Extensive Intramedullary Spread of Oral Squamous Cell Carcinoma with Minimal Intraoral Manifestation: A Case Report

Globally, Oral Squamous Cell Carcinoma (OSCC) is a significant public health problem, especially in developing countries, where delayed diagnosis often leads to advanced-stage presentation and poor outcomes. OSCC typically presents with visible intraoral changes (e.g., ulceration, swelling, mucosal alterations), but uncommon cases with extensive intramedullary spread and minimal intraoral manifestations pose specific diagnostic challenges. Hereby, the authors present a case report of a 31-year-old female with a 10-year history of tobacco chewing who presented with severe mandibular pain radiating to the right ear and mild discomfort during clenching activities. Clinical examination revealed a firm swelling on the right lower jaw with an intraoral ulcerative lesion over the gingivobuccal region. Imaging demonstrated extensive intramedullary spread, erosion of the mandible crossing the midline, pathological fracture, and perineural invasion. Histopathology confirmed OSCC. Despite minimal intraoral features, radiological studies highlighted the aggressive nature of the tumour, with neurovascular involvement and metastatic spread to the lungs. The tumour was deemed unresectable due to extensive involvement of vital structures, and the patient was started on primary chemotherapy with curative intent. The present case illustrates the misleading presentation of OSCC with only minor intraoral manifestations, underscoring the importance of advanced imaging for timely diagnosis, accurate staging, and treatment planning. It further emphasises the need for a high index of suspicion in patients with known risk factors and the integration of radiological assessment in atypical cases to improve diagnostic accuracy.