Surfy Surfy: March 2010

A special message from friend of Surfy Surfy, Kevin

From now on I am wearing a hood all winter long. I've already been religious about wearing ear plugs, but that might not be enough to stop surfer's ear progression.

Ear Canal with Surfer's Ear. Image: Norwest ENT Medical Group.

I had surgery on Monday to have my surfer's ear (a.k.a. bony exostosis of the external auditory canal) removed. I opted for removal via mallet and chisel.

Here are pieces of my skull they removed.

Micro-chisel Technique is Crazy
About 5 years ago when my right ear was about 90% closed I started looking for a surgeon in San Diego. I ended up talking on the phone with three who all used the cut behind your ear (i.e. post-auricular route) and drive a high speed drill downtown technique for surfer's ear surgery. They all thought it was totally nuts to use a chisel and to go straight through the ear canal. Dangerous and archaic was their response to the idea.

At that time there weren't many papers on the technique for surfer's ear surgery. A 1997 paper by Samuel Whitaker from UCI described a method of cutting a flap of skin away from the bony growth and then hitting the growth with a microchisel to carve off the exostosis from the canal wall.

Whitaker was old school. He is a bit older than many of the other surgeons that were around and his dad was a surgeon long before high speed drills, so he looked at a lot of things differently. He looked at the problem and figured the old school tool might be a good tool for the job. I got the impression that a lot of doctors dismissed his approach at first (or just thought it was koo koo). Think about it, it does sound pretty sketchy. I liked the idea!

It was troubling that when I called UCI around 2005, when I was first looking for a surgeon, they said their surgeons were using the drill technique, not the chisel (Whitaker was in private practice in Los Angeles at that time, not a UCI).

At the same time I found a surgeon named Dr. Reisman in Oceanside who let me believe that he would use the chisel on me, so I was good to go with him. He was highly recommended by many of my friends and I scheduled the surgery. At the pre-op appointment he was very clear that he would use the drill and not the chisel, so I bailed out on that because the story changed from my initial visit to the pre-op. Didn't feel comfortable with that scenario because if I hadn't specifically asked I would have never known how he did the surgery... because I would have been under general anesthesia when the drill started spinning.

That ordeal led me to track down Whitaker in Los Angeles. Whitaker evaluated my ear and made it very clear that he thought I could go years more before surgery, especially because I wasn't having chronic ear problems and you could still see things in the ear that the surgeon would want to see when doing the surfer's ear operation.

Craziness Spreads
Fast forward to today. Surgeons at UCSD still think the chisel is more dangerous than the drill. The UCSD surgeons believe there is more control with the drill and a better sense of position by cutting behind the ear. Dr. Jack Pulec, a highly respected academic surgeon published a short note about exostoses removal in 2001. He wrote, "The use of a postauricular incision for the treatment of exostoses offers no advantage. In fact, it can give the surgeon a false sense of security." Chisel surgeons are saying that part of the reason the drill guys use drills is because that is the way they were trained, not because its the best tool. The controversy continues today.

Using the high speed drill comes with some drawbacks. The drill gets really hot and can produce heat damage. The drill is also very loud and is thought to have a risk of hearing damage. It is also notorious for doing lots of skin damage, making recovery time lengthy and painful. I surf with two guys who had the drill and both say they aren't doing the surgery again.

On the other hand, there is the widely spread story that Dr. Money left San Diego because he started using the chisel and chiseled too far one time. It is sketchy trying to understand how the docs can keep from going to far. Going too far on the posterior side of the auditory canal can cut your facial nerve. Dr. Money did leave town, but he is now the Director of an ENT clinic in Indian and there is no public record of disciplinary action against him.

I haven't found any satisfactory data that does a good job at comparing the risks of the two approaches. I'm sure with either approach the skills of the surgeon are a major factor in the risk for an individual surgery, regardless of the tools being used.

Today, lots of surgeons have adopted the chisel. Santa Cruz's Dr. Hetzler published a large case history review paper on over 200 ear surgeries that he conducted using the chisel. Hetzler has popularized the technique in the surf community. His paper was followed a year later by a similar case history paper by House and Wilkison in Los Angeles. They use the drill technique. Hearing damage because of the high speed drill wasn't a real problem in their patients.

What is interesting is that even with the controversy more surgeons are turning to the chisel.

UCI now uses the chisel. Here is video of Dr. Djalilian using the chisel for surfer's ear.

From Dr. J's website:

We use a combination of a microchisel and drill to remove the exostoses. The use of the drill is best for exostoses that are wide-based in the anterior (front) part of the ear canal and those that are close to the ear drum. Using the chisel close to the ear drum can cause a rupture of the ear drum. The front wall of the ear canal borders the jaw joint. Attempting to fracture a large exostosis in the anterior canal wall may cause the bone that surrounds the TMJ to break with devastating consequences.

I spoke to a couple surgeons who did not think damage to the anterior wall or TMJ needed to be much of a risk or issue. Dr. Hetzler's paper describes a few anterior canal walls being mobilized, but the patients remained asymptomatic. Hetzler says he's never seen a result on the anterior wall that was "devastating".

Here is video from Dr. Hetzler

Shohet Ear Associates appears to be marketing to Orange County surfers as the go to surfer's ear surgeons. Shohet uses micro-chisels, and a drill to clean things up.

I have two doctor friends, and an ENT surgeon (who doesn't do surfers ear) who have recommended San Diego's Dr. Beros for surfer's ear surgery. One of them just had Dr. Beros do his own ear and it was done with the chisel.

Local/General Anesthesia
It appears that drill surgeries take a lot longer. I had the chisel and they weren't really working on my head for more than 40 minutes. The chiseling is really a tiny fraction of that time. I know because I was awake and I remember.

Dr. Whitaker has done almost all of his surgeries under local, with sedation. He was trained to be a surgeon when the use of general anesthesia was less common for many procedures. Dr. Jack Pulec's note also mentions that he did these under local anesthesia too. I know that for some people, the worst part of the whole experience is dealing with the general anesthesia.

It is not totally nutty to do it under local. My neighbor had his ear done two weeks ago by a Kaiser doctor (Dr. Broberg) under local anesthesia too. No biggie, and you are up and productive hours after you have surgery.

Because I was awake, I am certain to remember the bang, bang, bang (not tap, tap, tap) of the chisel on my skull the next time I even think about paddling out in cold water without my earplugs and hood.