Case Presentation
I didn’t start surfing until my early 20’s, but once the bug hit, it hit hard and I began plying the chilly waters of New England year-round. By the age of 40, I noticed that the earpiece of my stethoscope was bumping up against something in my right ear canal. When I stuck my little finger in that ear I thought I could feel a hard bump protruding into the ear canal. Finally a colleague of mine at the hospital took a peek with an otoscope, and no doubt about it, a mass was occluding about 60% of my auditory canal, completely obscuring the tympanic membrane. Suspecting surfer’s ear, but wanting to rule out anything more ominous, I visited a local ENT – actually all this guy does for a living is ears, which really makes him just an “E”.
He confirmed the diagnosis of an external auditory exostosis (known by most as “surfers ear”), tested my hearing, which surprisingly was normal, and told me there was no rush to operate given the fact that I had no symptoms to speak of. He expected that the growth would gradually enlarge, particularly if I continued to surf, suggested I use ear plugs when surfing (which I tried, but found annoying), and told me to come back in a few years, or sooner if I had developed any problems. I was worried that if it got much bigger it would be more difficult to remove, but my “E” wasn’t overly concerned.
I continued surfing without any major ear issues; no significant water trapping, no ear infections, no obvious hearing loss. My only problem was that using a stethoscope had become increasingly painful, so I swapped to soft-sealing earpieces which I found a bit more tolerable.
By age 50 the growth was huge, occluding at least 90% of my ear canal. (see fig 1) Still no ear infections, and only occasional water trapping. Went back to my “E” guy, and he figured it was time for me to go under the knife. Any bigger and removal would be more challenging. Furthermore, I ran a high risk of developing otitis externa. Hearing tests showed that I had some minor high-pitch hearing loss (even in my good ear) but this was thought to be primarily age-related. I elected to have surgery after hurricane season was over as my doctor told me I’d be dry docked for a month or so.
Fig 1 Before Surgery
View of the ear canal. Black arrow indicates extent of a
Large exostosis blocking view of T.M. White arrow indicates
open portion of external auditory canal.
Surgery
The operation was preformed at an outpatient surgi-center under general anesthesia, with intraoperative monitoring of the facial nerve. Operating through the ear canal, an incision was made over the exostosis and the overlying skin was carefully pushed aside. A microtome (chisel) was then used to chip away what turned out to be a single large bony growth. A drill bit was used to smooth out the underlying bone and the skin flap was sutured back together. Packing was then placed in the ear canal to keep the skin flap snug against adjacent bone.
The procedure, including the facility fee, anesthesia and surgeon’s fees was $3,411, not bad pay for less than an hours work! If you want to try this at home to save a few pesos (not recommended by author) check out Dr. Shoet’s excellent how-to Video , or famed Santa Cruz chiseller Dr. Doug Hertzler’s video.
Fig 2 After Surgery
With exostosis removed, Tympanic
Membrane is now visible
Recovery
I was expecting to wake up from the surgery in severe pain, but was pleased to find that the discomfort was minimal. I returned to work 2 days after surgery with only a small dressing over my ear. Though the ear felt fine, chewing solid food proved to be quite painful for the first week post-op. The posterior wall of the external auditory canal lies adjacent to the temporomandibular joint (TMJ) and it is possible that the surgery resulted in some inflammation of the joint. I returned to my doctor’s office about 10 days post-op to have packing removed from my ear canal, and the healing process appeared to be progressing nicely. Throughout this period I was instructed to keep water from entering my ear canal while showering. This was best accomplished by dabbing a cotton ball in Vaseline, placing it over the ear canal and taping it into place with a few strips of tape. Once the ear packing had been removed I was able to use less cumbersome, soft moldable silicone plugs in the ear canal when showering. On 3-week follow-up, the canal was almost completely healed and I was given the green light to start surfing again!
No more stethoscope issues, resumed surfing, ear’s been fine ever since.
Discussion
If you surf in cold water the question is not if, but when you will develop external surfer’s ear and how large they will be.
Wong et al. examined the ears of 307 surfers at the US Open of Surfing and found that the overall prevalence of “external auditory extosis” (EAE) was 73.5%. In the group that had surfed for over 20 years, a whopping 91% had evidence of EAE, with 16% of that group having severe exostosis, defined as blockage of over 66% of the auditory canal. Kroon et al. showed that those who surfed predominantly in colder waters were at significantly increased risk of EAE (odds ratio 5.8), and that the number of years surfed increased one’s risk of developing exostosis by 12% per year. Though more common among cold-water surfers, EAE is a condition seen in the tropics, and can even affect fresh water swimmers and surfers.
The pathophysiology is not completely understood, but a combination of wind, cold, and saltwater promote the formation of bony exostoses that protrude into the external auditory canal. For reasons that are unclear, given equal exposure time to wind and salt water, some surfers are prone to developing surfer ear more quickly and more severely than others.
While these growths are benign and painless, water, earwax and sand frequently gets trapped between the exostosis and the eardrum. This creates a warm, moist environment in which bacteria can grow resulting in a painful infection of the external ear canal, “otitis externa” a.k.a. “swimmer’s ear”. Furthermore, very large extoses can cause conductive hearing loss.
Normal Ear Drum (left); “Surfer’s ear” (right)
Credit: Royal Cornwall Hospital
The general consensus among otolaryngologists is that wearing earplugs or a hood while surfing significantly decreases ones chances of developing EAE, and slows the growth of any existing exostoses. A number of earplugs are commercially available. Doc’s Proplugs , developed by longtime SMA member Robert Scott, MD, are vented plugs which do not impede hearing and proprioception as much as solid ear plugs, yet keep wind and water out. Some prefer disposable moldable silicone earplugs, which are inexpensive and relatively comfortable but sometimes fall out, while others use more expensive custom earplugs. Hoods also keep ones ears warm, protected from the wind, and relatively dry. If you surf frequently in colder water it is prudent to use some sort of ear protection.
Surgery is recommended for those with recurrent otitis externa, hearing loss, or exostosis that occlude more than 66% of the ear canal. Because EAE are not visible without an otoscope, it is reasonable for long-time surfers to have their ears examined at least once every five years. If you do not live along a surfed coast, your local ENT may not have a lot of experience in the removal of exostoses. Seek out someone who has done lots of these surgeries – practice makes perfect. Less experienced surgeons often use the more invasive approach of making an incision behind the ear (a posterior auricular approach) to give them easier access to the auditory canal which will keep you out of the water 6-8 weeks vs. 3-4 weeks for a trans-canal approach. Furthermore, they also are more likely to rely exclusively on the use of drills – whose high frequency noise in close proximity to the tympanic membrane (TM) may cause some hearing loss.
The most feared complication, injury to the facial nerve, occurs in less than 1% of cases in the hands of experienced surgeons. However, as a precaution, many ENT’s employ the use of intraoperative electromyographic (EMG) facial nerve monitoring.
Perforation of the TM is possible, but will usually heal spontaneously. Unfortunately, surgery does not prevent exostosis from re-growing, and hard-core surfers prone to exostosis may require a second operation down the road.
References
Wong B, Cervantes W, Doyle K, Karamzadeh A, Boys P, Brauel G, Mushtaq E. Prevalence of external auditory canal exostoses in surfers. Arch Otolaryngol Head Neck Surg. 1999; 125:969–72.
Kroon D, Lawson M, Derkay C, Hoffmann K, McCook J. Surfer’s ear: external auditory exo- stoses are more prevalent in cold water surfers. Otolaryngol Head Neck Surg. 2002; 126:499–504.
Hertzler, DG. Osteotome technique for removal of symptomatic ear canal exostoses. Laryngoscope. 2007 Jan;117(1 Pt 2 Suppl 113):1-14.
Chapter 8 Ear Problems of Surfers in: Nathanson AT, Renneker M, Everline C: “Surf Survival: The surfer’s health handbook”. New York, NY Skyhorse publishing, 2011