Reflux in Singers

Experience suggests that gastro-oesophageal reflux disease (GORD) is relatively common in singers, an observation confirmed in an interesting study from Italy. Researchers in Rome studied the prevalence of GORD in a group of 351 professional opera singers from well known choirs in different regions of Italy. At the same time they identified a group of 578 non-singers from the same areas, with a similar distribution in age and sex. Appropriate statistical adjustments were made for smoking status, alcohol consumption, body mass index and other confounding factors. 
 
Results confirmed that opera singers had a much higher prevalence of heartburn, regurgitation, cough and hoarseness when compared with the non-singing population. In fact, hoarseness was almost 2.5 times more common in singers than non-singers. The authors speculate that this may be due to the fact that singing results in a significant increase in abdominal pressure, causing weakness at the point at which the oesophagus passes through the diaphragm, possibly resulting in a hiatus hernia. 
 
However, another report sheds more light on the possible mechanisms involved in the high rates of GORD observed in singers. In this study a 49-year old opera singer had detailed pressure and pH (acidity) measurements performed throughout the oesophagus whilst performing a vocal warm-up routine.  During this singing activity, pH monitoring showed 69 episodes of reflux, accounting for 10% of the total reflux time, which is >10 times higher than that found in health volunteers. It seems that the muscle of the diaphragm, which is an important component of the lower oesophageal sphincter mechanism, becomes fatigued during prolonged vocal activity, making reflux much more likely. Interestingly the singer in this study had a normal acid exposure before and after her usual warm-up exercises.
 
So it seems that the demands of singing and the specific mechanisms involved, contribute to an increased risk of reflux disease in professional singers. Unsurprisingly, similar findings have been reported among musicians playing wind instruments.
 
 
References
Cammarota G, Masala G, Cianci R et al. Reflux symtoms in professional opera choristers. Gastroenterology 2007; 132:892-898

Marchese M, Spada C, Costamagna G. Stress-Related Esophagopharyngeal Reflux During Warm-Up Exercises in a Singer. Gastroenterology 2008; 134:2192-2193

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