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ORGAN SYSTEMS Otolaryngeal system (ENT)

Surfer’s Ear

External auditory exostoses (EAE), also known as “Surfer’s ear” is a slowly progressive disease from benign bone growth as a result of chronic cold-water exposure.

External auditory exostoses (EAE), also known as “Surfer’s ear” is a slowly progressive disease from benign bone growth as a result of chronic cold-water exposure.


Etiology

Cold water exposure:

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 is directly proportional to the cumulative duration and frequency of cold water exposure
  • Surfing “swimmer’s ear” (M/C)
  • Other causes of cold water exposure: Swimmers, divers, kayakers, and participants of other maritime activities
Prevalence and severity of auditory exostosis
Prevalence and severity of auditory exostosis: *Denotes statistically significant difference between groups (p<0.05). n, number of individuals with auditory exostosis. | Simas, V., Hing, W., Pope, R., & Climstein, M. (2020). Australian surfers’ awareness of ‘surfer’s ear’. BMJ open sport & exercise medicine, 6(1), e000641. https://doi.org/10.1136/bmjsem-2019-000641

Presentation

Patient usually has multiple years of repetitive exposure to cold water, usually through water activities such as surfing, kayaking, diving, or swimming. Some studies suggest a minimum of five years of cold water exposure before significant external auditory exostoses develop while others suggest 10 years.

Asymptomatic presentation:

EAE is usually asymptomatic and benign

Symptomatic cases:

EAE is usually not the primary cause of a patient complaint, but can be a risk factor for the underlying etiology of the patient’s presentation. For example, very rarely does this disease cause pain directly, but pain may be a secondary result of an otitis externa infection incited by external auditory exostoses.
  • Decreased hearing (conductive hearing loss)
  • Chronic/recurrent otitis externa
  • Otalgia
  • Otorrhea
  • Cerumen impaction and water trapping

Diagnosis

Direct otoscopic examination:

Carefully perform an ear lavage to better visualize the ear structures.
  • Multi-nodular masses at tympanic ring (size proportional to degree of symptoms) in bilateral ears
  • Cerumen impaction (as a result of entrapment behind/within exostoses)
Exostosis grades of severity
Exostosis grades of severity: Grade 1: up to 33% of obstruction of the external auditory canal (EAC); grade 2: between 34% and 66% of obstruction of the EAC; grade 3: more than 67% of obstruction of the EAC. | Simas, V., Hing, W., Pope, R., & Climstein, M. (2020). Australian surfers’ awareness of ‘surfer’s ear’. BMJ open sport & exercise medicine, 6(1), e000641. https://doi.org/10.1136/bmjsem-2019-000641

Tuning fork test:

Demonstrate a conductive hearing loss as opposed to a sensorineural hearing loss
  • Rhine test
  • Weber test

CT scan:

Usually, the CT scan is reserved for surgical planning and is not necessary for every patient with EAE. MRI is also occasionally utilized for surgical planning.
  • Broad-based bony overgrowth in the external auditory canal
Computed tomography image of right temporal region
Computed tomography image of right temporal region. | Okuyama, Y., Baba, A., Ojiri, H., & Nakajima, T. (2017). Surfer’s ear. Clinical case reports, 5(6), 1028–1029. https://doi.org/10.1002/ccr3.929

Management

Early detection and prevention of progression of surfer’s ear is paramount as once the exostoses are formed, they are irreversible unless surgical intervention is performed.

Preventive measures:

EAE is a progressive disease, however the risk of progression can be mitigated with consistent preventive measures by reduce auditory canal to colder elements
  • Silicon earplugs
  • Neoprene hoods
Dave Werner, of the Manahawkin section of Stafford Township, wears a hood until March or April to protect his ears against the cold, winter water temperature. He had surgery for his left ear when it was 95 percent closed by bone growth. He plans to have surgery on his right ear, which is currently 70 percent closed. | The Press of Atlantic City

Medical management:

Help prevent the propagation of complications such as recurrent otitis externa, tympanic membrane rupture, and conductive hearing loss.
  • Regular cleaning of the external auditory canal to remove any entrapped debris

Surgical management:

If there is greater than 80% occlusion and symptoms are severe and persistent despite medical management, surgical intervention is required
  • Canalplasty: Post-auricular approach under general anesthesia by elevating the skin overlying the exostoses and removing the bone with a drill
    • Alternative approach: Direct external auditory canal approach and use chisels to remove the bony growth

Surgery complications:

Due to the rate of complication, surgery is reserved for those who are symptomatic and refractive to medical management. If the patient requires bilateral surgery, two canalplasties are performed about 6 weeks apart
  • Tympanic membrane rupture
  • Delayed healing
  • Canal stenosis
  • Loss of high-frequency hearing
  • Temporomandibular joint dysfunction
  • Facial nerve paralysis

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