{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,21]],"date-time":"2026-08-21T12:27:44Z","timestamp":1787315264101,"version":"build-2736575974"},"reference-count":28,"publisher":"BMJ","issue":"6","content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["BMJ Case Rep"],"accepted":{"date-parts":[[2021,4,15]]},"published-print":{"date-parts":[[2021,6]]},"abstract":"<jats:p>We present a case of non-surgically managed bilateral osteonecrosis of the external auditory canal with a history of long-term medical therapy for osteoporosis. A 79-year-old woman with severe osteoporosis and destructive osteoarthritis received &gt;10 years of once weekly bisphosphonate therapy before switching to denosumab. Four months later, the patient presented with bilateral loss of hearing and right-sided otalgia. Necrotising otitis externa, cholesteatoma and malignancy were considered but with histology, microbiological and CT assessment, bilateral osteonecrosis of the external auditory canal was diagnosed. Surgical debridement with canalplasty was avoided due to our patient\u2019s comorbidities. Treatment continued for 5\u2009months with regular aural toilet, Terra-Cortril ointment and bismuth-iodine-paraffin paste packing. At 1-year follow-up, bilateral external auditory canals were completely re-epithelialised with no pain or affected hearing. We report the first case of bilateral osteonecrosis of the external auditory canal associated with denosumab and bisphosphonates with successful conservative management.<\/jats:p>","DOI":"10.1136\/bcr-2020-241203","type":"journal-article","created":{"date-parts":[[2021,6,15]],"date-time":"2021-06-15T12:40:36Z","timestamp":1623760836000},"page":"e241203","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":13,"title":["Denosumab and bisphosphonate associated bilateral osteonecrosis of the external auditory canal"],"prefix":"10.1136","volume":"14","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-0931-7517","authenticated-orcid":false,"given":"Harry David","family":"True","sequence":"first","affiliation":[{"name":"University of Exeter Medical School, Exeter, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Rupert George","family":"Ricks","sequence":"additional","affiliation":[{"name":"Ear, Nose and Throat (ENT) Department, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Joel Anthony","family":"Smith","sequence":"additional","affiliation":[{"name":"Ear, Nose and Throat (ENT) Department, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"239","published-online":{"date-parts":[[2021,6,15]]},"reference":[{"key":"2025082709135019000_14.6.e241203.1","doi-asserted-by":"publisher","DOI":"10.1007\/s11657-017-0324-5"},{"key":"2025082709135019000_14.6.e241203.2","doi-asserted-by":"publisher","DOI":"10.1002\/jbmr.2405"},{"key":"2025082709135019000_14.6.e241203.3","doi-asserted-by":"crossref","first-page":"372","DOI":"10.1017\/S0022215118000324","article-title":"Bisphosphonate-Induced osteonecrosis of the ear canal: our experience and a review of the literature","volume":"132","author":"McCadden","year":"2018","journal-title":"J Laryngol Otol"},{"key":"2025082709135019000_14.6.e241203.4","first-page":"107","article-title":"Bisphosphonate-Associated ear canal osteonecrosis: a case report and review of the literature","volume":"2","author":"Takahashi","year":"2017","journal-title":"Acta Otolaryngol Case Rep"},{"key":"2025082709135019000_14.6.e241203.5","doi-asserted-by":"crossref","first-page":"705","DOI":"10.1007\/s00198-018-4791-3","article-title":"A systematic review and meta-analysis of the effect of bisphosphonate drug holidays on bone mineral density and osteoporotic fracture risk","volume":"30","author":"Nayak","year":"2019","journal-title":"Osteoporos Int"},{"key":"2025082709135019000_14.6.e241203.6","first-page":"CD012432","article-title":"Interventions for managing medication-related osteonecrosis of the jaw","volume":"10","author":"Beth-Tasdogan","year":"2017","journal-title":"Cochrane Database Syst Rev"},{"key":"2025082709135019000_14.6.e241203.7","unstructured":"Denosumab for the prevention of osteoporotic fractures in postmenopausal women, 2010. Available: https:\/\/www.nice.org.uk\/guidance\/ta204\/chapter\/1-Guidance [Accessed 5 Jul 2020]."},{"key":"2025082709135019000_14.6.e241203.8","doi-asserted-by":"crossref","first-page":"295","DOI":"10.1016\/j.jpainsymman.2018.05.021","article-title":"Denosumab","volume":"56","author":"Wilcock","year":"2018","journal-title":"J Pain Symptom Manage"},{"key":"2025082709135019000_14.6.e241203.9","unstructured":"Denosumab (Prolia, Xgeva): Reports of Osteonecrosis of the External Auditory Canal, 2017. Available: https:\/\/www.gov.uk\/drug-safety-update\/denosumab-prolia-xgeva-reports-of-osteonecrosis-of-the-external-auditory-canal [Accessed 24 Jun 2020]."},{"key":"2025082709135019000_14.6.e241203.10","first-page":"30163","article-title":"Denosumab-induced osteonecrosis of external auditory canal","volume":"S0385-8146","author":"Takeda","year":"2020","journal-title":"Auris Nasus Larynx"},{"key":"2025082709135019000_14.6.e241203.11","doi-asserted-by":"publisher","DOI":"10.1007\/s12105-018-0915-5"},{"key":"2025082709135019000_14.6.e241203.12","doi-asserted-by":"publisher","DOI":"10.1080\/00016489.2017.1295468"},{"key":"2025082709135019000_14.6.e241203.13","doi-asserted-by":"crossref","first-page":"407","DOI":"10.1007\/s12105-018-0908-4","article-title":"Squamous cell carcinoma of the external auditory canal and temporal bone: an update","volume":"12","author":"Allanson","year":"2018","journal-title":"Head Neck Pathol"},{"key":"2025082709135019000_14.6.e241203.14","first-page":"2811","article-title":"Differences between bisphosphonate-related and denosumab-related osteonecrosis of the jaws: a systematic review","volume":"29","author":"Querrer","year":"2021","journal-title":"Support Care Cancer"},{"key":"2025082709135019000_14.6.e241203.15","unstructured":"Ear infections, antibacterial therapy | treatment summary | BNF content published by NICE. Available: https:\/\/bnf.nice.org.uk\/treatment-summary\/ear-infections-antibacterial-therapy.html [Accessed 21 Mar 2021]."},{"key":"2025082709135019000_14.6.e241203.16","unstructured":"Cholesteatoma - Symptoms, diagnosis and treatment | BMJ Best Practice. Available: https:\/\/bestpractice.bmj.com\/topics\/en-gb\/1033\/treatment-algorithm [Accessed 21 Mar 2021]."},{"key":"2025082709135019000_14.6.e241203.17","unstructured":"Bisphosphonates: very rare reports of osteonecrosis of the external auditory canal, 2015. Available: https:\/\/www.gov.uk\/drug-safety-update\/bisphosphonates-very-rare-reports-of-osteonecrosis-of-the-external-auditory-canal [Accessed 23 Jun 2020]."},{"key":"2025082709135019000_14.6.e241203.18","unstructured":"Denosumab | drug | BNF content published by NICE. Available: https:\/\/bnf.nice.org.uk\/drug\/denosumab.html#sideEffects [Accessed 21 Mar 2021]."},{"key":"2025082709135019000_14.6.e241203.19","unstructured":"UK Chemotherapy Board . Medication-Related osteonecrosis of the jaw. guidance for the oncology multidisciplinary team. Report of a working Party on behalf of the UK chemotherapy board. UKCB, 2019."},{"key":"2025082709135019000_14.6.e241203.20","doi-asserted-by":"crossref","DOI":"10.1007\/s40278-017-32659-2","article-title":"Denosumab-linked osteonecrosis of external auditory canal","volume":"1659","year":"2017","journal-title":"Reactions Weekly"},{"key":"2025082709135019000_14.6.e241203.21","doi-asserted-by":"publisher","DOI":"10.1111\/j.1365-2141.2005.05833.x"},{"key":"2025082709135019000_14.6.e241203.22","doi-asserted-by":"crossref","first-page":"1219","DOI":"10.1007\/s00405-011-1496-z","article-title":"Bisphosphonate-Induced osteonecrosis of the external ear canal: a retrospective study","volume":"268","author":"Froelich","year":"2011","journal-title":"Eur Arch Otorhinolaryngol"},{"key":"2025082709135019000_14.6.e241203.23","doi-asserted-by":"crossref","first-page":"1127","DOI":"10.1007\/s00106-012-2554-6","article-title":"Beidseitige bisphosphonatassoziierte Osteonekrose des Geh\u00f6rgangs","volume":"60","author":"Bast","year":"2012","journal-title":"HNO"},{"key":"2025082709135019000_14.6.e241203.24","doi-asserted-by":"crossref","first-page":"257","DOI":"10.1159\/000353214","article-title":"Surgical management of benign idiopathic osteonecrosis of the external auditory canal","volume":"75","author":"Saxby","year":"2013","journal-title":"ORL J Otorhinolaryngol Relat Spec"},{"key":"2025082709135019000_14.6.e241203.25","doi-asserted-by":"crossref","first-page":"S51","DOI":"10.1017\/S002221511300100X","article-title":"Bisphosphonate-Associated osteonecrosis of the external auditory canal","volume":"127 Suppl 2","author":"Wickham","year":"2013","journal-title":"J Laryngol Otol"},{"key":"2025082709135019000_14.6.e241203.26","first-page":"3","article-title":"Bisphosphonate-Induced osteonecrosis of the external auditory canal: a case report","volume":"2","author":"Thorsteinsson","year":"2015","journal-title":"J Clin Med Case Reports"},{"key":"2025082709135019000_14.6.e241203.27","doi-asserted-by":"crossref","first-page":"209","DOI":"10.1097\/MAO.0b013e31827ca34d","article-title":"Osteonecrosis of the external auditory canal associated with oral bisphosphonate therapy: case report and literature review","volume":"34","author":"Salzman","year":"2013","journal-title":"Otol Neurotol"},{"key":"2025082709135019000_14.6.e241203.28","doi-asserted-by":"crossref","first-page":"e285","DOI":"10.1016\/j.bjoms.2013.02.013","article-title":"Bisphosphonate-Associated osteonecrosis of the auditory canal","volume":"51","author":"Kharazmi","year":"2013","journal-title":"Br J Oral Maxillofac Surg"}],"container-title":["BMJ Case Reports"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/syndication.highwire.org\/content\/doi\/10.1136\/bcr-2020-241203","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,8,27]],"date-time":"2025-08-27T16:13:59Z","timestamp":1756311239000},"score":1,"resource":{"primary":{"URL":"https:\/\/casereports.bmj.com\/lookup\/doi\/10.1136\/bcr-2020-241203"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2021,6]]},"references-count":28,"journal-issue":{"issue":"6","published-online":{"date-parts":[[2021,6,15]]},"published-print":{"date-parts":[[2021,6]]}},"alternative-id":["10.1136\/bcr-2020-241203"],"URL":"https:\/\/doi.org\/10.1136\/bcr-2020-241203","relation":{},"ISSN":["1757-790X"],"issn-type":[{"value":"1757-790X","type":"electronic"}],"subject":[],"published":{"date-parts":[[2021,6]]}}}