Denosumab-related osteonecrosis of the external auditory canal—benefit of the early surgical management

Abstract

Background: Antiresorptive drugs are widely used to reduce bone mineral loss in patients with osteoporosis and to prevent skeletal-related events in patients with metastatic cancers and multiple myeloma (MM). Both the bisphosphonates (BP) and denosumab typically used in this indication were shown to be effective and relatively safe. Obviously, this medication could have some adverse effects; one of them is osteonecrosis of the external auditory canal. Only sporadic cases of external auditory canal osteonecrosis have been published yet. Here, we provide a case of denosumab-related osteonecrosis of the external auditory canal successfully treated surgically in the early stage of the disease. Case report: A 68-year-old patient with breast cancer underwent comprehensive oncological treatment, including denosumab administration. She was diagnosed with osteonecroses in the jaw and ear canal. The necrotic bones in both regions were resected with primary wound closure. Both affected sites healed well with no signs of necrosis recurrence. Conclusions: Osteonecrosis of the external auditory canal is a rare but probably underdiagnosed complication of antiresorptive medication. It has a negative impact on patient quality of life if left untreated. Early surgical treatment appears to be effective. The authors highlight several similarities with medication-related osteonecrosis of the jaw. Therefore, an analogous disease staging and treatment rationale is suggested.

Imatinib associated temporal bone osteonecrosis

“…Aggressive management of side effects is vital to avoid treatment interruptions, which can be associated with rapid tumor regrowth. 1 Medication related ear canal osteonecrosis is rare, with case reports linking its development to bisphosphonates, 3 denosumab, 4 and sunitinib. 5 It can range from asymptomatic to requiring extensive surgical debridement.…”

Medication‐related osteonecrosis of the external auditory canal – A rapid review of the literature and relevance to special care dentists

“…In total, the author was able to identify 30 cases in the literature up until December 2022 11,15,17–33 . However, Peřina et al 2021 also reported one unpublished case of a 67– year– old female who they treated for rheumatoid arthritis with zoledronate and denosumab, who also presented with MRONJ in addition to MROEAC, but unfortunately the patient died due to cardiac comorbidity before they could publish the case 11 .…”

“…Signs and symptoms include otalgia, otitis, otorrhea, and in advanced stages facial paresis, hearing loss and potential mastoid and TMJ involvement may occur. Early treatment may help to prevent complications 11 . In certain cases, the patient maybe asymptomatic 27 .…”

“…Medication‐related osteonecrosis of the external auditory canal (MROEAC) is another lesser‐ known complication of these medications, which if untreated can also lead to a significant loss of quality of life 11 . The Medicines and Healthcare Products Regulatory Agency (MHRA) of the United Kingdom has recognised this complication in relation to bisphosphonates and denosumab since 2017, 12 but there is still very little awareness or knowledge about MROEAC among healthcare professionals 11 .…”

“…Medication‐related osteonecrosis of the external auditory canal (MROEAC) is another lesser‐ known complication of these medications, which if untreated can also lead to a significant loss of quality of life 11 . The Medicines and Healthcare Products Regulatory Agency (MHRA) of the United Kingdom has recognised this complication in relation to bisphosphonates and denosumab since 2017, 12 but there is still very little awareness or knowledge about MROEAC among healthcare professionals 11 . Some of the signs and symptoms associated with MROEAC may present as dental/orofacial disease in special care patients; therefore, it is important for dental surgeons (especially special care) to be aware of its potential clinical presentation and management, and refer potential cases for assessment.…”