European Archives of Oto-Rhino-Laryngology

https://doi.org/10.1007/s00405-023-07937-7

HEAD AND NECK

Non‑conventional laryngeal malignancies: a multicentre review

of management and outcomes
Rory J. O’Neill1,2   · Justin Hintze1,2 · Adrinda Sharifah3 · Stephen Garry2,5 · Graham Woods6 · Anthony Noone1 ·
Helen L. Barrett1 · Orla Young5 · Sherif Mamdouh1,2 · Neville Shine1 · Conrad Timon3,7 · John Kinsella3 ·
Patrick Sheahan4,8 · Paul Lennon3 · James Paul O’Neill1,2

Received: 7 January 2023 / Accepted: 20 March 2023

© The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature 2023

Abstract
Purpose  Non-conventional laryngeal malignancies (NSCC) often have limited published data to guide management despite
individual histopathological subtypes often exhibiting heterogeneous behaviour, characteristics, and treatment responses
compared to laryngeal squamous cell carcinoma (SCC). This study aimed to compare oncological outcomes with SCC,
specifically disease-free survival (DFS), disease-specific survival (DSS) and overall survival (OS). Secondary objectives
were to compare treatment differences and perform a state of the art review.
Methods  This was a multicentre retrospective cohort study at four tertiary head and neck centres. Survival outcomes between
NSCC and SCC patients were analysed with Kaplan–Meier curves and compared by log rank testing. Univariate Cox regres-
sion analysis was performed to predict survival by histopathological subgroup, T-stage, N-stage and M-stage.
Results  There were no significant differences in 3-year DFS (p = 0.499), DSS (p = 0.329), OS (p = 0.360) or Kaplan Meier
survival curves (DSS/OS) between SCC and overall NSCC groups. However, univariate Cox regression analysis identified
“rare” histopathologies (mostly small cell carcinoma) to be predictive of less favourable OS (p = 0.035) but this result was
not observed for other NSCC histopathological subgroups. N-stage (p = 0.027) and M-stage (p = 0.048) also predicted OS
for NSCC malignancies. Significant differences in treatment modalities were identified with treatment of NSCC typically
involving surgical resection and SCC often managed non-surgically (e.g., primary radiotherapy).
Conclusions  Although overall NSCC is managed differently compared to SCC, there do not appear to be differences in
survival outcomes between these groups. N-stage and M-stage appear to be more predictive of OS than histopathology than
many NSCC subtypes.

Keywords  Laryngeal cancer · Head and neck · Surgery · Radiotherapy · Oncology · Outcomes

Introduction strategies. On an individual level, many of these are rare and

Squamous cell carcinoma (SCC) is by far the most com-
mon histopathological type of laryngeal cancer accounting
for 95–98% of the disease burden [1]. As such, most of the
published research regarding the management of laryngeal
cancer is often based on SCC, with non-conventional malig-
nancies (NSCC) frequently excluded from studies [2, 3].
Head and neck surgeons will inevitably encounter cases of
laryngeal NSCC in their career, many of which can be more
aggressive and resistant to standard oncological management
there is often a paucity of high quality scientific data to help
guide management.
The aim of this study was to review the management of
patients treated for laryngeal NSCC at multiple national
head and neck oncology centres. The primary objectives
were to compare oncological outcomes between NSCC and
SCC, specifically disease-free survival (DFS), disease-spe-
cific survival (DSS) and overall survival (OS). Secondary
objectives were to compare treatment differences and per-
form a state of the art review.

* Rory J. O’Neill
oneillrjj@gmail.com
Extended author information available on the last page of the article

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 European Archives of Oto-Rhino-Laryngology

Materials and methods Results

A retrospective review of patients treated for laryngeal 33 patients with laryngeal NSCC were identified (Table 1).
NSCC from four tertiary head and neck centres in Ireland Demographics are summarised in Table 2. Standard radio-
was performed. Patients with histologically confirmed SCC logical assessment included computed tomography (CT) of
variants (e.g., sarcomatoid carcinoma) or non-SCC malig- the neck and thorax and 54.5% of patients received posi-
nancies of the larynx were included. Patients were excluded tron emission tomography (PET) imaging. There were no
if there was inadequate clinical data (histological subtype, clinically or statistically significant differences between
treatment received, response, recurrence or mortality) or cohorts across sex, age, subsite, and stage. NSCC patients
mixed tumors with a conventional SCC majority. Cases were were more frequently treated with primary surgery or sur-
identified from local head and neck oncology databases and gery plus adjuvant RT than SCC patients (69.7% vs 30.2%,
histopathology records with data collected from these as respectively) who were typically managed non-surgically
well as imaging systems and medical records. Data avail- (P = 0.015). Mean follow-up durations for NSCC and SCC
able on patients treated between 1997 and 2020 was col- were 43.3 months and 38.5 months, respectively.
lected. Tumors were staged-based after clinical, radiological
and histopathological assessment according to the AJCC 8th
edition. All malignancies were histologically confirmed. The Outcomes
following data from each case was extracted: age, sex, histo-
pathological type, stage, primary treatment, time to relapse, Overall, there were no statistically significant differences
time to death, and cause of death. We defined treatment non- for 3-year DFS, DSS and OS between NSCC and SCC
response as the presence of disease clinically, radiologically cohorts (Table 3).
or histopathologically within 6-month post-treatment. This The Kaplan Meier curves for DSS and OS are demon-
duration was chosen as post-treatment surveillance imaging strated in Fig. 1a, b, respectively. Despite similar trends of
is often advised to be performed within this time[4]. The NSCC tending towards less favourable outcomes compared
presence of disease after this time was considered recur- to SCC, results for DSS (p = 0.317) and OS (p = 0.353)
rence. Each case of NSCC was matched with a case of con- lacked statistical significance.
ventional SCC of the same clinical stage followed by age, On univariate Cox regression analysis, histopathologi-
gender and laryngeal subsite. Clinical research ethics com- cal subgroups did not predict OS except for malignancies
mittee approval (#6446) was received. in the “rare” subgroup (p = 0.035) which mostly consisted
of small cell carcinoma. N-stage (p = 0.027) and M-stage
(p = 0.048) were found to be predictive of OS but not
Statistical analysis T-stage (p = 0.932).
Staging, treatment and outcomes for each of the histo-
Statistical analysis was performed using SPSS v.26 pathological subtypes are summarized in Table 4 (sarco-
(Armonk, NY). Demographic and treatment variables were matoid carcinoma), Table 5 (MSGT), Table 6 (sarcoma)
cross tabulated between cohorts and compared using Pear- and Table 7 (rare malignancies).
son’s chi-square test and Fisher’s exact test for categorical
variables and the independent student t test for continu-
ous variables. Overall survival (OS), disease-specific sur-
Table 1  Histopathological subtypes
vival (DSS) and disease free survival (DFS) rates were
calculated as per National Cancer Institute definitions Histopathology Cases (n)
[5]. 3-Year data for these was compared between NSCC Sarcomatoid 14
and SCC cases by Wilcoxon (Gehan) statistical testing. Adenoid cystic 4
Kaplan Meier survival analysis was performed with spe- Mucoepidermoid 2
cific histopathological subgroups compared by log-rank Adenosquamous 1
(Mantel–Cox) testing. Rare histopathologies with less than Liposarcoma 1
five cases had a separate subgroup (“rare”). Univariate Rhabdomyosarcoma 2
cox regression analysis was performed for OS by histo- Chondrosarcoma 2
pathological subgroup (reference: SCC), T-stage (T1/2 Papillary squamous cell 1
vs T3/4), N-stage and M-stage. Multivariate analysis was Small cell 4
not performed due to limited case numbers. Results were Neuroendocrine 1
considered statistically significant if p < 0.05. Lymphoepithelial 1

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European Archives of Oto-Rhino-Laryngology

Table 2  Demographic data Despite this, however, survival rates have remained rela-
NSCC SCC P value tively stable over this time. Recent research in this area has
trended towards treatment rationalization and improving
Sex functional outcomes while maintaining rates of survival[8,
Male 24 (72.7) 27 (81.8) 0.378 9]. National cancer registry and international data suggest
Female 9 (27.3) 6 (18.2) an OS rate of 63.6% and DFS rate of 48.1% at 5 years[10,
Age: mean (range) 62.7 (32–85) 65.8 (49–83) 0.226 11].
Subsite In comparison, research on NSCC laryngeal malignan-
 Supraglottic 13 (39.4) 12 (36.4) cies is much less developed, which is concerning given they
 Glottic 17 (51.5) 20 (60.6) 0.656 often exhibit different oncological behaviour and responses
 Subglottic 2 (6.1) 1 (3) to surgery, RT and systemic therapies [12]. Many of these
T-stage are rare and treatment recommendations often rely on clini-
 1 12 (36.4) 11 (33.3) cal outcomes data from conventional SCC, case reports,
 2 7 (21.2) 7 (21.2) expert opinion, and similar malignancies in other anatomical
 3 6 (18.2) 5 (15.2) 0.797 sites [13]. To address these disparities, we aimed to present
 4 7 (21.2) 10 (30.3) our experience managing such malignancies with the inten-
Nodal stage tion to help guide future management.
 0 27 (81.8) 26 (78.8) In this study, 3-year estimates for DFS, DSS and OS for
 1 2 (6.1) 3 (9.1%) 0.715 overall NSCC compared less favourably than SCC; however,
 2 3 (9.1) 4 (12.1) these results were not found to be statistically significant,
 3 1 (3) 0 (0) likely related to limited case numbers. Although Kaplan
M-stage Meier survival analysis demonstrated similar survival pat-
 0 32 (97) 32 (97) 0.754 terns for DSS and OS between groups, this is limited by
 1 1 (3) 1 (3) an absence of statistical significance. Cox regression was
Primary treatment performed to analyse other predictors of survival for NSCC,
 S 16 (48.5) 8 (24.2) specifically TNM staging which is advocated by the AJCC
 RT 3 (9.1) 11 (33.3) to stage and prognosticate laryngeal SCC. Interestingly,
 CRT​ 5 (15.2) 8 (24.2) 0.015 N-stage and M-stage appeared to influence survival more
 S/RT 7 (21.2) 2 (6.1) accurately than most of the histopathological subgroups
 S/CRT​ 0 (0) 3 (9.1) from which it was only the rare laryngeal malignancies sub-
 Palliation 2 (6.1) 1 (3) group that was found to be an adverse predictor for OS. This
Values are expressed as number (%) is not surprising considering it was a small group including
S surgery, RT radiotherapy, CRT​chemoradiotherapy
malignancies often considered aggressive, such as small cell
and lymphoepithelial carcinoma. Further research is required
to further elucidate outcomes for these malignancies.
Table 3  3-Year outcomes data Other studies have reported less favourable outcomes
Non-SCC (%) SCC (%) P value
for NSCC. Chen et al. found NSCC to have lower OS for
NSCC compared to SCC (p < 0.01) [12]. Although their
3-Year DFS 65 74 0.499 study involved a different case mix of histopathological
3-Year DSS 75 87 0.329 subtypes, this suggests this to be a topic warranting further
3-Year OS 69 81 0.360 review with greater case numbers. N-stage as a significant
predictor of OS in NSCC patients has also been confirmed
in other studies [12, 14].
Discussion Sarcomatoid carcinoma has been known by a variety
of terms, such as spindle cell carcinoma, carcinosarcoma
The cases presented in this study represent a diverse range and pseudosarcoma, since it was first described by Rudolf
of malignancies that are reflective of the various tissue Virchow in 1864 [15]. They are biphasic tumors and con-
types that combine to form the larynx. SCC accounts for sidered a dedifferentiated SCC variant which often present
95% of cases and has received the majority of scientific as a polypoid mass with two components: a superficial part
attention regarding laryngeal cancer over the last 30 years, of intraepithelial dysplasia or invasive SCC, and a submu-
with significant amounts of published outcomes data to cosal spindle shaped pleomorphic cell component [16–18].
guide management at various disease stages[2, 3, 6, 7]. As a result, misdiagnosis of this as a laryngeal sarcoma
is considered a common histopathological mistake [16].

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Fig. 1  Survival
Observational studies on sarcomatoid carcinoma often
advocate surgical resection for localised disease, with no
clear survival advantages of adjuvant RT [19, 20]. For
patients at risk of or with metastatic disease, the role of
systemic treatments is unclear due to limited published
cases.
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European Archives of Oto-Rhino-Laryngology
Excellent responses to surgery or RT as monotherapy
were observed in this study with results suggesting RT alone
may be a reasonable primary treatment especially in patients
not suitable for surgery or with early stage disease.
The main types of MSGT of the larynx are mucoepider-
moid, adenosquamous and adenoid cystic carcinoma, all of
European Archives of Oto-Rhino-Laryngology

Table 4  Sarcomatoid carcinoma
Age/Sex Site Stage Primary treatment Response Recurrence Follow-up Mortality
(months)

70/M Supraglottic T3,N0 RT Y N 6 N

72/M Glottic T1b,N0 TLM, RT Y N 15 Y (MI)
85/M Glottic T1a,N0 TMD Y N 2 N
77/Fa Supraglottic T1a,N0 RT N/A N/A 1 Y (MI)
61/M Supraglottic T2,N0 CRT​ Y N 48 N
63/M Glottic T1a,N0 TLM Y N 36 N
73/M Supraglottic T3,N2c TLM, ND, adjuvant RT N (pulmonary N/A 12 Y (DOD)
metastasis)
66/M Glottic T1b,N0 TLM Y N 72 N
63/M Glottic T1a,N0 TLM Y N 60 N
71/Mb Glottic T1a,N0 RT Y N 3 N
49/M Glottic T1,N0 TLM Y N 132 N
57/M Supraglottic T4,N0 Total laryngectomy, ND, RT Y N 96 N
56/M Glottic T3,N0 CRT​ N N/A 48 N
53/M Supraglottic T1a,N0 TLM Y N 72 N

RT radiotherapy, TLM transoral laser microsurgery, ND neck dissection, TMD transoral microsurgical cold steel dissection, DOD died of disease,
CRT​chemoradiotherapy, MI myocardial infarct
a
 Sarcomatoid with rhabdomyologenous differentiation
b
 Sarcomatoid with SCC elements

Table 5  Malignant salivary gland tumors

Histological subtype Age/Sex Site Stage Primary Treatment Response Recurrence Follow- Mortality
up
(months)

Adenoid cystic 65/F Supraglottic T4,N0 Total laryngectomy Y N 120 N

Adenoid cystic 48/M Subglottic T4,N0 Total laryngectomy, Y N 12 N
ND, RT
Adenoid cystic 62/M Glottic T4,N0 PLE Y Y (pulmonary at 96 N
7 years)
Adenoid cystic 48/F Subglottic T4,N0 Total laryngectomy, Y N 48 N
bilateral ND, RT
Mucoepidermoid 49/F Thyroid T4,N1b PLE, ND, RT Y N 60 N
Mucoepidermoid 55/M Glottic T2,N0 Total laryngectomy Y Y (locoregional at 36 Y (DOD)
12 months)
Adenosquamous carci- 72/F Glottic T1a,N0 TLM Y N 12 N
noma

RT radiotherapy, PLE pharyngolaryngoesophagetomy, ND neck dissection, TLM transoral laser microsurgery, DOD died of disease

which were included in this study. They arise from minor
salivary gland tissue present along the aerodigestive tract
but have a higher concentration in the subglottis. MSGT
are often considered highly aggressive tumors due to a pre-
disposition for submucosal, perivascular and perineural
spread [21]. This frequently results in delayed diagnosis and
advanced disease on presentation and reported recurrence
rates of 60% at up to 10-year post-treatment [22].
Data regarding managing laryngeal MSGTs is often mod-
elled on treating primary tumors of the major salivary glands
[23]. Hay et al. reported a 30-year experience of managing
head and neck minor salivary gland tumors, where all 450
patients were managed surgically, with high stage tumors
being given adjuvant RT [24].
In this study laryngectomy was often performed due to
the frequency of advanced local disease at presentation
and difficulty in identifying appropriate tumor margins due
to the propensity for submucosal spread. Our results sug-
gest that aggressive surgical resection is needed to achieve
a curative response and that a low threshold approach for

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Table 6  Sarcoma
Histological subtype Age Site Stage
/Sex
Liposarcoma (low 54/M Supraglottic T2,N0
grade)
Embryonal rhabdo- 56/F Glottic T1,N0a
myosarcoma
Pleomorphic rhab- 71/M Glottic pT3,N1ab
domyosarcoma
(grade 3)
Chondrosarcoma 82/M Glottic pT2,N0
(high grade)
Chondrosarcoma 78/M Glottic Locally “Advanced” Repeated TMD
TLM transoral laser microsurgery, RL radiotherapy, TMD transoral microsurgical cold steel dissection, DOD died of disease
a
 French Federation of Cancer Centre's System Grading, (AJCC 8th)
b
 Node detected on postoperative histopathology
adjuvant RT should be considered for patients even in
the presence of clear surgical margins due to the risk of
perineural spread and “skip lesions”. The case of disease
recurrence at 7-year post-treatment also emphasizes the
importance of long-term follow-up of these patients [25].
Laryngeal sarcomas include a heterogeneous range of
malignancies that can be classified into “hard” and “soft”
types depending on the tissue of origin. Chondrosarcoma
is an example of a hard laryngeal sarcoma which most
commonly arises from the hyaline cricoid cartilage [26].
These are typically slow growing, low grade tumors with a
favourable prognosis (reported 5-year DSS of 91.4%) [26].
Nodal and distant metastases are rare [27]. In a system-
atic review of 500 patients, surgical resection with clear
margins was considered the treatment of choice [26]. Our
results are reflective of this. Recurrences are typically
related to incomplete margins and are an indication for
total laryngectomy [26, 28]. The role of RT is controver-
sial; low mitotic rates means it is often “relatively” radi-
oresistant but have a role for palliation in unresectable
disease or in cases with positive surgical margins [29, 30].
Chemotherapy is rarely used [26].
Rhabdomyosarcoma (RMS) and liposarcoma are exam-
ples of “soft” sarcomas. Despite this nomenclature, they
are often highly aggressive malignancies. Rhabdomyosar-
coma is a mesenchymal malignancy which originates from
striated muscle and is usually only seen in children. It is
divided into three subtypes: embryonal, alveolar and pleo-
morphic of which embryonal has the best prognosis[31,
32]. Our experience highlights the aggressive nature of
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European Archives of Oto-Rhino-Laryngology
Primary Treatment Response Recurrence Follow- Mortality
up
(months)
TLM Y N 27 N
Cordectomy, RT Y N 12 N
Total laryngectomy N (locoregional N/A 5 N
recurrence, pulmo-
nary metastasis)
Total laryngectomy Y N 5 N
(previous trache-
ostomy)
N N/A 48 Y (DOD)
(margins
involved), trache-
ostomy
RMS with the case of pleomorphic RMS experiencing
rapid disease progression while awaiting adjuvant RT.
Data on managing laryngeal RMS in adults is often
limited to case reports [33–37]. Outcomes data for RMS
in the head and neck typically report 5-year OS rates from
30% to 60% [32, 38]. Rarity of laryngeal cases means
optimal treatment regimens have not been elucidated but
are instead modelled on treatment from RMS in other
anatomical sites. Consensus it that this disease should be
treated with a multimodal approach [13]. Localised dis-
ease should be resected with a low threshold for giving
adjuvant RT [13, 32]. Adjuvant chemotherapy should be
used in patients with nodal or distant metastases [13].
We identified several other tumor types, such as small
cell carcinoma (SmCC). SmCC accounts for 13% of pul-
monary malignancies; however, 5% of SmCC cases are
extrapulmonary of which the head and neck is the most
common site [39]. It can present with paraneoplastic syn-
dromes, such as the syndrome of inappropriate antidiu-
retic hormone (SIADH), Cushinoid syndrome and Lam-
bert–Eaton myasthenic syndrome (LEMS) [40, 41]. SmCC
is characterised by rapid submucosal spread and vascular
invasion making this a deadly laryngeal malignancy. Due
to the risk of subclinical metastasis, surgery has a very
limited role especially as a monotherapy, and chemora-
diotherapy is considered the mainstay of treatment for all
disease stages [39].Van der Laan et al. performed a meta-
analysis including 183 cases of laryngeal SmCC, where
they reported frequent presentation with distant metastases
and a 5-year DSS of 30.8% [42].
 Table 7  Rare laryngeal malignancies
Histological Age/Sex Site Stage Primary Treatment Response Recurrence Follow-up Mortality
European Archives of Oto-Rhino-Laryngology

subtype (months)

Papillary 75/M Supraglottic T3,N3b CRT​ Y N 48 N

squamous
cell carci-
noma
Small cell 59/M Subglottic T4a,N0 Palliated N/A N/A 2 Y (DOD)
carcinoma/
SCC
Small cell 68/F Supraglottic T2,N0 CRT​ Y Y (intracranial at 18 months) 24 Y (DOD)
carcinoma
Small cell 56/M Glottic T1b,N0 CRT​ Y N 24 N
carcinoma
Small cell 32/F Supraglottic pT2N2 TLM, ND N N/A 4 Y (DOD)
carcinoma
Neuroendo- 48/M Supraglottic T2,N0 Total laryngectomy, ND Y Y (nodal at 36 months) 96 N
crine
Lymphoe- 74/M Glottic T3,N2b,M1 Palliative CRT​ N/A N/A 8 Y (DOD)
pithelial (hepatic)
carcinoma

CRT​chemoradiotherapy, TLM transoral laser microsurgery, DOD died of disease

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SmCC accounted for the majority of the rare laryngeal
subgroup which reflects the poor survival outcomes in this
cohort. Our results suggest chemoradiotherapy should be the
mainstay of curative treatment at present. It is important to
be aware of the aggressive nature of this malignancy even
in clinically early stage disease of poor responses to surgi-
cal resection.
There were several strengths to this study. A relatively
large number of cases were reported with treatment out-
comes summarised. Several steps were taken to minimise
confounding; information (data collection performed and
analysed by separate co-authors) and recall (data from clini-
cal records). Each case was control matched. Cases were all
managed at tertiary referral centres. There is evidence that
patients with rare head and neck malignancies often receive
further diagnostic investigations and changes to their pri-
mary treatment plan after review by multidisciplinary teams
in tertiary centres [43]. Compared to other similar papers on
this topic, this study provides greater insights into the spe-
cific histopathologies, treatments and nature of survival out-
comes (DSS/OS) than those with data extracted from coded
databases (e.g., SEER) allowing a more contextual analysis.
However, there were also limitations. The retrospective
nature of this study meant we could not fully adjust for other
certain types of confounding, such as information and selec-
tion confounding. Compared to studies specifically regarding
conventional laryngeal SCC, case numbers in this study were
relatively limited which impacted the statistical power; how-
ever, limited participant numbers are frequently encountered
in studies on rare diseases [44]. Despite this, statistically
significant findings were still able to be detected. This illus-
trates the importance of multicentre review, national data-
bases and systematic review [26]. This study encompassed a
wide chronological spectrum which could not account for all
therapeutic changes over this time. We did not specifically
report on patients’ comorbidities in this study; some were
managed non-surgically depending on these. In this study
there was an unequal ratio of men compared to women.
However, sex demographics in this study were reflective of
that in the general population as laryngeal cancer is a disease
that disproportionally affects men [7]
Conclusions
NSCC of the larynx represent a diverse range of malig-
nancies. Histopathological diagnosis is important as these
malignancies are often treated differently compared to
SCC. However, no significant differences in survival were
observed between SCC and overall NSCC. The role of
NSCC histopathological subgroups on survival requires fur-
ther elucidation. Results from this study identified N-stage
and M-stage to be potent prognostic indicators. Future
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European Archives of Oto-Rhino-Laryngology
research on this topic should be directed at increasing partic-
ipant numbers through multicentre review or meta-analysis
to compare treatment outcomes.
Funding  No funding was received for this study.
Declarations 
Conflict of interest None.
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 European Archives of Oto-Rhino-Laryngology

Authors and Affiliations

Rory J. O’Neill1,2   · Justin Hintze1,2 · Adrinda Sharifah3 · Stephen Garry2,5 · Graham Woods6 · Anthony Noone1 ·

Helen L. Barrett1 · Orla Young5 · Sherif Mamdouh1,2 · Neville Shine1 · Conrad Timon3,7 · John Kinsella3 ·
Patrick Sheahan4,8 · Paul Lennon3 · James Paul O’Neill1,2

1 5
Department of Otorhinolaryngology, Head and Neck Department of Otorhinolaryngology, Head and Neck
Surgery, Beaumont Hospital, Dublin, Ireland Surgery, University Hospital Galway, Galway, Ireland
2 6
Royal College of Surgeons, Dublin, Ireland Department of Histopathology, Beaumont Hospital, Dublin,
3 Ireland
Department of Otorhinolaryngology, Head and Neck
7
Surgery, St James Hospital, Dublin, Ireland Trinity College Dublin, Dublin, Ireland
4 8
Department of Otorhinolaryngology, Head and Neck University College Cork, Cork, Ireland
Surgery, South Infirmary Victoria University Hospital, Cork,
Ireland

13