A Voice Therapist’s Guide to Healing Silent Reflux

Raoul Düsterhus explores the challenges of treating reflux, especially LPR (laryngopharyngeal reflux), with surgery. He highlights how the nature of reflux—gas or acid—affects surgical options and stresses the value of experience and scientific evidence in selecting the right treatment, from traditional fundoplication to newer methods like LINX and Reflux Stop.

Raoul’s Background and Journey with LPR

Josef Kreitmayer

Welcome to another amazing session at the Reflux Summit. I’m joined by a wonderful guest, Raoul Düsterhus, a voice therapist from Germany who specializes in working with patients with LPR. Welcome, Raoul.

Raoul Düsterhus

Thank you. Welcome to everyone listening to our interview.

Josef Kreitmayer

Let me introduce you. Raoul is a state-certified voice therapist and opera tenor. He teaches singing and works daily with voice and vocal health, particularly with patients suffering from laryngopharyngeal reflux (LPR), also known as silent reflux. His approach integrates medical knowledge, voice therapy, and holistic interventions to help patients manage symptoms and restore vocal strength.

Raoul Düsterhus

I’ve nearly completed a master’s in health management, which adds another layer to how I approach patient care.

Josef Kreitmayer

Would you share your personal experience and how it led you to help others?

Raoul Düsterhus

I first experienced acid reflux symptoms during my opera singing studies. I went through multiple diagnostic procedures, including gastroscopies, which showed mild issues with acid and a weak lower esophageal sphincter—but not enough for a formal GERD diagnosis. Despite that, surgery was recommended.

I lived with symptoms for over five years before deciding I couldn’t let this continue. I eventually discovered that food intolerances—specifically fructose and sorbitol—were the main trigger. Once I identified those, everything changed.

The Role of Food Intolerances in LPR Symptoms

Josef Kreitmayer

How did you come to suspect food intolerances?

Raoul Düsterhus

I had two gastroscopies showing a weak sphincter and some acid issues, but nothing pathological. I was only 23 or 24 when surgery was proposed. That felt premature.

I requested intolerance testing—glucose, fructose, lactose, and sorbitol. I tested positive for fructose and sorbitol intolerance.

I was completely bloated. It affected my daily life and even my singing. Once I removed those triggers, I felt 99% better. I’m not “cured,” but I live freely again.

Josef Kreitmayer

And you didn’t have the surgery?

Raoul Düsterhus

No. They had scheduled it, but I asked for more time. I’m very glad I did.

Surgery, GERD vs. LPR, and the Role of Gas

Josef Kreitmayer

What’s your opinion on reflux surgeries?

Raoul Düsterhus

Surgery is over-recommended in many LPR cases. Some patients truly need it—but many don’t.

LPR is often about gas reflux, not acid. Even a tight LES won’t stop gas. The main damaging factor in LPR is pepsin, not acid itself.

Josef Kreitmayer

Can you explain the difference between GERD and LPR?

Raoul Düsterhus

GERD involves acid rising into the esophagus and causing heartburn.

LPR is more about gas carrying pepsin into the throat and upper airway. Pepsin damages sensitive tissues in the larynx and even the nasal passages.

Diagnosis: What to Ask For and How to Prepare

Josef Kreitmayer

What is proper diagnostic workup for LPR?

Raoul Düsterhus

It should include:
– ENT examination
– Gastroscopy
– 24-hour pH-metry
– Manometry for esophageal function

Patients should bring two tools to appointments:
– Reflux Symptom Index (RSI)
– Reflux Finding Score (RFS)

These help structure evaluation and communication between specialists.

Common LPR Symptoms and the Impact of Stress

Josef Kreitmayer

What symptoms do you commonly see?

Raoul Düsterhus

Chronic cough
Postnasal drip
Hoarseness
Loss of voice control
Swallowing issues
Throat tightness or lump sensation

Stress plays a major role. Trauma and chronic stress can worsen symptoms significantly.

Laryngeal Flexibility and Age-Related Stiffness

Josef Kreitmayer

Do you work directly with laryngeal muscle stiffness?

Raoul Düsterhus

Yes. The larynx should move freely. With age, cartilage can harden (ossification), reducing flexibility.

People who rarely use their voice may experience more stiffness. Singers often maintain flexibility due to regular training.

Exercises and Treatment Cautions

Josef Kreitmayer

Do you recommend exercises?

Raoul Düsterhus

It depends on the patient. The wrong exercises can harm.

Proper evaluation is critical before beginning voice or breathing work.

Treatment Modalities and Voice Therapy Tools

Raoul Düsterhus

There is no standardized SLP protocol for LPR yet, but I’m developing one.

We use tools like LaxVox (phonating through a tube in water), manual laryngeal mobilization, breathing retraining, and diaphragm activation.

Proper breathing can strengthen diaphragm support and potentially improve LES pressure balance.

Correct Breathing for Reflux Health

Raoul Düsterhus

The most efficient breathing is costal-abdominal breathing—using both diaphragm and intercostal muscles.

The diaphragm moves downward, expanding the belly during inhalation. Many resist this for aesthetic reasons, but it’s essential for proper breathing and reflux control.

The Role and Limits of PPIs

Josef Kreitmayer

What’s your view on PPIs?

Raoul Düsterhus

PPIs reduce acid and are useful for GERD.

In LPR, they are sometimes used diagnostically. If symptoms don’t improve, the cause is likely gas reflux—not acid.

Bloating, SIBO, and Intolerance Testing

Raoul Düsterhus

Patients with bloating should test for intolerances and SIBO.

Breath testing at a GI clinic is straightforward. Each sugar test is done separately and interpreted professionally. DIY testing is not recommended.

Lifestyle, Honesty, and Active Participation

Raoul Düsterhus

Therapy continues outside the session. Lifestyle tracking is essential—diet, stress, sleep, smoking, alcohol.

Honesty matters. Without full transparency, we cannot treat the root cause.

Breathing for Stress Reduction

Raoul Düsterhus

I often use the 4-7-8 breathing method:
Inhale 4 seconds
Hold 7 seconds
Exhale 8 seconds

Repeat three times. It calms patients immediately and improves swallowing and voice function.

Case Studies: Organic vs Psychological Components

Raoul Düsterhus

I worked with two patients diagnosed with LPR.

One had a purely organic cause and showed strong improvement.

The other had a significant psychological component. Diagnostics improved, but perception didn’t match results.

This highlights the mind-body connection in LPR.

Measuring Progress

Raoul Düsterhus

We use tools like:
– Phonetograms
– Voice Handicap Index (VHI-9)
– Reflux Symptom Index (RSI)
– Reflux Finding Score (RFS)
– Epworth Sleepiness Scale

Objective measurements are important because perception can differ from reality.

Key Messages for Patients and Professionals

Josef Kreitmayer

What’s your final advice?

Raoul Düsterhus

For patients:
Get proper diagnostics. Understand the root cause. Be willing to change.

For professionals:
Include Speech-Language Pathologists more. We spend 45–60 minutes per session and can provide depth of care that doctors often cannot due to time constraints.

Closing

Josef Kreitmayer

Thank you, Raoul. That was incredibly insightful.

Raoul Düsterhus

Thank you for the invitation.

Josef Kreitmayer

And to the audience, if you’d like to contact Raoul for consultation, his details are below. Thank you for watching.