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Squamous Cell Carcinoma | Nasal Tumours | Nose | Otorhinolaryngology (Ear Nose Throat / E.N.T) | 4th Year (Fourth Year) | MBBS | Detailed Free Notes

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PART 1 (DEFINITION → EPIDEMIOLOGY → ETIOLOGY → APPLIED ANATOMY → PATHOGENESIS → MORPHOLOGY & HISTOPATHOLOGY)

1. EXAM-READY DEFINITION

  • Squamous cell carcinoma (SCC) of the nose is a malignant epithelial tumour arising from squamous cells of the epidermis or mucosal lining, characterized by aggressive local invasion, early lymphatic spread, and significant metastatic potential.

  • It is the second most common malignant tumour of the external nose after basal cell carcinoma but is far more aggressive and life-threatening.

One-Line University Answer

Squamous cell carcinoma is a malignant tumour of squamous epithelium with local invasion and early regional lymph node metastasis.

2. WHY SCC OF NOSE IS EXTREMELY IMPORTANT IN ENT

  • Commonly asked in:

    • Long questions

    • Short notes

    • Viva

    • OSCE spotters

  • More aggressive than BCC

  • Higher chance of:

    • Lymph node metastasis

    • Bone destruction

    • Death

  • Requires early diagnosis and radical management

  • Often confused with BCC in exams → examiner trap

3. EPIDEMIOLOGY (VERY HIGH-YIELD)

3.1 INCIDENCE

  • Second most common skin cancer of nose

  • Accounts for 15–20% of nasal malignancies

3.2 AGE

  • Usually affects older adults

  • Peak incidence: 6th–7th decade

3.3 SEX

  • Male predominance

  • Male:female ≈ 2:1

3.4 GEOGRAPHICAL DISTRIBUTION

  • Higher incidence in:

    • Tropical countries

    • High sun-exposure regions

  • More common in:

    • Fair-skinned individuals

3.5 COMMON NASAL SITES (EXAM FAVORITE)

Site Frequency
Nasal vestibule Most common
Nasal septum (anterior) Common
Nasal ala Common
Tip of nose Common
Columella Less common

Exam Line

Squamous cell carcinoma most commonly arises from the nasal vestibule.

4. ETIOLOGY & RISK FACTORS (CORE EXAM CONTENT)

4.1 CHRONIC SUN EXPOSURE

  • UV radiation damages DNA

  • Causes mutations in tumour suppressor genes

  • Strong association with outdoor workers

4.2 TOBACCO USE

  • Smoking

  • Snuff use (especially vestibular SCC)

4.3 PREMALIGNANT LESIONS (VERY IMPORTANT)

  • Actinic keratosis

  • Leukoplakia

  • Bowen’s disease

  • Chronic scars and burns (Marjolin ulcer)

Exam Line

Actinic keratosis is a premalignant lesion for squamous cell carcinoma.

4.4 CHRONIC IRRITATION & INFLAMMATION

  • Chronic ulcers

  • Chronic vestibulitis

  • Poor nasal hygiene

4.5 OCCUPATIONAL EXPOSURE

  • Arsenic

  • Tar

  • Nickel

  • Industrial chemicals

4.6 IMMUNOSUPPRESSION

  • Organ transplant patients

  • HIV

  • Long-term steroids

5. APPLIED ANATOMY OF NOSE (ENT-SPECIFIC, HIGH-YIELD)

5.1 ANATOMICAL FEATURES PROMOTING SCC

  • Nasal vestibule lined by squamous epithelium

  • Rich lymphatic drainage

  • Close proximity to:

    • Upper lip

    • Nasolabial fold

    • Septum

5.2 LYMPHATIC DRAINAGE (VERY IMPORTANT)

Site Draining Nodes
Nasal vestibule Submandibular
External nose Submandibular, preauricular
Septum Submandibular

Exam Line

Early lymph node metastasis is common in squamous cell carcinoma.

5.3 STRUCTURES AT RISK

  • Alar cartilage

  • Septal cartilage

  • Nasal bones

  • Upper lip

  • Hard palate (advanced disease)

6. PATHOGENESIS (STEP-WISE, EXAM FAVORITE)

6.1 INITIATION

  • UV radiation or chemical exposure

  • DNA damage to squamous cells

6.2 PROMOTION

  • Failure of DNA repair

  • p53 gene mutation

  • Dysplasia → carcinoma in situ → invasive carcinoma

6.3 TUMOUR BEHAVIOR

  • Rapid growth

  • Ulcerative and infiltrative

  • Early lymphatic spread

  • Potential for distant metastasis

Exam Line

Squamous cell carcinoma spreads early through lymphatics.

7. MORPHOLOGY — CLINICAL TYPES (VERY HIGH-YIELD)

7.1 EXOPHYTIC (FUNGATING) TYPE

  • Cauliflower-like growth

  • Friable

  • Bleeds easily

  • Seen in vestibular SCC

7.2 ULCERATIVE TYPE (MOST COMMON)

  • Non-healing ulcer

  • Irregular margins

  • Everted edges

  • Indurated base

  • Painful

7.3 INFILTRATIVE TYPE

  • Hard, indurated lesion

  • Ill-defined margins

  • Deep tissue invasion

  • Poor prognosis

8. GROSS FEATURES (EXAM DESCRIPTION)

  • Irregular ulcer

  • Everted edges

  • Indurated base

  • Bleeds on touch

  • Foul-smelling discharge (secondary infection)

Classic Description

“Ulcer with everted edges and indurated base.”

9. HISTOPATHOLOGY (VERY HIGH-YIELD)

9.1 MICROSCOPIC FEATURES

  • Malignant squamous cells

  • Hyperchromatic pleomorphic nuclei

  • Increased mitosis

  • Keratin pearl formation

  • Intercellular bridges

Exam Line

Keratin pearl formation is characteristic of squamous cell carcinoma.

9.2 GRADING (EXAM RELEVANT)

Grade Feature
Well differentiated Prominent keratin pearls
Moderately differentiated Fewer keratin pearls
Poorly differentiated Minimal keratinization

10. GROWTH & SPREAD

10.1 LOCAL SPREAD

  • Skin

  • Cartilage

  • Bone

  • Upper lip

  • Nasal cavity

10.2 LYMPH NODE METASTASIS

  • Common

  • Submandibular nodes involved early

10.3 DISTANT METASTASIS

  • Lung

  • Liver

  • Bone (late stages)

11. EARLY CLINICAL PRESENTATION (INTRODUCTION)

  • Non-healing ulcer on nose

  • Painful lesion

  • Bleeding

  • Rapid increase in size

(Detailed clinical features, investigations, management, OSCE, MCQs will be covered in Part 2 & Part 3)

Written And Compiled By Sir Hunain Zia (AYLOTI), World Record Holder With 154 Total A Grades, 7 Distinctions And 11 World Records For Educate A Change MBBS 4th Year (Fourth Year / Professional) Otorhinolaryngology (ENT) Free Material

12. CLINICAL FEATURES (VERY HIGH-YIELD, EXAM CORE)

12.1 GENERAL CHARACTERISTICS

  • More aggressive than basal cell carcinoma

  • Faster growth rate

  • Early pain and ulceration

  • Early lymph node metastasis (key differentiator from BCC)

  • Constitutional symptoms may appear in advanced disease

12.2 LOCAL CLINICAL FEATURES (BY STAGE)

A. EARLY STAGE

  • Small ulcer or nodular lesion

  • Rough or scaly surface

  • Pain or tenderness present early

  • Bleeds easily on touch

  • Induration at base

B. INTERMEDIATE STAGE

  • Non-healing ulcer

  • Everted, irregular margins

  • Firm indurated base

  • Persistent pain

  • Secondary infection common

Classic Exam Description

“Painful non-healing ulcer with everted edges and indurated base.”

C. ADVANCED STAGE

  • Extensive ulceration

  • Destruction of:

    • Nasal ala

    • Septum

    • Upper lip

    • Nasal bones

  • Nasal obstruction

  • Foul-smelling discharge

  • Epistaxis

  • Facial deformity

12.3 SYMPTOMS BASED ON SITE

NASAL VESTIBULE

  • Painful ulcer

  • Bleeding

  • Crusting

  • Early nodal spread

NASAL SEPTUM

  • Epistaxis

  • Septal perforation

  • Nasal blockage

12.4 REGIONAL LYMPH NODE INVOLVEMENT (VERY IMPORTANT)

  • Early involvement common

  • Nodes involved:

    • Submandibular

    • Preauricular

  • Nodes are:

    • Hard

    • Non-tender

    • Fixed in advanced cases

Exam Line

Early lymph node metastasis is a hallmark of squamous cell carcinoma.

13. DIFFERENTIAL DIAGNOSIS (EXAM FAVORITE TABLE)

Condition Differentiating Feature
Basal cell carcinoma Painless, rolled pearly margins, rare nodes
Keratoacanthoma Rapid growth, central keratin plug
Actinic keratosis Premalignant, scaly patch
Lupus vulgaris Apple-jelly nodules
Chronic traumatic ulcer No induration, heals
Malignant melanoma Pigmented, irregular borders

14. INVESTIGATIONS (STEP-WISE, EXAM ORIENTED)

14.1 BIOPSY (MANDATORY)

  • Incisional biopsy

    • Preferred for large lesions

  • Excisional biopsy

    • Small early lesions

Exam Line

Histopathology is mandatory to confirm squamous cell carcinoma.

14.2 HISTOPATHOLOGY CONFIRMATION

  • Malignant squamous cells

  • Keratin pearls

  • Intercellular bridges

  • Pleomorphism and mitotic figures

14.3 IMAGING STUDIES

CT Scan (Nose & PNS)

  • Bone destruction

  • Cartilage invasion

  • Tumour extent

MRI

  • Soft tissue involvement

  • Perineural spread

14.4 LYMPH NODE ASSESSMENT

  • Clinical palpation

  • Ultrasound neck

  • FNAC of enlarged nodes

15. STAGING OF SCC OF NOSE (TNM — SIMPLIFIED FOR EXAMS)

15.1 TUMOUR (T)

  • T1: ≤2 cm, superficial

  • T2: >2 cm or minor invasion

  • T3: Cartilage or bone invasion

  • T4: Deep structures / skull base

15.2 NODES (N)

  • N0: No nodes

  • N1–N3: Regional nodal involvement

15.3 METASTASIS (M)

  • M0: No distant spread

  • M1: Distant metastasis

16. PRINCIPLES OF MANAGEMENT (CORE EXAM SECTION)

GOALS

  • Complete tumour eradication

  • Control nodal disease

  • Preserve function

  • Achieve acceptable cosmesis

  • Prevent recurrence

17. SURGICAL MANAGEMENT (TREATMENT OF CHOICE)

17.1 WIDE LOCAL EXCISION

  • Adequate margins (≥5–10 mm)

  • Margin clearance essential

  • Reconstruction after clearance

17.2 MANAGEMENT OF LYMPH NODES

  • Clinically positive nodes

    • Neck dissection

  • High-risk lesions

    • Elective nodal treatment considered

18. RADIOTHERAPY (IMPORTANT ADJUNCT)

INDICATIONS

  • Inoperable tumours

  • Advanced disease

  • Positive margins

  • Nodal metastasis

  • Poor surgical candidates

19. CHEMOTHERAPY (LIMITED ROLE)

  • Advanced or metastatic disease

  • Combined chemoradiotherapy

  • Palliative intent

20. RECONSTRUCTION AFTER SURGERY

  • Primary closure

  • Local flaps:

    • Nasolabial flap

    • Forehead flap

  • Skin grafts

  • Multistage reconstruction often required

Written And Compiled By Sir Hunain Zia (AYLOTI), World Record Holder With 154 Total A Grades, 7 Distinctions And 11 World Records For Educate A Change MBBS 4th Year (Fourth Year / Professional) Otorhinolaryngology (ENT) Free Material

21. COMPLICATIONS OF SQUAMOUS CELL CARCINOMA OF THE NOSE (VERY HIGH-YIELD)

Squamous cell carcinoma is biologically aggressive; complications arise early due to rapid local invasion and lymphatic spread.

21.1 LOCAL COMPLICATIONS

  • Progressive ulceration with tissue loss

  • Destruction of:

    • Nasal ala

    • Columella

    • Septal cartilage

    • Nasal bones

  • Septal perforation

  • Nasal obstruction

  • Secondary infection with foul discharge

  • Severe cosmetic deformity

Exam Line

Squamous cell carcinoma causes early and aggressive local tissue destruction.

21.2 CARTILAGE AND BONE INVASION

  • Early invasion compared to BCC

  • Leads to:

    • Collapse of nasal framework

    • External nasal deformity

    • Oro-nasal communication (advanced cases)

21.3 LYMPH NODE METASTASIS (KEY DIFFERENTIATOR FROM BCC)

  • Early spread to:

    • Submandibular nodes

    • Preauricular nodes

  • Nodes become:

    • Hard

    • Fixed

    • Matted (late)

Exam Line

Early regional lymph node metastasis is characteristic of SCC.

21.4 DISTANT METASTASIS

  • Occurs in advanced stages

  • Common sites:

    • Lung

    • Liver

    • Bone

  • Indicates poor prognosis

21.5 FUNCTIONAL COMPLICATIONS

  • Nasal obstruction

  • Epistaxis

  • Speech and cosmetic impairment

  • Psychological distress

22. PROGNOSIS (EXAM-CRITICAL)

22.1 OVERALL PROGNOSIS

  • Less favorable than basal cell carcinoma

  • Prognosis depends on:

    • Stage at diagnosis

    • Lymph node involvement

    • Adequacy of treatment

22.2 PROGNOSTIC FACTORS

Favorable Factors Poor Prognostic Factors
Early-stage tumour Advanced tumour
Small lesion Large ulcerative lesion
No nodal disease Lymph node metastasis
Complete excision Positive margins
Well-differentiated Poorly differentiated

22.3 SURVIVAL

  • Early-stage disease: good survival

  • Advanced disease with nodal spread: significantly reduced survival

Exam Line

Lymph node involvement is the most important prognostic factor in SCC.

23. OSCE / PRACTICAL STATIONS (COMPLETE SET)

23.1 SPOTTER STATION

Finding

  • Painful ulcer on nasal vestibule with everted edges

Diagnosis

  • Squamous cell carcinoma of the nose

23.2 HISTOPATHOLOGY STATION

Slide

  • Malignant squamous cells forming keratin pearls

Diagnosis

  • Squamous cell carcinoma

23.3 NECK EXAMINATION STATION

  • Palpate submandibular lymph nodes

  • Assess fixation and tenderness

23.4 COUNSELLING STATION

  • Explain:

    • Malignant nature

    • Need for surgery ± radiotherapy

    • Possibility of neck dissection

    • Reconstruction options

24. LONG & SHORT CASES (UNIVERSITY STYLE)

24.1 LONG CASE

History

  • Elderly male

  • Painful non-healing nasal ulcer

  • Recurrent bleeding

  • Progressive increase in size

Examination

  • Ulcer with everted margins

  • Indurated base

  • Palpable submandibular nodes

Diagnosis

  • Squamous cell carcinoma of nasal vestibule with nodal metastasis

Management

  • Biopsy confirmation

  • Wide local excision

  • Neck dissection

  • Adjuvant radiotherapy

24.2 SHORT NOTES

  • Difference between SCC and BCC

  • Keratin pearl

  • Actinic keratosis

  • Neck dissection in nasal malignancies

25. MCQs (EXAM-ORIENTED)

1. Most important prognostic factor in SCC of nose:
A. Tumour size
B. Histological grade
C. Lymph node involvement
D. Site of lesion
Correct Answer: C

2. Histological hallmark of SCC:
A. Peripheral palisading
B. Keratin pearls
C. Reed–Sternberg cells
D. Signet ring cells
Correct Answer: B

3. Most common lymph node involved in nasal SCC:
A. Jugulodigastric
B. Submandibular
C. Posterior cervical
D. Supraclavicular
Correct Answer: B

26. VIVA QUESTIONS (HIGH-FREQUENCY)

  • Define squamous cell carcinoma

  • Common sites of SCC in nose

  • Differences between SCC and BCC

  • Routes of spread

  • Management of nodal disease

  • Prognostic factors

27. EXAMINER TRAPS (VERY IMPORTANT)

  • Confusing SCC with BCC

  • Ignoring neck examination

  • Treating SCC with local excision only

  • Delaying biopsy

  • Missing premalignant lesions

28. PREVENTION (EXAM-RELEVANT)

  • Avoid excessive sun exposure

  • Use sun protection

  • Early treatment of premalignant lesions

  • Smoking cessation

  • Regular follow-up for high-risk individuals

29. CLINICAL PEARLS (EXAM GOLD)

  • SCC is more aggressive than BCC

  • Painful ulcer with everted edges suggests SCC

  • Early lymph node metastasis is common

  • Histology shows keratin pearls

  • Management requires local control + neck management

Written And Compiled By Sir Hunain Zia (AYLOTI), World Record Holder With 154 Total A Grades, 7 Distinctions And 11 World Records For Educate A Change MBBS 4th Year (Fourth Year / Professional) Otorhinolaryngology (ENT) Free Material

Hunain Zia

Hunain Zia has previously achieved considerable success in the high-school educational stream, gaining a massive 154 Total A Grades and 7 Major Distinctions, a process in which he broke/ set 11 different world records, including the most A grades ever achieved, most subjects ever appeared in, most distinctions, gaining distinctions across two separate boards (Pearson Edexcel and CAIE) within the same year/ ever, and even 19 hours of constant examination. All records stand intact today. Hunain pursued his Honors Accounting Degree from the prestigious Bentley University, and then completed an LLB (in Honors) from University of London. Currently, he manages multiple social and commercial projects, has founded digital streams and works tirelessly in the education sector.

Educate A Change focuses on truly bringing change in the educational sector worldwide. All our courses are designed to ensure success, and provide complete preparation without requiring any other external material. Therefore, it takes away the expense of academies, books, past paper compilations and other miscellaneous items. Instead, by just the courses we offer, the student can prepare fully for the best grades in their CAIEs, Edexcel and other high-school exams. The earnings from our course-sales are invested in social projects and growing the free educational activities of Educate A Change.