Words by surfer and medical professional, Dr David Baglow. Special thanks to consultant ENT surgeon Mr Phil Flanagan.
There are only two truly distinguishable types of surfers. Those who wear earplugs and those who don’t. Those of us who don’t wear ear plugs view them with feelings of curiosity, suspicion and occasionally guilt. Guilt that perhaps we should be wearing them. Most of us don’t give earplugs any further consideration, until the next time we see a person with Blue-Tac in their ears.
There must surely be surfers amongst us who are plug-curious. In an ideal world they see themselves wearing ear plugs whilst surfing, but something holds them back. Is it a lack of confidence to go public? Or perhaps there's something else that's stopping them taking the plunge towards ear utopia. Are ear plugs really that much of a hassle?
They complain about them being too uncomfortable, poorly fitting, expensive, deafening and generally ruining the overall surf experience. The poor earplug it seems, suffers from a large amount of negative stigma and general resistance.
Some of those who don't wear earplugs have experimented with them in the past, but claim it wasn't for them. They complain about them being too uncomfortable, poorly fitting, expensive, deafening and generally ruining the overall surf experience. The poor earplug it seems, suffers from a large amount of negative stigma and general resistance.
Why is that? Is it just that earplugs aren’t cool? Or perhaps we feel that they would blunt our senses and detract from our overall performance and experience?
Some surfers, however, have taken the plunge. They won’t go near water without first protecting their ears. These wise salty-dogs wear earplugs despite the reasons the rest of us don't. These are often surfers that have spent so much time in the sea pursuing their passion that the bones inside their ears have begun to grow. Chances are that they've suffered the consequences of this new growth. If they haven’t suffered, it's likely that they know someone who has and they don’t fancy one bit of it. What is it then that this plugged minority amongst us suffer or fear? What do they know that we don't?
It’s not a badge of surfing honour. It’s rubbish. It can keep you out of the surf, and make your life miserable with illness and pain. Pain in your head is hard to ignore and is miserable as a result.
You’d have to go a long way to come across a medical condition that is more poorly understood and neglected within a sporting community as surfer’s ear. It’s not a badge of surfing honour. It’s rubbish. It can keep you out of the surf, and make your life miserable with illness and pain. Pain in your head is hard to ignore and is miserable as a result.
In fairness, the main reason why surfers ear is poorly understood in the surfing community is that it's also relatively (to other conditions) poorly understood by most in the medical community. Unless you live in a cold water surfing area, it's unlikely your GP will know much about the condition. To a land locked surgeon it can remain a rare condition of seemingly little consequence. To those surgeons that live and operate in cold water surfing communities the condition is common, and they fully appreciate the impact it can have on people's quality of life.
What is surfer’s ear?
The ear canal is made from the joins of a few bones of the skull. For some reason exposure to cold water makes these bones grow. It is thought that the greater the exposure the greater the growth, but this is only a theory and not proven. When these bones in your ear canal grow they form exostosis. Exostosis comes from Greek language and means ‘new bone’. This bone grows into the ear canal making it narrower.
The ear canal is made from the joins of a few bones of the skull. For some reason exposure to cold water makes these bones grow. It is thought that the greater the exposure the greater the growth.
These bone growths aren’t dangerous, and most people who have surfer’s ear (exostosis) are completely symptom free. They may remain symptom free too. This is because a lot of people reduce the amount of time they spend in the sea before problems start. Getting a job or having children can be useful for that.
Some surfers who develop exostosis aren’t so lucky. They are plagued by constant pain, recurrent infections and rarely, in some of the worst cases, suffer with a constant ringing in their ear. Surfing to them, once perhaps irreplaceable as a pastime, now rapidly becomes something relegated to their past. Unless they wear ear plugs.
Wearing plugs stops cold water constantly flushing the ear canal. There seems to be a relationship between exposure of the ear canal to cold water and the progression of surfer's ear. They exact nature of this relationship isn't well understood by medical professionals.
Once your ears have narrowed for the worse, you are essentially risking getting an infection every time you get them wet. As the ear canal narrows with these bony growths, the ears become worse at draining water and drying out after every surf. You may notice this as your ear being blocked with water for longer after being in the sea.
Sea water is dirty. It’s teeming with bacteria, algae and zooplankton. The longer the ear canal has water within it, the more likely it is to get irritated and develop an infection.
Sea water is dirty. It’s teeming with bacteria, algae and zooplankton. The longer the ear canal has water within it, the more likely it is to get irritated and develop an infection. Ear infections hurt, make you feel unwell and can make you deaf while you have them. Going in the sea with an ear infection will make the infection worse and it will subsequently take a lot longer to heal. If left untreated ear infections can smell and look horrible. If severe they can leak pus out of your ear. Not to mention spread infection to the surrounding skin on your head.
It’s not really known why repeated exposure to cold water makes these bones grow. It's not an area of medicine or surgery that has attracted a huge amount of funding for research. The wide acceptance for exposure to the cold to be the trigger has come from personal observations from surgeons operating to surgically remove exostosis. On the Australian East Coast for example Ear Nose and Throat (ENT) surgeons have noticed much higher incidences of surfer's ear in surfers that live in Melbourne where the waters are cooler than in Brisbane and the Gold Coast, where the waters are considerably warmer.
Wetsuit technology has come on leaps and bounds in the last 10-20 years. In fact we're now actually able to make leaps and bounds whilst wearing them! Even summer wetsuits of yesteryear would have made such athleticism tricky. As a result of these developments we're able to spend more time in cold water and are able to push surfing boundaries North and South into frigid seas. Can we then expect to see surfer's ear incidence on the rise? It seems reasonable that we will.
The condition in not limited to humans. Other mammals such as seals get exostosis too.
How can I tell if I have surfer’s ear?
Unless a doctor looks in your ear you can’t. As the ear canal narrows you’ll start to notice it takes longer for your ears to empty during or after a surf. That sideways shaking of the head in the car park to clear them may be taking a bit longer. Or perhaps your ears clear hours later at work?
As the ear canal narrows you’ll start to notice it takes longer for your ears to empty during or after a surf. That sideways shaking of the head in the car park to clear them may be taking a bit longer. Or perhaps your ears clear hours later at work?
Some people notice their ears feel full for a while after a surf and can even begin to ache. Aching can be a sign of irritation. Irritation is a stepping stone to infection. Bacteria and fungi absolutely love skin irritation. Especially in a nice damp and warm ear canal. You’ll know if you have an ear infection. Your ear will start to really ache. Ear ache is really unpleasant, especially if you have it with a (temporary) loss of hearing in the same ear.
A large number of surfers will have these boney growths in their ear canals (of varying size) and be completely symptom free.
How can I prevent it?
Wear earplugs. Newer designs can look cool and don’t come out during that horrific low tide winter flogging. Ear utopia can actually exist. Ear plugs really do work to prevent you getting surfer's ear. It's not essential they keep your ear completely dry either. They only need to reduce cold water flushing in your ear canal enough to allow the water in there to stay at body temperature. Much like how a wetsuit works on your skin. Don’t stick things in your ear like cotton buds to try and clean or clear them. This irritates the skin further.
If your ears are feeling full and taking a while to drain then there are ‘Surfactant’ drops that you can use. You can ask your GP about them but there's a good chance they won't know much about surfactant ear drops. Their knowledge can depend on how many surfers they have on their books and therefore how often they see surfer's ear. You could ask in your local (surfing community) pharmacist or surf shop as they are often well versed on keeping on top of problem ears. Surfactant drops work by reducing the surface tension of the water in your ear and help it drain. A bit like washing up liquid’s effect on oily water.
Don’t stop surfing over winter. The overwhelming message has to be to for us to go out and buy decent ear plugs and actually start wearing them. All year round.
What is the management of surfer’s ear?
If you start getting recurrent ear infections, you've already lost the first battle. Your GP may give you courses of antibiotic drops to help your ear infections to clear. For your infection to clear effectively however, the pus in the ear canal needs to be able to drain out. The exostosis in your ear canal can make this difficult. Your GP may refer you to an ENT surgeon to have 'micro-suction' of the ear canal to have the pus and infected debris physically removed. The debris is usually dead skin, wax and potatoes (if my Grandad is to be believed). Micro-suction is then followed by a course of antibiotic ear drops. The exostosis, due to their obstruction of the ear canal, can block the insertion of the suction equipment and make removal of the pus tricky and less effective.
The good news is that these bone growths can be removed. The principle of surgery is to widen the ear canal to improve water drainage.To understand the technique of surgery will help dispel hearsay and misinformation.
A cut is made just in front or behind the ear. The skin of the ear canal that’s overlying the bony growths is then lifted up as a skin flap. This skin flap is kept intact so that it can be replaced at the end of the operation to reline the ear canal. A drill being used to remove the bone at the base of the exostosis.
ENT surgeons are a highly skilled group of surgeons. They’ve been removing these boney growths from ear canals for years. They’re extremely skilled at it. There are two techniques surgeons use for removing the bone: drilling and/or chiseling. You are put to sleep with a general anaesthetic for the operation. A cut is made just in front or behind the ear. The skin of the ear canal that’s overlying the bony growths is then lifted up as a skin flap. This skin flap is kept intact so that it can be replaced at the end of the operation to reline the ear canal. A drill being used to remove the bone at the base of the exostosis. The drill provides fine control and precision in areas of the ear canal where the surgeon requires.
Drilling is the traditional method used for ear canal bone removal. The drill bits are very small and it is an accurate and precise way of removing the bone. This can mean that bone growing next to, or against, the fragile eardrum can be removed with fine control. The downside of using the drill is that it is more often associated with damage to the skin overlying the bone growths. This would delay your post-op recovery time (time till you can surf again). It has also been noted that on very rare occasions some patients have had post-operative tinnitus or nerve hearing loss - which has been assumed to be due to the noise created by the drill during the operation. Tinnitus is hearing a sound when there actually is none. Like the ringing you can get in your ears after listening to loud music.
Using a chisel to remove the bone has become more popular particularly in the UK and US over the last decade. The chisel is used to gently fracture along these natural planes of cleavage (weak points in the bone). A bit like how you would use an axe to split wood.
Using a chisel to remove the bone has become more popular, particularly in the UK and US, over the last decade. Chiseling takes advantage of the way these exostosis grow. They consist of horizontal flat layers of bone cells. The chisel is used to gently fracture along these natural planes of cleavage (weak points in the bone). A bit like how you would use an axe to split wood, but with a lot more finesse. This technique makes it much easier to preserve the ear canal skin in a healthy state and the ear canal heals quickly after the operation. Surgeons who prefer the drill would however argue that the chisel is unsafe as it could create a fracture into the delicate structures in the middle ear.
Due to the surf culture in Cornwall UK, The Royal Cornwall Hospital in Truro undertake many of these operations each year. They have had 10 years experience of using both techniques alone and in combination, reserving the drill for exostoses close to the ear drum as it offers a greater degree of accuracy. When they looked at their results they found that chisel techniques were safe, with less risk of tinnitus and hearing loss. They also observed that patients healed faster after their surgery and seemed to have less pain post-operatively.
How long until I can safely surf again after surgery?
After surgery it is important to allow time for the replaced skin flap to heal. This usually means 6-8 weeks out of the sea. The actual length of time will depend on the state of your ears and the extent of surgery you had. To go surfing too early means a skin infection. That leads to a nasty painful ear infection, and ultimately longer out of the surf.
Can surfer’s ear reoccur after surgery?
Yes if you surf without earplugs. The data on how long it takes for the bones to grow back and whether drilling or chiselling makes a difference hasn’t been collected and analysed. It has been suggested though that once you've had surfer's ear, the bone in your ear is more 'sensitive' to cold water than an ear that has no history of exposure.
My GP says I have surfer's ear and I'm getting ear problems. What now?
If you're getting recurrent infections you should discuss with your GP the possibility of a referral to meet ENT surgeons. A discussion about the risks and benefits of surgery is very important. We're all unique, and the way our surfer's ear presents itself and effects us is specific to us. A plan that works for one surfer may not be the best plan for you.
Meeting ENT surgeons initially is about forming a plan together. Surgery doesn't have to be performed. Surfer's ear can be managed with just earplugs and surfactant drops. Perhaps you don't mind getting the odd ear infection. Your discussion will focus on the benefits of surgery vs the risks of not having it.This discussion is really important as the surgeon is able to give you a balanced view of surgery in terms of relative risk to you.
Don't seek management advice from people who aren't in a position to give it. Listening to friends who have surfer's ear and their experience can be very useful to help inform you, but shouldn't substitute professional consultation. Surgeons aren't robots who want to operate on every person that they get referred. Unlike friends or bloggers with their personal accounts, surgeons have a huge amount of experience dealing with surfer's ear. They have seen all the risks and all the benefits from following up patients over decades of treating surfer's ear. They have your best interests as heart.
Reaching earplug utopia
Not everyone reading this article will be convinced of the merits of ear plugs. Good luck to them. Most that do believe in the merits, will probably only go so far as to make a mental step closer towards being an ear-plugged-surfer. Understandable human behaviour and still a worthy outcome for this article.
Some will try ear plugs for a while, and then give up. Not seeing results challenges motivation. Hopefully a small percentage will join me by taking the plunge and embracing plugs for good, and surf happily ever after. Who knows what will happen in the future? One day ear plugs may be cool.
For those of you who are interested in protecting your inner ears, you can purchase ear plugs at the MSW store HERE.
This is the latest of a series of articles by Dr David Baglow, in which he explores the health risks inherent in surfing, while advising how to minimise risk and take action when things go wrong. For more advice from Dr Dave, visit his website getswellsoon.com.