Keratinising squamous cell carcinoma of the nasopharynx is a rare type of throat cancer that begins in the upper part of the throat behind the nose. Unlike other forms of nasopharyngeal cancer, this type involves cancer cells covered with keratin—the same protein that forms your hair and nails. Understanding this distinct form of cancer can help patients and families navigate diagnosis, treatment, and recovery with greater confidence.
What Makes This Cancer Different
Keratinising squamous cell carcinoma is classified as World Health Organization (WHO) type 1 nasopharyngeal carcinoma. The nasopharynx is the uppermost section of the throat, located just above the roof of your mouth at the base of your skull. When you breathe through your nose, air flows through this area before reaching your lungs. This cancer type stands apart from other nasopharyngeal cancers because the cancer cells produce an excess amount of keratin, which hardens the outermost layer of the tumour.[1][4]
The keratinising type represents less than 20% of nasopharyngeal cancer cases in the United States. It differs significantly from the non-keratinising forms (WHO types 2 and 3) in its causes, who it affects, and how it behaves in the body. While non-keratinising types are strongly associated with viral infections and are common in younger people, keratinising squamous cell carcinoma follows a different pattern entirely.[6][10]
Where This Cancer Occurs
Nasopharyngeal cancer typically originates in the fossa of Rosenmuller, a small recess on the lateral wall of the nasopharynx near the opening of the Eustachian tube. This location accounts for about 50% of all nasopharyngeal carcinoma cases. The nasopharynx has a cuboidal shape, with the roof sloping downward from front to back. Anteriorly, it connects to the back of the nasal cavity, while posteriorly it is bordered by the muscles of the pharyngeal wall. The lateral walls are formed by the Eustachian tube and the fossa of Rosenmuller, and inferiorly, it ends at the level of the soft palate.[3][6]
The cancer originates from the epithelial cells that line the nasopharynx. These are flat, skin-like cells that cover the internal surfaces of the nose, mouth, and throat. When these cells become cancerous and produce excess keratin, they form the distinctive keratinising type of squamous cell carcinoma.[10]
How Common Is This Cancer
Nasopharyngeal cancer overall is rare in the United States, affecting only about 1 out of 100,000 people each year. The keratinising type specifically accounts for less than one-fifth of these cases. This makes keratinising squamous cell carcinoma of the nasopharynx exceptionally uncommon in Western countries.[1][6]
Globally, nasopharyngeal cancer shows striking geographic variation. The disease is much more common in southern China, Southeast Asia, the Arctic regions, North Africa, and the Middle East. However, in these high-incidence areas, the non-keratinising types predominate. The keratinising form is more characteristic of low-incidence regions like the United States and Europe.[6][10]
This cancer affects more men than women, with males experiencing roughly twice the rate of females. In the United States, nasopharyngeal cancer typically affects two age groups: younger people between 15 and 24 years old, and older adults between 65 and 79 years. The keratinising type, however, is usually found in older adults and is less common in the younger age group.[1][12]
What Causes This Disease
The exact cause of keratinising squamous cell carcinoma of the nasopharynx is not fully understood. Unlike the non-keratinising types of nasopharyngeal cancer, this form is not associated with the Epstein-Barr virus. This is a crucial distinction, as viral infection plays a major role in most nasopharyngeal cancers worldwide, but not in this particular subtype.[6][10]
Cancer develops when cells in the body undergo changes that cause them to grow and divide uncontrollably. In keratinising squamous cell carcinoma, the epithelial cells lining the nasopharynx develop mutations that allow them to multiply without normal controls. These abnormal cells accumulate to form tumours that can invade nearby tissues and eventually spread to lymph nodes and distant organs such as the liver, lungs, and bones.[1]
Who Is at Risk
Keratinising squamous cell carcinoma of the nasopharynx has distinct risk factors that differ from other nasopharyngeal cancer types. Heavy alcohol consumption is a significant risk factor for this form of cancer. People who drink large amounts of alcohol frequently over many years face increased risk. The alcohol may damage the cells lining the nasopharynx, making them more susceptible to cancerous changes.[6][10]
A history of smoking is another major risk factor. Tobacco use, whether through cigarettes, pipes, cigars, or chewing tobacco, exposes the nasopharynx to numerous carcinogenic substances. These chemicals can cause DNA damage in the epithelial cells, leading to cancer development. The risk increases with both the amount and duration of tobacco use.[6][10]
Age plays a role, as keratinising squamous cell carcinoma typically develops in people over 40 years old. This is older than the typical age for non-keratinising types. Unlike other nasopharyngeal cancers, this type is not linked to Chinese or Asian ancestry, nor is it associated with consuming preserved foods like salted fish. These dietary and ethnic factors are primarily relevant to non-keratinising forms.[8]
Recognising the Symptoms
The most common symptom of keratinising squamous cell carcinoma of the nasopharynx is a painless lump or mass on the side or back of the neck. This lump appears when the cancer spreads to the lymph nodes in the neck, causing them to swell. Lymph nodes are small bean-shaped structures that are part of the immune system and filter harmful substances from the body. The lump usually does not hurt, which can lead people to delay seeking medical attention. There may be one lump or multiple lumps, and they are often found on both sides of the neck.[1][12]
Ear-related symptoms are common and may include ringing in the ears, also known as tinnitus, or hearing loss, usually affecting only one ear. Some people experience a feeling of fullness in the ear, as if it is blocked or under pressure. Recurring ear infections that do not respond to usual treatments may also signal a problem in the nasopharynx. In adults, ear infections are less common than in children, so persistent ear problems without an obvious upper respiratory infection should prompt examination of the nasopharynx.[1][7]
Nasal symptoms include a blocked or stuffy nose, usually affecting only one side. Nosebleeds may occur without obvious cause. Some people experience a persistent sore throat that does not improve with standard treatments. Headaches can develop, particularly if the cancer grows into nearby structures or affects cranial nerves.[1][12]
Facial symptoms may include pain or numbness, especially in the lower part of the face. Some people develop double vision or blurred vision if the cancer affects nerves that control eye movement. Difficulty opening the mouth fully, called trismus, can occur if the tumour invades the muscles involved in jaw movement. Difficulty breathing or speaking may develop as the tumour grows larger and obstructs the airway or affects the structures needed for speech.[1][12]
Many of these symptoms can also be caused by conditions that are not cancer, such as sinus infections, ear infections, or other benign problems. However, if symptoms persist for more than two weeks or keep returning despite treatment, it is important to consult a healthcare provider for evaluation. Early detection can significantly improve treatment outcomes.[1]
Preventing the Disease
While there is no guaranteed way to prevent keratinising squamous cell carcinoma of the nasopharynx, avoiding known risk factors can reduce your chances of developing this cancer. The most effective prevention strategy is to avoid tobacco in all forms. If you currently smoke, quitting is one of the most important steps you can take for your health. Smoking cessation programmes, medications, and counselling can all help people successfully quit tobacco use.[6]
Limiting alcohol consumption is another important preventive measure. If you choose to drink alcohol, doing so in moderation can help reduce your risk. Healthcare providers generally recommend no more than one drink per day for women and two drinks per day for men. Heavy and frequent alcohol consumption over many years significantly increases the risk of developing this type of cancer.[6]
Maintaining overall good health through a balanced diet and regular physical activity may help reduce cancer risk in general, though specific dietary recommendations for preventing keratinising nasopharyngeal cancer have not been established. Unlike non-keratinising types, this cancer is not associated with consuming preserved meats or salted fish, so dietary modifications specific to those foods are not relevant for this subtype.[1]
Regular health check-ups are important, especially for people with risk factors. While routine screening for nasopharyngeal cancer is not recommended for the general population, people with concerning symptoms or risk factors should seek medical evaluation promptly. Early detection, when the cancer is smaller and has not spread, generally offers better treatment outcomes.[1]
How the Cancer Changes the Body
In keratinising squamous cell carcinoma of the nasopharynx, the normal epithelial cells that line the nasopharynx undergo malignant transformation. These cells lose their normal growth controls and begin producing excessive amounts of keratin, forming a hardened outer layer on the tumour. This keratinisation is what distinguishes this cancer type from non-keratinising varieties.[4][14]
As the tumour grows, it can invade local structures. The nasopharynx is surrounded by important anatomical features including the base of the skull, the nasal cavity, the sphenoid bone, and cranial nerves. When the tumour grows upward, it may erode into the base of the skull. Forward growth can extend into the nasal cavity, causing obstruction and bleeding. Lateral spread can affect the Eustachian tubes, leading to ear symptoms like hearing loss and chronic infections.[3]
The cancer commonly spreads to lymph nodes in the neck. In fact, about 75% of patients with nasopharyngeal carcinoma present with swollen lymph nodes at diagnosis. The lymphatic drainage from the nasopharynx flows to nodes along the back and sides of the neck. Keratinising squamous cell carcinoma tends to have a lower rate of lymph node involvement compared to non-keratinising types, with approximately 29% showing lymph node metastasis in some studies. However, when lymph nodes are involved, it indicates more advanced disease.[6][14]
Advanced tumours can affect cranial nerves, which are nerves that emerge directly from the brain to control various functions in the head and neck. Involvement of cranial nerves can cause headaches, facial numbness, double vision, difficulty swallowing, and other neurological symptoms. The location of the nasopharynx near the base of the skull means that even relatively small tumours can cause significant symptoms if they grow in certain directions.[6]
If left untreated or if treatment is unsuccessful, nasopharyngeal cancer can spread to distant organs through the bloodstream. The most common sites of distant spread include the bones, liver, and lungs. When cancer spreads to these organs, it is called metastasis, and this represents advanced stage disease. Bone metastases can cause pain and fractures. Liver metastases may cause abdominal discomfort and jaundice. Lung metastases can lead to breathing difficulties and coughing.[1]
Research has shown that keratinising squamous cell carcinoma behaves differently than non-keratinising types. Patients with keratinising cancer have been found to have a higher incidence of locally advanced tumours at diagnosis, with about 76% presenting with advanced local disease compared to 55% for non-keratinising types. However, the pattern of spread and response to treatment differs between these subtypes, which is why accurate identification of the cancer type is important for treatment planning.[14]