These Go to Eleven: Music-induced hearing loss

In the mockumentary This Is Spinal Tap, Chris Guest's rocker "Nigel Tufnel" proudly points out that the volume controls for his amplifiers are "one louder" than standard amps. "These go to 11." In real life, This Isn't Spinal Tap, and one can have too much of a good thing. The "good thing" we are talking about is playing or listening to your favorite music too loudly and possibly damaging your hearing. Once you have hearing loss, music will never sound the same; ringing in the ears will rob you of the sound of silence.

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Whether it's rock, classical, hip hop, or something in between, at certain sound levels, repeated exposure to music can cause permanent hearing loss and/or ringing in the ears known as tinnitus. Recent studies by NIOSH researchers and others at nightclubs and other music venues show that all employees studied, regardless of occupation (waiters, bartenders, DJs, etc), were exposed to noise levels above the internationally recommended limits of 82-85 dB(A)/8 hours and were at a higher risk of developing hearing loss and/or tinnitus. A new term, music-induced hearing loss, has been coined to reflect this growing condition.

Musicians and others working in entertainment and sports (see related blogs) are often overlooked in terms of occupational safety and health. Few countries (Australia, Switzerland, Italy, Austria, Finland, and Sweden) have specific recommendations for occupational exposure limits when it comes to musical activities or noise in the entertainment industry. While great strides are being made in terms of research on music-induced hearing loss, hearing conservation efforts have been minimal.

Hearing loss prevention approaches need to be customized, since "classic" conservation initiatives—those geared toward industrial settings—may not be appropriate. For example, removing the hazardous noise source or removing the worker (i.e., the musician) are not really applicable. Assessing hearing risk can be complicated when it comes to music. Correct and consistent use of hearing protection can prevent hearing loss among musicians, but convincing DJs, musicians, and others at risk of hearing loss to use appropriate hearing protection is challenging. Finally, since we are not dealing with "noise," hearing conservationists have to think about hearing loss prevention from an artistic view—not just medically or scientifically.

So what can be done? Targeted communication campaigns are needed to highlight the value of hearing, the risks associated with continuous exposure to loud music and more importantly, the availability of services and products that preserve sound quality and are suited to musicians' needs. Examples of efforts to reach musicians and other professionals exposed to music come from three recipients of an award created by NIOSH in partnership with the National Hearing Conservation Association (NHCA), the Safe-in-Sound Excellence in Hearing Loss Prevention Award™:

2009 Innovation Winner (Services Sector). In terms of getting the message out to those who need it, possibly no one has had a bigger impact than Sensaphonics Hearing Conservation, Inc*. Their client list illustrates how effective they have been at teaching hearing conservation awareness and expanding services available to musicians. Sensaphonics developed training on the basics of live performance audio, technique and product solutions for safe music playing, backstage etiquette, and how to work effectively with music industry clients. They develop products that allow artists and engineers to translate that knowledge into great live performances in a way that preserves the hearing of those exposed. One of their major contributions to hearing conservation is the focus on In-Ear Monitors (IEMs). Bringing the mix directly to the musician places less reliance on stage and monitor volumes. Most recently, Sensaphonics has integrated sound level meters into the IEM so the musician can know the actual levels they are dialing in. Sensaphonics has placed a great deal of emphasis on personal choice and responsibility. Their aim is to empower musicians with the knowledge and resources to manage their hearing health.

2010 Innovation Winner (Manufacturing Sector). Etymotic Research, Inc*, was arguably the first company to offer solutions to the problem of music related hearing damage. They approached the problem of managing risk by thinking like musicians and working with them. Conventional earplugs can offer too much attenuation or distort sounds, but today we have better hearing protection alternatives for music performance and enjoyment. In terms of music and conservation, one of Etymotic's greatest contributions is the flat attenuating "Musician's Earplug". While many industries regard hearing protection devices as a last resort in terms of conservation, for many musicians this may be the only realistic and readily available option for protecting their ears. Etymotic's most recent contribution (Electronic BlastPLG earplugs) received a 2011 Innovation Award from the Consumer Electronics Association. The EB15 model automatically becomes a 15-dB high-fidelity hearing protector when ambient noise exceeds safe levels.

2010 Innovation Winner (Services Sector). Professor Kris Chesky (a musician himself, who has hearing loss since college) and the College of Music at the University of North Texas (UNT) are taking a broad approach to raise awareness of the importance of hearing loss prevention by changing the pedagogy of music education. They have developed educational goals, policies, support materials for music educators and an occupational health course for music students. They are also conducting research on measuring sound pressure levels in music classes and establishing exposure databases for different music school scenarios.

Professor Chesky's work has been inspired by his belief that: "...every person learning about music in the United States, from early grade school through college, must be taught to understand that music is a sound source capable of harming hearing and that music can be studied, practiced, performed, and consumed in ways that are not risky to hearing."

UNT's innovative research and methodology, education, and advocacy have reached music educators and students, university administrators and board members of accreditation agencies. It is also bringing additional attention to the risk of music-induced hearing loss to other professionals in entertainment venues and to the general public.

So, we are making strides and can go beyond "don't go one louder!" by offering some do's, which can work for musicians, workers exposed to music, and music lovers:

Know the risks. Overexposure to excessively loud sounds can cause irreversible damage to your hearing.Exposure time is just as important as exposure levels when it comes to creating risk. Be sure to take breaks in quieter areas. Limit your time in noise (from sports, transportation, firearms, etc). It all adds up!Wear earplugs. Consider custom- or universal-fit Musicians Earplugs to keep fidelity but decrease intensity.Move around venues to find a "quieter spot." Sound reverberates and you might decrease your exposure level if you stand in a spot where you are not getting sound directly from the source.If you are a professional performer in a constant venue (house player), examine or ask about engineering controls that could be implemented to improve the acoustics of the room or hall and reduce exposure levels. If you experience ringing or "muffling" for more than 24 hours, you may want to consider a hearing check-up. Tinnitus and temporary changes in hearing might be a sign of early onset of permanent damage.

Are there reasons for optimism? Plenty! In Sweden, a country that has invested in educational campaigns early on, higher percentages of young people wear hearing protection when exposed to loud music or noise, in comparison to other countries (61% study participants in Sweden, 9% in the US and 2% in Brazil; Zocoli et al., 2009). Hearing protection use for music exposure is increasing in Australia following reports issuing recommendations (Binge Listening, 2010).

Spreading the information from campaigns such as those referenced above and included below can help those exposed to loud music preserve their hearing and extend the enjoyment they get from music.

—Thais C. Morata, Ph.D., and Ryan Johnson, B.A.

Dr. Morata is a research audiologist in the NIOSH Division of Applied Research and Technology.

Ryan Johnson, a musician-audiology student, worked at NIOSH as a student member of the Safe-in-Sound Expert Committee in 2010.

*Inclusion of a company name or product does not constitute an endorsement from NIOSH or the Federal Government.

Beach E, Williams W, Gilliver M. Hearing protection for clubbers is music to their ears. Health Promot J Austr. 2010 21(3):215-21. Bray A, Szymanski M, Mills R. Noise induced hearing loss in dance music disc jockeys and an examination of sound levels in nightclubs. J Laryngol Otol. 2004 118(2):123-8.Gunderson E, Moline J, Catalano P. Risks of developing noise-induced hearing loss in employees of urban music clubs. Am J Ind Med. 1997 31(1):75-9. Jansen EJ, Helleman HW, Dreschler WA, de Laat JA. Noise induced hearing loss and other hearing complaints among musicians of symphony orchestras. Int Arch Occup Environ Health. 2009 82(2):153-64. Mendes MH, Morata TC, Marques JM. Acceptance of hearing protection aids in members of an instrumental and voice music band. Braz J Otorhinolaryngol. 20077 3(6):785-92.Potier M, Hoquet C, Lloyd R, Nicolas-Puel C, Uziel A, Puel JL. The risks of amplified music for disc-jockeys working in nightclubs. Ear Hear. 2009 30(2):291-3. Sadhra S, Jackson CA, Ryder T, Brown MJ. Noise exposure and hearing loss among student employees working in university entertainment venues. Ann Occup Hyg. 2002 46(5):455-63. Santos L, Morata TC, Jacob LC, Albizu E, Marques JM, Paini M. Music exposure and audiological findings in Brazilian disc jockeys (DJs). Int J Audiol. 2007 46(5):223-31. Zhao F, Manchaiah VK, French D, Price SM. Music exposure and hearing disorders: an overview. Int J Audiol. 2010 49(1):54-64.Zocoli AM, Morata TC, Marques JM, Corteletti LJ. Brazilian young adults and noise: attitudes, habits, and audiological characteristics. Int J Audiol. 2009 48(10):692-9.Posted 1/25/2011 at 2:15 pm

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Take Aim at Protecting Yourself: Solutions for Preventing Lead Poisoning and Hearing Loss at Indoor Firing Ranges

If you work or train regularly at indoor firing ranges, you could be exposed to hazardous levels of lead and noise. An estimated 16,000–18,000 indoor firing ranges operate in the United States. Some do not have sufficient environmental and occupational health controls in place to effectively protect the health of shooters and firing range personnel from exposure to lead (from lead bullets and cartridge primers), noise, and other contaminants. Those at risk include thousands of employees at indoor firing ranges, more than a million Federal, State, and local law officers who are required to train regularly at these facilities, and 20 million active target shooters.

NIOSH recently issued a new Alert, Preventing Occupational Exposures to Lead and Noise at Indoor Firing Ranges. The Alert presents five case reports that document lead and noise exposures and examines firing range operations, exposure assessment and control methods, existing regulations, and exposure standards and guidelines.

Numerous factors and routes of exposure can contribute to workers' and patrons' exposures to lead at indoor firing ranges. Environmental factors include the type of ventilation system used at the firing range, the types of ammunition used, and the length of time that shooting occurs. Exposure risk factors include the type and frequency of work practices conducted at the range, particularly those involving cleaning the firing range and other maintenance activities. At indoor firing ranges, lead dust from firearms discharge can be inhaled or contaminate surfaces and then transferred to people's skin, especially the hands. Lead from the hands can be ingested while handling food, beverages, and other items that contact the mouth. Elevated blood lead levels can lead to lead poisoning. Symptoms of lead poisoning include the following:

NauseaDiarrheaVomitingPoor appetiteWeight lossAnemiaExcessive lethargy or hyperactivityHeadachesAbdominal painKidney problems

In addition, lead poisoning, neurological effects, and mental retardation have occurred in children of workers who bring lead home on their clothes, skin, or other surfaces.

In one case study of law enforcement trainees described in the Alert, blood lead levels at an indoor firing range rose from a pre-training mean of 6.5 µg/dL to 50.4 µg/dL post training. Mean airborne lead concentrations were more than 40 times the OSHA permissible exposure limit. After changes were made to the ventilation system, airborne lead concentrations dropped to below detectable levels. In addition, using ammunition that had nylon-coated and copper-jacketed bullets substantially reduced (94% to 97%) airborne lead concentrations.

Detailed recommendations for employers and workers are available in the Alert. Controlling exposures to occupational hazards is the fundamental method of protecting workers. Traditionally, NIOSH uses a hierarchy of controls to reduce or eliminate workplace hazards:

Elimination of the hazardSubstitution of a less hazardous materialEngineering controlsAdministrative controls (to reduce time of exposure)Personal protective equipment

Proper ventilation, good housekeeping practices, and basic personal hygiene practices will limit or eliminate the risk of lead exposure. Examples of NIOSH recommendations for workers include the following:

Wear respirators and full protective outer clothing when performing range maintenance.Wear gloves and eye protection when using chemicals to clean weapons or firing range surfaces.Wash hands, forearms, and face before eating, drinking, smoking, or contact with other people.Change clothes and shoes before leaving the firing range facilities.Wash clothes or uniforms used at the firing range separately from family's clothing.

The discharge of firearms in an indoor firing range produces peak noise levels that exceed the occupational health limits of 140 dB SPL. NIOSH recommends that workers and shooters who use a firing range as part of their occupation (i.e, law enforcement officers) wear double hearing protection (earplugs and earmuffs) as part of an overall hearing conservation program. Special attention must be paid to the use of safety glasses under earmuffs so not to create an acoustical leak and degrade the performance of the hearing protectors.

Exposure to high levels of noise can lead to the following:

Hearing lossTinnitus (ringing in the ear, which might be permanent)StressAnxietyHigh blood pressureGastro-intestinal problemsChronic fatigue

NIOSH would like to hear from you regarding your experiences working or training at indoor firing ranges. What prevention methods do you or your employer take? What has worked? What has not worked? Would you be interested in receiving more information or review other products from NIOSH on indoor firing ranges? More information is available in the NIOSH Alert and on the NIOSH Indoor Firing Ranges topic page.

—Chucri A. Kardous, M.S., P.E.

Mr. Kardous is a research engineer in the NIOSH Division of Applied Research and Technology.

Posted 05/18/09 at 2:21 pm

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QuickFitWeb Hearing Protection Test

Approximately 30 million workers are exposed to hazardous noise on the job. While we would prefer to eliminate noise through engineering controls or reduce exposure to noise through administrative controls, hearing protectors are critical when noise is unavoidable. 

Hearing protectors only work if they fit your ears and you wear them properly.  An earplug that doesn't quite fill your ear canal or an earmuff with a small crack in the padding will let lots of noise into the ears through any gaps, even tiny ones.

For best results, conduct this test in a quiet room (background noises can interfere with the test sounds). You can listen through speakers or headphones connected to your computer. Speakers will work with either earmuffs or earplugs. Headphones can be used with earplugs and should be the full-sized "circumaural" type that covers the entire ear and does not press on the inserted earplug.Click "1. Without hearing protection" in the sound player display above and adjust the volume so the sound is barely audible. (You may need to use the controls on your computer along with the on-screen slider.)Put on your hearing protection. If using soft foam earplugs, we recommend the NIOSH Roll-Pull-Hold method. Click "2. With hearing protection" and listen for the test sound. You should not be able to hear the test sound if your hearing protection is fitted properly. If you can hear this track, re-fit your hearing protection and repeat this step.

To help you get the most from your hearing protectors, researchers at the National Institute for Occupational Safety and Health's (NIOSH) Pittsburgh Research Laboratory developed QuickFitWeb, an online tool to check your hearing protection in a minute or less.

Studies of hearing protector users have shown repeatedly that average protection values in the real world are much lower than the labeled Noise Reduction Ratings (NRR) determined in laboratories with trained and motivated subjects. Even worse, many hearing protector users get virtually no protection at all because of poor fit. It's hard to tell if your hearing protectors are working well just by looking at them. A more accurate approach is to check how much they block or "attenuate" noise. Hearing protectors vary in their attenuation characteristics, with most providing a maximum of 20 to 35 decibels of noise reduction when worn correctly. Any hearing protector that's suitable for use in noisy settings will attenuate noise by at least 15 decibels.

The NIOSH QuickFitWeb helps you determine if your hearing protection is giving you at least 15 decibels of attenuation by comparing two "threshold" tests—one without hearing protection and one with the devices on or in your ears. To use QuickFitWeb, play the test sound (a pulsing random noise that sounds like "wooshing" to most people) from the website. As you listen to the sound, adjust the volume on your computer until the sound is right on the edge between audible and too quiet to hear. That sound level is your "threshold of hearing." Then put on your hearing protectors and play the next test sound. The second sound is exactly the same as the first except that it's 15 decibels louder. If you can hear the louder sound through your hearing protection, the devices are attenuating sound by less than 15 decibels and are not protecting you adequately. You need to correct the problem by trying hearing protectors that fit you better or correcting the way you put them on. Then you can try the test again until you get a good fit.

The QuickFitWeb is a highly simplified variation of standard hearing protector evaluations. The QuickFitWeb tests only one octave band centered at 1000 Hz. That is, we filtered a sample of random noise to have maximum energy at 1000 Hz and with energy dropping to zero at 500 Hz and 2000 Hz. Using just a single test frequency saves time and serves the purpose of checking for adequate fit since well-fit hearing protectors will have good attenuation on all frequencies. The QuickFitWeb also streamlines testing by checking for just one attenuation value: 15 decibels. If a protector is poorly fitted, it will usually provide far less than 15 decibels of attenuation. Protectors suitable for noisy environments are generally rated to provide at least 20 decibels of attenuation so they should completely block a sound that's just 15 decibels over the user's hearing threshold.

QuickFitWeb is a spinoff from the NIOSH QuickFit standalone device. QuickFit is a small, self-contained device that looks like one side of a set of earmuffs and allows the user to play test sounds, adjust the threshold,and check for at least 15 decibels of protection. It was designed to use inexpensive off-the-shelf circuits and parts so that it could be produced at very low cost. Ideally, it could be placed affordably near any noisy worksite so workers could check their earplugs every time they put them in. Prototypes of the QuickFit device started a series of field evaluations in February 2008.

Another related product is QuickFitMP3—a set of digital sound files in the popular MP3 format that can be played on almost any computer or music player. By playing the sounds in sequence, users can test whether their hearing protectors are attenuating noise by at least 15 decibels. These MP3 files are downloadable now from the QuickFitWeb page. A future enhancement of this approach will be to provide a sequence of MP3 "tracks" that vary by 5 decibels to allow users to assess approximately how much attenuation they are getting from their hearing protectors. They will also use the separation possible with stereo headphones to permit testing earplugs inserted in right versus left ears independently. These added sound files will allow some additional training and evaluation scenarios that are beyond the scope of the current QuickFit products.

Noise-induced hearing loss is 100 percent preventable but once acquired it is permanent and life-altering.  The QuickFit products are tool for workers to ensure that their hearing protection is actually working and preventing hearing loss. 

—Robert F. Randolph, M.S.
The author is the Manager of the Hearing Interventions Team at NIOSH's Pittsburgh Research Laboratory

More information on work-related hearing loss is available on the Noise and Hearing Loss Prevention page on the NIOSH website.

Posted 5/12/08 at 12:08 pm

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Don't Let Tinnitus Affect Your Quality of Life

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• Tinnitus is the sensation of a sound in the ear or head that is not being produced by an external source. Tinnitus is usually caused by a fault in the hearing system. It is a symptom, not a disease in itself. Tinnitus is a physical condition, experienced as noises or ringing in the ears or head when no such external physical noise is present. Tinnitus is often referred to as "ringing in the ears" which, upon testing, proves to be best matched by a single high frequency tone. Tinnitus is typically not a serious condition, but, it is frequently accompanied by hearing loss. Tinnitus is also a side effect of some oral medications, such as aspirin, and may also result from an abnormally low level of serotonin activity. Possible causes of tinnitus are ear wax impaction, exposure to loud noises, ear infection, tumors, ototoxic drugs, meniere's disease, and lyme disease.
  
  
  Tinnitus can be cured when the cause of tinnitus is corrected. Tinnitus can be extremely disturbing to people who have it. Tinnitus can have a great impact on a patients quality of life. Tinnitus usually appears first as a continuous high pitched sound. Tinnitus will not cause you to go deaf and statistically, 50 percent of patients may express that their tinnitus with time decreases or is hardly perceptible. Tinnitus that is not annoying and well tolerated should not be treated. Drugs that commonly cause or increase tinnitus NSAIDS (motrin, naproxin, relafen,) aspirin and other salicylates Lasix and other "loop" diuretics "mycin" antibiotics quinine and related drugs. Chemotherapy such as cis platin Rarely, some of the SSRI antidepressants.
  
  Hearing loss from being around loud noises is also often accompanied by tinnitus. Hearing loss worsens the effect of tinnitus, so hearing protection and avoiding loud noises is very important in preventing worsening of the symptoms. Hearing aids are ideal if there is an associated hearing loss with the tinnitus. Hearing aids are among the most effective tools for providing relief from tinnitus in individuals with hearing loss. Hearing aids take away the strain of listening and distract from the tinnitus by bringing you more environmental sounds from the outside world.
  
  
  Treatment of tinnitus should be directed toward the underlying disease, because its treatment may lessen the tinnitus. Treatment is selected based on lifestyle, personal preferences, tinnitus hyperacusis severity and cost. Treatment consists of biofeedback exercises in hourly sessions, in which the patient learns to control circulation to various parts of the body and relax muscles attached to the head. Treatment, however, does not mean cure since most tinnitus is not correctable.
  
  Patients with objective tinnitus typically have a vascular abnormality, neurologic disease, or eustachian tube dysfunction. Patients can mistake headache, drug reaction, fatigue, hypertension, flu, and even depression as tinnitus. Patients may hear blowing sounds within the ear coincident with breathing. Patients often have difficulty describing their tinnitus due to the scarcity of adjectives available to describe sounds of any sort. Patients should be advised to avoid loud noise, or if unavoidable, to wear appropriate ear protection.
  
  
  Stress is a prime cause of tinnitus, and in cases where this is the cause the removal of the cause of the stress is the aim. Stressful situations cause changes in our chemical make up, and alterations in such can result in forms of tinnitus that are very irritating and sometimes debilitating. Stress management, whether through relaxation therapy, biofeedback or exercise, may provide some relief.
  
  
  Masking refers to exposing the patient to other sounds in an effort to block out, or take their mind off their tinnitus. Masking is simply arranging an external sound which covers-up the tinnitus and which is readily acceptable to the patient as a substitute for their tinnitus. Masking devices are similar in appearance to hearing aids. Masking seems to work for only a few patients, but like most treatments, it is impossible to predict in advance of testing and trial which patients can be helped with this treatment.
  
  Medications may occasionally help lessen the noise even though no cause can be found. Medications that help people with obsessive compulsive disorder may be helpful. Medications such as anti-arrhythmics (usually used for irregular heart rhythms), antidepressants, vasodilators, tranquilizers, and anticonvulsants may help.
  
  Pulsatile tinnitus is usually due to a small blood vessel that is coupled by fluid to your ear drum. Pulsatile (like a heartbeat) tinnitus is often caused by sounds created by muscle movements near the ear, changes in the ear canal, or blood flow (vascular) problems in the face or neck. Pulsatile tinnitus, in which the tinnitus sounds are intermittent, continuous, or pulsating in time with the heartbeat. Pulsatile tinnitus subsides with light digital pressure applied over the ipsilateral internal jugular vein of the side with tinnitus. Pulsatile tinnitus of this nature usually goes away with time.
  
  
  Subjective tinnitus is described as a ringing, buzzing, hissing, or whistling sound that resembles bells, crickets, or a variety of complex sounds. Subjective tinnitus differs in that it is louder in quiet. Subjective tinnitus, which is more common, is heard only by the patient. Subjective tinnitus is by far the most common type of tinnitus.
  
  Objective tinnitus occurs when certain blood vessels become noisy. Objective tinnitus can be heard through a stethoscope placed over head and neck structures near the patient's ear. Objective tinnitus can occur suddenly and may be temporary because it can accompany elevated blood pressure; when the blood pressure is reduced, the tinnitus may stop as suddenly as it started. Objective tinnitus is a much rarer form of tinnitus and consists of head noises that are audible to other people in addition to the sufferer. Objective tinnitus is far less frequent than subjective tinnitus. Objective tinnitus is mostly associated with vascular or muscular disorders and relates to less than 5 percent Tinnitus cases.
  
  Surgery should be considered when there is a clear structural reason for tinnitus that can be improved with surgery. Only rarely is surgical treatment indicated, and even more rarely, is Tinnitus relieved. Surgery of the ear or brain is extremely dangerous, and is considered a treatment of last resort. Surgery is seldom justified and can aggravate tinnitus.
  
  
  Tinnitus is a symptom, not a disease. Tinnitus is most common in people over age 40. Tinnitus is common; nearly 36 million Americans have constant tinnitus and more than half of the normal population has intermittent tinnitus. Tinnitus is usually most bothersome at night or other times when it is quiet. Tinnitus is not a disease in itself. Tinnitus is usually more marked after one goes to bed and his surroundings become quiet. Tinnitus is most commonly treated with a calming sedative. Tinnitus is rarely linked to any serious problem and people usually learn to manage it quite successfully. Tinnitus is bothersome but does not impair function; consequently, people who have tinnitus usually do not seek treatment. Management consists simply of reassuring the patient and treating the underlying disorder. Avoid loud noise, loud noise is the enemy of the tinnitus patient. Avoid stimulants such as caffeine and nicotine. Avoid exposure to loud noises and sounds. To find out more click this link>>Tinnitus Help
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