External auditory canal exostoses in white water kayakers

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.

An awareness and prevalence study of Irish cold-water athletes and external auditory canal exostoses

Objective

This study aimed to determine the awareness, otological symptoms and prevalence of external auditory canal exostoses in Irish cold-water athletes.

Method

An online and in person cross-sectional survey was undertaken with Irish cold-water athletes to explore athletes' awareness, known prevalence of external auditory canal exostoses and attitudes towards preventive measures.

Results

Of the 926 participants surveyed, 67.5 per cent were aware of external auditory canal exostoses. Triathletes reported the lowest awareness (39.9 per cent) among water athletes. A total of 9.7 per cent (n = 90) had previously been diagnosed with external auditory canal exostoses and 46.7 per cent (n = 42) were non-surfers. Ear symptoms were reported in 76 per cent of athletes. Otoscopic examinations showed that 23.7 per cent had external auditory canal exostoses, 3.6 per cent of whom were aware of their diagnosis.

Conclusion

The majority of Irish surfing athletes are aware of external auditory canal exostoses. There is less awareness with regard to Ireland's newly emerging sports such as open water swimming and triathlons. Over 90 per cent of athletes surveyed had no idea they had external auditory canal exostoses, which highlights the need to increase public awareness.

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.

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.

Common Injuries in Whitewater Rafting, Kayaking, Canoeing, and Stand-Up Paddle Boarding

Paddle sports continue to be popular forms of outdoor recreation in the United States and around the world. This includes not only the more traditional sports of rafting, kayaking, and canoeing but also the newer and growing sport of stand-up paddle boarding. Because these sports are based in an aquatic environment, and frequently whitewater, there are unique, significant risks of injury. Overall, injuries in paddling sports are mostly musculoskeletal and are both acute and chronic in nature. Some injuries, such as environmental and head injuries, are especially problematic because they can lead to serious morbidity and mortality, most importantly drowning. This review describes the epidemiology, type, and location of injuries across paddle sports. It not only focuses on whitewater injuries but also includes information on injuries sustained in other aquatic paddling environments.

External auditory exostoses and early Neolithic aquatic resource procurement in Cyprus: Results from Cypro-PPNB Kissonerga-Mylouthkia in regional context

OBJECTIVE

This research is designed to evaluate the occurrence of external auditory exostoses (EAEs) in skeletal remains from the oldest known water wells in the world (Kissonerga-Mylouthkia, Cyprus, 8,200-7,200 BCE).

MATERIALS

Six individuals (MNI = 6), five fragmentary temporalia, two preserved auditory canals.

METHODS

Macroscopic and microscopic (up to x30) observation, with illumination; presence, type, side, severity, occlusion, number, and position of bony growths recorded.

RESULTS

Bony growths within two auditory canals were discovered. Differential diagnosis includes osteomata and external auditory exostoses, with the latter consistent with the bony growths (Grade 1 EAEs, two adult males, one with single, another with two EAEs).

CONCLUSIONS

The emergence of the Neolithic in Southwest Asia is thought to involve increases in dietary breadth among foraging societies (Broad-Spectrum Revolution). EAEs likely indicate maritime activity in this context, given the lack of freshwater bodies, and zooarchaeological evidence points to dietary and other uses of maritime organisms.

SIGNIFICANCE

This EAE evidence is the oldest known in maritime contexts in Eastern Mediterranean and the Middle East, and first in Cyprus. It contributes towards understanding the initial colonization events by Neolithic farming communities in the 9th millennium BC, and the emergence of broad-spectrum economies at the dawn of the Neolithic in Southwest Asia, crucial for re-considerations of paradigms on the transition to the Neolithic way of life in the Near East.

LIMITATIONS

Only a few skeletal remains from these prehistoric contexts were available for observation.

SUGGESTIONS FOR FURTHER RESEARCH

Further intensive review of Cypriot skeletal collections for EAEs is advised.

New Insights into Activity-Related Functional Bone Adaptations and Alterations in Neolithic Liguria (Northwestern Italy)

This study offers a combined analysis of longbone mechanical properties (cross-sectional geometry, CSG), upper-limb enthesopathies (entheseal changes, ECs), and external auditory exostoses (EAEs) among Neolithic people from Liguria (Italy). Previous CSG studies have suggested a high degree of mobility in mountainous terrain and sexual dimorphism in the upper limbs, with males being more oriented toward unimanual activities and females performing strenuous bimanual tasks. The aims of the study were to: 1) increase the sample size of the CSG analysis via the acquisition of surface 3D models, 2) provide a solid chronological framework through direct dating in order to allow for subsampling of individuals dated to the Impresso-Cardial Complex (ICC, c. 5800–5000 BCE) and the Square-Mouthed Pottery culture (c. 5000–4300 BCE), 3) integrate the results of CSG analysis with information on ECs of the humeral epicondyles, and 4) assess possible marine activities through analysis of EAEs. Results from the CSG analysis confirmed those of previous studies, with no significant diachronic change. ECs in the humeral medial epicondyle parallelled CSG adaptations: males tended to display more changes, especially unilaterally. Only one individual from the ICC period showed bilateral EAE, suggesting that marine activities were not prevalent. This study adds to our knowledge on activity patterns in the Neolithic in Liguria, and shows that integrating structural adaptations with information from specific entheseal alterations and exostoses can improve reconstructions of past habitual activities.

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.

A revision of the conductive hearing loss in Cranium 4 from the Middle Pleistocene site of Sima de los Huesos (Burgos, Spain)

Pathological conditions have been previously documented in the Middle Pleistocene Sima de los Huesos hominins from northern Spain, and several of these have clear behavioral implications. Within this fossil assemblage, Cranium 4 shows bilateral external auditory exostoses which have been preliminarily interpreted as causing a significant hearing loss in this individual. If confirmed, this would be the oldest recorded case of deafness in human history and could have important implications for the antiquity of this condition, as well as social interactions. To further investigate this case, the current study presents 3D reconstructions of the entire outer and middle ear, based on computed tomography scans of both temporal bones in Cranium 4. We established the degree of stenosis in both external auditory canals, showing that in both cases the degree of stenosis is less than 52% of the original cross-sectional area of each canal. Based on clinical studies in living humans, the buildup of wax due to the degree of stenosis in Cranium 4 is unlikely to have caused frequent external ear infections. In addition, we estimated the pattern of sound power transmission up to 5 kHz in both ears relying on a comprehensive model developed in the bioengineering literature and which has been applied previously to the Sima de los Huesos hominins. The model was modified to account for the peculiar shape of the pathological external ear canals in Cranium 4. The results show that this pathology had little to no influence on the sound power transmission in this individual. Thus, we conclude that the exostoses present in both ears of Cranium 4 did not significantly affect their hearing.

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.

External auditory exostoses in the Xuchang and Xujiayao human remains: Patterns and implications among eastern Eurasian Middle and Late Pleistocene crania

In the context of Middle and Late Pleistocene eastern Eurasian human crania, the external auditory exostoses (EAE) of the late archaic Xuchang 1 and 2 and the Xujiayao 15 early Late Pleistocene human temporal bones are described. Xujiayao 15 has small EAE (Grade 1), Xuchang 1 presents bilateral medium EAE (Grade 2), and Xuchang 2 exhibits bilaterally large EAE (Grade 3), especially on the right side. These cranial remains join the other eastern Eurasian later Pleistocene humans in providing frequencies of 61% (N = 18) and 58% (N = 12) respectively for archaic and early modern human samples. These values are near the upper limits of recent human frequencies, and they imply frequent aquatic exposure among these Pleistocene humans. In addition, the medial extents of the Xuchang 1 and 2 EAE would have impinged on their tympanic membranes, and the large EAE of Xuchang 2 would have resulted in cerumen impaction. Both effects would have produced conductive hearing loss, a serious impairment in a Pleistocene foraging context.

External auditory exostoses and hearing loss in the Shanidar 1 Neandertal

The Late Pleistocene Shanidar 1 older adult male Neandertal is known for the crushing fracture of his left orbit with a probable reduction in vision, the loss of his right forearm and hand, and evidence of an abnormal gait, as well as probable diffuse idiopathic skeletal hyperostosis. He also exhibits advanced external auditory exostoses in his left auditory meatus and larger ones with complete bridging across the porus in the right meatus (both Grade 3). These growths indicate at least unilateral conductive hearing (CHL) loss, a serious sensory deprivation for a Pleistocene hunter-gatherer. This condition joins the meatal atresia of the Middle Pleistocene Atapuerca-SH Cr.4 in providing evidence of survival with conductive hearing loss (and hence serious sensory deprivation) among these Pleistocene humans. The presence of CHL in these fossils thereby reinforces the paleobiological and archeological evidence for supporting social matrices among these Pleistocene foraging peoples.

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.

Injuries, ill-health and fatalities in white water rafting and white water paddling

White water (WW) activities such as paddling (canoeing and kayaking) and rafting are popular sports for recreational and professional participants. An increase in participation has been seen worldwide. However, these activities come with a risk of injury and even death if not conducted safely. A review was conducted to identify the types of injuries and ill-health that occur as a result of these activities. Injury and fatality rates were assessed to establish the risk attributed to these activities. Web of Science, PubMed, Ergonomics Abstracts and PsycINFO databases were searched and a total of 16 published articles were identified and reviewed. The shoulders and back were the most vulnerable sites for injury in WW paddling. Injuries to the face and lower limbs were most common in WW rafters. However, injury rates are low and estimates are discussed. Due to different methods used across the studies, the reported injury rates are not comparable. This review identified three illnesses incurred through WW activities. There may be more but these are not currently reported in the literature. A relative paucity of studies regarding injuries and fatalities in WW activities was identified. Directions for future research are suggested and discussed.

[Exostoses of the external auditory canal in professional diving. A case for the German Social Accident Insurance Institution]

Exostoses of the external auditory canal are often diagnosed incidentally but may also cause complications, e.g., conductive hearing loss and/or recurrent inflammations of the external ear canal due to stenosis. This paper presents current scientific data on the pathogenesis of ear canal exostoses, which obviously focus on the cold water hypothesis. We present a case of an expert opinion on occupational illness and discuss whether the legal preconditions for recognition "like an occupational disease" according to article 9(2) Social Code Book VII are met. A systematic reporting of suspected cases is recommended in order to obtain reliable data on the epidemiology and the clinical course of external auditory exostoses among individuals occupationally exposed to cold water and to enter an expert discussion on the reasonability of an inclusion in the list of occupational diseases.

Exostoses of the paranasal sinuses

While bony exostoses of the external auditory canal have long been recognized as a complication of cold-water swimming, bony exostoses of the paranasal sinuses have not been previously reported. We present an unusual case of multiple exostoses of the paranasal sinuses, which began coincident with nasal irrigation with cold gentamicin solution. The patient had had prior endoscopic sinus surgery. Topical antibiotic gentamicin irrigation lessened recurrence of bacterial sinus episodes. He admitted to using the irrigation directly from the refrigerator daily for two years. A biopsy was consistent with exostosis. Patients should be counseled to avoid irrigating their paranasal sinuses with cold irrigants. Laryngoscope, 2010.