I have a voice problem associated with reflux disease. I've had an endoscopy, as well as a 24-hour pH test. I have taken Prilosec, Prevacid, Tagamet and another drug that I can't recall, all with no relief. Are there other options? I don't know where to go from here. My voice problem is really affecting every aspect of my life.

Trina

Gastroesophageal reflux disease (GERD) is caused by abnormal reflux of stomach acid into the esophagus. Although the typical symptoms of GERD are heartburn and an acid taste in the mouth, other less common symptoms, known as extraesophageal symptoms, stem from acid irritation and damage to other organs. These may include laryngitis because of acid reflux into the larynx and vocal cords. Chronic cough and asthma may also occur if the acid spills into the windpipe. Pneumonia may occur because of repeated aspiration of stomach acid, most commonly during sleep. So, in short, your voice problem is not an unknown complication of reflux disease.

Although reflux is typically treated effectively with over-the-counter medications, some patients require stronger suppression of stomach acid to relieve symptoms. Proton-pump inhibitors (PPIs), including omeprazole (Prilosec) and lansoprazole (Prevacid), are the most potent suppressors of stomach-acid production. In most patients (85-90 percent), PPI medications provide significant relief.

However, people with extraesophageal symptoms are often resistant to therapy and may not fully respond to PPIs or require much higher doses. In such patients there are other treatment options. One involves adding medications, such as cisapride (Propulsid), that help propel food and secretions down into the stomach while preventing reflux back up the esophagus. In addition, cisapride strengthens the sphincter muscle between the esophagus and stomach, thereby reducing reflux. Cisapride is generally reserved as a second-line drug or for severe cases of GERD because of its potential side effects. These include abnormal heart rhythms, which are most likely to occur in patients who have pre-existing heart disease or who take other medications that may interact with cisapride to increase its blood levels. [Editor's note: Because of such side effects, Propulsid's manufacturer decided to remove the drug from the market in July 2000. For more information, see the article Substitutes for Propulsid?]

Another therapeutic possibility in patients with GERD and extraesophageal symptoms who do not respond to PPI therapy is surgery. This operation, known as fundoplication, basically involves a wrapping of the upper stomach (the fundus) around the lower esophagus to strengthen the sphincter and reduce the chances for reflux. This procedure is now done laparoscopically with low complication rates and recovery times.

Before you consider any further treatment options, it must be determined that your voice problem truly stems from GERD. I assume that your endoscopy and 24-hour pH study (the gold-standard test for GERD) produced results consistent with this diagnosis. You should also have an ear, nose and throat doctor evaluate your vocal cords and larynx. If your voice problem proves to be GERD-related, then you should discuss further treatment options with your gastroenterologist.