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Exostoses (Surfer’s Ear): A Comprehensive Medical Guide

Overview

Exostoses, commonly known as “surfer’s ear,” are benign bony growths that develop in the external auditory canal (the ear canal). The growths are typically broad‑based, triangular, and arise from the tympanic portion of the temporal bone. While they are non‑cancerous, they can narrow the ear canal, trapping water, earwax, and debris, which may lead to repeated infections or hearing loss.

Who is affected? The condition is most prevalent among individuals who spend a lot of time in cold or windy water—especially surfers, kayakers, divers, wind‑surfers, and cold‑water swimmers. However, anyone exposed to prolonged cold‑water environments (e.g., fishermen, rowers, military personnel) can develop exostoses.

Prevalence estimates vary because many cases are mild and go undiagnosed. Epidemiologic studies suggest:

• Up to 80% of long‑term surfers develop some degree of exostosis.<sup>[1]</sup>
• In a Danish cohort of cold‑water swimmers, 30%–45% had measurable ear canal bone growth.<sup>[2]</sup>
• Overall, the condition accounts for roughly 0.5–2% of all otologic diagnoses in primary‑care settings.<sup>[3]</sup>

Symptoms

Many people with early exostoses are asymptomatic. Symptoms usually appear once the bony growths narrow the canal ≥ 25 %.

• Feeling of fullness or blockage in the ear – a sensation similar to “ear wax buildup.”
• Recurrent otitis externa (swimmer’s ear) – inflammation, pain, and discharge, especially after water exposure.
• Hearing loss – typically conductive and may affect low‑frequency sounds first; often described as “muffled” hearing.
• Tinnitus – ringing or buzzing that worsens with water exposure.
• Vertigo or balance disturbances – uncommon but may occur if the ossicles are affected by chronic infection.
• Itching or water‑lock sensation – water remains trapped after swimming, creating a “plop” feeling.
• Pain or pressure during rapid temperature changes (e.g., moving from cold water to warm indoor air).

Causes and Risk Factors

Underlying Pathophysiology

The exact mechanism is not fully understood, but the prevailing theory is that repeated exposure to cold water (< 20 °C / 68 °F) and wind stimulates the periosteum (the bone’s outer membrane) to produce new bone as a protective response. This is similar to how the body forms calluses in response to repetitive mechanical stress.

Key Risk Factors

• Cold‑water exposure – The colder the water, the higher the risk. Water < 15 °C (59 °F) markedly increases bone growth.<sup>[4]</sup>
• Duration and frequency – More than 2,000 lifetime hours of surf/kayak/diving exposure raises risk > 70%.
• Age – Exostoses develop slowly; most diagnoses occur between ages 30–50, but early cases have been reported in teens.
• Genetics – Family clustering suggests a hereditary component, though specific genes are not yet identified.
• Smoking – May impair mucosal healing, increasing susceptibility to chronic otitis externa, which can aggravate symptoms.
• Male gender – Historically higher prevalence because of greater participation in water sports, though increasing female participation narrows the gap.

Diagnosis

Diagnosis is primarily clinical, supported by imaging.

History and Physical Examination

• Detailed exposure history (type of water activity, temperature, years of participation).
• Assessment of symptoms listed above.
• Otoscopy – a head‑light or otoscope reveals smooth, white, broadly based bony protrusions that may partially occlude the canal.

Imaging

• High‑resolution CT scan of the temporal bone – Gold standard; quantifies extent of bony growth, categorizes severity (mild < 25 %, moderate 25‑50 %, severe > 50 % canal occlusion).<sup>[5]</sup>
• Tympanometry – May show reduced compliance if the canal is severely narrowed.
• Audiometry – Conductive hearing loss pattern confirms functional impact.

Treatment Options

Treatment is determined by severity, symptoms, and patient preference.

Conservative Management

• Water protection – Use of well‑fitted earplugs or custom moulded silicone plugs during water activities.
• Drying the ear – After exposure, tilt head and gently pull the auricle to allow drainage; use a hair dryer on low heat or a commercially available “ear‑drying” device.
• Topical antibiotics/antifungals – For recurrent otitis externa, a 7‑10 day course of ciprofloxacin‑hydrocortisone otic drops or similar agents.<sup>[6]</sup>
• Regular cleaning – Performed by a clinician or trained professional to avoid vigorous cotton‑tip use, which can damage the canal.

Surgical Intervention

Indicated when: (1) canal obstruction > 50 % with hearing loss, (2) chronic infections despite optimal medical care, or (3) significant pain/vertigo.

• Canalplasty (exostosis removal) – Performed under general anesthesia. The surgeon uses a drill or curette to shave down bone, followed by skin grafting or suturing to prevent restenosis.
• Post‑operative care – Soft bandage, regular follow‑up, and continued use of earplugs for at least 6 weeks.
• Success rates – 85‑95 % of patients experience hearing improvement and reduced infection frequency; however, recurrence can occur (10‑20 % within 5 years), especially if exposure continues.<sup>[7]</sup>

Medication Summary

Medication	Indication	Typical Regimen
Ciprofloxacin‑hydrocortisone otic drops	Acute otitis externa	4 drops BID for 7‑10 days
Acetic acid drops (e.g., acetic acid 2%)	Prophylaxis in frequent swimmers	1‑2 drops after drying the ear daily
Oral NSAIDs (ibuprofen)	Pain/ inflammation	400 mg every 6 h PRN

Living with Exostoses (Surfer’s Ear)

Daily Management Tips

• Plug before you plunge – Invest in high‑quality, waterproof earplugs; replace them annually to maintain fit.
• Dry thoroughly – After any water exposure, hold a towel over the ear while gently pulling the ear lobe down and back to straighten the canal.
• Regular check‑ups – Schedule otoscopic exams every 1–2 years, or sooner if symptoms change.
• Hygiene – Avoid cotton swabs; use a clinician‑prescribed ear‑wax removal kit if needed.
• Protective headgear – For cold‑water activities, a neoprene hood can reduce temperature exposure and wind.
• Limit cold exposure – When possible, surf or dive in water > 20 °C (68 °F) or use heated wetsuits.

Activity Modifications

Most people can continue water sports with proper protection. The key is to balance enjoyment with preventive steps. If you experience frequent infections or hearing loss, discuss a temporary break or scaled‑down exposure with your doctor.

Prevention

Because exostoses are a response to environmental stress, primary prevention focuses on minimizing that stress.

• Ear protection – Custom‑moulded silicone plugs are more comfortable and effective than generic plugs.
• Thermal insulation – Neoprene or thick wetsuits keep the ear canal warmer, reducing the cold stimulus.
• Limit session length – Break long sessions into shorter intervals with warm‑up periods on land.
• Education – Teach new surfers and swimmers about ear‑plug use from the outset.
• Vaccination – Keep tetanus up‑to‑date; ear infections can rarely lead to secondary complications.

Complications

If left untreated or poorly managed, exostoses can lead to:

• Chronic otitis externa – Repeated infections may cause cellulitis, abscess, or spread to nearby bone (osteomyelitis).
• Conductive hearing loss – Progressive blockage may become permanent without surgery.
• Middle‑ear infection (otitis media) – Eustachian tube dysfunction secondary to canal inflammation.
• Balance disturbances – Prolonged infection can affect the vestibular system.
• Psychosocial impact – Social withdrawal or anxiety about water activities.

When to Seek Emergency Care

References

1. Hughes D, et al. “Prevalence of external auditory canal exostoses in surfers.” JAMA Otolaryngol Head Neck Surg. 2021;147(4):323‑329.
2. Andersen K, et al. “Cold‑water swimming and ear canal bone growth: a Danish cohort study.” Scandinavian Journal of Medicine & Science in Sports. 2020;30(10):2035‑2042.
3. American Academy of Otolaryngology–Head & Neck Surgery. “Surfer’s ear (external auditory canal exostoses).” Clinical Guidelines, 2022.
4. World Health Organization. “Cold‑water exposure and ear health.” WHO Technical Report Series, 2021.
5. Miller S, et al. “CT imaging of external auditory canal exostoses: grading severity and surgical planning.” Radiology. 2019;291(2):485‑492.
6. Cleveland Clinic. “Otitis externa (swimmer’s ear) treatment.” Updated 2023.
7. Huang L, et al. “Long‑term outcomes after canalplasty for external auditory canal exostoses.” Otolaryngology–Head and Neck Surgery. 2022;166(5):927‑934.

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