Surfer's ear

Alternate Names

• External auditory exostoses (EAE)

Definition

• Surfer’s ear, or exostoses of the external auditory canal, is a slowly progressive disease from benign bone growth as a result of chronic cold water exposure. It is a condition most commonly associated with surfing but can be seen in anyone repeatedly exposed to cold water such as swimmers, divers, kayakers, and participants of other maritime activities. Although usually asymptomatic and benign, external auditory exostoses (EAE) can cause conductive hearing loss, recurrent otitis externa, otalgia, otorrhea, cerumen impaction, and water trapping . EAE are irreversible.

Etiology

• Exostoses develop from prolonged irritation of the external auditory canal, typically with repeated cold seawater exposure.
• This exposure stimulates new bone formation at the tympanic ring within the external auditory canal.
• The prevalence and severity of (EAE) is directly proportional to the cumulative duration and frequency of cold water exposure.

Epidemiology

• In the general population, the prevalence of external auditory exostoses is 6.3 per 1000 people. External auditory exostoses are more prevalent in coastal regions where water exposure is common, especially those with a cooler climate and colder water temperatures. In more at-risk populations such as surfers, the prevalence ranges between 26% to 73%.
• The disease is more common in males than in females, most likely due to their higher involvement in cold water activities.

External auditory exostoses

Signs and symptoms

• External auditory exostoses is usually an asymptomatic disease. However, a patient with more progressed EAE may present with decreased hearing, ear fullness, chronic otitis externa, otorrhea, or a sensation of water trapped inside the ears.
• On physical exam, the practitioner should be able to visualize multi-nodular masses at the tympanic ring with an otoscope In general, the size of the masses is proportional to the degree of symptoms. The masses are firm, multiple, and often seen in the external auditory canal bilaterally. If the exostoses are large enough, they may obscure sight of the tympanic membrane.
• If hearing loss is present, performing a Rhine and Weber test will demonstrate a conductive hearing loss as opposed to a sensorineural hearing loss.

Diagnosis

• The history and physical exam are typically all that is needed to diagnose external auditory exostoses. The most important component of the physical exam is otoscopy. External auditory exostoses have a firm, bony, and nodular appearance at the tympanic ring within the External auditory meatus. They are usually multiple and bilateral. While their position within the ear canal can vary, the first lesions most commonly are medial and anterosuperior.
• The degree of ear canal obstruction caused by the exostoses is usually proportional to the severity of symptoms.
• The severity of exostoses is graded from 1 to 3 based on the percentage of occlusion of the canal as seen on physical exam. Less than 33% occlusion is mild (grade 1), 33% to 66% occlusion is moderate (grade 2), and greater than 66% occlusion is considered severe (grade 3).
• To further evaluate, a CT scan of the external auditory canal with less than 1mm thin slices may be performed. Usually, the CT scan is reserved for surgical planning and is not necessary for every patient with EAE

Management

• Early detection and prevention of progression of surfer’s ear is paramount once exostoses have been detected.
• Prevention involves patient education for the use of silicon earplugs and/or neoprene hoods to reduce auditory canal cold water exposure. EAE is a progressive disease, however the risk of progression can be mitigated with consistent preventive measures.
• Treatment consists of medical management involving regular cleaning of the external auditory canal to remove any entrapped debris. This can help prevent the propagation of complications such as recurrent otitis externa, tympanic membrane rupture, and conductive hearing loss.
• Once the exostoses are formed, they are irreversible unless surgical intervention is performed. If there is greater than 80% occlusion and symptoms are severe and persistent despite medical management, a canalplasty by an otolaryngologist may be considered. The surgery typically involves general anesthesia with a post-auricular approach by elevating the skin overlying the exostoses and removing the bone with a drill.

Differential diagnosis

• If masses are noted in the external auditory canal on otoscopic exam, there are several differential diagnoses to consider. These include EAE, osteomas, cholesteatoma, keratosis obturans, aural polyps, and tumors.

Prognosis

• External auditory exostoses are benign and usually asymptomatic. Generally, they can be medically managed with frequent ear cleaning to improve symptoms and prevent complications. EAE is a progressive disease and without appropriate preventive measures, they can lead to complications such as conductive hearing loss, recurrent otitis externa, otalgia, otorrhea, cerumen impaction, and water trapping.
• If the exostoses occlude more than 80% of the auditory canal and symptoms persist and despite medical management, surgical excision may be required. The outcomes in most patients are good, but the rates of surgical complications to relieve the disorder are somewhat high.

Complications

• EAE complications include hearing loss, otalgia, otorrhea, cerumen impaction, water trapping, recurrent otitis externa, and in severe circumstances mastoiditis, and tympanic Membrane rupture.
• Conductive hearing loss is a common complication of EAE. The degree of hearing loss is relative to the degree of ear canal occlusion, which is predominantly determined by the size of exostoses. The associated hearing loss is generally due to cerumen impaction on the tympanic membrane caused by blockage from the exostoses. This can be improved with ear lavage. The process of buildup of cerumen or other debris is what leads to symptoms of otalgia, otorrhea, and water trapping.

References

• Kevin Landefeld; Ryan M. Bart; Henry Lau; Jeffrey S. Cooper. Surfer's ear.[Updated July 14, 2020]. In StatPearls[Internet]. Available at: https://www.ncbi.nlm.nih.gov/books/NBK534874/
• J R DiBartolomeo. Exostoses of the external auditory canal. Nov-Dec 1979;88. Available at: https://pubmed.ncbi.nlm.nih.gov/118696/

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