1010
Characterization of Laryngopharyngeal Reflux in
Patients with Premalignant or Early Carcinomas of
the Larynx
Jan S. Lewin, Ph.D.1
Ann M. Gillenwater, M.D.1
J. David Garrett, Ph.D.3
Julie K. Bishop-Leone, M.S.1
Dominic D. Nguyen, B.S.1
David L. Callender, M.D., M.B.A.1
Gregory D. Ayers, M.S.2
Jeffrey N. Myers, M.D., Ph.D.1
1
Department of Head and Neck Surgery, The Uni-
versity of Texas M.D. Anderson Cancer Center,
Houston, Texas.
2
Department of Biostatistics, The University of
Texas M.D. Anderson Cancer Center, Houston,
Texas.
3
Communication Sciences and Disorders, Baylor
University, Waco, Texas.
The authors thank Kate OSuilleabhain for editorial
assistance and. Janet Hampton for help in prepar-
ing the article.
Address for reprints: Jan S. Lewin, Ph.D., Depart-
ment of Head and Neck Surgery, Box 441, The
University of Texas M. D. Anderson Cancer Center,
1515 Holcombe Boulevard, Houston, TX 77030-
4009; Fax: (713) 794-4662; E-mail: jlewin@mail.
mdanderson.org
Received May 17, 2002; revision received August
23, 2002; accepted September 30, 2002.
2003 American Cancer Society
BACKGROUND. An association between laryngopharyngeal reflux (LPR) and laryn-
geal carcinoma has been suggested, but remains unproven. The current pilot study
was performed to determine the incidence of LPR among patients with early
laryngeal carcinomas or dysplasia and to examine the associations between levels
of LPR and histologic stage, smoking status, the symptom of heartburn, and body
position during reflux episodes.
METHODS. Behavioral and 24 hour pH monitoring data were prospectively acquired
and analyzed for 40 previously untreated adults with dysplasia, T1or T2 laryngeal
carcinomas.
RESULTS. Eighty-five percent of patients had LPR. No significant association was
shown between the level of LPR and histologic stage or smoking status. Heartburn
did not predict LPR. The incidence of LPR in the upright body position was 91%,
compared with 9% in the supine position, among patients with LPR.
CONCLUSIONS. When compared to available normative data, the current findings
show a high incidence of LPR in patients with premalignant and early laryngeal
cancer. These findings highlight the need for a matched-control study evaluating
LPR as a potential predisposing factor for laryngeal carcinoma. Cancer 2003;97:
1010 4. 2003 American Cancer Society.
DOI 10.1002/cncr.11158
KEYWORDS: laryngopharyngeal reflux, gastroesophageal reflux, laryngeal carcino-
genesis, larynx, pH probe, reflux.
A n association has been suggested between laryngeal carcinoma
and laryngopharyngeal reflux (LPR), the retrograde propulsion of
stomach acid to the level of the larynx and pharynx.1,2 Despite pub-
lication of several clinical reports, there is no consensus on whether
LPR is associated with squamous cell carcinoma of the larynx, nor is
there data establishing LPR as a definitive risk factor for this malig-
nancy. Furthermore, no definitive criteria and little information are
available to assist clinicians in managing patients with both LPR and
potentially malignant laryngeal lesions. As the first step in an ongoing
investigation of the relationship between LPR and laryngeal carcino-
genesis, we determined the incidence and pattern of presentation of
LPR in patients with premalignant lesions or early carcinomas of the
larynx.
The mutagenic effects of tobacco carcinogens that lead to genetic
abnormalities in the multistep development of laryngeal carcinoma are
well described.3 In addition, smoking decreases lower esophageal
sphincter tone, delays gastric emptying, and stimulates gastric acid se-
cretion, thereby increasing the potential for gastroesophageal reflux
(GER) and LPR.2 The reflux of gastric contents may act as a cocarcinogen
 Laryngopharyngeal Reflux and Larynx Cancer/Lewin et al.
to potentiate the mutagenic effects of tobacco.2 In non-
smokers, acid reflux may act as an independent risk
factor for laryngeal carcinoma, similar to the role of
gastroesophageal reflux in the development of Barrett
esophagus and esophageal neoplasia.4
Currently, there is no consensus regarding the
appropriate methodology to detect or quantify LPR,
the indications for treatment, and the optimal assess-
ment of treatment response.1,57 Although 24 hour
ambulatory pH monitoring is a well-established
method for evaluating GER, it has not yet attained the
same level of validation for LPR. The level of normal
reflux into the laryngopharynx remains controver-
sial.5,8,9 As a result, data characterizing the incidence
and pattern of LPR remain sparse and the signs and
symptoms of LPR that may distinguish it from GER
have not been identified.
The aim of the current pilot study was to deter-
mine, using objective methodology and criteria, the
incidence of LPR in patients with early (T1 or T2)
laryngeal carcinomas or premalignant lesions (dyspla-
sia). In addition, we looked for associations between
levels of LPR and histologic stage, smoking status, the
symptom of heartburn, and body position during re-
flux events. These data will form the foundation for
future investigations of the potential role of LPR in
laryngeal carcinogenesis and its impact on the man-
agement of early neoplasia.
METHODS
The current study was approved by The University of
Texas M.D. Anderson Cancer Center institutional re-
view board, and all patients provided written in-
formed consent to participate. Forty previously un-
treated patients presenting with moderate to severe
laryngeal dysplasia or early laryngeal carcinoma (stage
T1 or T2) were recruited to participate. Patients who
had been previously biopsied and/or treated for GER
were eligible for inclusion.
Data Acquisition
Standard 24 hour dual-probe monitoring was per-
formed using a Zinetics 24 single-use internal refer-
ence pH catheter with dual sensors and an 18 cm
interprobe distance (Medtronics Functional Diagnos-
tics, Inc., Shoreview, MN). The pH probe was placed
under direct visualization using a flexible fiberoptic
endoscope as described by Vincent et al.8 The catheter
distance measured at the level of the nares was re-
corded for confirmation of stability following the 24
hour monitoring period. The catheter was secured to
the nasal dorsum with adhesive. The pH data were
recorded at four second intervals throughout the
monitoring period on a Digitrapper III ambulatory pH
monitor (Medtronics Functional Diagnostics).
1011
During the 24 hour monitoring period, patients
kept a diary of all oral intake except water and other
specific information, such as meal times, intervals
spent in the supine position, etc. for later correlation
with reflux events. Participants were asked to refrain
from taking antireflux medications, including over-
the-counter antacids, gastric-acid pump inhibitors, or
histamine blockers, for a minimum of 72 hours before
examination. The patients were instructed to maintain
their normal routine during the 24 hour study period.
All patients tolerated the procedure well and com-
pleted the 24 hour study without experiencing adverse
effects.
The data were uploaded to a personal computer
using the Polygram for Windows with the Esophagram
Reflux Analysis Module version 2.05 software package
(Medtronic Functional Diagnostics, Inc., Skovlunde,
Denmark) for analysis after completion of data acqui-
sition. The subjects diaries were used to verify and
confirm all start and end times for marked events and
to insert any events that had been recorded in the
diaries but not on the monitor.
The treating head and neck surgeon performed
indirect laryngoscopy to identify and record signs of
laryngeal reflux. The clinical signs of reflux used in the
current study included laryngeal erythema, edema,
granulomas or ulcers, pachydermia of the interaryte-
noid mucosa, and subglottic edema.
Scoring of Reflux Episodes
An LPR episode was defined as a decrease in pH to a
level of 4.0 or below in the pharynx or upper esopha-
gus. Each episode was confirmed by a similar decrease
in the pH level detected by the distal sensor immedi-
ately before the occurrence of proximal reflux. We
used normative data published by Vincent et al.8 to
define three levels of LPR in the current study. Vincent
et al. reported a majority of normal patients (52%,
12/23 patients) had at least one reflux episode (mean
2.0, median 1.0, 95th percentile 6.9). Forty-
eight percent of normal subjects had a RAI (reflux area
index) of 0 (95th percentile 6.3). The RAI is a mea-
sure of the area under the pH curve below 4.0, cor-
rected for the duration of the study for each individ-
ual.8 On the basis of this data, we divided the study
population into three subgroups according to the total
number of reflux episodes (TRE) and the RAI. Each
patient was assigned to levels 0, 1, or 2, according to
their pH monitoring results. Patients in level 0 sub-
group had no evidence of reflux as defined by 0 TRE
and a RAI of 0. All other patients were categorized as
having LPR and were assigned to level 1 or 2 based on
their TRE or RAI, whichever was higher. Patients in
level 2 subgroup had a higher than 7 TRE and/or an
RAI 6.3. These values represent reflux levels above
1012 CANCER February 15, 2003 / Volume 97 / Number 4

TABLE 1 TABLE 2
Inclusion Criteria and Patient Distribution for Laryngopharyngeal Characteristics of 40 Patients with Laryngopharyngeal Reflux
Reflux
Characteristic n %
Criteriaa Distribution
Gender
LPR Level TRE RAI n % Male 27 68
Female 13 32
0 0 and 0 6 15 Histologic diagnosis
1 17 and/or 0.16.3 12 30 Precancer
2 7 and/or 6.3 22 55 Supraglottic 1
Glottic 25
LPR: laryngopharyngeal reflux; TRE: total number of reflux episodes; RAI: reflux area index. Total 26 65
a
Patients were categorized into LPR levels based on either their TRE or their RAI, whichever was higher. Cancer
Supraglottic 3
Glottic 11
Total 14 35
the 95th percentile reported for normal subjects. Level Smoking status
1 subgroup was made up of patients who exhibited Never 14 35
reflux episodes that fell below the 95th percentile re- Former 15 37
Current 11 28
ported for normal subjects. The criteria for the three
subgroups are shown in Table 1.
TABLE 3
Data Analysis Data Summary for All Variables and Levels of Laryngopharyngeal
To avoid erroneous inclusion of reflux events while the Reflux
patients were eating, all events that occurred during
Level 0 (n 6) Level 1 (n 12) Level 2 (n 22)
meal intervals and within two minutes after the re-
corded meal end time were excluded from analysis. Characteristic n % of level n % of level n % of level
Each level of LPR (0, 1, or 2) was analyzed and com-
pared with respect to four parameters: 1) histologic Diagnosis
Precancer 5 83 6 50 15 68
stage, 2) smoking status (nonsmoker, former smoker,
Cancer 1 17 6 50 7 32
or current smoker), 3) the symptom of heartburn, and Smoking status
4) body position (upright or supine) during episodes Never 3 50 4 33 7 32
of reflux. Supine position was defined as a reclining Former 1 17 5 42 9 41
position at an angle 45 degrees. Current 2 33 3 25 6 27
Heartburn
Associations among categoric variables were
Asymptomatic 2 33 8 67 5 23
tested using the Fisher exact test. Ninety-five percent Symptomatic 4 67 4 33 17 77
confidence intervals for point estimates of proportions Body position
were exact. All analyses were conducted using SAS Upright Supine 11 92 20 91
statistical software (SAS Institute, Inc., Cary, NC). Upright Supine 1 8 0 0
Upright Supine 0 0 2 9

RESULTS
Of the 40 adult patients who participated in the study,
27 (68%) were men and 13 (32%) were women. The The overall incidence of LPR in this group of pa-
median age was 59 years (range, 29-73 years). All pa- tients was 85% (95% confidence interval, 70 94%).
tients had histologically confirmed moderate to severe Only 15% of patients did not show evidence of LPR
dysplasia or early carcinoma (T1 or T2) of the larynx. (level 0). Thirty percent of the patients had level 1 LPR,
Twenty-six patients (65%) had premalignant lesions, and 55% had level 2 LPR. Table 1 shows the distribu-
one of which was supraglottic and 25 of which were tion of the patient population. A description of patient
glottic. Fourteen (35%) had early carcinomas of the characteristics at each level of LPR is summarized in
larynx, 3 of which were supraglottic and 11 of which Table 3 according to histologic stage, smoking status,
were glottic. Fourteen patients (35%) had never the symptom of heartburn, and body position at the
smoked, 15 (37%) were former smokers (i.e., had time of reflux.
stopped smoking at least one year before accrual), and The level 0 group comprised six patients who had
11 (28%) were current smokers (i.e., had stopped no evidence of LPR (TRE and RAI values of 0). Five of
smoking less than one year before accrual or were these patients had premalignant lesions, while one
smoking at the time of accrual). Table 2 shows the had carcinoma. Three patients had never smoked, one
characteristics of the study population. was a former smoker, and two were current smokers.

TABLE 4
Cancer Diagnosis, Smoking Status, and Laryngopharyngeal
Reflux Level
LPR level, n (%)
Characteristic n 0 1 2
Histologic diagnosis
Precancer 26 5 (19.2) 6 (23.1)
Cancer (T1, T2) 14 1 (17.1) 6 (42.9)
Smoking status
Never 14 3 (21.4) 4 (28.6)
Former 15 1 (6.7) 5 (33.3)
Current 11 2 (18.2) 3 (27.3)
LPR laryngopharyngeal reflux.
a
Fisher exact test.
Four patients (67%), without objective evidence for
LPR, reported symptoms of heartburn, while two pa-
tients (33%) were asymptomatic.
Of the 12 patients in level 1, 6 had premalignant
lesions and 6 had cancerous lesions. Four of the 12
patients had never smoked, 5 were former smokers,
and 3 were current smokers. Eight of the 12 patients
(67%) in level 1 were asymptomatic for heartburn,
while 4 patients (33%) reported periodic symptoms.
Twenty-two patients had level 2 LPR. Fifteen pa-
tients had premalignant lesions, while seven had early
laryngeal carcinoma. Seven patients had never smoked,
nine were former smokers, and six were current smok-
ers. Five (23%) of the 22 patients were asymptomatic,
while 17 (77%) reported symptoms of heartburn.
We evaluated the relationship between LPR and
histologic diagnosis and smoking status using the
Fisher exact test. Our results, presented in Table 4,
show no statistically significant associations between
the histologic stage and the level of LPR (P 0.38). Of
the 26 patients with premalignant lesions, 21 (81%)
had objective evidence of LPR, of whom 15 (71%) had
level 2 LPR. Of the 14 patients with early carcinoma of
the larynx, 13 (93%) had objective evidence of LPR, yet
only 7 of these 13 (54%) presented with level 2 LPR.
Similarly, we found no significant association between
smoking status and the level of LPR (P 0.88).
We also analyzed the relationship between reflux
and body position. Overall, the frequency of reflux
occurrences was greater in the upright position than
in the supine position in 91% of the 34 patients with
LPR (95% confidence interval, 76 98%).
Thirty-six patients (90%) had two or more signs of
reflux as indicated by their surgeon. Interestingly, four
patients (10%) had no clinical evidence of reflux on
laryngoscopic examination, yet one had level 1 and
three had level 2 LPR as documented by 24 hour pH
monitoring.
Laryngopharyngeal Reflux and Larynx Cancer/Lewin et al. 1013
DISCUSSION
Clinicians are increasingly aware of the deleterious
effects to the larynx caused by reflux of gastric con-
tents. Although some authors have suggested an asso-
ciation between LPR and laryngeal carcinogenesis,
P valuea there is insufficient data to either prove or disprove
this hypothesis. Future investigations of LPR as a pre-
0.38
15 (57.7) disposing factor for laryngeal carcinoma require accu-
7 (50.0) rate, objective data characterizing the incidence and
0.88 presentation of reflux in patients at risk for develop-
7 (50.0) ment of this malignancy.
9 (60.0)
6 (54.5)
We determined the incidence of LPR among 40
patients with early cancer or premalignancy of the
larynx. In this group of patients, 85% showed objective
evidence of LPR. In comparison, 52% of normal sub-
jects were found to have LPR in the study reported by
Vincent et al.8 Importantly, 55% of the current patients
with premalignant and early malignant laryngeal le-
sions were above the 95th percentile of the normal
range of LPR reported by those authors. Only 15% of
the current patients had a TRE and an RAI of 0, com-
pared to 48% of normal subjects who had an RAI of 0.8
The results of the current study support the find-
ings of other investigators that LPR is a common oc-
currence among patients diagnosed with carcinoma of
the larynx. Copper et al.10 reported a 62% incidence of
LPR documented with 24 hour pH monitoring in 24
patients with head and neck carcinoma. The current
study, however, specifically examined LPR in patients
with dysplasia and early cancer of the larynx; a popu-
lation where the presence of LPR may be more clini-
cally relevant. We found no significant association
between histologic stage and incidence of LPR. How-
ever, of those patients who did have LPR, more of
those with premalignant lesions (71%) had level 2 LPR
compared to those with early carcinoma (54%).
While several investigators have suggested a
strong relationship between the use of tobacco and
the development of GER,2,11 the current results did not
show a significant relationship between smoking and
LPR. However, the small numbers enrolled in the cur-
rent pilot study prevented meaningful subset analysis
of the three smoking categories. Other studies12 did
not find strong associations between reflux and to-
bacco use. Thus, in the current study, the presence of
LPR did not correlate with the histologic stage of the
laryngeal lesion or the smoking status of the patient.
Although the small sample size prevents us from mak-
ing definitive conclusions, these results may imply
that any effect of LPR on laryngeal carcinogenesis is
independent of other variables.
Although alcohol use is a potentially important
risk factor for both GER and laryngeal carcinoma, to
our knowledge, there is no definitive data available on
1014 CANCER February 15, 2003 / Volume 97 / Number 4
the potential association between alcohol use and LPR
in the process of laryngeal carcinogenesis. We did not
include alcohol use in the current analysis because the
reporting of alcohol use was nonuniform in this study,
making it difficult to quantify in a statistically mean-
ingful way. However, we acknowledge that alcohol use
may contribute to the development of LPR and/or
laryngeal carcinoma and plan to analyze this variable
in the next phase of the current study.
The current results support a distinction between
the presentations of LPR and those reported for GER.
LPR occurred most commonly while the patient was in
the upright position, unlike GER, which more often
occurs when the patient is supine. Furthermore, while
heartburn is one of the cardinal symptoms of
GER,1,12,13 we found no significant relationship be-
tween the occurrence of heartburn and LPR in our
patients. In fact, four of the six patients with level 0
LPR complained of heartburn, even though pH probe
testing did not reveal any evidence of laryngopharyn-
geal reflux. The current results suggest that heartburn
may not be a reliable indicator of LPR, as others have
also reported.1,8,13 In addition, the reliability of clinical
signs as indicators of LPR requires further investiga-
tion with larger sample sizes. The current results sug-
gest that aggressive evaluation for LPR may be indi-
cated in patients with premalignant and early
laryngeal carcinomas whether or not they report
heartburn or have laryngeal signs suggestive of reflux.
The current data also show that LPR episodes in
patients with laryngeal carcinoma or dysplasia occur
primarily while patients are in the upright position. In
the current study, 91% of patients who showed evi-
dence of LPR were in the upright position. This result
corroborates the findings of other investigators that
LPR, in contrast to GER, occurs predominantly while
the patient is in the upright rather than the supine
position.9 Therefore, common treatment recommen-
dations, such as elevating the head while in the supine
position, may not be effective in reducing or prevent-
ing the occurrence of LPR in this population. Clear
differentiation of the pathophysiologic mechanisms of
GER from those of LPR is needed to determine the
most effective treatment regimens for each problem.
CONCLUSIONS
To our knowledge, this is the first study that has sci-
entifically evaluated a population of patients with la-
ryngeal dysplasia and early carcinoma using objective
data from 24 hour pH monitoring based on method-
ologically defined levels of LPR. Eighty-five percent of
patients in the current pilot study showed one or more
episodes of LPR, 55% of whom experienced levels of
reflux above the 95th percentile reported for a group
of normal subjects.8 Thus, when compared to the
available normative data, the current findings suggest
a high incidence of LPR in patients with early carci-
nogenic changes in the larynx. These findings clearly
highlight the critical need for future investigations
with larger sample sizes and matched controls to ob-
jectively define the parameters of pathologic reflux
into the laryngopharynx and the potential role of LPR
as a predisposing risk factor for the development of
laryngeal carcinoma.
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