The First 50 Ears

 After the first 50 ears, feedback from many surfers, colleagues, and research on current publications about Surfer’s Ear this is what the project will try to achieve:

Know your ears: By showing surfers their ear canal, telling them if they have Surfer’s Ear and how advanced it is, and by explaining to them how they can protect themselves this is a project to keep surfers healthy and arise awareness about Surfer’s Ear.

How good is a hood? By learning more about the effects of wind on Surfer’s Ear we can find out more about how to protect ourselves.

What about warm water? How high are the odds of getting Sufer’s Ear when you surf mainly in warm water without the need for a wetsuit?

Here is what I saw in the first 50 ears I examined in Central Baja California, Mexico. This is a post for medically interested readers, a post with specific information for surfers will follow.

Out of 25 surfers I had to exclude 2 due to bad visibility and another one because of an untypical growth that will be removed surgically. Of the 22 surfers included 4 were females 18 males. 77% (17) showed signs of exostosis in at least one ear. Of these 17 surfers with exostosis 15 (88%) showed a side difference with correlation to the main wind direction at their home break. The ear more exposed to wind (in California it’s typically the right ear due to northwest winds) had a higher percentage of closure via exostosis (in average 18 % difference). The degree of exostosis was correlated to the amount of time spent in the water. Of the 5 surfers without exostosis three had spent less than an estimated 1000 hours surfing. The remaining two surfers without exostosis were from Ensenada, Mexico, and Byron Bay, Australia. 100 % (16 out of 16) of Californian and Canadian surfers who had been surfing more than 1000 hours had exostosis.

Comparing these results to current research shows that the prevalence  of exostosis in this group is slightly higher than in previous studies. A number of studies have shown a prevalence of exostosis in surfers from 38 % to 73.5 % [1-5]. A recent study from Ireland [8] showed a prevalence of 66%.

One reason for the high prevalence of exostosis in this study could be that the examination was undertaken in remote surfing areas which are mainly frequented by very dedicated surfers. Another reason might be the significantly higher percentage of Irish surfers wearing a hood (91% versus 13%) and ear plugs (37% versus 9%) compared to the collective of this study.

The benefit of wearing ear protection is still controversial. A study with UK surfers showed that protection decreases the odds of having severe Surfer’s Ear [6]. A postoperative study showed a significant decrease in exostosis in those patients who wore earplugs in the water after surgery [7]. Other studies show no effect of wearing earplugs in the surf [10, 12]. Proving the effect of ear protection on exostosis is difficult even though its benefits seem to be obvious. Surfers tend not to use protection as long as they don’t have symptoms even though the vast majority of them has heard about Surfer’s Ear before [13].

The impact of the wind direction on the percentage of ear canal closure in this collective is impressive and has not been shown like this before. In 88 % the exposed ear was more affected than the more protected ear. Other studies on surfers have pointed that phenomenon out [3,7]. And the lack of laterality in divers [8] supports the idea that wind has a major impact on the development of exostosis. Yet, there is more data needed and a recent study on Sufer’s Ear from the UK (6) did not show a side difference which the scientists explained by variable winds.

Furthermore, so far no study has been able to show typical locations of bone growth in affected surfers. This is surprising considering current theories about the development of exostosis and taking into account the embryogenetic development and anatomy of the ear canal.

Most studies do not elaborate on the exact location of the bone growth. If they do it is done in a way that makes it hard to evaluate it statistically. ENT doctors usually describe findings in the ear canal by using the Maleolus as orientation and by dividing the ear in four parts. I found this not to be effective when examining the ear canals of surfers since quite often only a very slim part of the ear drum is visible due to exostosis. Therefore, in this project I use the numbers of a clock to describe the location of the bone growth. This makes a statistic evaluation possible. The laterality can easily be adjusted by flipping the clock.

Many Surfer’s Ear studies concentrate on surfers in cold water but only little research has been done on the impact of warmer water on exostosis. This might have to do with the fact that warm water surfers rarely seem to need an operation and the bone growth seem less severe. It could also have to do with the fact that most cold water surfing nations are economically strong and have more research funds at their disposal.

However, Surfer’s Ear does occur in warm water. This has been shown in a small study as part of a bigger study on cold water (1). To be able to find out more about the underlying mechanisms of Surfer’s Ear this is a gap that should be closed through more research.


1  Kroon DF, Lawson ML, Derkay CS, Hoffmann K, McCook J (2002) Surfer’s ear: external auditory exostoses are more prevalent in cold water surfers. Otolaryngol Head Neck Surg 126:499–504

2  Chaplin JM, Stewart IA (1998) The prevalence of exostoses in the external auditory meatus of surfers. Clin Otolaryngol Allied Sci 23:326–330

3  Nakanishi H, Tono T, Kawano H (2011) Incidence of external auditory canal exostoses in competitive surfers in Japan. Otolaryngol Head Neck Surg 145:80–85

4  Wong BJ, Cervantes W, Doyle KJ et al (1999) Prevalence of external auditory canal exostoses in surfers. Arch Otolaryngol Head Neck Surg 125:969–972

5  Altuna Mariezkurrena X, Gomez Suarez J, Luqui Albisua I, Vea Orte JC, Algaba Guimera J (2004) Prevalence of exostoses among surfers of the Basque Coast. Acta Otorrinolaringol Esp 55:364–368

6  Alexander, V., Lau, A., Beaumont, E., & Hope, A. (2015). The effects of surfing behaviour on the development of external auditory canal exostosis. European Archives of Oto-Rhino-Laryngology, 272(7), 1643-1649.

7  Timofeev I, Notkina N, Smith IM (2004) Exostoses of the external auditory canal: a long-term follow-up study of surgical treatment. Clin Otolaryngol Allied Sci 29(6):588–594

8  Lennon, P., Murphy, C., Fennessy, B., & Hughes, J. P. (2016). Auditory canal exostoses in Irish surfers. Irish Journal of Medical Science (1971-), 185(1), 183-187.

9  King, J. F., Kinney, A. C., Iacobellis, S. F., Alexander, T. H., Harris, J. P., Torre III, P., … & Nguyen, Q. T. (2010). Laterality of exostosis in surfers due to evaporative cooling effect. Otology & Neurotology, 31(2), 345-351.

10  Ito, M., & Ikeda, M. (1998). Does cold water truly promote diver’s ear?. Undersea & hyperbaric medicine, 25(1), 59.

11 Hurst, W., Bailey, M., & Hurst, B. (2004). Prevalence of external auditory canal exostoses in Australian surfboard riders. The Journal of Laryngology & Otology, 118(05), 348-351.

12 Chaplin, J. M., & Stewart, I. A. (1998). The prevalence of exostoses in the external auditory meatus of surfers. Clinical Otolaryngology & Allied Sciences, 23(4), 326-330.

13  Reddy VM, Abdelrahman T, Lau A, Flanagan PM (2011). Surfers’ awareness of the preventability of ‘surfer’s ear’ and use of water precautions. J Laryngol Otol 125(6):551–553

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