Exostoses of the external auditory canal: a long-term follow-up study of surgical treatment

External ear canal exostectomy: influence of surgeon's experience on 3-years recurrence and occurrence of complications

BACKGROUND

External ear canal exostoses are usually bilateral and broad-based, secondary to external ear canal chronic cold exposure, especially water.

OBJECTIVES

The objectives were to analyze the influence of the surgeon's experience on the 3-year recurrence and on the complication. We also studied the influence of prolonged exposure to cold water on the incidence of recurrence.

MATERIAL AND METHODS

This monocentric retrospective study included 98 ears operated for canalplasty between 2009 and 2016 by nine different operators including one senior, a junior, and seven beginner surgeons. Senior, Junior, and Beginner groups were compared.

RESULTS

3-year recurrence rate was higher in the Beginner and Junior groups than in the Senior group (69% and 38% vs 18%, P = .001). Although there was a difference between the Beginner (69%) and Junior (38%) groups, it was not significant (P = .407). Among the recurrences, 48% had continued exposure to cold water while only 7% of the ears without recidivism were still exposed (P < .001, OR = 1.25 [4.4; 36.1]). The complication rates were similar between groups, concerning pain (8% vs 30% vs 12%), per procedure perforation (17% vs 10% vs 16%), scarring disorders (25% vs 20% vs 13%), and osteitis (8% vs 0% vs 1%). Hearing was unaffected.

CONCLUSIONS

This is the first study evaluating the risk of recurrence of external ear canal exostoses after canalplasty based on the surgeon's experience. This risk of recurrence seems to decrease with the surgeon's experience. There was no difference in complication rates.

External auditory exostosis among surfers: a comprehensive and systematic review

OBJECTIVE

External auditive exostosis (EAE), known as surfer's ear, is a temporal bone outgrowth resulting from ear exposure to cold air and water. This review aims to shed light on the prevalence of EAE among worldwide surfers.

METHODS

By a thorough retrieval of the PubMed, we found all original investigations performed on EAE among suffers. The retrieval time was from the construction of the database to December 2022. Agency for Healthcare Research and Quality (AHRQ) methodology checklist for assessing the quality of cross-sectional/prevalence study was performed.

RESULTS

19 articles were selected involving 2997 surfers on whom 2032 presented EAE. The prevalence of EAE was ranged from 53 to 90% with a mean at 67.8%. 3 investigations were performed from USA, five from UK and Ireland, five from Australia and New Zealand and six from Japan and Europe.

CONCLUSION

Cold water exposure, combined with wind and prolonged surfing activity, contributes to the development of EAE. Symptoms range from mild discomfort to hearing loss and recurrent infections. Preventive measures, such as raising awareness and promoting the use of ear protection, are crucial. Further research is needed to improve prevention strategies and understand the underlying mechanisms of EAE.

What do windsurfers and kitesurfers in Germany know about surfer's ear and how is it influenced by protective measures?

OBJECTIVE

This study investigated the frequency of ear canal protection use and looked at its influence on external auditory exostosis severity and knowledge about external auditory exostosis among windsurfers and kitesurfers on the German coast.

METHOD

This retrospective cross-sectional study interviewed 130 windsurfers and kitesurfers along the German coast on knowledge of external auditory exostosis, exposure time, use of neoprene hoods and earplugs, and otological complaints. Participants underwent bilateral video-otoscopic examination.

RESULTS

Knowledge of external auditory exostosis was 'good' or 'excellent' in 78 of 130 (60 per cent) individuals and 'poor' or non-existent in 52 of 130 (40 per cent) individuals. Knowledge was positively correlated with hours of exposure, otological complaints and frequency of ear canal protection use. A significant negative influence of neoprene hood use on external auditory exostosis severity was shown.

CONCLUSION

The positive effect of external auditory exostosis knowledge on the frequency of ear canal protection and the reduction of external auditory exostosis risk implies a need for health education on this topic.

Complication Rates in Osteotome and Drill Techniques in External Auditory Canal Exostoses: A Systematic Review and Meta-Analysis

OBJECTIVES

To assess and compare complication rates of symptomatic external auditory canal (EAC) exostoses treated with drill versus osteotome canalplasty.

DATABASES REVIEWED

PubMed/Medline, OVID, EMBASE, Web of Science, Google Scholar.

METHODS

A systematic review and meta-analysis in accordance with PRISMA guidelines and standardized bias assessment using the JBI critical appraisal checklist was performed. Studies containing original outcome data on drill and osteotome canalplasty were included. The primary study outcome was complication rates.

RESULTS

Fifteen studies were included, encompassing 1399 total patients (1788 ears) with 530 and 1258 ears in the osteotome and drill groups, respectively. Ten studies used a drill, 2 used an osteotome, and 3 used both. The most frequently reported complications were tympanic membrane (TM) perforation (osteotome group: 5.3% [95% CI: 1.7%-10.9%]; drill group: 3.8% [1.5%-7.1%]), sensorineural hearing loss (SNHL) (0.69% [0.07%-1.9%]; 4.3% [2.2%-7.0%]), and postoperative stenosis (1.1% [0.0005%-4.3%]; 4.1% [1.9%-7.0%]). Use of the osteotome was associated with a lower rate of SNHL (P < .05) and stenosis (P < .05), and a higher rate of TM perforation (P < .05). Heterogeneity of the studies included in the analyzed complications ranged from moderate to high. Level of evidence in the included studies ranged from 2b to 4 and all studies had an overall low risk of bias.

CONCLUSION

While an osteotome technique may increase the risk of TM perforation, drill canaloplasty may increase the risk of SNHL and postoperative stenosis in EAC exostectomy. The exact quantity of hearing loss could not be definitively evaluated. Additional research with participant randomization is needed to assess clinical efficacy.

LEVEL OF EVIDENCE

Level 8.

Prevention of external auditory canal exostosis in the Colorado whitewater community

Context

External auditory canal exostoses (EACE) are bony formations that develop insidiously in the auditory meatus from chronic exposure to cold water and, in severe cases, require surgery. This condition has been understudied in the whitewater kayakers and not yet studied in the riverboarding population. Precautions such as earplugs are thought to prevent the formation of EACE because they mechanically block cold water from contacting the sensitive skin in the external auditory canal; however, earplugs are not commonly utilized by athletes. Inquiring about hobbies and the use of protective equipment can be done during osteopathic physicians’ preventive care visits.

Objectives

This article aims to determine the prevalence of EACE in Colorado whitewater athletes and their attitudes about wearing ear protection before and after an educational intervention directed at increasing awareness and prevention of EACE.

Methods

In July 2020, participants of this cross-sectional study completed a 10-min survey that collected demographics, whitewater experience, and perceptions of EACE, followed by an educational intervention. Participant ears were photographed utilizing a digital otoscope to assess EACE, and severity ratings were categorized into one of four occlusion levels: none (0%), mild (<25%), moderate (25–75%), or severe (>75%). Spearman correlation coefficients and Wilcoxon signed-rank tests were utilized to assess changes in attitudes before and after the educational intervention.

Results

Eighty-one participants (mean [SD] age = 36.3 [12.6] years, 25.9% female) completed the study: 74 kayakers and seven riverboarders. After the intervention, 60.5% (49/81) (p<0.001) reported greater understanding of EACE and 75.0% (60/80) were more likely to wear ear protection (p<0.001). Most (58.0%, 47/81) never wore ear protection. Of the 61 (75.0%) participants with at least one ear severity rating, most (55.7%, 34/61) had moderate EACE, 29.5% (18/61) had no to mild EACE, and 14.8% (9/61) had severe EACE (p<0.001). Impaired hearing was the biggest barrier to utilizing ear protection (51.6%, 33/64).

Conclusions

Our results suggested that the educational intervention improved understanding of EACE and may increase utilization of ear protection in this population. Such prevention efforts may lead to better health of whitewater paddlers by reducing the incidence of EACE. Encouraging osteopathic physicians to inquire about hobbies and protective equipment during primary care preventive visits is essential to help keep athletes in the river doing what they love for longer, contributing to a healthier and happier whole person.

Canalplasty for Exostosis Removal Comparing Microscopic Versus Endoscopic Ear Surgery Techniques

OBJECTIVE

To compare an endoscopic versus microscopic approach to removal of exostoses and osteomas in canalplasty procedures.

STUDY DESIGN

Retrospective case review.

SETTING

Private and tertiary referral centers.

PATIENTS

Adult patients requiring canalplasty procedures performed either microscopically or endoscopically for removal of exostosis or osteoma and/or canal stenosis.

INTERVENTION

Microscopic or endoscopic canalplasty.

MAIN OUTCOME MEASURE

Major outcome measures included assessment of hearing improvement as well as rates of major and minor complications. Standard audiological data were collected before and after the operative procedure. Major complications queried included stenosis, perforation of the tympanic membrane, hearing loss, facial palsy, and osteomyelitis. Minor complications queried included signs of poor wound healing, graft failure, and bleeding or discharge.

RESULTS

Forty three canalplasties were performed on 36 patients. Audiometric tests did not significantly differ between endoscopic and microscopic surgeries. There was a moderate linear relationship between date of surgery and duration of surgery for the endoscopic technique, with more recent surgeries taking less time. No major complications were noted. However, significantly fewer endoscopic cases had evidence of minor postoperative complications relative to microscopic cases.

CONCLUSIONS

An endoscopic approach to canalplasty is a safe and minimally invasive technique. Significantly fewer postoperative complications occurred after endoscopic canalplasty procedures as compared with microscopic procedures. Endoscopic repair may be preferred to microscopic repairs due to the improved view of the end of the instruments while maintaining a minimally invasive approach with what is likely a decreased operative time as well.

External auditory exostoses in wind-dependent water sports participants: German wind- and kitesurfers

Purpose

Cold water and wind are known to cause exostoses of the external auditory canal. Different prevalences in different sports have been described in the literature. The aim of this study was to investigate the prevalence of external auditory exostosis (EAE) and EAE severity in coastal German wind- and kitesurfers who are exposed to cold water and strong winds. Furthermore, influencing factors such as the total exposure time and frequency of activity as well as the correlations between symptoms and the severity of EAE were investigated.

Methods

In this retrospective cross-sectional study, German non-professional wind- and kitesurfers along the North and Baltic Sea coasts were recruited between September 2020 and November 2020. Each participant was interviewed about exposure time and otological symptoms and underwent bilateral video otoscopic examination to determine EAE severity.

Results

A total of 241 ears from 130 subjects were analysed. The prevalence of EAE was 75.1%. In 19.9% of the participants, severe EAE was found. Exposure time and the frequency of activity had significant effects on the severity of EAE. Compared to surfers, EAE growth seems to progress faster in wind- and kitesurfers. The number of symptoms requiring medical treatment increased when two-thirds of the external auditory canal was obstructed.

Conclusion

The prevalence of EAE in wind- and kitesurfers is high. Total exposure time and the frequency of activity influence EAE growth. EAE growth occurs faster in wind- and kitesurfers than in surfers. The additional influence of wind and the evaporative cooling of the EAC are thought to be responsible. The results of this study should increase awareness of the dynamics of EAE among ENT specialists and improve patient counselling.

External auditory canal exostoses: long-term surgical satisfaction and its relationship with surgical complications

OBJECTIVE

The main purpose of the present study was to evaluate whether complications related to surgery for exostoses are associated with a decrease in patients' quality of life.

METHODS

This was a retrospective study for which the following information was collected: sex, age, pre- and post-operative symptoms, pre- and post-operative audiological evaluation results, surgical approach, instruments used, complications, and Glasgow Benefit Inventory score.

RESULTS

The study included 67 patients (94 ears). The three main complaints reported were wax retention, otitis externa and hearing loss. Surgical complications occurred in 14.9 per cent of patients. Patients experienced a significant benefit from surgery, especially in relation to somatic state, with a global Glasgow Benefit Inventory score of + 44.3. No significant difference was found between the global Glasgow Benefit Inventory changes and surgery-related complications (p = 0.093).

CONCLUSION

After surgery for exostoses, the vast majority of patients showed improvement. Complications related to surgery in general do not seem to influence patients' satisfaction with surgery.

Auditory exostosis in Australian warm water surfers: a cross-sectional study

BACKGROUND

Surfing is a popular sport in Australia, accounting for nearly 10% of the population. External auditory exostosis (EAE), also referred to as surfer's ear, is recognized as a potentially serious complication of surfing. Cold water (water temperature below 19 °C) is a commonly cited risk factor, with prevalence of EAE in cold water surfers ranging from 61 to 80%. However, there is a paucity of studies reporting the prevalence of EAE in surfers exposed to water temperatures above 19 °C. With mean water temperature ranging from 19 °C to 28 °C, the Gold Coast region of Australia provides the ideal environment to assess the main goal of this study: to assess the prevalence and severity of EAE in warm water surfers.

METHODS

Eligible participants were surfers living and surfing on the Gold Coast (Queensland, Australia). Currently active surfers over 18 years of age, surfing year-round, with a minimum of five consecutive years of surfing experience were recruited to participate. Included individuals were asked to complete a questionnaire and underwent bilateral otoscopy.

RESULTS

A total of 85 surfers were included, with mean age 52.1 years (standard deviation [SD] ±12.6 years) and mean surfing experience of 35.5 years (SD ±14.7 years). Nearly two-thirds of participants (65.9%) had regular otological symptoms, most commonly water trapping (66%), hearing loss (48.2%), and cerumen impaction (35.7%). Less than one-fifth of the surfers (17.7%) reported regular use of protective equipment for EAE. The overall prevalence of exostosis was 71.8%, with most of the individuals having bilateral lesions (59%) and a mild grade (grade 1, 47.5%). There was insufficient evidence for any significant associations between the main outcomes (presence and severity of EAE) and factors related to age, surfing experience, winter exposure, surfing ability, symptoms, and use of protective equipment.

CONCLUSION

To the best of our knowledge, this is the first study assessing EAE in surfers exposed to warm waters (above 19 °C). The prevalence of 71.8% highlights the high prevalence of the condition in the surfing population, regardless of water temperature. Future research should focus on ways to prevent EAE.

Impact of ear protection on occurrence of exostosis in surfers: an observational prospective study of 242 ears

PURPOSE

The aim of the study was to investigate the efficacy of ear protection (earplug and surf hood) in preventing the development of external auditory exostosis (EAE) in surfers.

METHODS

We performed a prospective observational study. Volunteer surfers were recruited from June 2016 to October 2017 on the Brittany coast in France. Each participant filled in a questionnaire and underwent otoscopic digitalized photography to establish the degree of external ear obstruction by two different practitioners. The correlation between the percentage of external ear obstruction and the time spent in water with or without protection was evaluated. Risk factors of EAE were assessed.

RESULTS

Two hundred and forty-two ears were analysed. The incidence of EAE was 89.96% with an average rate of obstruction of 37.65%. Risk factors for EAE were male sex (p = 0.0005), number of years practicing surf (p < 0.0001) and symptoms of ear obstruction (p = 0.0358). A significant correlation was found between EAE severity and number of hours spent in water without any protection (earplugs or surf hood) (p < 0.0001). No correlation was found between EAE severity and time spent in water with earplugs (p = 0.6711) but a correlation was identified between obstruction and time spent in water with surf hood (p = 0.0358).

CONCLUSIONS

Wearing earplugs is an effective way to prevent EAE in surfers unlike surf hood.

Chronic and Gradual-Onset Injuries and Conditions in the Sport of Surfing: A Systematic Review

The majority of the previous literature investigating injuries in surfing have focused on acute or traumatic injuries. This systematic review appears to be the first to investigate the literature reporting on chronic and gradual-onset injuries and conditions in surfing populations. A search strategy was implemented on five databases in June 2020 to locate peer-reviewed epidemiological studies on musculoskeletal injuries or non-musculoskeletal conditions in surfing. A modified AXIS Critical Appraisal Tool was used to appraise all included texts. Extracted data included key information relevant to the epidemiology of the injuries and conditions. Twenty journal articles were included with the majority rated as good quality and a substantial agreement between raters (k = 0.724). Spine/back (29.3%), shoulder (22.9%), and head/face/neck (17.5%) were the most frequently reported locations of musculoskeletal injury, whilst the most common mechanism of injury was paddling (37.1%). Exostosis was the most frequently described injury or condition in surfing populations, with the most common grade of severity reported as mild obstruction. The key findings of injury type, location, severity, and mechanism can be used to develop relevant injury management and prevention programs for the surfing population, with an emphasis on chronic or gradual-onset spine/back and shoulder injuries, paddling technique, and education on the development and management of exostosis.

Australian surfers' awareness of 'surfer's ear'

Objectives

To assess awareness of external auditory exostosis (EAE) among Australian surfers.

Methods

This is a cross-sectional observational study, assessing professional and recreational Australian surfers. Currently, active surfers over 18 years of age, surfing year-round, were eligible to participate. After initial screening, individuals were asked to complete a questionnaire. All included volunteers underwent bilateral otoscopic examination, to assess the presence and severity of EAE.

Results

A total of 113 surfers were included in the study and were divided into two groups, based on surfing status: 93 recreational surfers and 20 professional surfers. Recreational surfers were significantly older (p<0.005), more experienced (greater years surfing; p<0.005), with lower prevalence of otological symptoms (p<0.05). The most common symptoms were water trapping, impacted wax and hearing loss. Prevalence of EAE was high for both groups (95% in the professional surfers and 82.8% in the recreational surfers); however, recreational surfers had mild grade EAE (grade 1) as the most common presentation, as opposed to professionals who had severe grade EAE (grade 3) as the most common presentation (p<0.05 between groups). Awareness of the term ‘surfer’s ear’ was high for both groups, as was knowledge of prevention options. However, fewer considered the condition to be preventable, and an even lower number reported regular use of prevention methods.

Conclusion

Australian surfers had a high level of awareness of EAE; however, few reported using prevention methods, despite having a high prevalence of the condition. Health practitioners should screen susceptible individuals in order to recommend appropriate preventive measures.

The Prevalence and Severity of External Auditory Exostosis in Young to Quadragenarian-Aged Warm-Water Surfers: A Preliminary Study

External auditory exostosis (EAE) has previously only been shown to occur in cold water surfers. We assessed young surfers living and surfing in Queensland, Australia, for EAE in water temp ranges from 20.6 °C (69.1 °F, Winter) to 28.2 °C (82.8 °F, Summer). All participants underwent a bilateral otoscopic examination to assess the presence and severity of EAE. A total of 23 surfers participated with a mean age of 35.4 years (8.3 years) and a mean surfing experience of 20.0 years (9.9 years). Nearly two-thirds of participants (n = 14, 60.9%) had regular otological symptoms, most commonly water trapping (n = 13, 56.5%), pain (n = 8, 34.8%), and hearing loss (n = 6, 26.1%). Only 8.7% (n = 2) of all surfers reported regular use of protective equipment (e.g., earplugs) on a regular basis. The overall prevalence of exostosis was 69.6% (n = 16), and the majority (n = 12, 80.0%) demonstrated bilateral lesions of a mild grade (<33% obstruction of the external auditory canal). This is the first study assessing EAE in young surfers exposed to only warm waters (above 20.6 °C). The prevalence of EAE in this study highlights that EAE is not restricted to cold water conditions, as previously believed. Warm water surfing enthusiasts should be screened on a regular basis by their general medical practitioner and utilize prevention strategies such as earplugs to minimize exposure to EAE development.

External auditory exostoses among western Eurasian late Middle and Late Pleistocene humans

External auditory exostoses (EAE) have been noted among the Neandertals and a few other Pleistocene humans, but until recently they have been discussed primary as minor pathological lesions with possible auditory consequences. An assessment of available western Eurasian late Middle and Late Pleistocene human temporal bones with sufficiently preserved auditory canals (n = 77) provides modest levels of EAE among late Middle Pleistocene archaic humans (≈20%) and early modern humans (Middle Paleolithic: ≈25%; Early/Mid Upper Paleolithic: 20.8%; Late Upper Paleolithic: 9.5%). The Neandertals, however, exhibit an exceptionally high level of EAE (56.5%; 47.8% if two anomalous cases are considered normal). The levels of EAE for the early modern humans are well within recent human ranges of variation, frequencies which are low for equatorial inland and high latitude samples but occasionally higher elsewhere. The Early/Mid Upper Paleolithic frequency is nonetheless high for a high latitude sample under interpleniglacial conditions. Given the strong etiological and environmental associations of EAE development with exposure to cold water and/or damp wind chill, the high frequency of EAE among the Neandertals implies frequent aquatic resource exploitation, more frequent than the archeological and stable isotopic evidence for Middle Paleolithic/Neandertal littoral and freshwater resource foraging implies. As such, the Neandertal data parallel a similar pattern evident in eastern Eurasian archaic humans. Yet, factors in addition to cold water/wind exposure may well have contributed to their high EAE frequencies.

Lifetime prevalence of exostoses in New Zealand surfers

INTRODUCTION External auditory exostosis (EAE) is a benign, irreversible bony outgrowth that arises from the temporal bone. EAE projects into the external ear canal, potentially causing recurrent otitis externa and conductive hearing loss. AIM To determine lifetime prevalence of EAE in New Zealand (NZ) surfers. METHODS This study used an online national survey. RESULTS Respondents were 1376 NZ surfers (recreational = 868, competitive = 508). Mean surfing experience was 16.2 years. Most self-classified as advanced surfers (36.5%), followed by intermediate (30.2%), expert (20.1%) and beginner (13.2%). Surfers reported an average of 214.2 h surfing (28.6% during winter) for the previous year. Overall lifetime prevalence of EAE was 28.9% (32.1% male, 14.6% female; P < 0.001), with the highest proportion of EAE was observed bilaterally (21.3%). Competitive surfers reported a significantly (P < 0.001) higher lifetime prevalence of EAE than recreational surfers (45.3% vs. 19.2%). A significantly higher (P < 0.001) lifetime prevalence of EAE was identified as skill level increased (7.1% in beginners to 55.6% in experts) and a two-fold increase (P < 0.001) of EAE in the highest (vs. lowest) quartile of surfing exposure. Neither winter surfing exposure nor which Island surfed were associated with EAE prevalence. DISCUSSION Although not as prevalent as in previous NZ research using otologic examinations, this study indicated that almost one-third of NZ surfers reported having had a diagnosis of EAE. Regular general practitioner otologic assessment and advice on appropriate prevention strategies for patients who surf may help prevent large lesions, recurrent ear infections and progressive hearing loss.

Removal of external ear canal exostoses by piezo surgery: a novel technique

Background

External auditory canal exostoses are known to occur in patients who engage in cold-water sports. Although the majority of patients with exostosis remain asymptomatic, larger lesions can cause wax impaction, conductive hearing loss and predispose to recurrent otitis externa.

Objective

A novel technique is described of using a piezo saw to excise exostoses that are symptomatic. The piezo saw is used to perform various procedures, but its use in removing exostoses has not been described in the literature.

Conclusion

Excision of exostoses of the ear canal using a piezo saw is a safe technique and patients have a speedy recovery. This paper describes a new technique for removing exostoses.

Awareness and attitudes towards external auditory canal exostosis and its preventability in surfers in the UK: cross-sectional study

Objectives:

To determine the proportion of UK surfers aware of external auditory canal exostosis, to identify surfer characteristics associated with knowledge of the condition and to explore attitudes to earplug use.

Method:

An online, cross-sectional survey of UK-based surfers.

Results:

Of 375 surfers, 86.1 per cent (n = 323; 95 per cent confidence interval = 82.3–89.3) reported awareness of external auditory canal exostosis. Further investigation revealed that, despite their awareness of the condition, 23.4 per cent of these surfers (88 out of 323; 95 per cent confidence interval = 19.5–28.0) had little or no knowledge about external auditory canal exostosis. Predictors of knowledge included: distance from nearest surfing beach (p = 0.001), surfing standard (ability) (p = 0.008), earplug use (p = 0.024) and positive external auditory canal exostosis diagnosis (p = 0.009).

Conclusion:

The findings suggest that a significant minority of UK surfers have no knowledge about this condition. Knowledge of external auditory canal exostosis was significantly associated with earplug use when surfing. Efforts to improve surfers’ knowledge are required to enable surfers to better protect themselves, which could reduce the incidence of external auditory canal exostosis.

Prevalence of 'surfer's ear' in Cornish surfers

OBJECTIVES

To establish the prevalence of external auditory canal exostosis ('surfer's ear') in Cornish surfers and investigate the potential impact on healthcare.

METHOD

A total of 105 surfers were interviewed and otologically assessed on popular Cornish beaches. The degree of exostosis was graded as mild, moderate or severe.

RESULTS

The prevalence of external auditory canal exostosis was 63.81 per cent (33.33 per cent mild, 18.10 per cent moderate and 12.38 per cent severe). The degree of exostosis showed a significant correlation with absolute cold-water exposure time. However, there was individual variation in susceptibility to external auditory canal exostosis; 12 per cent of surfers with excessive cold-water exposure showed no exostosis. Regression analysis of surgical operations performed at the Royal Cornwall Hospital for exostosis over the last 13 years revealed an average increase of 1.23 operations per year, with an average of 13 cases per year over the last 9 years.

CONCLUSION

Exostosis of the external auditory canal is common in Cornish surfers. There appears to be individual variation in terms of susceptibility to this condition. The possible reasons for this are discussed. The increase in the technically difficult surgical operations performed for exostosis is likely to have implications for health resources in the future.

Endoscopic transcanal removal of symptomatic external auditory canal exostoses

Exostoses are bony outgrowths of the external auditory canal (EAC) that can lead to cerumen entrapment, recurrent infections, and conductive hearing loss. When surgical removal is indicated, a drill or osteotome may be used via a post-auricular, endaural, or transcanal approach. Studies suggest that exostoses removed by transcanal osteotome result in decreased morbidity when compared to open, drilled approaches; however, inadvertent injury to the facial nerve or inner ear is a theoretical concern given the restrictive geometry of the EAC and challenges of visualizing the tip of the chisel through the microscope. The endoscope provides superior visualization of the external auditory canal and tympanic membrane compared to the microscope. We sought to demonstrate the efficacy and safety of endoscopic exostosis surgery with an osteotome. We find that the endoscope provides improved wide angled views without blind spots. There were no intraoperative complications. Endoscopic canaloplasty for exostoses may be readily applied.

Exostoses of the external auditory canal

Ear canal exostoses are bilateral, usually symmetric multiple bony growths occurring in the medial portion of the external auditory canal. Also known as surfer’s ear, exostosis is thought to be a reactive process from repeated stimulation by cold water and is much more common than external auditory osteoma. Exostoses are usually asymptomatic and discovered on routine otoscopy. Indications for surgical treatment are recurrent otitis externa, hearing loss, otalgia and other conditions in which access medial to the exostoses is required. Surgery is not risk-free and postoperative complications are the most important factor for negative impact on the patient’s health-related quality of life. This review offers an overview of the recent advances in the understanding of this condition, with a special focus on the etiology and physiopathology of this condition, the different surgical procedures and their outcomes, the risk factors for recurrence and the results of preventive measures. Finally, this review suggests the need for the otological surgeon to acquire a great deal of experience before undertaking surgical treatment of exostoses as it is a challenging operation and, besides expertise, demands great patience and extreme care in order to achieve good results.

Auditory canal exostoses in Irish surfers

AIM

Surfing is increasing in popularity in Ireland. Exostoses of the external auditory canal are a common finding in those who surf in cold water. The aim of this study was to examine the prevalence of external canal exostoses in a population of Irish surfers.

METHODS

A cross-sectional study of Irish surfers was carried out. Patients were examined and questioned on their knowledge of exostoses, surfing routine, use of barrier protection and symptoms experienced.

RESULTS

119 surfers were analysed. 66 % of the surfers examined exhibited exostoses and 88 % were unaware of their diagnosis. Those that developed exostoses had surfed for a mean of 5,028 h, those that did not had surfed for a significantly shorter mean of 1,909 h (p = 0.0002).

CONCLUSIONS

This is first study of this nature in the UK or Ireland. With a 5- to 6-year lag phase for exostoses to develop, these patients are likely to become an increasing part of Otolaryngologist's workload.

The effects of surfing behaviour on the development of external auditory canal exostosis

To examine how individual surfing behaviour affects the development of external auditory canal exostosis and to produce a model to predict exostosis severity. A standardised questionnaire was completed and each participant underwent an otoscopic examination. Surfers were recruited from August to October 2011 from surfing competitions and from colleges in the South West of England. 207 surfers were included, 53 % had evidence of external auditory canal; exostosis: grade 1, 23%; grade 2, 16%, grade 3, 16%. This risk of exostosis significantly increased with (1) surfing for 6 or more years, (2) surfing in the winter months, (3) surfing five or more times per month in the winter and (4) reported ear symptoms. Interestingly, participation in other water sports and wearing earplugs or a hood reduced the risk of developing exostosis. Surfers who surf in England are at significant risk of exostosis. A probability model was designed, incorporating different surfing behaviours and ear symptoms, the first of its kind in exostosis research. This model will be a useful tool for raising awareness of external ear canal exostosis in the surfing community and in assessing individual need for surgical intervention.

Audiological implications of earplugs used for the prevention of aural exostoses

External auditory canal exostoses may be a preventable disease, so it is surprising that the regular use of water precautions is not greater among surfers. One reason for this is the impairment of hearing whilst wearing earplugs. The objective of this study is to establish the hearing impairment of commonly available earplugs used by surfers. Staff and patients with normal hearing were recruited to have pure tone audiometry performed multiple times, initially with no earplugs, and subsequently with earplugs. Three earplug types were tested which differed in their nature and material (prefabricated elastomer, custom-fitted silicone, and custom-fitted acrylic). Vented and non-vented forms of the earplugs were tested. 30 normal hearing ears were included. Two-tailed paired t-tests comparing hearing thresholds between different earplugs identified that the elastomer earplugs caused the least hearing impairment (p < 0.001). There was no significant difference in hearing thresholds between vented and non-vented elastomer earplugs (p = 0.148), but the difference between vented and non-vented forms of other earplugs was statistically significant (silicone p = 0.010, acrylic p = 0.018). Prefabricated ear plugs produce less hearing impairment than other commonly available earplugs. A customised earplug made of hard material causes the greatest impairment of hearing. We therefore recommend that for aquatic sports where hearing is important, a soft prefabricated earplug is preferable.

Surfers' awareness of the preventability of 'surfer's ear' and use of water precautions

OBJECTIVE

To establish surfers' knowledge of the preventability of external auditory canal exostoses ('surfer's ear'), and their use of water precautions.

METHOD

Survey of surfers conducted between December 2009 and March 2010 at beaches in Cornwall, UK.

RESULTS

Ninety-two surfers were included (78 males and 14 females, mean age 27 years, standard deviation 7.9 years). Participants were grouped according to their awareness of the preventability of surfer's ear (55 aware, 37 unaware). These groups were comparable in age, surfing history and gender mix (p > 0.05). Surfers aware of the preventability of exostoses (66 per cent) were more likely to use water precautions than those who were not (38 per cent) (p < 0.01). Two surfers used water precautions regularly and 48 used them occasionally. Sixty-one of the 76 surfers who did not use water precautions (ear plugs) suggested they would consider doing so in the future.

CONCLUSION

Awareness of the preventability of surfer's ear was associated with greater use of water precautions. Further research should explore reasons for the low uptake of such precautions. Most surfers not already using ear plugs would consider doing so in the future.

Water-related occupations and diet in two Roman coastal communities (Italy, first to third century AD): correlation between stable carbon and nitrogen isotope values and auricular exostosis prevalence

The reconstruction of dietary patterns in the two Roman imperial age coastal communities of Portus and Velia (I-III AD) by means of stable isotope analysis of bone remains has exposed a certain degree of heterogeneity between and within the two samples. Results do not correlate with any discernible mortuary practices at either site, which might have pointed to differential social status. The present study tests the hypothesis of a possible connection between dietary habits and occupational activities in the two communities. Among skeletal markers of occupation, external auricular exostosis (EAE) has proved to be very informative. Clinical and retrospective epidemiological surveys have revealed a strong positive correlation between EAE development and habitual exposure to cold water. In this study, we show that there is a high rate of occurrence of EAE among adult males in both skeletal samples (21.1% in Portus and 35.3% in Velia). Further, there is a statistically significant higher prevalence of EAE among those individuals at Velia with very high nitrogen isotopic values. This points to fishing (coastal, low-water fishing) as the sea-related occupation most responsible for the onset of the ear pathology. For Portus, where the consumption of foods from sea and river seems to be more widespread through the population, and where the scenario of seaport and fluvial activities was much more complex than in Velia, a close correlation between EAE and fish consumption by fishermen is less easy to establish.

Exostoses of the external auditory canal in white-water kayakers

OBJECTIVES/HYPOTHESIS

Exostoses of the external auditory canal are benign bony tumors associated with frequent cold-water exposure. Obstruction may lead to conductive hearing loss and recurrent otitis externa, requiring surgical correction when symptoms become intolerable. This study aimed to characterize the prevalence of exostoses in white-water kayakers and identify associated risk factors and protective measures.

STUDY DESIGN

Cross-sectional.

METHODS

Six hundred eleven white-water kayakers from across the United States were included in the study. Percent occlusion was graded as minimal (<25%), moderate (25%-75%) or severe (>75%). Subjects completed a survey of risk factors and protective measures. Kruskal-Wallis and chi(2) tests were performed to determine significant associations with percent occlusion. A multivariate proportional odds regression model was fit to adjust for confounding between the variables.

RESULTS

The prevalence of exostoses in kayakers was 79% (482/611); 13% (78/611) had >or=75% occlusion. Percent occlusion was associated with total years kayaked (P < .001), frequency >or=1 day/week (P < .001), male gender (P < .001), and increasing age (P = .005), although frequency, gender, and age were confounded by total years. Styles that involve repeated submersion were also associated with greater occlusion (freestyle, P = .036; squirt, P = .016). Subjects who used earplugs for a greater proportion of their kayaking career were less likely to have exostoses (P < .001). When adjusted for confounding, only total years (P = .0003) and age (P = .0027) remained significant.

CONCLUSIONS

Kayakers are the first inland population to experience exostoses at the rates seen in coastal populations (e.g., surfers). When used long-term, earplugs may be protective.

External auditory exostoses: Evaluation and treatment

Objective

To determine (1) if external auditory exostosis (EAE) severity in a surgical exostosis population differs between ears and (2) the incidence of complications from postauricular canalplasty for EAE.

Study Design

A retrospective review.

Subjects and Methods

Three hundred twenty-seven patients (401 ears) underwent drill canalplasty for EAE from 1990 to 2006. EAE severity was graded, and air and bone thresholds were used to evaluate hearing changes.

Results

There were no significant differences in surgery rate or severity between right and left ears (71% grade 3 in both ears), with 95 percent grade 3 in operated ears. Prolonged healing occurred in 4.5 percent, with 1 TM perforation (0.2%). Sensorineural hearing at 4 kHz worsened slightly (mean change = 3.7 dB, P ≤ 0.001), with 4.8 percent worsening > 15 dB (maximum 30 dB), but sensorineural bone average was unchanged (mean = 0.2 dB). EAE recurred in 8 of 91 ears with long-term follow-up, occurring up to 15 years postsurgery.

Conclusions

EAE severity in surgical patients does not differ between right and left ears. Drill canalplasty via the postauricular approach minimizes complications.

Auditory exostoses as an aquatic activity marker: a comparison of coastal and inland skeletal remains from tropical and subtropical regions of Brazil

Auditory exostoses are bone masses located in the external auditory canal. Currently, most researchers agree that the environment (especially water temperature, but also atmospheric temperature and wind action) plays a pivotal role in the development of this trait. This article discusses whether the presence of auditory exostoses can be used as an aquatic activity marker in bioarchaeological studies, especially in groups that inhabited tropical and subtropical regions. We analyzed 676 skeletons (5,000 years BP to historical times) from 27 coastal and inland native Brazilian groups. Very low frequencies of auditory exostoses were found in the inland groups (0.00-0.03), but the expected high frequency of auditory exostoses in the coastal groups was not always observed (0.00-0.56). These differences might be explained by the combination of water and atmospheric temperatures in conjunction with wind effects. In areas with mild atmospheric temperatures and wind chill factors, the coastal populations analyzed do not show high frequencies of auditory exostoses. However, high frequencies of auditory exostoses develop where cold atmospheric temperatures are further lowered by strong wind chill. Therefore, the association between aquatic activities, low atmospheric temperature, and wind chill is strongly correlated with the presence of auditory exostoses, but where these environmental factors are mild, the frequencies of auditory exostoses are not necessarily high. Concluding, auditory exostoses should be cautiously used as a marker of aquatic activity in bioarchaeological studies in tropical and subtropical regions, since these activities do not always result in the presence of this trait.

Osteotome technique for removal of symptomatic ear canal exostoses

OBJECTIVES/HYPOTHESIS

This study was undertaken to assess a transcanal osteotome technique for removing symptomatic ear canal exostoses. Outcome measures included healing rates and the rate of complications.

STUDY DESIGN

Prospective study in a private practice.

METHODS

A straight 1-mm osteotome and a curved 1-mm osteotome were used by way of a transcanal approach to incrementally remove obstructive ear canal exostoses. If anterior or superior bone growths were closely approximating the tympanic membrane, they were partially removed with a 1.5 mm cylindrical end- and side-cutting burr. Healing rates were monitored with weekly postoperative visits.

RESULTS

Two hundred twenty-one ear canals (140 patients) were consecutively treated with this technique. Healing was achieved at 2 to 8 (average 3.50) weeks, with 90% healed by 4 weeks. There were 4 mobilizations of a full-thickness segment of anterior bony canal wall; 3 exposures of periosteum anterior to the anterior bony wall; 1 tear of the tympanic membrane requiring a tympanoplasty; 18 anterior and 11 posterior tympanic membrane tears that healed spontaneously; 3 instances of sensorineural hearing decrease; 3 cases of new-onset postoperative tinnitus; and 1 instance of postoperative positioning vertigo. There were no lacerations of the tympanic membrane by an osteotome, no facial nerve injuries, no soft tissue stenoses of an ear canal, and no skin grafting of an ear canal.

CONCLUSIONS

The described technique of using osteotomes transcanal for removal of symptomatic obstructive ear canal exostoses promoted rapid healing and was effective and safe.