Hoarseness is typically associated with a cold. A cold usually passes fairly quickly, and the voice sounds normal again.
If the hoarseness lasts for a long time, though, airway reflux could be the cause. Airway reflux is also known as laryngopharyngeal reflux (LPR).
What is LPR?
LPR describes the rise of acidic aerosols from the stomach through the esophagus to the throat and airways. In contrast to classic acid reflux (known as GERD), where acidic gastric juice irritates the esophagus, airway reflux does not cause typical reflux symptoms such as heartburn.
LPR is also called silent reflux because it causes unspecific symptoms, making the diagnosis difficult.
How LPR causes hoarseness
An enzyme from the stomach, called pepsin, is carried along with the acidic aerosols (a fine mist). Pepsin breaks down proteins and is thereby involved in the digestive process. It can cause a lot of damage outside the stomach, though, because it continues to perform their digestive functions where they’re not needed.
Once pepsin reaches the throat and airways, it irritates the mucous membranes and causes inflammation.
Inflammation of the larynx (voice box) leads to hoarseness. Because the larynx is close to the esophagus, it can easily be affected by acid reflux.
Our voice-box is a sensitive organ that is easily impaired by even small amounts of inflammation. That is why even light LPR can cause hoarseness.
How to recognize when hoarseness is caused by LPR
Affected people report that they perceive their voice as unfamiliar and that their voice sounds rough and raspy. Moreover, they experience feelings of tension in the larynx and that their voice gets tired easily.
People who use their voice a lot, such as singers and speakers, observe that their voice takes longer to warm up. Singers might have difficulties in controlling their voice as they are used to. The voice might get tired unusually quick.[1]
Hoarseness that is caused by acid reflux does not really differ from hoarseness from other causes. That is what can make the diagnosis just based on this one symptom difficult. Often the symptoms are contributed to poor voice hygiene, particularly in people who need to talk a lot for work. However, reflux is actually a common contributor to voice problems and often overlooked.
Silent reflux doesn’t only cause hoarseness but many other symptoms. If you have not just one but multiple symptoms of LPR, it makes it much more likely that you indeed do suffer from airway reflux. One useful tool to find out whether the symptoms point towards LPR is the RSI test.[2] It simply asks you about the severity of different typical LPR symptoms to calculate a symptom score. You can take the test online on Refluxgate. However, particularly for people who use their voice a lot, hoarseness often shows up long before other symptoms do.
Early treatment of LPR is recommended. The earlier action is taken, the easier and more successful is the treatment. Dietary changes are a meaningful treatment approach because they target the root cause of the disease.
References
[1] Lechien JR, Huet K, Khalife M, et al. Impact of laryngopharyngeal reflux on subjective and objective voice assessments: a prospective study. J Otolaryngol Head Neck Surg. 2016;45(1):59.
[2] Befalsky PC, Postma GN, Koufman JA. Validity and reliability of the Reflux Symptom Index (RSI). Journal of Voice – The Voice Foundation 2002;16(2):274-7.
