed very often (Sataloff, 2005; Chapman et al; Patrick).
Adjunctive Therapies and New Directions
Alternatives to conventional therapies fall under three main categories:
dietary/herbal, body modalities and psychological/therapeutic. Although alternative
therapies are extremely popular, authoritative and peer reviewed literature of clinical
studies is not abundant. The two articles in the Journal of Singing dealing with "The
Use of Nutrition and Integrative Medicine or Complementary and Alternative Medicine
for Singers” were little more than a list of different modalities that singers use and not an
extensive one at that. Lyn Patrick in his article about conventional and alternative
therapies is extensively researched and provides many detailed descriptions of treatments
for people who suffer from GERD. The author advocates more studies to be done
dealing with melatonin therapy, Iberogast (used in Germany for over 40 years), DLimonene, Arte misia asiatia and acupuncture. His research indicates that these
treatments have proven to be effective in small trials with little side effects.
11
Current advances in the area of dietary changes come from Dr. Koufman and her
team. Recent journal articles and a book about a low acid elimination diet have been
major contributions to the reflux dialogue (Koufman et al 2010; Koufman, 2011). What
is unique in these particular articles is that they are written with the average person in
mind and contain practical advice in an easy to access format. Their latest area of
investigation is the benefits of drinking pH 8.8 alkaline water as an adjunct to
conventional treatment (Koufman & Johnston, 2011).
Two Italian studies contain data indicating that a gluten free diet may benefit
reflux sufferers (Cuomo & Usai et al). Both studies found a correlation between Celiac
disease and reflux. The design of the studies were similar in that they took Celiac
patients with demonstrated reflux and first put them on standard twice a day PPI doses
for eight weeks. The Celiac group was put on a gluten free diet and the control group
was not. It was demonstrated in both studies that after two years, the patients on the
gluten free diet had a statistically significant rate of success while the control group had
to return to PPI therapy . While this study has not been repeated with non-Celiac
patients, further study is warranted (Cuomo & Usai et al).
Literature about the benefits of body modalities is scarce. Two articles
concerning case studies about Chiropractic care and GERD patients (Alcantara &
Anderson, Hein) presented with positive results. More studies need to be conducted in
order to determine validity for a wider range of patient. A review of the literature about
acupuncture and reflux led to two very important studies (Patrick; Dickman et al & Chen
et al). Both studies promoted integrated treatment of PPI’s and Chinese medicine. As
with the Italian gluten studies, PPI’s were administered for eight weeks before
12
acupuncture was delivered twice a week by an expert. The second group received a
doubled dose of PPI’s (Dickman et al). In both studies the data revealed evidence of
more success in the acupuncture patients. Further investigation in this field seems
justified.
Voice professionals stress the importance of both voice therapy and psychological
therapy as adjuncts to medical treatment for patients with LPR (Boone et al; Aronson &
Bless; Satoloff, 2005; Behlau & Oliviera). Stress and psychological influences
exacerbate symptoms, most specifically increase resting LES pressure (Wright et al;
Cammarota et al). In the study conducted by Wright et al, they found evidence of a
correlation, but a relationship contradiction. No difference in pH monitoring was found
when they were under stress, however, the sings self -reported more symptoms.
Voice hygiene is considered “indirect therapy” (Behlau and Oliviera), best as a
preventative strategy and a component of a comprehensive therapeutic program (Behlau
& Oliviera; Sataloff, 2006; Murry et al). The most significant benefit of vocal hygiene
exercises is increased awareness of various aspects of voice production and therefore any
vocal changes (Vashani et al). With little data available, further study is warranted
(Behylau & Oliviera; Sataloff, 2006).
Conclusion
In the realm of reflux research there is a wealth of research, many articles
exploring signs and symptoms but still many uncertainties (Wright et al; Sataloff 2006).
A standard definition of “normal” is needed and continued interdisciplinary discourse
with multi-center studies, unbiased collaboration and excellently designed studies with
rigorous inclusion criteria (Sataloff, 2010). There is no cure for LPR as of yet, only ways
13
of managing the condition. Still, LPR is becoming increasingly prevalent especially
amongst singers due to stress, late night performances, irregular eating patterns and the
support mechanism itself (Camarota et al; Sataloff, 2006; Aronson & Bless; Boone et al).
Even subtle changes in the larynx can have significant effects on the voice professional
(Sataloff, 2006; Aronson & Bless; Boone et al; Larson). What is needed is a
multidisciplinary team approach (Sataloff 2006; Spencer; Koufman et al). Beyond the
importance of more specific studies on specific treatments, a comprehensive compilation
of information is needed to help both the practitioner and patient.
14
References
Alcantara, J. & Anderson, R. (2008). “Chiropractic Care of a Pediatric Patient with
Symptoms Associated with Gastroesophageal Reflux Disease, Fuss-Cry
Irritability with Sleep Disorder Syndrome and Irritable Infant Syndrome of
Musculoskeletal Origin.” J Can Chiropractic Association, Vol. 52, No. 4.
Amin, M.R., Postma, G.N., Johnson, P., Digges, N., & Koufman, J.A. (2001). “Proton
Pump Inhibitor Resistance in the Treatment of Laryngopharyngeal Reflux.”
Otolaryngology Head and Neck Surgery Vol. 125, pp. 374-378.
Aronson, A. E. & Bless, D. M. (2009). Clinical Voice Disorders, 4th Edition. New York,
NY: Thieme Medical Publishers, Inc.
Behlau, M. & Oliveira, G. (2009). “Vocal hygiene for the voice professional.” Current
Opinion in Otolaryngology & Head and Neck Surgery, Vol. 17, No. 3, pp. 149154.
Belafsky, P. C., Postma, G. N., Koufman, J. A. (2001). “The Validity and Reliability of
the Reflux Finding Score.” Laryngoscope, Vol. 111, pp. 1313 – 1317.
Belafsky, P. C., Postma, G. N., Amin, M. R. & Koufman, J. A. (2002). “Symptoms and
findings of Laryngopharyngeal reflux.” Ear Nose & Throat Journal, Suppl 2,
September 2002.
Belafsky, P. C., Postma, G. N., Amin, M. R. & Koufman, J. A. (2002). “Validity and
Reliability of the Reflux Symptom Index (RSI).” Journal of Voice,Vol. 16, No 2,
pp.274-277.
Boone, D. R., McFarlane, S. C., Von Berg, S. L. & Zraick, R. I. (2010). The Voice and
Voice Therapy 8th Edition. New York, NY: Pearson Education, Inc.
Bransky, R. C. & Sulica, L. (2009). Classics in Voice and Laryngology. San Diego, CA:
Plural Publishing, Inc.
Cammarota, G., Elia, F., Cianci, R., Galli, J., Paolillo, N., Montalto, M. & Gasbarrini, G.
(2003). “Worsening of Gastroesophageal Reflux Symptoms in Professional
Singers during Performances.” Journal of Clinical Gastroenterology, Vol. 36,
No. 5, pp. 403-404.
Chen, P., Xu, Y., Chen, G. (2009). “Integrated Traditional Chinese and Western
Medicine Therapy in Treating Gastroesophageal Reflux Cough.” Journal of USChina Medical Science, Vol., 6, No. 6, pp. 48-53.
Cuomo, A., Romano, M., Rocco, A., Budillon, G., Del Vecchio Blanco, C. & Nardone,
G. (2002). “Reflux oesophagitis in adult coeliac disease: beneficial effect of a
gluten free diet.” http://www.gutjnl.com.
15
Davies, D.G. & Jahn, A. (2004). Care of the Professional Voice, 2nd Edition. New York,
NY: Rutledge Publications.
Dickman, R., Schiff, E., Holland, A., Wright, C., Sarela, S.R., Han, B., and Fass, R.
(2007). “Clinical trial: acupuncture vs. doubling the proton pump inhibitor dose
in refractory heartburn.” Alimentary Pharmacology & Therapeutics, Vol. 26,
pp.1333-1344.
Edman, J. S., Kondrad, L. B., & Rakel, B. (2011). "The Use of Nutrition and Integrative
Medicine or Complementary and Alternative Medicine for Singers, Part 1."
Journal of Singing, Vol. 68, No.2: 165-173.
Edman, J. S., Kondrad, L. B., & Rakel, Birgit (2012). "The Use of Nutrition and
Integrative Medicine or Complementary and Alternative Medicine for Singers,
Part 2." Journal of Singing, Vol. 68, No. 3: 291-297.
Gainor, D., Chowdhury, F. & Sataloff, R. T. (2011). “Reinke edema: Signs, symptoms,
and findings on strobovideolaryngoscopy.” Ear, Nose & Throat Journal, April,
2011.
Halum, S.L., Postma, G.N., Johnston, C., Belafsky, P.C., & Koufman, J. A (2005).
“Patients with Isolated Laryngopharyngeal Reflux are not Obese.” Laryngoscope
Vol. 115, pp.1042-5, 2005.
Hein, T. (1999). “Some effects of chiropractic manipulation on reflux oesophagitis: a
case report.” The British Journal of Chiropractic, Vol. 3, No. 3, pp. 59-61.
Hershcovici, T., & Fass, R. (2011). "Gastro-Oesophageal Reflux Disease - Beyond
Proton Pump Inhibitor Therapy." DRUGS 71, no. 18: 2381-2389.
Hopkins, C., Yousaf, U. & Pedersen, M. (2009). “Acid reflux treatment for hoarseness.”
http://www.thecochranelibrary.com.
Johnston, N., Bulmer, D., Gill, G.A., Panetti, M., Ross, P.E., Pearson , J.P., Pignatelli,
M., Axford, A., Dettmar, P.W., & Koufman, J.A. (2003). “Cell Biology of
Laryngeal Epithelial Defenses in Health and Disease: Further Studies.” Annals
of Otology, Rhinology & Laryngology Vol. 112, pp. 481-491.
Johnston, N., Knight, J., Dettmar, P.W., Lively, M.O., & Koufman, J. (2004). “Pepsin
and Carbonic Anhydrase Isoenzyme III as Diagnostic Markers for
Laryngopharyngeal Reflux Disease.” Laryngoscope Vol. 114, pp. 2129-34.
Kahn, A.M, Hashmi, S.R., Elahi, F. Tariq, M. Ingrams, D. R (2006).
“Laryngopharyngeal reflux: A Literature Review.” Surgeon, Vol 4, No. 4: 221225.
16
Karkos, P. D., Yates, P. D., Carding, P. N. & Wilson, J. A. (2007). “Is Laryngopharygeal
Reflux Related to Functional Dysphonia?” Annals of Otology, Rhinology &
Laryngology 116: 24-29.
Kelchner, L. N., Horne, J., Lee, L., Klaben, B., Stemple, J. C., Adam, Stewart, K., T. &
Levin, L. (2005). “Reliability of Speech-Language Pathologist and
Otolaryngologist Ratings of Laryngeal Signs of Reflux in an Asymptomatic
Population Using the Reflux Finding Score.” Journal of Voice, Vol. 21, No 1, pp.
92-100.
Koufman, J. A. (2011). "Low-Acid Diet for Recalcitrant Laryngopharyngeal Reflux:
Therapeutic Benefits and Their Implications." Annals of Otology, Rhinology &
Laryngology 120, No. 5: 281-287.
Koufman, J. A., & Johnston, N. (2012). "Potential Benefits of pH 8.8 Alkaline Drinking
Water as an Adjunct in the Treatment of Reflux Disease." Annals of Otology,
Rhinology & Laryngology 121, No. 7: 431-434.
Koufman, J. A., Aviv, J. E., Casiano, R.R., Shaw, G.Y. (2002). “Laryngopharyngeal
Reflux: Position Statement of the Committee on Speech, Voice, and Swallowing
Disorders of the American Academy of Otolaryngology-Head and Neck Surgery.”
Otolaryngology-Head and Neck Surgery, Vol. 127, pp. 32-35.
Koufman, J., Stern, J., Bauer, M. (2010). Dropping Acid: The Reflux Diet Cookbook &
Cure. New York: The Reflux Cookbooks, L.L.C.
Lloyd, A. T. (2011). The Relationship Among Perceptual and Objective Reflux Measures
in Singers. Unpublished Master’s Thesis, University of Central Florida, Orlando,
Florida.
McGuirt, W. F. (2003). “Gastroesophageal reflux and the upper airway.” Pediatric
Clinics of North America, Vol. 50: pp.487-502.
Miskovitz, P. & Betancourt, M. (2005). Doctor's Guide to Gastrointestinal Health :
Preventing and Treating Acid Reflux, Ulcers, Irritable Bowel Syndrome,
Diverticulitis, Celiac Disease, Colon Cancer, Pancreatitis, Cirrhosis, Hernias
and More. Hoboken, NJ: Wiley Publications.
Mjönes, A,, Ledin, T., Tibbling Grahn, L. & Hultcrantz, E. (2005). “Hoarseness and
misdirected swallowing before and after antireflux surgery.” Acta OtoLaryngologica, Vol 125: 82-85.
Møller Grøntved, A. & West, F. (2000). "pH Monitoring in Patients with Benign Voice
Disorders." Acta Otolaryngology (Supplement) 543: 229-231.
17
Monini, S., Di Stadio, A., Vestri, A., & Barbara, M. (2006). “Silent Reflux: Ex
juvantibus criteria for diagnosis and treatment of laryngeal disorders.” Acta OtoLarygologica 126: 866-871.
Moss, A. C. & Kelly, C. P. (2007). “Reflux, Dyspepsia, and Disorders of the Foregut.”
Southern Medical Association, Vol. 100: 3, pp. 266-272.
Murry, T., Tabaee, A., Owczarzak, V., Aviv, J. E. (2006). "Respiratory Retraining
Therapy and Management of Laryngopharyngeal Reflux in the Treatment of
Patients with Cough and Paradoxical Vocal Fold Movement Disorder." Annals of
Otology, Rhinology & Laryngology Vol. 115, No. 10: 754-758.
Nowak, M., Büttner, P., Harrison, S. & McCutchan, C. (2010). "How do dietitians treat
symptoms of gastro-oesophageal reflux disease in adults?" Nutrition & Dietetics
Vol. 67: 224-230.
Patrick, L. (2011). "Gastroesophageal Reflux Disease (GERD): A Review of
Conventional and Alternative Treatments." Alternative Medicine Review, Vol.
16, No. 2: 116-133.
Pitman, M. (2010). “Singer’s Dysphonia: Etiology, Treatment, and Team Management.”
Music and Medicine Vol. 2, No. 2: pp. 95-103.
Rees, C. J. & Belafsky, P. C. (2008). “Laryngopharyngeal Reflux: Current Concepts in
Pathophysiology, Diagnosis and Treatment.” International Journal of SpeechLanguage Pathology, Vol. 10, No. 4, pp. 245-253.
Ross, J., Noordzji, J. P. & Woo, P. (1998). “Voice Disorders in Patients with Suspected
Laryngo-Pharyngeal Reflux Disease.” Journal of Voice, Vol. 12, No.1: pp.84-88.
Sana, S., Sana, M., Johnston, N. & Mittal, S. K. (2011). “Hoarseness and chronic cough:
Would you suspect reflux?” The Journal of Family Practice, Vol. 60, No. 8: pp.
458-462.
Sandage, M. & Emerich, K. (2002). "Singing Voice: Special Considerations for
Evaluation and Treatment." ASHA Leader, Vol. 7, No. 13: 6-8, 15.
Sataloff, R. T. (2010). “Controversies and Confusions in Diagnosing Laryngopharyngeal
Reflux.” Journal of Singing, Vol. 66, No. 5: pp. 553-557.
Sataloff, R. T., Hawkshaw, M. J., Johnson, J. L., Ruel, B., Wilhelm, A. & Lurie, D.
(2012). “Prevalence of Abnormal Laryngeal Findings in Healthy Singing
Teachers.” Journal of Voice, Vol. 26, No 5: pp. 577-583.
Sataloff, R. T. (1991). Professional Voice, the Science and Art of Clinical Care. New
York, NY: Raven Press Ltd.
18
Sataloff, R. T., Castell, D. O., Katz, P. O. & Sataloff, D. M. (2006). Reflux Laryngitis and
Related Disorders, 3rd Edition. San Diego, CA: Plural Publishing, Inc.
Sataloff, R. T. (2006). Treatment of Voice Disorders. San Diego, CA: Plural Publishing,
Inc.
Sataloff, R. T. (1998). Vocal Health and Pedagogy. San Diego, CA: Singular Publishing
Group, Inc.
Sataloff, R. T. (2005). Voice Science. San Diego, CA: Plural Publishing, Inc.
Sereg-Bahar, M., Jansa, R. & Hocevar-Boltezar, I. (2005). “Voice disorders and
Gastroesophageal reflux.” Logopedics Phoniatrics Vocology, 30: 120-124.
Smoak, B.R. & Koufman, J.A. (2001). “Effects of Gum Chewing on Pharyngeal and
Esophageal pH.” Annals of Otology, Rhinology, & Laryngology Vol. 110, pp.
1117-1119.
Spencer, M. (2006). "Laryngopharyngeal Reflux and Singers: Diabolus in Gula?"
Journal of Singing, Vol. 63, No. 2: 177-184.
Syed, I., Daniels, E. & Bleach, N. R. (2009). “Hoarse voice in adults: an evidence-based
approach to the 12 minute consultation.” Clinical Otolaryngology, Vol 34, 54-58.
Timmermans, B., Vanderwegen, J. & De Bodt, M. S. (2005). “Outcome of vocal hygiene
in singers.” Current Opinion in Otolaryngology and Head and Neck Surgery,
Vol. 13, No. 3, pp. 138-142.
Usai, P., Manca, R., Cuomo, R., Lai, M. A., Russo, L. & Boi, M. F. (2008). “Effect of
gluten-free diet on preventing recurrence of gastroesophageal reflux diseaserelated symptoms in adult celiac patients with nonerosive reflux disease.”
Journal of Gastroenterology and Hepatology, Vol 23, pp. 1368-1372.
Vashani, K., Murugesh, M., Hattiangadi, G., Gore, G., Keer, V., Ramesh, S., Sandur, V.
& Bhatia, S. J. (2010). "Effectiveness of voice therapy in reflux-related voice
disorders." Diseases of the Esophagus, Vol 23: 27-32.
Watson, R.G.P., Tham, T.C.K., Johnston, B.T. & McDougall, N.I. (1997). “Double blind
cross-over placebo controlled study of omeprazole in the treatment of patients
with reflux symptoms and physiological levels of acid reflux – the “sensitive
oesophagus.” Gut, Vol. 40: 578-590.
Wright, C. E., Ebrecht, M., Mitchell, R., Anggiansah, A. & Weinman, J. (2005). “The
effect of psychological stress on symptom severity and perception in patients with
gastro-oesophageal reflux.” Journal of Psychosomatic Research 59, pp. 415-424.
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