Surfer’s Ear

What is Surfer’s Ear?

Surfer’s ear, also known as exostoses of the external auditory canal, is a condition where noncancerous bone growth happens slowly due to long-term exposure to cold water. It’s named “surfer’s ear” because it’s commonly found in surfers, but anyone who often interacts with cold water—like swimmers, divers, and kayakers—can develop it too.

In most cases, these bone growths (known as external auditory exostoses or EAE) don’t cause any symptoms and aren’t harmful. However, sometimes, they can lead to complications like hearing loss, frequent outer ear infections, ear pain, ear discharge, excess earwax, and water getting trapped in the ear.

Once these bone growths form, they’re permanent. If the symptoms become severe, treatment can involve medication or even surgery. The good news is that it’s possible to prevent surfer’s ear. By being aware of the risks and consistently wearing ear protection when exposed to cold water, you can significantly reduce the chances of developing this condition.

What Causes Surfer’s Ear?

Exostoses, which are bone growths, can appear due to constant irritation of the outer part of the ear canal. This usually happens with repeated exposure to cold seawater. The cold seawater exposure leads to the development of new bone near the eardrum within the ear canal. The amount and severity of these growths in the ear canal, called (EAE), directly depend on how long and how often someone has been exposed to cold water.

Risk Factors and Frequency for Surfer’s Ear

Surfer’s ear is a condition that has existed since prehistoric times and is often associated with cultures that have regular contact with water. While it affects 6.3 in every 1,000 people in general, it is more prevalent in coastal regions with colder climates and water temperatures. The risk of developing this condition is particularly high amongst surfers, standing at around 26 to 73%. The condition is more prevalent in males, likely due to more participation in cold water activities.

• Men who surf regularly for 20 years or more have a 50% chance of significant exostoses, with significant being defined as more than two-thirds ear canal obstruction.
• For women with the same surfing history, the risk is a little lower, with a 3 in 7 chance.
• The condition can appear at any age but is most common in people in their 30s and 40s.
• The biggest risk factor is long-term and repeated exposure to cold water, which increases the chances of developing exostoses by almost six times.
• People partaking in winter water sports showed more exostoses than those participating only during the summer.
• Each additional year of cold water exposure increases the risk of developing exostoses by 12%.
• Also, the severity of ear canal obstruction directly correlates with the number of years of cold water exposure.
• The condition can be more severe with colder water, and surfing more than 50 sessions per year may increase the severity of exostoses, especially for those who have been surfing for less than 5 years.

With advancements in wetsuit technology, more people are able to brave cold waters, which may lead to an increase in the occurrence and severity of Surfer’s ear, unless additional preventative measures are taken.

Signs and Symptoms of Surfer’s Ear

External auditory exostosis (EAE) is a condition often associated with no distinct symptoms. However, some individuals with advanced EAE might experience problems such as decreased hearing, a sensation of fullness in the ears, chronic ear inflammation (otitis externa), ear discharge (otorrhea), or the feeling of water trapped inside the ears. EAE typically doesn’t cause discomfort by itself, but can lead to pain secondary to infections incited by the condition. It’s important to note that EAE is often linked to a history of repetitive exposure to cold water over a long period, such as through water activities like surfing, kayaking, diving, or swimming. Some research suggests that it could take a minimum of five to ten years of cold water exposure for significant exostoses to develop.

In a physical examination, professionals should be able to observe multi-nodular masses at the tympanic ring with the help of an otoscope. Generally, the size of these masses matches the severity of symptoms. These masses are firm, numerous, and are often noticed in both external ear canals. If large enough, they could block the view of the ear drum (tympanic membrane). It’s not uncommon for earwax (cerumen) to get stuck on the ear drum due to being trapped behind or within the exostoses. If this happens, an ear lavage, or ear wash, may be performed for better visualization of the ear structures. Assessments for hearing loss should be considered, and if present, tests like the Rhine and Weber test can be done to determine whether the hearing loss is conductive (caused by issues in the ear canal, eardrum or middle ear and its bones) or sensorineural (caused by issues in the inner ear, such as nerve damage).

Testing for Surfer’s Ear

Patients can come to the doctor’s office with different complaints such as ear pain, hearing loss, or feeling stuffed-up ears. These symptoms could suggest various issues, including problems called external auditory exostoses, which are bony growths in the ear canal. This condition can be a result of other ear problems like swimmer’s ear (otitis externa), compacted earwax (cerumen impaction), a ruptured eardrum, or something stuck in your ear.

The doctor can usually diagnose external auditory exostoses by collecting personal information and conducting a physical exam. During your physical exam, the doctor will look into your ear using an otoscope, a tool used to view the ear canal. They may then observe firm, bumpy growths on a structure in the ear called the tympanic ring, which is located inside the ear canal. This condition can be found in both ears and the growths can pop up anywhere in the ear, but they usually appear towards the front and inner part of the ear.

The size of these growths and how much they block the ear canal can often tell how severe the problem is. The health professional will rank the severity of your condition from 1 to 3. Less than 33% blockage of the canal is mild (grade 1), 33% to 66% blockage is moderate (grade 2), and more than 66% blockage is considered severe (grade 3).

In some cases, a computed tomography (CT) scan, which is a type of X-Ray, might be done to get a better look at your ear canal. The scan takes multiple images in thin slices for a very detailed view. However, the findings from a CT scan alone can be hard to interpret, and you would need a proper examination to distinguish exostoses from other conditions such as cancer or infections. Typically, the scans are used to plan surgeries and are not needed for every patient with this condition.

Sometimes a Magnetic Resonance Imaging (MRI) scan, a type of imaging that uses magnetic fields and radio waves to create detailed images of the body, might be needed to plan for surgery. It’s not commonly used, but it can be helpful in certain situations.

Treatment Options for Surfer’s Ear

Surfer’s ear is a condition that can be identified early and its progression can be prevented once it’s detected. The cornerstone of prevention is teaching patients about the importance of using silicone earplugs or neoprene hoods. These accessories can help to limit the amount of cold water that comes into contact with the inner ear. Although Surfer’s ear is a progressive condition, risk can be significantly reduced by consistently taking preventive measures.

One aspect of treatment involves maintaining the cleanliness of the outer part of the ear to get rid of any trapped dirt or debris. By doing this, it can help to avoid complications such as frequent outer ear infections, rupture of the eardrum, or hearing loss that occurs due to a blockage.

Once surfer’s ear has developed, it can’t be reversed unless surgery is performed. If the ear canal is blocked by more than 80% and the symptoms are severe and persistent even after cleaning the ear regularly, a procedure called canalplasty may be considered. This surgery is performed by a ear, nose, and throat specialist, often while the patient is under general anesthesia. The procedure usually involves making an incision behind the ear and using a drill to remove the bony growths in the ear. This can also be done by approaching directly from the outer ear and using surgical instruments to chip away the excess bone.

According to one study, about 68% of patients reported a better quality of life following the surgery, though 14% experienced surgical complications. These complications could include a ruptured eardrum, delayed healing process, narrowing of the canal, loss of ability to hear high-frequency sounds, dysfunction of the temporomandibular joint (the joint that connects the jaw to the skull), and paralysis of the facial nerve. Due to these possible complications, surgery is typically only considered for those patients who are experiencing symptoms and whose condition doesn’t improve with regular cleaning of the ear. For patients who need surgery in both ears, the surgeries are usually scheduled about six weeks apart.

What else can Surfer’s Ear be?

If a doctor sees some abnormal growths in your ear canal during an examination, there could be a few different things causing them. These include conditions like EAE, osteomas, cholesteatoma, keratosis obturans, aural polyps, and tumors.

It can be hard to tell the difference between EAE and osteomas just by looking. The doctor will use your medical history to help figure this out. For example, if you often exposure your ears to cold water, you might be more likely to have EAE. This condition usually affects both ears and shows up as multiple growths, while osteomas are usually single, one-sided growths located on the side of the ear canal. Osteomas can also sometimes be found in the skull bones, cheekbones, and jaw. Both EAE and osteomas have special characteristics that can be confirmed with a test after they are surgically removed.

• A cholesteatoma, is a ball of old skin cells and debris located in the middle ear, often due to chronic ear infections. It grows more rapidly than exostoses and can sometimes be a birth defect.
• Keratosis obturans is a buildup of a substance called keratin in the ear canal. This could be due to overactive wax glands, or a problem with the skin cells of the ear. This condition usually affects one ear and typically occurs in younger people.
• Aural polyps are harmless bumps that form in the outer or inner ear. These may be caused by irritation from things like cholesteatomas, foreign objects, or an inflammation from chronic outer ear infection.
• Lastly, tumors can also occur in the ear canal, including squamous cell carcinomas, carcinoid tumors, and embryonal rhabdomyosarcomas. These tumors are less common. Squamous cell carcinomas usually affect older people, while embryonal rhabdomyosarcomas – which are very dangerous – are most commonly seen in children.

What to expect with Surfer’s Ear

External auditory exostoses are harmless growths in the ear which usually don’t cause any symptoms. They can be managed by regularly cleaning the ears to relieve symptoms and prevent complications. This disease can slowly worsen over time and if not managed properly, can lead to issues like hearing loss, repeated ear infections, ear pain, discharge from the ear, a build-up of earwax, and trapped water in the ear.

If these growths block more than 80% of the ear canal and symptoms continue despite regular cleaning and care, it might become necessary to remove them surgically. While most patients get better after this, it’s worth noting that the rates of complications from this surgery can be slightly high.

Possible Complications When Diagnosed with Surfer’s Ear

The difficulty and seriousness of ear bone growth complications, also known as external auditory exostoses, depend on the size of the growth. The size of these growths and their severity often depends on how long and how frequently they have been exposed to cold water.¹ As time passes, especially if the person continues to be exposed to cold water, the complications can become more problematic. These complications could include several disturbing symptoms:

• Hearing loss
• Ear pain or otalgia
• Discharge coming out of the ear or otorrhea
• Wax stuck in your ear or cerumen impaction
• Water trapped in the ear
• Recurring outer ear infection also known as otitis externa

In particularly severe cases, there could even be mastoiditis, which is an infection of the mastoid bone behind the ear, and the tympanic membrane, or eardrum, might rupture.

One common issue people face with external auditory exostoses is losing their ability to hear. How much is lost usually depends on how severely the ear canal is blocked, primarily determined by the size of the growths. The hearing loss often occurs as a result of earwax becoming lodged against the eardrum due to the blockage caused by the growths.⁴ This situation can be improved with an ear wash procedure. This obstruction from the earwax or other debris can lead to ear pain, discharge from the ear, and trapped water. These symptoms could also be caused by the growths themselves if they block a large part of the ear canal. If left untreated, the pressure from the trapped water and debris could cause the eardrum to break or rupturate. People participating in high-impact water activities, like surfing, are at a higher risk for this complication.

Large ear bone growth can also start an inflammatory process resulting in acute external otitis or initial stage of external ear infection.⁴ This condition can become a long-term and repeating issue. The best treatment for outer ear infection is via antimicrobial ear drops. Oral medicines are usually less effective as they can’t fully reach the tissues of the external ear canal.

In severe cases, when outer ear infection keeps coming back or is left untreated, patients can risk developing a mastoid infection. This risk increases when a person develops a perforation in their eardrum. Seawater can enter the middle ear through this hole, causing severe infection. An infection of the mastoid bone requires immediate treatment with intravenous (IV) antibiotics. If left untreated, this condition can lead to permanent hearing loss.²² A head CT scan is necessary if a mastoid infection is suspected to see if the infection has spread inside the skull. Treatment should not be delayed as the condition can lead to serious permanent complications.

Preventing Surfer’s Ear

External auditory exostoses, a condition that affects the ears, can be avoided. One effective way to prevent these is to raise awareness among those most at risk, and educate them about the hazards of repeated and chronic exposure to cold water. However, in one research, only 60% of people who enjoyed surfing in cold water knew they could prevent this condition. Among those who were aware, just 60% took precautions like wearing a wetsuit hood or earplugs. Even fewer, just 5%, used these precautions every time they went surfing in cold waters.

A similar study showed that even among surfers who didn’t know about these precautions initially, they were open to wearing earplugs in the future. Consistently using physical protection for the ears during cold water exposure, like earplugs and hood, can stop water from getting into the ear canal, which can help prevent the onset and progression of this condition.

In one study, it was observed that wearing earplugs or a hood significantly reduced the risk of developing this condition. Earplugs offer a seal and are better at stopping water from getting into the outer part of the ear canal. On the other hand, wetsuit hoods don’t entirely stop water from entering the ear but limit the amount and speed at which it can. Wetsuit hoods also provide warmth and insulation, which are beneficial to the ears.

The most effective precaution against this condition for those frequently exposed to cold water includes using both earplugs and a wetsuit hood.