The Science of Surfer’s Ear: Research, Insights & Prevention

Spend enough time around people who love being in the water – surfers, freedivers, kayakers, swimmers – and sooner or later the conversation turns to ears. Someone’s been sidelined by recurring infections. Someone’s ruptured an eardrum on a heavy bail. And someone mentions that the doctor found bone growing in their ear canal.

Surfer’s ear, formally known as external auditory exostoses (EAE), is a progressive condition in which bony growths develop inside the ear canal in response to repeated water and wind exposure. Surfer’s ear affects the majority of people who spend significant time in the water, and most of them don’t realize it.

At SurfEars, we believe we have a genuine opportunity, and responsibility, to spread awareness about ear health. This article collects and presents the current body of research on surfer’s ear in a clear and accessible way.

Understanding Surfer’s Ear: The Mechanism

Surfing, or engaging in other sports in cold water, wasn’t always something you could do for hours at a time. The development of neoprene wetsuits in the 1950s, and the steady improvements since, have made prolonged cold-water exposure practical for far more people.^1,2 While it’s a huge benefit for water sports, the ear canal may pay a price for that added exposure.

Here’s what’s actually happening in your ear canal when you go in the water: cold water hits your ear, causing the blood vessels in your ear canal to expand. This creates inflammation in the tissue covering the canal. Your body responds by growing new bone. Interestingly, this is thought to be a defense mechanism; a way to protect the eardrum from further cold exposure.¹ Your body is trying to help. The problem? That extra bone growth narrows your ear canal, and unlike a surf rash, it doesn’t start healing once the session ends.

In simple words: water exposure stimulates new bone formation within the external auditory canal.¹ But, as with any medical condition, it’s way more complicated than at first glance.

The Biological Mechanism in Detail

The research suggests that cold water induces vasodilation (widening of blood vessels) in the ear canal, which creates an elevated vascular tension. This is linked to inflammation, leading to periostitis, an inflammatory condition of the periosteum (the tissue covering the bone). The inflammatory process stimulates osteoblast activity (cells responsible for bone formation), followed by fibrosis and ossification, resulting in new bone growth inside the external auditory canal.¹

The skin tissue covering the area over the tympanic ring is exceptionally thin, measuring only 0.1 mm, and sits directly atop the temporal bone. Because there is virtually no subcutaneous fat (insulating tissue) between this outer layer and the underlying bone surface, the area is uniquely vulnerable to thermal changes triggering the underlying bone-forming tissue (the periosteum) directly. This specific anatomical setup is what’s thought to make this region the primary pathologic location where bony exostoses begin to form.¹

Prevalence: A Common Condition Among Water Sports Enthusiasts

If you’ve been in the water year-round for at least five years, with an estimate of five or more sessions per month, there’s a better than 2 in 3 chance you have some degree of surfer’s ear.

In the general population, the prevalence of external auditory exostoses is 0.63%.¹ However, for water sport practitioners, the numbers look a bit different. Across multiple cohorts, from Europe to Japan, from surfing the sun-drenched coast of Queensland, Australia, to kayaking chilly rivers in Colorado, exostoses prevalence rates range from 38% all the way up to 90%, with most findings clustering around 70–75%.^3-11

For example, in a French study of surfers, the incidence of EAE was 89.96% with an average obstruction rate of 37.65%.⁴ Similarly, a study of long time warm-water surfers from the Gold Coast region of Australia reported 71.8% being affected.⁶ Among California surfers, the prevalence was found to be 73.5%,¹³ and among kayakers in Colorado, 70.5% had moderate or severe surfer’s ear.¹¹

Among those with exostoses, mild grade lesions are most common, though more severe cases are far from rare. Research shows that roughly 12% to 33% of surfers have severe obstruction (definition varies; commonly above 67% occlusion) .^5,8,12,13

The Link Between Surfer’s Ear and Ear Problems

Unsurprisingly, research has established a significant relationship between the severity of exostoses and various ear complications.

While surfer’s ear is often asymptomatic, a lack of appropriate preventive measures can lead to complications such as conductive hearing loss, recurrent otitis externa (outer ear infections), otalgia (ear pain), otorrhea (ear discharge) and cerumen impaction (earwax buildup).¹

One study found that approximately one-third of subjects reported recurrent ear infections or pain, and the presence of symptoms increased significantly with the severity of exostosis.⁸ Another study showed a connection between the number of self-reported ear infections and the severity of EAE.¹⁴ This correlation makes physiological sense: as the bony growths narrow the ear canal, they create spaces where water can become trapped, debris can accumulate, and proper drainage is impaired.

One study found that while water trapping was the most common symptom, occurring more frequently in subjects with severe exostosis, there was no correlation between the severity of the condition and other otological symptoms. Furthermore, hearing loss was not found to be an accompanying symptom in this specific cohort.¹⁰

So, how do you know if you have it? Well, it’s hard to fully know without the correct instruments, e.g., an otoscope or video otoscope. If you start suffering from the symptoms described above more frequently, it might be time to have your ears checked.

Beyond the Cold: Water Temperature and Surfer’s Ear

A common misconception is that surfer’s ear only affects those exposed to cold water. Research from Australia in the 2020s challenges this assumption.

While athletes active in colder water have been shown to have more exostoses than those who stick to warmer temperatures,^1,3,15 and studies demonstrate that exposure to water colder than 19° C (66° F) leads to the more frequent development of exostoses.⁸ That does not mean only cold water causes surfer’s ear.

A study of surfers who had surfed for a mean of 20 years, in Queensland, Australia, where water temperatures range from 20.6°C in winter to 28.2°C in summer, found that 69.6% had exostoses.⁵ A larger follow-up study in the Gold Coast region, with mean water temperatures ranging from 19°C to 28°C, reported a prevalence of 71.8%. The participants in this study had surfed for a mean of 35.5 years.⁶ These findings highlight that the condition can develop regardless of water temperature, though it seems to progress more slowly in warmer climates. Wind chill is a factor thought to contribute to bone formation in water temperatures above 19°C.¹

Interestingly, surfers in the abovementioned warm-water studies also reported high rates of otological symptoms. Nearly two-thirds of participants (60.9–65.9%) had regular ear-related symptoms. Most common among these were water trapping (56.5–66%), hearing loss (26.1–48.2%), and pain (34.8%) or cerumen impaction (35.7%).^5,6 However, these issues do not necessarily have to be related to surfer’s ear, and it should be noted that most of the participants had milder grades of exostoses. Further research will be needed to increase the understanding of exostoses developed in warmer waters.

Surfer’s Ear Across Different Water Sports

While the condition is termed “surfer’s ear”, research demonstrates that it goes beyond just surfing: it has been documented across a wide range of water sports and aquatic activities.

Whitewater Kayaking: White-water kayakers show high prevalence of surfer’s ear (69.5–79%), with severity linked to years and frequency of participation.^14,16

Diving: Studies support a relationship between the formation of auditory exostoses and diving in cold water.¹⁷ While being less common than in surfing and kayaking cohorts, a prevalence of up to 40% has been found among professional divers.¹⁸ Moreover, a study on freedivers attending an international competition found exostoses in 87.7% of ears scored. That’s comparable to surfers, though the severity was somewhat less pronounced than in surfing populations.²⁰

Swimming: The link between swimming and exostoses has been documented since the early 20th century. Classic studies from the 1930s were among the first to describe this relationship, finding an incidence rate of 42.8% among members of swimming clubs, compared to patients in a general clinic where the incidence was 2.02%.^21,22 Further research has confirmed that the severity of the condition is directly proportional to the frequency of water exposure; one study found a 64% incidence rate among individuals swimming three times a week.²³

Wind and Kite Surfing: Wind- and kitesurfers show particularly high prevalence rates (75.1%), with 19.9% experiencing severe EAE. Notably, research suggests that exostoses may progress faster in wind- and kitesurfers compared to traditional surfers, possibly due to the additional influence of wind and evaporative cooling of the external auditory canal. The number of symptoms requiring medical treatment increased significantly when two-thirds of the external auditory canal became obstructed.²⁴

The Relationship Between Exposure and Severity

One of the most consistent findings across the research is the strong relationship between exposure and the severity of exostoses.

Longer history in the water and more frequent cold-water sessions are consistently associated with higher risk and more severe obstruction.³ This has been observed across a range of water sports, including surfing, kayaking, diving, swimming, wind- and kite surfing.^{3,16,20,24,25}

Here is what the data shows, activity by activity.

Surfing: While nearly 45% of those who had surfed for 10 years or less maintained normal ear canals, that number dropped to just 9.1% after 20 years of surfing. Most notably, the risk of developing severe obstruction increased nearly threefold over time; only 6% of newer surfers were severely affected, compared to 16.2% of those with over 20 years in the water. Moreover, the data shows that severe cases were overwhelmingly a long-term issue, with 82.4% of all severe exostoses occurring in individuals who had surfed for more than 10 years.¹³

An Irish study found that those with exostoses had surfed for an average of 5,028 hours.¹⁹ Furthermore, each additional year of surfing in predominantly cold waters raised the risk of developing exostoses by about 12% per year, and the chance of more severe canal obstruction by 10% per year.³ In other words, the more you surf and the colder the water, the greater is your risk for developing severe surfer’s ear.

Whitewater Kayaking: Similar trends are reported in kayakers. A large study of 611 white-water kayakers showed a 79% overall prevalence of exostoses, with severity strongly tied to kayaking history. The total number of years kayaking was significantly associated with greater ear canal occlusion, as was frequent paddling (one or more days per week). After adjusting for confounders, years of exposure remained the key predictor of exostosis severity.¹⁶

Diving (Freediving): In competitive breath-hold divers, over 87% of ears examined had exostoses, and environmental exposure factors were critical. Notably, colder water temperatures at dive sites were identified as the strongest predictor of exostosis prevalence and severity. In these divers, prolonged exposure to low sea temperatures led to significantly greater bony growth. This emphasizes that repeated exposure to cold water, a common element in diving, is directly linked to more severe canal obstruction.²⁰

Windsurfing/Kitesurfing: Water sports involving both high wind and water exposure show accelerated exostosis development. A recent study of German wind- and kitesurfers found that each additional year of participation increased the likelihood of developing severe exostoses by about 19%. Moreover, each extra day per week of surfing quadrupled the odds of severe exostosis, and each extra hour per session roughly tripled the odds. These results confirm that the duration and frequency of exposure have a direct relationship with exostosis severity in wind/kite surfers.²⁴

Swimming: Outside of surf and paddle sports, cold-water swimmers are also known to develop surfer’s ear. Early medical reports noted higher rates of ear canal exostoses in individuals with long-term habitual cold-water swimming exposure.²⁵
The same core principle is prevalent everywhere: the greater the frequency, over a longer amount of time, the greater the risk of developing surfer’s ear.

Awareness and Knowledge Gaps

Despite the high prevalence of surfer’s ear, awareness of the condition varies considerably across different populations and geographical regions.

Some studies report relatively good knowledge levels. For instance, one study of wind- and kitesurfers in Germany found that 60% of individuals had ‘good’ or ‘excellent’ knowledge of external auditory exostosis.²⁶

However, other research reveals striking gaps in awareness. One study found that 88% of surfers with exostoses were completely unaware of their diagnosis.¹⁹

Even among those who are aware of surfer’s ear, knowledge doesn’t always translate into protective behavior. In California surfers, while 90% had heard of EACE; 64.9% had never used earplugs.⁷

Studies from warm-water surfing regions found that despite high prevalence of the condition, only 8.7% to 17.7% of surfers reported regular use of protective equipment.^5,6

Barriers to Protection

Understanding why water sports athletes don’t use ear protection despite awareness is crucial for improving prevention efforts. Research has identified some key barriers.

The most commonly reported reasons against earplug use include reduced hearing, discomfort, and social hindrance.⁷ In a kayaking community, impaired hearing was identified as the biggest barrier to ear protection use.¹¹ These practical concerns highlight the importance of developing ear protection solutions that minimize these drawbacks, maximizing comfort and usability.

Surfers also report a clear preference for where they want to receive information: from community members, doctors, and surf events.⁷ That finding points to something worth sitting with: The most effective education on surfer’s ear may come from one water sports enthusiast telling another. If you learn something here, pass it on, and you will be a part of that chain.

Preventing Surfer’s Ear: The Role of Ear Protection

Research provides compelling evidence for the effectiveness of ear protection in preventing surfer’s ear, though all forms might not be equally effective.

Research has found a significant correlation between EAE severity and the number of hours spent in water without any protection, such as earplugs or surf hood.⁴ Clinical literature emphasizes patient education for the use of earplugs and/or neoprene hoods to reduce auditory canal cold-water exposure.^{1, 9} However, one French observational study found a difference between earplugs and hoods. The study concluded that wearing earplugs is an effective way to prevent EAE in surfers, but couldn’t find any evidence that using a hood alone would do so.⁴

Studies have shown that ear protection is effective across different aquatic activities. For instance, a study examining wind- and kitesurfers found a significant protective effect of neoprene hood use on external auditory exostosis severity.²⁴ Among winter swimmers, one study showed that the prevalence of external auditory canal exostoses was about 12 times higher in the group without ear protection than in the group that used ear protection (33.0% vs 2.8%).²⁷ Among kayakers, long-term earplug use was associated with lower likelihood of developing exostoses.¹⁶

Even after surgical removal of exostoses, wearing ear protection in the form of earplugs, or earplugs and a hood, was shown to prolong the recurrence-free period by a factor of five compared with no ear protection at all or the use of a wet-suit with hood.²⁸

Ultimately, the evidence points most consistently to earplugs as the primary protective measure. Combined use of earplugs and a hood is also supported by clinical guidance, though the data on hood use alone shows mixed results.

Managing Surfer’s Ear: Disease Progression and Treatment

EAE is a progressive disease, meaning that once exostoses begin to form, they will continue to grow with ongoing water exposure. However, the risk of progression can be significantly mitigated with consistent preventive measures, particularly the use of ear protection.

Prevention of progression is paramount once exostoses have been detected. Medical management involves regular cleaning of the external auditory canal to remove any entrapped debris, which can help prevent complications such as recurrent infections, eardrum rupture, and conductive hearing loss.¹

The mere presence of exostoses in the ear canal does not mandate surgical removal. Surgery should be reserved for cases where the growths cause obstructive symptoms that are intolerable to the patient or prevent medial access in the ear canal for other procedures.²⁹ Generally, surgical intervention is considered when exostoses occlude more than 80% of the auditory canal and symptoms persist despite medical management.¹

Surgical Approaches and Outcomes

For those who do require surgery, different surgical techniques exist with varying outcomes and recovery times.

The traditional approach typically involves general anesthesia with a post-auricular approach (making an incision behind the ear and folding it forward), elevating the skin overlying the exostoses and removing the bone with a drill. Following surgery with this traditional approach, 68% of patients reported improved quality of life, while 14% experienced surgical complications.³⁰ Possible complications include tympanic membrane rupture, delayed healing, canal stenosis, loss of high-frequency hearing, temporomandibular joint dysfunction, and facial nerve paralysis.¹

An alternative technique involves a transcanal approach using straight and curved osteotomes (similar to chisels) with selective drilling. Research on this method found it to be safe and effective, facilitating healing of ear canal skin at an average of 3.5 weeks (range 2–8 weeks) with a 90% rate of successful ear canal healing at 4 weeks, allowing a return to water sports sooner than most previously described drilling-only techniques.²⁹

However, given the complexity and potential complications, surgery for external auditory canal exostoses should be reserved only for symptomatic cases and performed only by experienced specialists in order to minimize complications and unnecessary operations.³⁰ The outcomes in most patients are good, but the rates of surgical complications are somewhat high, emphasizing the importance of specialist care.¹

Importantly for those who undergo surgery, the evidence strongly supports the use of ear protection afterward. As mentioned earlier, post-surgical use of earplugs or earplugs and a hood extends the recurrence-free period by a factor of five compared with no protection or the use of a wetsuit hood, underscoring that even after surgical correction, ongoing prevention remains essential.²⁸

Conclusion

The body of research on surfer’s ear paints a clear picture: it is a highly prevalent, progressive condition affecting the majority of those who regularly expose their ears to predominantly cold water and wind. Warmer temperatures have also been shown to cause the condition. The severity tracks directly with cumulative exposure, and the condition can lead to significant symptoms and complications.

However, the research also offers hope. Ear protection has been consistently shown to prevent the development and progression of exostoses, extend recurrence-free periods after surgery, and reduce the burden of this condition across multiple water sports. The challenge lies not in the effectiveness of prevention, but in improving awareness and addressing practical barriers. For the water sports community, the message is straightforward: Surfer’s ear builds quietly over years, but with consistent protection, it is preventable.

References

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