Respiratory system pathologies in patients who underwent total laryngectomy due to larynx cancer

Laryngeal cancer continues to be the most widespread tumors of the head and neck regions [1,2]. Despite the signifi cant advancements in the care of laryngeal cancer patients during the last several decades, therapeutic complications and the increased attention to quality of life have led to the need to carry out further studies on this population [3]. In addition to laryngeal malignity itself, factors related to acute and late or chronic treatment, secondary primary cancers, intercurrent disease and psychosocial factors are responsible from patient morbidity and mortality. Loss of the protective function of the nose and upper respiratory tracts resulting from the total laryngectomy operation due to larynx cancer make these cases more sensitive to lung infections in comparison with normal Abstract


Materials and method
A total of 54 larynx cancer patients who have undergone total laryngectomy operation admitted to our clinic during July 2016-November 2019 due to accompanying respiratory system pathology were retrospectively evaluated with regard to clinical radiologic and histopathologic fi ndings. The median age of the patients was 65+8 and all the cases were male.
Histopathological diagnosis was made by biopsy in all cases.
The youngest patient was 37 years old, and the oldest was 79 years old. Four (7%) of the cases had chemotherapy and 36 (33%) of them had simultaneous chemo-radiotherapy and all of them were regional hyperfractionated radiotherapy. The fi ndings were examined comparatively with relevant literature data. The study was approved by the local ethics committee and informed consent was obtained from the study participants.

Statistical analysis
Statistical Package for the Social Sciences (SPSS, Inc. Chicago IL) version 22 was used for data analysis the results of which were presented as mean ± standard deviation, number (n) and percentage (%). X 2 test was used for the comparison of categorical variables between groups, whereas Student T test was used for comparing continuous variables. P values of <0,05 were accepted as statistically signifi cant.

Results
Fifty-four patients underwent the procedure and were followed up for at least 48 mounts or until death. Incidence of distant metastases was greatest between 1.5 and 4 years after initial treatment with a mean incidence being less than or equal to 3.2 years. Seventeen underwent the surgery for recurrence after failure of radiation therapy for cure. All cases were male.
Age average was 65+8 years. They had a smoking history of 62+42 packs per year on average. All cases had undergone total laryngectomy operation due to epidermoid type larynx carcinoma and had tracheostomies. The respiratory system pathologies observed in the cases are summarized in Table 1.
Of the cases with non-small lung carcinoma, 12 were squamous cell carcinoma and 2 were adenocarcinoma. Twelve of these cases were Stage 3B, whereas one was Stage 1A. The average duration until the lung carcinoma patients applied to our hospital following laryngectomy was 48+36 months.
The case with malignant pleurisy applied to our hospital 84 months after laryngectomy. The patient was diagnosed with pleural function cytological examination. Cytological fi ndings were in accordance with adenocarcinoma metastasis.
Primary focus was not observed in the patient examined via fi beroptic bronchoscopy, thorax and computerized abdominal tomography.
One case was hospitalized on the 12 th month after laryngectomy due to bilateral multiple metastatic nodules in the lung. No other primary focus was observed as a result of bronchoscopy and the examination of other systems. However, it was later found that the prostate cancer had lung metastasis.
Esophagus-pleural fi stula was determined in a patient who had undergone laryngectomy at another center after which epidermoid type esophagus carcinoma was determined on the 46 th month who had been referred to our hospital due to pleural effusion in the left hemithorax following diagnosis.
The esophagopleural fi stula diagnosis was placed following the detection of food particles in the drainage fl uid and via barium esophagus passage graphy in the patient subject to closed water-seal drainage due to the detection of empyema in pleural puncture.
Rigid bronchoscope was used for excision of the polypoid appearance mass detected at the 1/3 distal end anterior localization in the trachea after which it was reported as hamartoma following the pathological examination.
Twelve of the patients (22%) had previously diagnosed COPD disease. These cases were fi rst hospitalized at our service due to acute fl are up on average about 87+64 months following laryngectomy. Their hospitalizations for the same reason were excluded from the present study. The smoking histories of these cases were 44+30 packs per year on average.
Pneumonia was detected in 8 cases (15%), whereas lung abscess was detected in 2 cases (3.7%). Stafi lococcus Aerius grew in the non-specifi c phlegm culture of one of the cases who applied with pneumonia clinic, whereas Acinetobacter grew in one of the cases with lung abscess both of which ended with exitus. The factor could not be isolated in the other 7 cases with pneumonia, however they benefi ted from the empirical antibiotherapy applied.
Chronic osteomyelitis was determined via partial rib resection in 1 patient who applied with swelling and pain in the right 5 th and 6 th costochondral junction.
Solitary pulmonary nodule was present in two out of 4 cases (7.5%) who could be subject to radiological examination, bilateral multiple pulmonary nodules were present in one and mass lesion accompanying the pleural fl uid in the right lung  for Acinetobacter development [19]. It is suggested that the patients are taken in bronchial hygiene training programs for protection against severe lung infections by way of repressing the mucus [20,21]. Repeating infections may lead to rare complications such as the costa osteomyelitis observed in one of our cases [22,23].
This study has various limitations that should be indicated.
The fact that all cases who took part in the study are male was the most important limiting factor. This restricts our ability to generalize the fi ndings of the present study.  [24,25]. In our study incidence of distant metastases was greatest between 1.5 and 4 years after initial treatment with a mean incidence being less than or equal to 3.2 years. To obtain higher cure rates, it will be important to diagnose distant and delayed regional metastasis Early detection and treatment of local recurrence, management of functional defi ciencies due to treatment, and early detection of secondary primary carcinomas should be essential for the follow-up of patients with laryngeal cancer. Thus, cases who have undergone total laryngectomy due to larynx cancer should be closely followed up at frequent intervals with regard to common epidemiological factors such as smoking and secondary lung pathologies as well as the metastases of the fi rst primary disease. We hope that the detection of the respiratory pathologies examined in larynx cancer patients will act as a guide for future interventions for improving the quality of life of these individuals.