Medication-related osteonecrosis of the external auditory canal and treatment with teriparatide

Medication-related osteonecrosis of the external auditory canal (MROEAC) is a rare complication of antiresorptive therapy, and guidance for diagnosis and management remains limited. We describe 2 patients with prolonged antiresorptive exposure who developed MROEAC and were treated with teriparatide. An 81-year-old woman developed bilateral external auditory canal erosions after 10 years of denosumab therapy. An 8-week course of teriparatide was associated with clinical improvement and a transient rise in bone formation markers, but computed tomography findings remained unchanged. Denosumab withdrawal led to delayed rebound bone resorption, prompting denosumab reintroduction. A 67-year-old woman developed left-sided MROEAC after 15 years of alendronate followed by a short course of denosumab. Four months of teriparatide was associated with symptomatic and biochemical improvement, but radiologic abnormalities persisted, and definitive surgery was required. These cases highlight the difficulty of differentiating MROEAC from more common otologic disorders, the discordance between clinical, biochemical, and radiologic response, the importance of multidisciplinary management, and therapeutic challenges created by denosumab discontinuation. Teriparatide was well tolerated and was associated with increased bone turnover markers, but radiologic resolution was incomplete. Surgical management may still be necessary.