Diseases of the Esophagus (2010) 23, 27–32

DOI: 10.1111/j.1442-2050.2009.00992.x

Original article dote_992 27..32

Effectiveness of voice therapy in reflux-related voice disorders

K. Vashani,1 M. Murugesh,2 G. Hattiangadi,1 G. Gore,1 V. Keer,1 V. S. Ramesh,2 V. Sandur,2 S. J Bhatia2

1
Departments of Audiology and Speech Therapy, and 2Gastroenterology, BYL Nair Hospital and TN Medical
College, Mumbai, India

SUMMARY. Gastroesophageal reflux (GER) with laryngopharyngeal reflux plays a significant role in voice
disorders. A significant proportion of patients attending ear, nose, and throat clinics with voice disorders may have
gastresophageal reflux disease (GERD). There is no controlled study of the effect of voice therapy on GERD. We
assessed the effect of voice therapy in patients with dysphonia and GERD. Thirty-two patients with dysphonia and
GERD underwent indirect laryngoscopy and voice analysis. Esophageal and laryngeal symptoms were assessed
using the reflux symptom index (RSI). At endoscopy, esophagitis was graded according to Los Angeles classifi-
cation. Patients were randomized to receive either voice therapy and omeprazole (20 mg bid) (n = 16, mean [SD]
age 36.1 [9.6] y; 5 men; Gp A) or omeprazole alone (n = 16, age 31.8 [11.7] y; 9 men; Gp B). During voice analysis,
jitter, shimmer, harmonic-to-noise ratio (HNR) and normalized noise energy (NNE) were assessed using the Dr.
Speech software (version 4 1998; Tigers DRS, Inc). Hoarseness and breathiness of voice were assessed using a
perceptual rating scale of 0–3. Parameters were reassessed after 6 weeks, and analyzed using parametric or
nonparametric tests as applicable. In Group A, 9 patients had Grade A, 3 had Grade B, and 1 had Grade C
esophagitis; 3 had normal study. In Group B, 8 patients had Grade A, 2 had Grade B esophagitis, and 6 had normal
study. Baseline findings: median RSI scores were comparable (Group A 20.0 [range 14–27], Group B 19.0 [15–24]).
Median rating was 2.0 for hoarseness and breathiness for both groups. Values in Groups A and B for jitter 0.5 (0.6)
versus 0.5 (0.8), shimmer 3.1 (2.5) versus 2.8 (2.0), HNR 23.0 (5.6) versus 23.1 (4.2), and NNE -7.3 (3.2) versus
-7.2 (3.4) were similar. Post-therapy values for Groups A and B: RSI scores were 9.0 (5–13; P < 0.01 as compared
with baseline) and 13.0 (10–17; P < 0.01), respectively. Ratings for hoarseness and breathiness were 0.5 (P < 0.01)
and 1.0 (P < 0.01) and 2.0. Values for jitter were 0.2 (0.0; P = 0.02) versus 0.4 (0.7), shimmer 1.3 (0.7; P < 0.01)
versus 2.3 (1.2), HNR 26.7 (2.3; P < 0.01) versus 23.7 (3.2), and NNE -12.3 (3.0, P < 0.01) versus -9.2 (3.4;
P < 0.01). Improvement in the voice therapy group was significantly better than in patients who received omepra-
zole alone. Dysphonia is a significant problem in GER. Treatment for GER improves dysphonia, but in addition,
voice therapy enhances the improvement.
KEY WORDS: gastroesophageal reflux (GER), laryngopharyngeal reflux (LPR), omeprazole, placebo,
randomized-controlled study, voice therapy.

INTRODUCTION ways: impaired intelligibility, self-image difficul-

The human voice makes a major contribution to the
audibility of verbal communication. The voice
serves as a powerful conveyor of personal identity,
emotional and physical state, education, and
social status.1 Voice disorders reduce the speaker’s
communicative effectiveness in the following
Address correspondence to: Professor Shobna J Bhatia, MD,
DNB (gastro), Head, Department of Gastroenterology, Seth GS
Medical College and KEM Hospital, Parel, Mumbai, India.
Email: sjb@kem.edu
© 2009 Copyright the Authors
Journal compilation © 2010, Wiley Periodicals, Inc. and the International Society for Diseases of the Esophagus
ties, fatigue, psychosocial effects, and economic
consequences.1
Cherry and Margulies2 described 3 patients suffer-
ing from contact ulcers, which failed to heal by voice
therapy and voice rest, but was cured by antacids and
lifestyle modifications after a period of 3–6 months.
Further work by Delahunty3 resulted in an awareness
of a distinct entity described as ‘posterior laryngitis’
or ‘reflux laryngitis’. The posterior larynx is the area
most often affected, probably because of positional
and gravitational effects.4 Less than 50% of indi-
viduals with voice disorders, in whom reflux is a
27
28 Diseases of the Esophagus
primary contributory factor, have overt symptoms of
heartburn and regurgitation.5
Koufman6 stressed that the reflux in these patients
was different from that seen in patients who visit
gastroenterology clinics, giving it the name laryn-
gopharyngeal reflux (LPR). The term LPR denotes
gastroesophageal reflux (GER) that reaches the struc-
tures above the upper esophageal sphincter (UES).
The effect on voice is greater in LPR as the refluxate
may damage the vocal folds directly.7
The prevalence of LPR in patients with voice and
laryngeal disorders has been estimated to be as much
as 50%8 to 78%.9 LPR can give rise to unpleasant
sensory sensations and changes in the voice,1 namely
hoarseness. Therapeutic approaches in (gastre-
sophageal reflux disease) GERD-associated voice
problems include effective lifestyle modifications
coupled with pharmacologic management (4–6 week
regimen). Resolution of symptoms especially hoarse-
ness, have been shown to be objectively documented
using acoustic testing.10 In another study, 80% of 30
patients reported an improvement in symptoms.11
Concurrent voice therapy often boosts the recov-
ery period and may be essential to overcome the
damaging vocal behaviors and reduce laryngeal dis-
comfort. Few nonrandomized controlled studies of
voice therapy plus medical therapy have been
reported. The best response rates were observed for
hoarseness (69%) and choking sensation (80%).12
There is no randomized controlled study, which
has objectively evaluated the effectiveness of combi-
nation of medical therapy of GER and voice therapy.
We evaluated the effect of omeprazole alone or in
combination with voice therapy in patients with
dysphonia.
METHODS
Prior to starting the study, a pilot study of 12 subjects
was done.
Thirty-two subjects (14 men) with an unequivocal
diagnosis of GERD (on the basis of endoscopy/
symptomology questionnaire), having symptoms of
hoarseness of voice or change of voice quality, were
included. Children (age < 18 years), pregnant women,
smokers, and tobacco chewers were excluded. Also,
individuals who presented with vocal cord lesions
unrelated to GERD, those who reported history of
laryngeal surgery or previous treatment for GERD,
or those who reported history of voice therapy taken
earlier were excluded.
Subjects with dysphonia underwent detailed
history evaluation using symptomology question-
naire for GER and reflux symptom index (RSI) ques-
tionnaire13 for LPR. Endoscopy was done to look for
esophagitis. Esophagitis was graded according to the
Los Angeles grading system. The subjects were then
Journal compilation © 2010, Wiley Periodicals, Inc. and the International Society for Diseases of the Esophagus
referred to the otolaryngologist for indirect laryngos-
copy (IDL). Subjects underwent perceptual voice
analysis and a computerized acoustic analysis using
the Dr. Speech software (Vocal assessment, Version 4
[1998] Tigers DRS, Inc,. Seattle, WA, USA). Subjects
who met all inclusion criteria were randomly allo-
cated to one of the two treatment groups: pharmaco-
logical therapy (omeprazole 20 mg twice a day) in
combination with voice therapy twice a week for a
period of 6 weeks (Group A) or pharmacological
therapy (omeprazole 20 mg twice a day) along with
placebo for voice treatment twice a week, for a period
of 6 weeks (Group B). The detailed study design is
given in Fig. 1.
Symptoms, perceptual voice analysis and acoustic
analysis were reassessed after 6 weeks.
All subjects were informed of the nature of the
study and gave informed consent. The Ethics Com-
mittee of our institution approved the protocol of our
study.
OUTCOME MEASURES
Reflux score
Symptoms of heartburn, regurgitation, chest pain,
and dysphagia were each rated on a severity scale of
0–3. Frequency was recorded as 1–4 (1 – less than
once a week; 2 – twice a week; 3 – three to six times a
week; and 4 – daily. The products of frequency and
severity for each symptom were added to get the
reflux score.
RSI
Nine items are rated from 1 to 5 by the subject where
0 = no problem and 5 = severe problem, with a
maximum total score of 45. Items of the RSI are:
hoarseness or problem with voice, clearing throat,
excess mucus or postnasal drip, difficulty swallowing
foods, liquids or pills, coughing after eating or lying
down, breathing difficulties of choking episodes,
troublesome or annoying cough, sensation of lump or
something sticking in throat, heartburn, chest pain,
indigestion or regurgitation.
Acoustic analysis
The parameters measured included jitter, shimmer,
normalized noise energy (NNE) and harmonic-to-
noise ratio (HNR) for vowel /a/. The software defines
normal jitter values up to 0.5% and shimmer values
up to 3.0%. Glottal noise is considered to be present
at an acoustic spectral level of -10 dB. Normal values
of HNR have not been specified.
The procedure consisted of recording the produc-
tion of three sustained vowels /a/, /i/, /u/, after taking
a deep breath and at a comfortable loudness and
© 2009 Copyright the Authors

Fig. 1 Flow chart shows the detailed study design.
pitch level. The recording of the voice sample was
done by a unidirectional condenser microphone,
which was held by the clinician at a distance of 4–6
inches from the subject’s mouth. To evaluate test–
retest reliability, the acoustic analysis was repeated
after an interval of 2 hours on the same day of the
pretherapy session, for 16 subjects viz. half the
sample size.
Perceptual voice analysis
Each subject’s voice was recorded in a quiet room,
using Sony TCM-343 cassette-corder, positioned
approximately 6 inches from the patient’s mouth. The
voice qualities of hoarseness and breathiness were
rated as ‘normal’, ‘mild’, ‘moderate’, and ‘severe’ for
the vowel /a/. For the purpose of statistical analysis,
this descriptive analysis was assigned a numerical
value on a rating scale form of 0 to 3 (0 = normal,
1 = mild, 2 = moderate, 3 = severe). To evaluate inter-
judge reliability, the second judge rated the subject’s
voice quality using same parameters as mentioned
previously (both pre- and post-therapy), for 16 sub-
jects viz. half the sample size. However, the two
judges were not present at the same time for the
analysis.
Voice therapy
All subjects in Group A received voice therapy, twice
a week for 6 weeks for a period of about 20–25 min
each. A standard therapy protocol was followed and
a record of the number of sessions was maintained.
© 2009 Copyright the Authors
Journal compilation © 2010, Wiley Periodicals, Inc. and the International Society for Diseases of the Esophagus
Effectiveness of voice therapy in GERD 29
The therapy was divided into two parts: vocal
hygiene program aimed at reducing vocal hyperfunc-
tion and direct techniques aimed at encouraging easy
onset of phonation, decreasing muscular tension, and
improving respiratory support:
Vocal hygiene program included the following
aspects: Voice rest, adequate hydration, reduction/
elimination of laryngeal irritants, reduction of vocal
abuse and hard glottal attack, reduction of vocal
loudness and speech rate, elimination of chronic
throat clearing and coughing.
Direct techniques included the following: Relax-
ation exercises like neck-rotation and laryngeal
massage, breathing exercises like diaphragmatic
breathing, facilitating techniques like yawn sigh,
glottal fry, chewing exercises, chant talk and
humming.
Placebo
For patients in Group B, during each session, the
clinician would discuss compliance with medication
and give reassurance to each subject that the symp-
toms would reduce in time. No voice therapy was
given.
RESULTS
Pilot study
In the pilot study, out of 12 subjects, 6 subjects (3
males) were assigned to Group A and 6 (3 males)
to Group B. Results revealed that there was no
30 Diseases of the Esophagus

Table 1 Symptom parameters of reflux symptom index, esophageal reflux score, hoarseness rating and breathiness rating (for vowel /a/)
pre- and post-therapy

Group A Group B

Symptom parameters Pre Post Pre Post

RSI (Median [range]) 20.0 (14–27) 9.0 (5–13) P = 0.001 19.0 (15–24) 13.0 (10–17) P = 0.001*
Esophageal reflux score (Median [range]) 20.0 (11–33) 7.0 (4–12) P = 0.001 18.5 (11–35) 10.0 (6–16) P = 0.001
Hoarseness (Median [range]) 2.0 (1–3) 0.5 (0–2) P = 0.002 2.0 (1–3) 2.0 (0–3) P = ns*
Breathiness (Median [range]) 2.0 (1–3) 1.0 (0–2) P = 0.001 2.0 (1–3) 2.0 (0–3) P = ns*

Values are as Median (range). P values indicate the significance between pre- and post-therapy values in each group. *P < 0.05 for
post-therapy values in the two groups. RSI, reflux symptom index.

significant difference in HNR post-therapy for both
groups; however, there was a significant difference in
jitter, shimmer, NNE, and RSI. The parameter of
jitter showed greater improvement in Group A as
compared with Group B. Perceptual assessment
revealed significant change in Group A in the overall
severity of the voice problem; however, no significant
change was seen for Group B.
Reliability of outcome measures
The outcome measures, i.e. acoustic analysis, percep-
tual ratings, and RSI were evaluated for reliability
using 16 subjects comprising 8 subjects from each
group. Pearson’s product-moment correlation coeffi-
cient for jitter, shimmer, NNE, and HNR for vowels
/a/ and /i/ ranged between 0.79 and 0.96. Spearman’s
rank correlation coefficient was calculated for
hoarseness and breathiness ratings to estimate inter-
judge reliability. Correlation coefficients for percep-
tual analyses ranged between 0.94 and 0.99.
IDL findings in Group A showed normal larynx in
one patient, edema of arytenoids in 4 patients,
erythema of arytenoids in 6, congested posterior pha-
ryngeal wall in 1, early vocal nodules in 4, mild false
cord hypertrophy in 1, bowing of cords in 1, phona-
tory gap in 3; 7 patients had multiple findings. In
Group B, the findings were edema of arytenoids in 5
patients, erythema of arytenoids in 8, congested pos-
terior pharyngeal wall in 5, early vocal nodules in 3,
phonatory gap in 1; 7 patients had multiple findings.
Post-therapy, the symptoms of esophageal reflux
and RSI improved in both groups, but the improve-
ment in RSI was greater in those who received voice
therapy (Table 1). The voice analysis parameters
shimmer and HNR, improved only in the voice
therapy group (Table 2); jitter and NNE improved in
both treatment groups, but the improvement was by
a greater degree in the voice therapy group.
DISCUSSION

The purpose of our study was to determine whether

Present study
All patients had heartburn, and hoarseness, lump in
throat sensation, throat clearing, and annoying
cough.
The baseline symptoms and voice analysis param-
eters were similar in the two groups (Tables 1 and 2).
Endoscopy in Group A patients revealed normal
endoscopy in 3 patients, Grade A esophagitis in 9,
Grade B in 3, and Grade C in 1. In Group B, 6
patients had normal endoscopy, and Grade A and B
esophagitis was seen in 8 and 2 patients, respectively.
omeprazole plus voice therapy was more effective in
the management of reflux-related voice disorders
as compared with omeprazole alone. We found that
though the RSI improved in all patients, the improve-
ment was of a greater degree in patients who received
voice therapy. Symptoms of hoarseness and breathi-
ness, as also shimmer and HNR improved only in the
voice therapy group; jitter and NNE improved by a
greater degree in the voice therapy group.
All our patients had hoarseness. Other laryngeal
symptoms related to GERD were throat clearing,

Table 2 Mean (SD) values of acoustic parameters i.e. jitter, shimmer, harmonic noise ratio and normalized noise energy for the vowel /a/

Group A Group B

Acoustic Parameters Pre Post Pre Post

Jitter (%) 0.5 (0.6) 0.2 (0.0) P = 0.018 0.5 (0.8) 0.4 (0.7) P = 0.001
Shimmer (%) 3.1 (2.5) 1.3 (0.7) P = 0.001 2.8 (2.0) 2.3 (1.2) P = ns*
HNR (dB) 23.0 (5.6) 26.7 (2.3) P = 0.006 23.1 (4.2) 23.7 (3.2) P = ns*
NNE (dB) -7.3 (3.2) -12.3 (3.0) P = 0.001 -7.2 (3.4) -9.2 (3.4) P = 0.001*

All values are as Mean (SD). P values indicate the significance between pre- and post-therapy values in each group. *P < 0.05 for
post-therapy values in the two groups. HNR, harmonic-to-noise ratio; NNE, normalized noise energy.
© 2009 Copyright the Authors
Journal compilation © 2010, Wiley Periodicals, Inc. and the International Society for Diseases of the Esophagus

annoying cough, and globus sensation. This finding is
similar to a previous study by Koufman,6 where in
225 patients suspected of GERD were evaluated.
Typical symptoms of heartburn and regurgitation
were present in all our patients. Several authors6,14
have suggested that typical symptoms of GERD may
be absent in such subjects. However, we selected
patients who presented with heartburn.
Among patients who present primarily with voice
disorders, the patient may be having the symptoms of
GERD but may not report them as he may not think
that they are related to the voice problem.1
In the case of hoarseness and breathiness, a signifi-
cant change was observed perceptually post-therapy
for both the groups. The significant change in percep-
tual ratings that has occurred in the control group is
expected, as medical treatment of GERD, with or
without lifestyle modifications, reduces laryngeal
symptoms of reflux, including hoarseness. Selby
et al.7 found a small but significant improvement in
the perception of voice quality post-treatment using a
combined approach. Only one study15 found no sig-
nificant change in the perceptual evaluation in reflux-
related dysphonia patients post-antireflux treatment.
Compared with pretherapy baseline, it was found
that both the groups demonstrated a decrease in total
RSI scores. Belafsky et al.13 found the mean RSI to
improve from 19.3 to 13.9, after 2 months of therapy
with proton-pump inhibitors in patients with laryn-
geal symptoms of GERD. Greater improvement in
symptoms occurred in the experimental group in our
study. Voice therapy thus appears to have been effec-
tive in bringing about a greater improvement in reflux
symptoms.
Fraser et al.12 noted that many laryngeal symp-
toms related to reflux had a multifactorial basis, and
that close attention to problems in abnormal voicing
and the supportive nature of the multidisciplinary
clinic were all part of the therapeutic effect.
Laryngoscopic findings revealed that the most
common laryngeal sign was erythema and edema of
the arytenoids. Previous studies have also found
similar abnormalities.16,17
In our study, jitter and NNE improved post-
therapy in both the groups. Hanson et al.18 found a
significant improvement in acoustic measures of
jitter, shimmer, and signal-to-noise ratio (SNR) in
subjects with hoarseness after treating with medica-
tion and lifestyle changes. However, other authors19
did not find a change in acoustic measures of voice
after antireflux medication for 4 weeks. In our study,
shimmer and HNR did not improve in patients who
received omeprazole alone.
The improvement in jitter and NNE was greater
for the experimental group. Selby et al.7 found no
significant change in any of the acoustic parameters
post-therapy, except for HNR. As LPR subjects are
commonly perceived as being hoarse, HNR is consid-
© 2009 Copyright the Authors
Journal compilation © 2010, Wiley Periodicals, Inc. and the International Society for Diseases of the Esophagus
Effectiveness of voice therapy in GERD 31
ered to be a useful measure in documenting the effects
of LPR on vocal function. Thus, it would be expected
that HNR (the amount of noise in a speech signal)
would reduce post-treatment if the severity of hoarse-
ness reduces,20 as was also found in our study. A
significantly greater improvement in acoustic param-
eters occurred in the experimental group. As Card-
ing21 advocated, acoustic analysis can be powerful
measures of voice quality, only if used in conjunction
with other measures such as perceptual ratings.
The effect of placebo cannot be ignored in the
control group. The slight improvement that has
occurred in the control group is probably a result of
the combination of medication and placebo. Several
studies22,23 have reported a placebo effect in the treat-
ment of laryngeal symptoms of reflux using medica-
tion alone as the empirical therapy. However, we are
not aware of any controlled study, which has com-
pared the combination of medical and voice therapy
versus medical therapy alone.
The limitations of this study are a relatively small
sample size and IDL was not repeated post-therapy
to determine change in laryngeal status. Also, we
could not compare the voice changes in various
grades of GERD as there were very few patients who
had severe esophagitis. It is said that ‘what the mind
does not know the eye does not look for it,’ which can
be said about voice symptoms and GERD. Earlier,
the concept of the role of GERD in a voice problem
was less clear, which was probably the reason why
voice therapy may not have been utilized to comple-
ment medical therapy for GERD. To summarize,
management of a voice problem related to GERD
should include antireflux medication as well as voice
therapy.
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© 2009 Copyright the Authors