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Wavescape - Surfing in South Africa

Thu, 20 October 2011

What do Surfer’s Ear and HIV have in common? To prevent them, you have to wear protection. A major problem among surfers is the buildup of bone in the ear from exposure to cold temperatures. Listen to Dr John.


ear What we're talking about is something surfers really don’t want to know about, but should, because if you're a surfer, you're taking part in a sport where surfer's ear is one of the most common problems and a price you may have to pay for being a surf-aholic.


So, let's talk about the history of surfer's ear, what causes it and what can, and should, be done about it.Being ignorant on such a relevant topic is not smart, it's plain dumb. And that’s not something the surfer community should be. Surf Kings and Queens for sure, but not dummies.

If you're a smoker, you know the small print. The same should apply to surfers and their ears. So at the end of this chat, I hope to have you better informed.Having started with a sexual innuendo, I think it only fair to mention that in 1891, when “surfer's ear” was first described, syphilis was suspected as a possible cause. The first described surgery took place in 1877.

The operation took seven hours using chloroform anaesthesia. They also used leeches to facilitate blood flow. But relax. Just as technology for surfboards and wetsuits has flourished, so have modern surgical techniques and anaesthesia. So chill... you're safe from leeches.

What causes surfer's ear? I worked in London for Sir Donald Harrison who found the reason. He found ear canal skin temperature increased after swimming in cold water. This increase was due to dilatation of the blood vessels. Irrigating the ear with 15°C seawater for 15 seconds caused blood vessels to swell and increase the warmth for some 45 minutes. And in those who already had surfer's ear, the same exposure caused 80 minutes of reflex warming due to vessel dilatation.

So the colder the water, the greater the duration of the reflex dilation and heating up. Basically increased vascular temperature can cause new bone formation because there's no insulating layer of subcutaneous tissue between the lining of the ear canal and the underlying bone. This theory has been found to be true.

Susceptible populations:

In terms of history, a relatively small number of people engaged in long-term cold-water activities as an occupation, but with invention in the 1950s of the neoprene suit, everything changed and one could spend prolonged periods of time in what had previously been uncomfortably cold water. Unless the ear canal was protected from cold-water exposure, the price for greater participation in cold-water activities increased, as did formation of surfer's ear.

The sport predominantly affected by these trends was surfing: so you're at riskSurfers are people who continually have their heads under water and participate in their sport for hundreds of hours per year and, what's more, many for decades. In fact the term “surfer's ear” first appeared in medical literature in 1977.

Since then most discussions on surfer's ear describe mainly surfing populations since this is the group with the highest incidence of the condition. Essentially, a surfing generation was born. A generation of water buddies who spend hundreds of hours in cold water with uncovered ears. Some for decades. All surfers are potentially at risk, so if you're sensible, responsible and all those other boring things, you'd have your ears checked out by someone who understands this condition ... not an amateur ..., firstly to see whether you have them, and what, if anything, needs be done. Certainly protection is top of the list.

How many surfers get surfer's ear

This varies depending on whether you're susceptible, the water temperature and how often and for how long you surf, always repeating the bottom line as to whether you wear protection. This makes a huge difference. What I mean is, “wear an ear condom.”

It needn’t be a Rough Rider or equivalent, just a hood, Doc's pro plugs or Prestik, recalling the mantra of “KEEP IT COVERED.” In this case, both of them.

International incidence

A Californian study with water temperature 19-20°c found 86% of surfers to have a degree of canal closure from surfer's ear. Interestingly, more involvement in the right ear than left. Most didn’t wear protection because, either they didn’t think of it, or it was uncomfortable and unglamorous.Japanese professional surfers have an 80% incidence with canal closure of between 50 – 80%. Again the colder the water, the greater the incidence.

In New Zealand the incidence was some 73% with 40% having 50% or more closure. Those surfing in winter were worst off regards canal closure.Another Californian survey found a 75% incidence in those surfing over 20 years.

An Australian report from Victoria showed males to have 50% and females 43% chance of developing more than 66% closure when surfing more than 20 years.We currently have no South African figures but I'm asking Spike to organise a Cape Town survey.

There'll hopefully be a Wavescape banner and table and I'll be on the beach checking your ears and giving you the result.

Handling surfer's ear:Let's get this straight. By no means every surfer's ear needs surgery. We need understand that. But you, the surfer, need to know firstly whether you have the condition and if so, to what extent. Mild to moderate surfer's ear needs no more than being aware of the condition, taking precautions and regular check ups. But, don’t let them get to what I call “North face of the Eiger” – a wall of bone - before you accept surgery is necessary.

Remember your hearing can be absolutely perfect with only a tiny aperture between the osteoma. It's amazing how small a sound wave needs to get through to keep your hearing normal. This is often the case. When you tell a surfer they need something done, they turn pale with fear and run for the door... back to the waves.

The mantra being “it'll never happen to me.”It does, and recall the more extensive the surfer's ear, the more difficult the surgery, and the more “small print” comes into play. When you have what I call “North face of the Eiger”, the “landmarks” are distorted and one tells the surfer, that in many ways delaying the operation to this stage is equivalent almost to constructing du Toit's Kloof tunnel with no GPS. So don’t get into this situation.

Understand the more severe the osteoma, the more potential complications. If you require surgery, have it done before you get to this extreme state.Every ENT surgeon has a case or two of these extensive osteoma where complications occurred because of surgical difficulty.

The current surgical techniques make use of sophisticated binocular microscopes, micro instruments and safe anaesthesia. The combination makes for delicate surgery. The most frequently used technique is high-speed drill, drilling the osteoma away often utilising tiny 1 – 2mm osteotome chisels as adjuncts. Incision is either straight through the canal, or behind the ear. It depends on the surgeon's preference. It's day case surgery and pain not usually a significant factor. The osteoma are removed and an as normal as possible canal recreated by removing the obstruction. Absolutely vital to swift recovery is preservation of the very thin and sensitive skin lining to the canal. If you can retain this, the surfer is back in the water within 4 – 6 weeks. Sometimes sooner.

However, if you present with huge osteoma, then keeping that skin cover can be exceeding difficult and sometimes impossible. In that case, and we've all heard about those that had to stay out of the water for a couple of month's after surgery, because they delayed the procedure and reaped the consequences.The main thing is don’t allow them to get to a massive size by running away and then blame the surgeon when your recovery is prolonged.Also, in terms of regular surfing, recall outer ear infections are not uncommon and, just as there's no such thing as clean air, the same applies to much of the ocean in which you surf. The bacteria involved here are often bowel related with all that that implies.

Surgical follow up

Getting a surfer to accept surgery is required is, in itself, especially difficult because of the denial factor. The “running away” syndrome is substantial and largely based on misplaced fear and lack of awareness. The same applies to coming for regular follow up. Remember surgery will have reduced the osteoma, but the possibility of recurrence is real as the cause of the osteoma formation is dilation of blood vessels, something that cannot be surgically removed. It's a physiologic reaction to cold water.

One report on a 10 year follow up showed there was more than 60% closure in 25%, 30- 60% closure in 31% and less than 30% closure in the remaining 42%. So you need follow up.Not surprisingly, those who surf all year round, recurred quicker as did those who were older at the time of their initial surgery. And here's a vital fact. Ear protection reduced the chance of regrowth 5 fold.So what's the bottom line?

Firstly you're in a sport, which constantly exposes you to cold water. A fair number of you will be in a group where this causes the blood vessels to dilate, stimulating new bone formation hence “surfer's ear.” Just as you shouldn’t drink and drive, so you shouldn’t surf without having your ears checked to get the bottom line. Recall, by no means every surfer's ear needs surgery, but every surfer should protect. That’s not a big price to pay, all things considered.Now you see the connection between HIV and surfer's ear. It pays to protect. I recently saw a beautiful young Fish Hoek surfer with significant surfer's ear. She was 14, but wasn’t keen on wearing protection because of the aesthetics. I've also operated on a matric girl with massive surfer's ear. She too wasn’t keen on protection. The chances of her osteoma recurring are enormous.

Please wear protection!

That’s a plea from someone very involved in the surfer's ear syndrome situation.We'll talk further, but this is what you might call an opening round.

Get back to the surf, but as they say in the classics “KEEP IT COVERED.”

John Steer

ENT Surgeon Cape Town 021 797 4245



0 #17 DrJohn Steer 2013-07-30 12:01
It certainly can be useful in protecting the ear and worth a try - in essence it's keeping water out of contact with the ear and will help regards reducing possible infections... but don't imagine it's going to help prevent you getting the bony swellings of "surfer's ear". So basically it only helps in trying to reduce infection
Dr John
0 #16 mrdowls 2013-07-12 11:10
What is your opinion of Surf Seal (silicone Drops)
0 #15 Neilster 2012-05-21 16:50
This may be rhetorical, but how do you know how badly you are affected without consulting an ENT?
What are the symptoms, hearing loss, failure to drain?
0 #14 Dr John 2011-11-08 10:26
Dear Sherif - go well. And be patient - the post op course and management must not be hurried so don't put "pressure" on the surgeon to "get the plugs out" until he's ready.
Doc John
0 #13 Sheriff 2011-11-03 18:08
Ive got 90% closure in both ears and booked in on monday for my op, got to be done i guess... Great article, thanks!
0 #12 PierreB 2011-11-01 17:26
perfect tks for reply - best regards
0 #11 Dr John 2011-11-01 17:10
Like all things in life, nothing is perfect. Re Protection, ear plugs work for some and not for others. Some people find good old fashione Prestik the answer but don't stick it in too far, because getting it out can be hellish difficult, even with a microscope. Wearing a hoodie is simple and it keeps the water trapped in the ear canal(which it certainly will be, unless you have a fantastic waterproof hood)warm and as mentioned, its the temperature which is critical. The colder the water the more chance of that vaso dilatation and osteoma formation.
Go well - John
0 #10 Tank 2011-10-26 12:57
I use sorky ear plugs . They work wonders , I'm very pron to ear infections . Havent had a problem since using them .
0 #9 John Rattey 2011-10-25 09:40
I used soft bread plastic cut to approx 200mm x 200mm scrumpled up and stuffed into the ears for approx 36 yrs after being told I must stop surfing or face an operation. It worked!! No op. PROTECTION DOES WORK!!
0 #8 PierreB 2011-10-24 15:46
so hoody alone good enough ?

anyone got the docs contact perhaps?

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