Prevention of external auditory canal exostosis in the Colorado whitewater community
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Annalise E. Wille
,
Vanessa K. Pazdernik
Abstract
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 canal exostoses (EACE) are painless bony formations that develop in the tympanic ring of the external auditory canal in response to repeated mechanical, chemical, or thermal irritation of the canal [1, 2]. They have been associated with repeated exposure to cold water [1], [2], [3], [4] (19 °C or 66 °F) [2], where hyperemia is thought to cause increased osteoblastic activity in the deeper part of the canal because of the relatively thin layer of skin covering the periosteum [1], [2], [3], [4]. Colder water leads to more prolonged hyperemia and an accelerated disease course [4]. The bony growths are generally asymptomatic until the later stages, when approximately 80% of the canal is occluded [3, 5]. Once severe canal obstruction occurs, the body’s self-cleaning and self-regulating abilities are impaired, leading to secondary symptoms such as infection [1, 3, 6], [7], [8], [9], conductive hearing loss [1, 3, 7], [8], [9], foreign object sensation [8], [9], [10], otalgia [3, 7, 8, 10], pruritus [8], tinnitus [1, 3, 7, 8], and cerumen impaction [3, 8]. The only restorative treatment is surgical intervention [3], and the most common indications for surgery are recurrent otitis externa and conductive hearing loss [3, 7]. The development of this disease may lead to athletes no longer being able to participate in their sport, which may have profound negative impacts on the sense of self, motivation, happiness, and spirit of the affected athletes.
Historically considered a disease of surfing, EACE can occur in anyone with repeated exposure to cold water, including cold water swimmers, divers, and sailors [11]. In a 611-person study, Moore et al. [5] found that EACE prevalence was high in US whitewater kayakers (79%) because of their frequent Eskimo rolls (complete roll from upright to submerged to upright while remaining in the kayak). Moore et al. [5] also concluded that athletes who engage in kayaking styles that involve more submersion (e.g., squirt and freestyle) are more likely to have severe EACE. Various studies have associated the degree of EACE with the number of years participating in the sport [5], [6], [7], [8], [9], [10], frequency of submersion [2, 6, 8], ear symptoms [8], increased age [5, 7, 8], and male sex [3, 7, 8, 10], although sex was not a factor in some multivariate analysis [5, 9]. Severe EACE generally occur after a decade of repeated cold water exposure [1, 5], [6], [7], but some cases occur after only 3–4 years [5]. To our knowledge, no studies have investigated EACE in riverboarders, which is a growing sport that consists of surfing on standing river waves rather than breaking ocean waves.
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 [1, 5], [6], [7, 10]. In a recent observational prospective study of volunteer surfers in France (n=242 ears, mean age 29.9 years, 117 [86.7%] males), a significant correlation was found between hours spent surfing without ear protection and EACE severity (p<0.0001), whereas no correlation was found between with the use of ear plugs (p=0.6711) [10]. According to one study that assessed long-term follow-up after surgical intervention (n=31 patients, 46 ears), wearing ear plugs during cold water exposure was associated with decreased severity of EACE both before and after (p=0.015) surgical intervention [12]. EACE may recur even after cessation of water sport activities if chronic inflammatory changes have taken hold in the ear canal [12]. Studies agree that wearing ear protection should be recommended for this population [5–10, 12, 13].
Unfortunately, wearing ear protection is not common among kayakers and surfers even when they are aware of the disease [3, 5, 7], [8], [9]. In a study by Morris et al. [7] investigating awareness and attitudes toward EACE and its preventability, 86.1% (n=375, 303 male, 72 female, mean age 34.4) of United Kingdom (UK) surfers were aware of EACE, and 60.0% did not wear earplugs due primarily to hearing being adversely affected, interference with the feeling of emergence in the sea, and comfortability. Results from this study also indicated that those who did not wear earplugs would be willing to wear them if they knew more about EACE [7]. A study of 207 UK surfers (173 males, mean age 26; 36 females, mean age 23) found that 63% of participants did not wear ear protection, but wearing a neoprene hood or earplugs significantly decreased the chances of having high-grade EACE [8]. Another study of 92 (78 males, 14 females, mean age 27) surfers revealed that 60% were aware of EACE, but only 54% wore ear protection “sometimes.” [14] Two of the above studies [7, 14] found that UK surfers may be more likely to utilize ear protection after being educated about EACE. Outreach campaigns have been recommended to reduce the burden of this disease [7, 8], and additional research was also recommended to determine the reason for low earplug usage [14].
The river becomes a part of a whitewater athlete’s identity and their soul. If a person is a unit of body, mind, and spirit, engaging in kayaking and riverboarding keeps the body healthy, the mind sharp, and the spirit strong. Without it, the wellness of the athlete suffers. Our motivation is to prevent this disease in more athletes by increasing awareness, so that more athletes can stay on the water longer. The Colorado whitewater kayaking population is particularly at risk for the development of EACE because the main season occurs during snowmelt when the water is approximately 41 °F (5 °C), which is well under the determination made by Kennedy [2]. The importance of early EACE prevention in this community cannot be understated. The purpose of the current study was to determine the attitudes of whitewater kayakers and riverboarders about wearing ear protection before and after an educational intervention to increase awareness and prevention of EACE. The authors believe that there is a high prevalence of EACE in Colorado whitewater athletes, and an educational intervention will increase their understanding of preventive measures for EACE, thereby fostering behavior change through community engagement and education.
Methods
A.T. Still University-Arizona institutional review board approved the study (no. 2020-064).
Study population
The current cross-sectional study of Colorado whitewater kayakers and riverboarders was conducted over four weekends (Friday-Sunday) in July 2020. A 10-min survey was utilized to assess knowledge of EACE and attitudes about wearing ear protection. The survey also included an embedded brief educational intervention about EACE. Next, EACE severity was assessed for each participant utilizing a digital otoscope. Convenience sampling was utilized to recruit participants through an advertisement on local whitewater Facebook pages and at a table set up near the river’s edge where potential participants were identified and approached as they exited the river. Only whitewater kayakers or riverboarders were recruited. Potential participants were excluded if other ear pathology was present or if they did not speak English. Participation was voluntary, and participants completed informed consent on provided mobile devices before participating in the project. Informed consents were uploaded to the REDCap online server. No compensation was offered.
Survey
The study survey with educational intervention (Appendix A) was created specifically for the current study utilizing REDCap online survey software. It included seven sections: (1) five demographic questions (sex, age, primary whitewater activity, previous cold water exposure, and history of otological problems); (2) four or eight whitewater history questions (four general questions: time since first started, primary location, level of expertise, and months during which they participated last year; plus four additional questions for kayakers only: type of kayaking [creek boating, freestyle, river running, slalom, squirt], days kayaked per month in last year, number of Eskimo rolls, and preferred roll side); (3) two EACE knowledge questions (pre-intervention understanding of EACE, understanding cold water exposure is a risk factor for ear problems); (4) five ear protection questions (pre-intervention frequency of wearing ear protection, types of ear protection worn, time since first started wearing ear protection, factors or barriers to wearing ear protection, and likelihood of recommending ear protection to others); (5) seven ear history symptom questions (trouble getting water out, ear infections, obstructive sensation, otalgia, tinnitus, large amounts of cerumen, and hearing loss); (6) the educational intervention; and (7) three post-intervention questions (perceived risk of EACE, understanding of EACE, and likelihood of wearing ear protection). Survey response choices were binary (yes/no), multiple choice, or write in. The survey was accessible offline utilizing the REDCap Mobile App on one of four different devices (OnePlus 6T, iPhone 7, iPad, or 2018 iPad Pro 11). Data were uploaded to the REDCap server after each day of data collection.
The educational intervention was embedded in the survey and utilized a written infographic defining EACE, describing its pathophysiology and prognosis, identifying at-risk populations, and detailing treatment and prevention options. At the end of the education, the participant was prompted to ask the researcher if they had questions or needed clarification about any of the educational content.
The post-intervention attitude questions asked whether the participant felt that they were at risk for developing EACE (yes, maybe, no, or unsure), how well they felt they understood the disease (0–4 scale), and how likely they were to wear ear protection in the future.
EACE identification
After completing the survey, the participant’s ears were inspected utilizing a digital otoscope connected through Bluetooth to a handheld device. One of two commercially available Rotek wireless digital otoscopes (model iW99A) was utilized to visualize the ear canals. The participant assisted the researcher by taking a photo with the device when prompted, and the photo was saved to the phone with an anonymous photo identification number. If one or both ear canals could not be fully visualized, the participant’s survey responses were still included in the study and analyzed. There were no complications during the ear examinations. Photo identification numbers for each ear were recorded in the survey for each participant.
After data collection, the photographs of ears were uploaded to a shared Google Drive folder (with password-restricted access to study personnel only) that was organized by the research station location and the date collected. A licensed physician accessed the Google Drive folder remotely and determined the percent occlusion for each ear. This outcome was categorized to a severity rating according to Moore et al. [5] as none (0%), mild (<25%), moderate (25–75%), or severe (>75%) occlusion.
Statistical analysis
Survey responses were summarized utilizing frequency and percentage or mean and standard deviation (SD) or median (min, max). Spearman correlation coefficients assessed the relationships between pre-intervention understanding of EACE, understanding that cold water exposure is a risk factor for ear problems, and pre-intervention frequency of wearing ear protection with time since first starting activity and each type of kayaking activity. Wilcoxon signed-rank tests assessed whether—after the educational intervention—belief in their risk for developing EACE tended toward yes or no, a change in understanding of EACE, and likelihood of wearing ear protection. Spearman correlation coefficients assessed whether post-intervention change in the likelihood of wearing ear protection correlated with time since first starting sport, level of expertise, or pre-intervention understanding of EACE (none or any amount).
For analyses related to the severity of EACE, the maximum severity rating from both ears was utilized. Only two participants had no EACE, so the none and mild severity ratings were collapsed for analysis. Spearman correlation coefficients assessed relationships between EACE occlusion severity category and the following risk factors: sex, age, primary activity, previous cold water exposure (number of years multiplied by number of days per year), time since first starting sport, level of expertise, exposure index, pre-intervention understanding of EACE, symptoms and severity (trouble getting water out of ears, ear infections, obstructive sensation, otalgia, tinnitus, large amounts of cerumen, hearing loss), and ear infection treatment method (drops, pills). We also tested whether EACE severity was greater on the kayaker’s preferred roll side utilizing the Wilcoxon signed-rank test. The exposure index was specific to kayakers and was calculated to estimate the effect of total Eskimo rolls utilizing the following equation: number of Eskimo rolls per day × number of days kayaking per month × number of months kayaking per year × number of years kayaking. This survey allowed partial survey completion, allowing for some variability in the number of responses to questions.
SAS version 9.4 statistical software (SAS Institute, Inc., Cary, NC) was utilized to conduct the analyses. A p<0.05 was considered statistically significant.
Results
Eighty-eight participants were recruited for the current study, but one was excluded for minimal survey completion and six were subsequently excluded because they had a history of otological problems. Therefore, 81 participants (age range 18–65 years, mean [SD] age = 36.3 [12.6] years, 21 [25.9%] females and 60 [74.0%] males) completed the study (Table 1). In 10 (12.3%) participants, one ear was unable to be visualized, and in 20 (24.7%) participants, both ears were unable to be visualized.
Participant responses to demographic, whitewater history, and external auditory canal exostoses (EACE) knowledge survey questions (n=81).
| Survey item | No. (%) or mean (SD) or median (min, max) |
|---|---|
| Demographics | |
| Sex | |
| Male | 60 (74) |
| Female | 21 (26) |
| Agea, y | 36.3 (12.6) |
| Primary activity | |
| Whitewater kayaking | 74 (91) |
| River boarding | 7 (9) |
| Previous cold water exposure | 41 (51) |
| Previous cold water exposure, d | 6.3 (0,1500) |
| Whitewater History | |
| Time since first starting sport, y | |
| <1 | 4 (5) |
| 1–5 | 29 (36) |
| 6–10 | 14 (17) |
| 11–15 | 9 (11) |
| 15–20 | 13 (16) |
| >20 | 12 (15) |
| Level of expertise | |
| Beginner | 6 (7) |
| Intermediate | 33 (41) |
| Advanced | 28 (35) |
| Expert | 14 (17) |
| No. months doing activity last year | 6.7 (3.4) |
| Type of kayaking activities (all that apply) | |
| Freestyle | 37 (50) |
| Creek boating | 53 (72) |
| River running | 67 (91) |
| Slalom | 6 (8) |
| Squirt boating | 8 (11) |
| EACE Knowledge | |
| Pre-intervention understanding EACE | |
| None | 17 (21) |
| I have heard of it but don’t know what it is | 9 (11) |
| I know a little bit about it | 29 (36) |
| I understand quite a bit about it | 10 (12) |
| I understand what causes it, what symptoms you get from it, and how to prevent it | 16 (20) |
| Pre-intervention understanding cold water exposure is a risk factor for ear problems | 59 (73) |
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an=80 because one participant did not provide age. EACE, external auditory canal exostoses; SD, standard deviation.
Participant responses for demographic, whitewater history, and EACE knowledge survey items are reported in Table 1. Participant responses to ear protection survey items are reported in Table 2. The majority (58.0%, 47/81) of participants reported never wearing ear protection, but 17.3% (14/81) reported wearing ear protection always or most of the time. Of these, half (7/14) had worn ear protection since first starting the sport.
Participant responses to ear protection survey questions (n=81).
| Ear protection characteristics | No. (%) | |
|---|---|---|
| Pre-intervention frequency of wearing ear protection | ||
| Always | 6 (7) | |
| Most of the time | 8 (10) | |
| About half the time | 7 (9) | |
| Rarely | 13 (16) | |
| Never | 47 (58) | |
| Types of ear protection worn (all that apply)a | ||
| Drying ear drops | 9 (26) | |
| Ear flaps on helmet | 8 (24) | |
| Earplugs | 26 (76) | |
| Skull cap | 10 (29) | |
| Other | 0 (0) | |
| Time since started wearing ear protection, ya | ||
| <1 | 2 (6) | |
| 1–5 | 21 (62) | |
| 6–10 | 6 (18) | |
| 11–15 | 4 (12) | |
| 15–20 | 1 (3) | |
| >20 | 0 (0) | |
| Factors or barriers to wearing ear protectionb | All that apply | Biggestc |
| Comfort | 47 (58) | 11 (17) |
| Cost | 17 (21) | 1 (2) |
| Impaired hearing on the river | 47 (58) | 33 (52) |
| Discomfort of having cold water in ears | 13 (16) | 1 (2) |
| Fit | 31 (38) | 5 (8) |
| Losing ear protection items | 13 (16) | 6 (9) |
| Appearance | 1 (1) | 0 (0) |
| Other | 4 (5) | 3 (5) |
| Not ever considered | 17 (21) | 4 (6) |
| Likelihood of recommending ear protection to others | ||
| Highly likely | 21 (26) | |
| Somewhat likely | 18 (22) | |
| Neither likely nor unlikely | 26 (32) | |
| Not likely | 16 (20) | |
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an=34 because 47 never wore ear protection; bParticipants first selected all factors that applied when they considered wearing ear protection and then selected the biggest barrier to wearing ear protection; cn=64 because 17 participants indicated that they had not ever considered factors to wearing ear protection for the survey question that asked them to choose all that apply. However, five indicated other factors (comfort, cost, impaired hearing on river, fit, losing ear protection items).
Time since they first started the sport was positively correlated with pre-intervention understanding of EACE (r s=0.42), understanding that cold water exposure is a risk factor for ear problems (r s=0.24), and pre-intervention frequency of wearing ear protection (r s=0.25, all p≤0.03). For kayakers, there were positive correlations between several types of kayaking activities (freestyle, creek boating, and squirt boating) and pre-intervention understanding of EACE (all r s≥0.23, p≤0.046). No associations were found with river running or slalom (both r s≤0.10, p≥0.40). Creek boating kayakers generally understood that cold water exposure is a risk factor for ear problems better than kayakers who did not do creek boating (r s=0.32, p=0.006). No other associations were found with other kayaking activities (freestyle, river running, slalom, or squirt boating) (all r s≤0.17, p≥0.14). Freestyle kayakers tended to wear ear protection more frequently than kayakers who did not do freestyle (r s=0.33, p=0.004). No other associations were found with other kayaking activities (creek boating, river running, slalom, or squirt boating) (all r s≤0.14, p>0.23).
Post-intervention survey questions are reported in Table 3. After the educational intervention, more participants felt that they were at risk for developing EACE than not (p<0.001); 59.3% (48/81) felt they were at risk, 37.0% (30/81) were unsure or felt they were maybe at risk, and 3.7% (3/81) felt they were not at risk. Participants tended to report an increased post-intervention understanding of EACE (p<0.001); 60.5% (49/81) increased, 32.1% (26/81) were unchanged, and 7.4% (6/81) decreased. Participants tended to report an increased likelihood of wearing ear protection (p<0.001); 75.0% (60/80) indicated that they were more likely or much more likely to wear ear protection, 25.0% (20/80) were unchanged, and none were less likely. Less change in the post-intervention likelihood of wearing ear protection was associated with greater pre-intervention understanding of EACE (r s=−0.27, p=0.02) and longer time since first starting the sport (r s=−0.30, p=0.008). No relationship was found with the level of expertise (r s=−0.13, p=0.25).
Participant responses to post-intervention survey questions (n = 81).
| Post-intervention characteristics | No. (%) |
|---|---|
| Perceived risk of EACE | |
| Yes | 48 (59) |
| Maybe | 25 (31) |
| No | 3 (4) |
| Unsure | 5 (6) |
| Post-intervention understanding EACE | |
| None | 0 (0) |
| I Have heard of it but don’t know what it is | 4 (5) |
| I Know a little bit about it | 21 (26) |
| I Understand quite a bit about it | 29 (36) |
| I Understand what causes it, what symptoms you get from it, and how to prevent it | 27 (33) |
| Post-intervention likelihood of wearing ear protectiona | |
| Much more likely | 14 (17) |
| More likely | 46 (57) |
| Unchanged | 20 (25) |
| Less likely | 0 (0) |
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an=80 because one participant was missing a response; EACE, external auditory canal exostoses.
Of the 61 (75.3%) 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). Pre-intervention understanding of kayaker’s ear was positively correlated with both exostoses severity (r s=0.30, p=0.02) and the total days of previous cold water exposure (r s=0.27, p=0.03) (Table 4). Previous cold water exposure, time since first started sport, other primary location, and level of expertise all suggested positive, but not statistically significant, correlations with EACE severity (all p≤0.09). No association was found between EACE severity and sex, age, primary activity, or exposure index (all p≥0.12).
Spearman correlation coefficients between risk factors and exostoses occlusion severity category (n=61).
| Risk factor | Correlation coefficient | p-Value |
|---|---|---|
| Sex | 0.16 | 0.21 |
| Age, y | 0.20 | 0.12 |
| Primary activity | 0.11 | 0.39 |
| Previous cold water exposure | 0.23 | 0.08 |
| Previous cold water exposure, d | 0.27 | 0.03 |
| Time since first starting sport, y | 0.22 | 0.08 |
| Level of expertise | 0.22 | 0.09 |
| Exposure index | 0.17 | 0.20 |
| Pre-intervention understanding of EACE | 0.30 | 0.02 |
| Trouble getting water out of the earsa | 0.04 | 0.76 |
| Ear infections in the last year | −0.01 | 0.92 |
| Infections treated with ear dropsb | 0.00 | >0.99 |
| Infections treated with pillsb | −0.61 | 0.27 |
| Obstructive sensation | −0.04 | 0.78 |
| Otalgia (ear pain) | 0.18 | 0.17 |
| Pain affect scale (1–10)c | −0.14 | 0.56 |
| Tinnitus (high-pitched ringing)a | 0.30 | 0.02 |
| Large amounts of cerumen (wax) | 0.12 | 0.36 |
| Hearing loss | −0.06 | 0.66 |
| Hearing loss affect scale (1–10)d | 0.20 | 0.47 |
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For sex and primary activity, a positive correlation indicated that males and kayakers tended to have more severe exostoses than females and riverboarders, respectively; an=60 because one participant was missing a response; bn=5 because 46 participants did not have ear infections. Participants could indicate both treatment types; cn=21 because 40 participants did not have otalgia; dn=15 because 46 participants did not have hearing loss. EACE, external auditory canal exostoses.
The most common symptoms reported were trouble getting water out of the ears (53.8% [43/80]), obstructive sensation (44.4% [36/81]), and tinnitus (42.5% [34/80]). The only symptom associated with EACE severity was tinnitus (r s=0.30, p=0.02) (Table 4). Of the 74 kayakers, 40 (54.1%) had severity ratings for both ears and a preferred roll side. No significant difference in EACE severity was found between roll side and non-roll side ears (p=0.61).
Discussion
The current study assessed the attitudes of whitewater kayakers and riverboarders about wearing ear protection before and after an educational session on EACE. Our findings suggested that a portion of the Colorado whitewater kayaking and riverboarding population are unaware of EACE and the importance of wearing ear protection. We included a public health education intervention as part of our study design to promote awareness of EACE and prevent its complications. As a result, the majority of participants reported an increased understanding of the condition.
Increased pre-intervention knowledge was associated with the type of kayaking activity (freestyle, creek boating, and squirt boating), suggesting differing levels of education for participants of the various types of whitewater activities. Although not statistically significant, time since first starting the sport suggested a positive correlation with EACE severity, which supports the findings of Cooper et al. [6], who conducted a 92-person (69 males, 23 females, mean age 29.3) evaluation of EACE in UK whitewater kayakers. We found no significant difference in severity rating between ears (i.e., preferred roll side ear and non-roll side ear). A study of US whitewater kayakers by Moore et al. [5] (n=611), as well as Cooper et al. [6], also had similar findings. Gender was not a significant risk factor for developing EACE in the current study.
The biggest barrier to wearing ear protection was impaired hearing on the river, consistent with the leading barrier found in one study of 375 UK surfers [7]. This finding was expected given the considerable dangers of kayaking and riverboarding and the necessity of clear communication on the river. A study of 15 healthy volunteers (30 ears) investigated the implications of earplugs on sound transmission in the setting of EACE prevention and found that all types of ear plugs caused significant hearing loss when compared to baseline, but prefabricated, soft earplugs with vents caused the least impairment of hearing and were recommended for aquatic sports enthusiasts [15]. Awareness of this consideration may be useful for future efforts to increase the use of ear protection in this population.
Most participants who wore ear protection started wearing it within 5 years of participating in this study, suggesting a recent awareness of EACE in the river community. Studies in the surfing community have found similar results [7, 8]. Most of the participants who had never worn ear protection were new to their activity within the last 5 years. It would be in the best interest of these athletes to be educated about EACE at the time they are learning their sport, perhaps through whitewater instructors including this information in their classes. One recent study of EACE in French surfers found that among those who wore ear plugs while surfing, 33.4% first learned about the condition from their physician and recommended raised awareness of this condition in general practitioners [10]. Another recent study of 113 Australian surfers recommended screening and recommendation of prevention measures by health practitioners [16]. Osteopathic physicians can contribute to the prevention of EACE by screening through social history and utilizing education as a component of providing holistic healthcare.
Limitations
The current study had several limitations. Because we utilized convenience sampling to recruit participants, our results may be affected by selection bias. The study was conducted toward the end of the whitewater recreation season (which is dependent on snowmelt), so our sample size was smaller than intended and fewer riverboarders were recruited. We still believe that this group is at high risk for developing EACE and should be included in future studies. A pilot study was not performed to evaluate the construct validity of the survey, which caused conflicting responses to some survey questions and suggested misunderstanding of the content. For instance, when asked about the primary barrier to wearing ear protection, four participants indicated that they had not considered it. Another question that asked about all barriers to wearing ear protection did not elicit a similar response. Therefore, our results may not accurately convey the attitudes of some of our participants. Future studies should also investigate whether increased understanding influences behaviors around the use of ear protection on a longitudinal basis.
Conclusions
Whitewater athletes may be unaware of their risk for EACE, and their osteopathic primary care healthcare providers should include education about EACE and the benefits of preventive measures like wearing ear protection. Although the majority of the whitewater kayakers and riverboarders in the current study were somewhat aware of EACE, our results suggested that improved understanding of the disease after an educational intervention may increase the likelihood of wearing ear protection in this population. This early discussion may prevent premature discontinuation of their sport due to the development of EACE and improve their whole-person wellness.
Acknowledgements
The authors thank William Phillips, BS, for his assistance with data collection and throughout the project, and Deborah Goggin, MA, ELS, scientific writer with the Department of Research Support at A.T. Still University, for her editorial assistance.
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Research funding: None reported.
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Author contributions: All authors provided substantial contributions to conception and design, acquisition of data, or analysis and interpretation of data; all authors drafted the article or revised it critically for important intellectual content; all authors gave final approval of the version of the article to be published; and all authors agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
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Competing interests: None reported.
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Informed consent: All participants in this project provided written informed consent to participate in the project by completing a questionnaire and allowing inspection of the external auditory canal with a device prior to participation.
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© 2022 Annalise E. Wille et al., published by De Gruyter, Berlin/Boston
This work is licensed under the Creative Commons Attribution 4.0 International License.
Articles in the same Issue
- Frontmatter
- Behavioral Health
- Review Article
- The psychological burden associated with Ehlers-Danlos syndromes: a systematic review
- General
- Original Article
- The impact of COVID-19 on otolaryngology research: a cross-sectional analysis of discontinued trials
- Neuromusculoskeletal Medicine (OMT)
- Original Article
- Cranial osteopathic techniques and electroencephalogram (EEG) alpha power: a controlled crossover trial
- Obstetrics and Gynecology
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- Effect of visceral manipulation on menstrual complaints in women with polycystic ovarian syndrome
- Pediatrics
- Original Article
- Investigating the safety and feasibility of osteopathic medicine in the pediatric oncology outpatient setting
- Public Health and Primary Care
- Original Article
- Prevention of external auditory canal exostosis in the Colorado whitewater community
- Clinical Image
- Intraoperative appearance of gonadal vein embolization coil
- Letters to the Editor
- Lymphatic osteopathic manipulative treatment and soreness after receiving the COVID-19 vaccine
- Response to “Lymphatic osteopathic manipulative treatment and soreness after receiving the COVID-19 vaccine”
Articles in the same Issue
- Frontmatter
- Behavioral Health
- Review Article
- The psychological burden associated with Ehlers-Danlos syndromes: a systematic review
- General
- Original Article
- The impact of COVID-19 on otolaryngology research: a cross-sectional analysis of discontinued trials
- Neuromusculoskeletal Medicine (OMT)
- Original Article
- Cranial osteopathic techniques and electroencephalogram (EEG) alpha power: a controlled crossover trial
- Obstetrics and Gynecology
- Original Article
- Effect of visceral manipulation on menstrual complaints in women with polycystic ovarian syndrome
- Pediatrics
- Original Article
- Investigating the safety and feasibility of osteopathic medicine in the pediatric oncology outpatient setting
- Public Health and Primary Care
- Original Article
- Prevention of external auditory canal exostosis in the Colorado whitewater community
- Clinical Image
- Intraoperative appearance of gonadal vein embolization coil
- Letters to the Editor
- Lymphatic osteopathic manipulative treatment and soreness after receiving the COVID-19 vaccine
- Response to “Lymphatic osteopathic manipulative treatment and soreness after receiving the COVID-19 vaccine”
