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Abstract (summary

Noise-induced hearing loss (NIHL) still remains a problem in developed countries, despite
reduced occupationalnoise exposure, strict standards for hearing protection and extensive
public health awareness campaigns. Therefore NIHL continues to be the focus
of noise research activities. This paper summarizes progress achieved recently in our
knowledge of NIHL. It includes papers published between the years 2008-2011 (in English),
which were identified by a literature search of accessible medical and other relevant
databases. A substantial part of this research has been concerned with the risk of NIHL in
the entertainment sector, particularly in professional, orchestral musicians. There are also
constant concerns regarding noise exposureand hearing risk in "hard to control"
occupations, such as farming and construction work. Although occupationalnoise has
decreased since the early 1980s, the number of young people subject to social noise
exposure has tripled. If the exposure limits from the Noise at Work Regulations are applied,
discotheque music, rock concerts, as well as music from personal music players are
associated with the risk of hearing loss in teenagers and young adults. Several recent
research studies have increased the understanding of the pathomechanisms of acoustic
trauma, the genetics of NIHL, as well as possible dietary and pharmacologic otoprotection in
acoustic trauma. The results of these studies are very promising and offer grounds to expect
that targeted therapies might help prevent the loss of sensory hair cells and protect the
hearing of noise-exposed individuals. These studies emphasize the need to launch an
improved noise exposure policy for hearing protection along with developing more efficient
norms of NIHL risk assessment.

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Exposure to excessive noise is one major cause of hearing disorders. It has been estimated
that worldwide as many as 500 million individuals might be at risk of developing noiseinduced hearing loss (NIHL). [1]
Prolonged exposure to noise at high intensity is associated with damage to the sensory hair
cells of the inner ear and development of permanent hearing threshold shift, as well as poor
speech in noise intelligibility. There is also evidence that noise exposure frequently leads to
tinnitus which might be due to alterations in the central auditory function. [2] In the adult

population it may significantly influence quality of life, and constitute a major limitation in
relation to hearing-critical jobs, decreasing the potential worker's chance of employment.
Thus, NIHL not only affects health, but is also a major social problem.
The aim of this review was to provide an overview of the studies and
reports from international bodies published in English over the last four years (2008-2011)
on NIHL. If appropriate, the results of the recent studies were then compared to previous
findings. The papers were identified by a literature search of accessible medical and other
databases (PubMed, Embase, Scopus, BioMed Central, Web of Science). This review
summarizes some progress achieved over the recent years in our knowledge of noise effects
on hearing loss. In particular the paper concerns the risk of hearing loss due to
occupational exposures of musicians, farmers and construction workers, the advances in
molecular genetics of NIHL and pharmacological/dietary otoprotection, and hearing
conservation issues.
Hearing loss in professional musicians
According to several studies, including the most recent ones, professional orchestral
musicians are often exposed to sounds (so-called "orchestral noise") at levels exceeding the
upper exposure action values referred by the 2003/10/EC noise directive. [3],[4],[5]
Classical orchestral musicians are usually exposed to sounds at equivalent continuous Aweighted sound pressure levels of 81 - 90 dB (10 th-90 th percentiles), for 20-45 h (10 th90 th percentiles) per week. According to the ISO 1999:1990 model,
occupational exposures to such sound levels over 40 years ofemployment might cause
hearing loss exceeding 35 dB (expressed as average of hearing threshold level at 2, 3 and 4
kHz) in up to 26% of individuals. The highest risk (above 20%) is related to playing the
horn, trumpet, tuba and percussion. [5]
Recently, bilateral sound exposure of classical symphony orchestra musicians was assessed
by noisedosimetry simultaneously in the left and right ear. [6] It confirmed that
'sound exposure depends significantly on the specific instrument and the repertoire played
by the exposed musician'. Concerts, group rehearsals and individual practice were all
significant contributors to the sound exposure. The highest LAeq of 86-98 dB was found
among the brass players. High string players were exposed from 82 to 98 dBA and their left
ear was exposed 4.6 dB more than the right ear. Percussionists were exposed to high sound
peaks >115 dBC but less continuous sound exposure was observed in this group. Musicians

Even so. there is still disagreement and speculation about the risk of hearing loss in professional musicians from their overexposure to music alone. [14] Farming is ranked among the top occupations with the highest risk for hearing loss. was nearly twice that of the national sample. [16] Baseline data including audiometric thresholds were collected from US youths living on farms in 1994-1996 (n = 212) with follow-up in 2003-2004 (n = 132). [6] Because of insufficient audiometric evidence of hearing loss caused purely by music exposure.[8].4 to 85.6 to 92.[11] It has been shown that the distribution of hearing loss among musicians corresponded to that of the general population. [11]. an 8-h time-weighted average among adult farm workers rangedfrom 46. with some evidence that it begins in childhood. growing and harvesting seasons. Respective values for children were from 15. Youths in this study had a higher prevalence of hearing loss when compared to nationallyrepresentative data.[12] Musicians are also less exposed to other contaminants generally found in industrial settings.[9]. Despite a high level of sound exposure and a fairly large selection of earplugs available. music seems to damage hearing by less than what could be predicted based on the ISO 1999:1990 standard for occupational noise exposures. and nearly 50% of them exhibited high-frequency hearing loss (mainly at 6 kHz).5 dB. [7]. [17] These data indicate that hearing . mainly because of non-useof hearing protection devices. The prevalence of noise-induced threshold shifts. This might be explained by the relatively low number of individual susceptibility risk factors found in this group of professionals. musicians reported 'only seldom use' of personal hearing protectors. It was estimated that during planting.4 to 81. characterized by an audiometric notch.1 to 89. For better hearing conservation.were exposed up to LAeq8h of 92 dB and a majority of musicians were exposed to sound levels exceeding LAeq8h of 85 dB.[10].2 and from 42. [15] It has been shown that hearing loss is prevalent among adults in farming communities.6 dB using the OSHA criteria. and from 62. but highly exposed musicians had somewhat greater hearing loss at frequencies above 3 kHz than less-exposed ones. [13] Hearing loss in farmers Noise exposures among farming communities can exceed recommended levels.1 dB using NIOSH/ACGIH action level. like vibration or chemicals. it is important to identify and eliminate the reasons for low motivation in using hearing protection in this professional group.

It has been shown that among 169 construction employees examined for Hand-Arm Vibration Syndrome. Hearing loss in construction workers Construction workers are also at high risk of developing NIHL. task-based exposure level. rock concerts. Although the use of hearing protector devices is much more common in construction workers than in agriculture. [20] Hearing loss due to personal music players use among youths It has been estimated that over 20 years.3%) had hearing loss at or above the level at which a workers' compensation pension would be granted in Ontario (Canada).644 Dutch construction workers has shown that noise-exposed subjects had greater hearing losses compared to their non-noise-exposed colleagues. but also in teenagers living on farms. Responding to . [18] Future studies are planned using different metrics of noise exposure (trade-meanequivalent continuous exposure level. and music from personal music players (PMP).7% to 18. and a hybrid combining task-based and subjective information) to evaluate the exposure-response relationship betweennoise and NIHL in this group of workers. the measured full-shift noise exposure exceeded permissible and recommended exposure limits in one-third to three-quarters of 1310 construction workers. as well as to the reference population reported in ISO1999. The major sources of sound/noise exposures in teenagers and young adults are discotheque music. the age when NIHL begins among farmers remains unknown. [19] The very recent study performed in a much larger population of 29. probably because of the limitations in accuracy of noise exposureestimates.8%. When the daily noise exposure level rose from 80 dB(A) towards 96 dB(A) only a minor increase in hearing loss was shown.loss is common not only in adult farmers. 31 (18. Depending on the metric used. the number of young people with social noise exposure has tripled from 6. they often have no regular audiometric testing. [21] This emphasizes that exposure to different types of noise and sounds since early childhood should be recognized as having potential cumulative effects on hearing impairment in adulthood and in old age. since the early 1980s to 2000. However. Duration of noise exposure was a better predictor than noise exposure levels.

When transformed to A-weighted field equivalent sound pressure levels (SPLs). that may indicate excessive noise exposure. Yves Cazals. Poland. If the answer was yes. the European Commission recently decided to check that sufficient preventive measures are in place to prevent hearing loss among children and adolescents exposed to music from devices like personal music players (PMP). However. members: Adrian Davis. whether used in workplace or leisure settings. they were asked to identify the level of noise emission which would safeguard the hearing health of citizens. . Australian. It was estimated that there are twelve million daily users of PMP in Europe. The opinion was delivered to the Scientific Committee on Emerging and Newly Identified Health Risks (SCENIHR) in 2008 by a group of experts (Chairman . According to the literature data. Lodz. this increase in prevalence has been seen recently in young females. Paolo Ravazzani. Swedish and American populations where PMPs were commonly in use since the 1980s. [22] On the basis of the available literature on the subject. in particular hearing loss. some studies point to an increasing overall prevalence of high-frequency hearing impairment in young people between 1987-2005. Deepak Prasher.[23] The investigations were performed in German. Although this regulation and its limits apply to the workplace. and weekly exposure time is from <1 h-14 h. but this rate seems to have remained constant over the last 30 years. the fact that they rely on the exposure level and duration means that they can be successfully applied to other situations where sound can have a detrimental effect. in up to 11% of adults it can occur in the absence of any positive noise history. Lodz. and identify priority issues for further research. Nofer Institute of Occupaytiona Medicine. Poland. [24] In addition. the conclusion from all these epidemiological studies should be viewed with caution.Mariola Sliwinska-Kowalska. thelevels of exposure to sounds from using PMP on regular basis range widely from 60 to almost 120 dB(A) among the users. the expert group posed the question whether the exposure to music sounds (noise) from PMP and other devices with music player function might cause a quantifiable health risk. Based on a literature search it was estimated that 5 to 20% of young people have audiometric "notches" at 4-6 kHz. Thomas Yung. Nofer Institute of Occupational Medicine.increasing demands from the public. because notched audiogram prevalence varied greatly by definition. Hans Vershuure. James Bridges). either occupational or leisure. [25] However. Staffan Hygge. Rapporteur . [26] The SCENIHR group of experts has agreed that the Noise at Work Regulations can be used for calculatingexposure and risk level related to PMP use. compared to that in the '70s and early '80s.Konrad Rydzynski. [22]. moreover.

and overexposure focused on mostly young (college-age) people. [29] The risk in people older than 30 was negligible. These are the individuals listening to music for over 1 h a day at high volume control setting (>50%). [27] Amongst 28 Canadian teenagers.sound levels are on average from 75 to 85 dB. a risk of hearing loss seems to be minimal. In conclusion. When typical sound levels were considered in combination with self-reported duration of daily use. They emphasized that long-term longitudinal cohort studies are needed to show whether the exposure to PMP music as teenagers can influence hearing loss in old age. the group of experts concluded that 5-10% of young listeners (approx. mainly males. In relation to the priority issues for further research. [27] . or at 89 dB(A) for 1 h a day. assuming that this exposure is repeated over a long period. indicating that up to 25% of this population is at risk of developing hearing loss when listening to music at this level for 8 h. and the percentage of overexposed individuals dropped from 25% to 17%. the group underlined the lack of a proven causal relationship between temporary threshold shift after exposure to music and subsequent permanent hearing damage. Since the SCENIHR report was produced in 2008. The results of the studies published up to 2008 indicated that equivalent SPL referred to 8-h time exposure (LAeq . over a long period of time.5 million teenagers in Europe) are at high risk of developing hearing loss after five or more years of exposure.8h) ranging between 75 to 85 dB(A). in the majority of PMP users. there has been a growing body of literature published on assessing the risk of hearing loss due to PMP use in teenagers and young adolescents. the median sound levels at typical and "worst case" volume settings were 71 dBA and 79 dBA respectively. Williams' comparative study of Australian teenagers' listening habits with PMPS showed that average equivalent sound levels of music had decreased in 2009 compared to those in 2005. Thus. or of a change from post-exposure tinnitus to permanent tinnitus. The mean decrease was 5 dB (from 80 dB (A) in 2005 to 75 dB (A) in 2009). If the equivalent value of 80 dB (lower action level according to the 2003 / 10/EC noise directive) is converted using the time-intensity trade-off of 3 dB increase for halving the time. 2. [28] The listening time was around or below 2 h a day. then the minimal action exposure levelwould be reached after listening to a PMP at 95 dB(A) for 15 min a day. none of the participants surpassed Leq(8h) 85 dBA.

The efficacy of this kind of a hearing conservation program has been recently assessed in elementary school (Grade 6) children. then at two weeks and six months after administration of a hearing conservation program (Sound Sense TM ). discuss possible protective measures and safety guidelines and the consequences of hearing loss. [32] Also. as compared to those listening to levels <80 dB(A) (16% individuals vs. 90% reported listening to music through earphones on MP3 players. despite full recovery of cochlear thresholds. The study concluded that the majority of PMP users are at increased risk for NIHL. it has been shown that acoustic overexposure can also produce a rapid and irreversible loss of cochlear nerve terminals on inner hair cells and a slow degeneration of spiral ganglion cells. 42% of individuals were shown to be exposed to music from PMP at equivalent sound levels of 85 dB and more. found that 58. in a New York City college. to reduce the duration of use of personal music devices in the intervention group. 4%).6% were categorized as listeners at risk for hearing loss as a result of estimated exposure of 89 dBA for >1 h per day. Differences between the intervention and control group responses to a behavioral questionnaire interview were measured at baseline. launch public health campaigns to improve awareness of the risks to hearing from listening to high-volume music. findings from some recently published studies are alarming. [33] This review of evidence makes a good case that preventive measures are needed to reduce the risk of hearing loss in adolescents and young adults from PMP use. although non-significant in statistical terms.5% of PMP teenage users were exposed tolevels above 100 dBA. rock concerts and other loud-noise events in the long and short term. in Canadian high school students. This could include encouraging manufacturers to produce safer products. amongst these. [30] As many as 5. This intervention resulted in significant improvement of protective measures for hearing such as ear plug use at dances. There was also a tendency. [34] Dietary and pharmacologic otoprotection in acoustic trauma Noise-induced hearing loss is associated with the damage and loss of sensory outer hair cells in the cochlea. Out of 1687 adolescents in Dutch secondary schools who underwent a questionnaire survey. the authors showed fourfold significant increase of tinnitus prevalence in teenagers listening to music at the level >80 dB (A). 18-53 years of age. raising concerns of hearing loss.However.2% exceeded daily the 85 dB A-weighted 8-h equivalent sound levels (LAeq ). Moreover. [31] Another study of 189 college students. Recently. whilst none of them were exposed to such high levels from disco music. 28. and .

which produced significant increases in plasma concentrations of vitamins C and E. Recently. placebo-controlled crossover study was conducted on 53 male workers exposed to 88. such as calcium antagonism.[43] some studies did not confirm this finding in the same strain of animals [44] and in other species (C57BL/6J mice). [37] Permanent hearing threshold shift has been seen in CBA/J mice maintained on a diet supplemented with a combination of beta-caroten. it seems to be a very promising drug candidate to be applied in humans (like military soldiers).[36] Alongside progress made over recent years in understanding molecular mechanisms involved in hair cell and nerve damage after noiseoverexposure and a large number of experimental studies in animals. Long-term (one month) administration of magnesium has been shown to be an effective treatment in terms of hair cell preservation in guinea pigs exposed to impulsenoise (three gunshots. Since oxidative stress plays an important role in noise-induced cochlear injury. vitamins C and E and magnesium. These effects were seen even at low doses and when given orally by gavage. anti-ischemic effect or NMDA (N-methyl-D-aspartate) receptor channel blockage. and that antioxidative compounds could be effective in preventing both TTS and PTS. However.4 dB noise [47] which showed that NAC significantly reduced TTS. [23]. 170 dB SPL).. a precursor of glutathione. Kopke et al. [41] showed that N-acetyl-L-cysteine (L-NAC). [42] Although L-NAC efficacy was shown by other authors. a double-blind. [35]. [45] Since L-NAC is approved for clinical use and is very loss of inner and outer hair cells.4-89.. [39] This data suggests that free radical formation contributes to temporary threshold shift (TTS) as well as permanent threshold shift (PTS). are obtained from dietary sources. including these that directly influence the availability of antioxidant precursors. antioxidant compounds appear very promising for therapeutic use in humans. This effect was more prominent in . [40] Multiple mechanisms could be involved in this effect. Many antioxidants. some therapies are now becoming available for use in humans. also effectively reduced temporary hearing loss in guinea pigs after acute exposure to noise. In a series of experiments. and magnesium. protected the hearing of chinchillas from the effects of a single exposure to noise. a clinical open trial performed by Kramer et al. when compared with methylprednisolone and placebo. [46] in 31 normal-hearing participants did not confirm that NAC can protect humans against noise-induced temporary threshold shifts after 2 h of exposure to live music in a nightclub. [38] This combination of nutrients.

Over the last few years there has been a great increase in association studies trying to identify the susceptibility genes for NIHL in humans. D-met has good oral bioavailability and appears to have a good safety profile. indicating that the effectiveness of treatment might depend on gene polymorphisms. a disease susceptibility allele is expected to occur more often in the susceptible group than in a resistant one. So far. [48] D-methionine (D-met). and were sufficient in size to yield high power for the detection of a causative allele. [55].[56] because they were replicated in the independent population. The other genes of interest are oxidative stress .[50] even when first administered hours after a noise exposure. like NIHL. oral drugs to protect against acoustic trauma should be available within the next 5-10 years. a component of cheese and yogurt. and their genotyping is believed to be a successful tool in analyzing the genetic background of complex diseases. eliminate noise-induced hearing loss. In such studies. Tens and hundreds of Single Nucleotide Polymorphisms (SNPs) of different genes known to play a functional and morphological role in the inner ear were screened. An option for the future could be N-acetylcysteine amide (NACA). This compound has been proved to prevent NIHL in animal studies [49]. the most promising results were obtained for genes involved in the inner ear potassium ion recycling [53]. is an oral pharmacologic otoprotective agent that could soon become available to reduce. SNPs are common point mutations in the genome (occurring every 100 .[54] and heat shock protein genes (HSP70). [52] Genetics of noise-induced hearing loss It is widely accepted that noise-induced hearing loss (NIHL) is a complex disease which results from the interaction of genetic and environmental factors. or for some exposures. Inherited factors might explain up to 50% of the hearing loss variability after exposure to noise. and would need to be used in much higher doses than currently approved clinical prescriptions. but seems to easily reach brain fluids. [51] With the current pace of development. The limitation to effective use of L-NAC in humans is that this drug does not readily cross the blood-brain barrier.300bp). The drug is approaching clinical trials with the US Army. a novel antioxidant and potent heavy metal chelator which has a similar chemical structure to N-acetylcysteine (NAC).subjects with glutathione S transferases null genotypes (both GSTM1-null and GSTT1-null).

it is. Nose and Throat Disorders Group Trials Register and the Cochrane Central Register of Controlled Trials. association studies on susceptibility genes for NIHL have been conducted based on candidate gene approach. Identification of susceptibility genes may lead to the development of genetic tests which would allow treatment to be personalized . In four studies. One study evaluated the effect of new legislation in reducing noise exposure.0) despite hearing protection. It found that the median noise level decreased by 27. Fourteen studies with 75. Because of difficulties in replicating the results on the one hand. Identification of susceptibility genes can also be helpful in identifying the population at high risk. Noiseattenuation ratings of hearing protection under field conditions were consistently lower than the ratings provided by manufacturers. the significance of genetic variation in NIHL development has been also shown for otocadherin 15 and myosin 14 genes. a logical next step for research on the genetics of NIHL is Whole Genome Association Studies. as well as enabling better hearing protection in predisposed individuals. It has been shown that several gene polymorphisms are probably involved in determining susceptibility to NIHL.672 participants evaluated hearing loss prevention and six studies with 169 participants evaluated hearing protection.gene therapy is a possible approach. [58] Hearing conservation Recent studies indicate that hearing loss prevention programs (HLPPs) are still not satisfactory. [59] The search comprised several databases.0 (95% CI 1. The effectiveness of non-pharmaceutical interventions for preventing occupational noise exposure or occupational hearing loss was compared to no intervention or alternative methods. workers in hearing loss prevention programs had 0. Recently. but applying specific medications might also be advisable. The odds ratio for hearing loss was 3. The authors have concluded that there is contradictory evidence that hearing loss prevention programs are effective for . [57] Up to the present time. and the development of high-throughput genotyping methods along with the growing databases of SNPs on the other. 21 studies were included.1-8. however.7 dB(A). with a change in trend in time of -2.genes. In establishing the role of some of them. such as the Cochrane Ear. necessary to search for the interaction between gene variations and environmental factors.1 dB per year. In total.5 dB HL greater hearing loss at 4 kHz than non-noise-exposed workers.

a draft European standard had been developed by the relevant working group in CENELEC European Committee for Electrotechnical Standardization. [61] The necessity to launch an improved noise policy for hearing protection along with developing a good theoretical model of noise-induced hearing loss risk assessment has been emphasized in studies. Individuals monitoring daily noise exposure experienced on average no further aggravation of high-frequency hearing loss. a sound level of 85 dBA is considered to be safe under all conditions of PMP use. [62] In this document. Recently. as well as technical interventions are needed. Conclusions . and better implementation and reinforcement. [60] In relation to environmental exposures. while matched controls showed decelerating hearing loss. limiting environmental exposures to loud noise. The factors which are most effective in reducing the damage to the cochlea caused by noise seem to be encouraging theuse of hearing protectors. comprehensive educational intervention was shown to have very limited effectiveness in preventing NIHL. The sound level can be increased up to a maximum average of 100 dBA. the results are also not satisfactory. and change in lifestyle. [11] Noise policy As a result of the SCENIHR report conclusions. [62] CENELEC is expected to continue with the next step of mandated work comprising the development of "smart" methods of providing protection against excessive sound pressure levels from PMP based on the measurement of sound dose. [59] A promising intervention to increase the effectiveness of hearing conservation programs is the daily monitoring of at-ear exposure along with regular feedback on exposures from supervisors. but in that case the user has to be provided with warnings about the risks. In the 16-year follow-up study performed among students of 34 rural high schools. which should be repeated after each 20 h of listening time. Although the intervention group reported significantly greater use of hearing protection.long periods. annual rates of loss were compared between 78 intervention subjects and 234 controls in an aluminum smelter company. there was no significant difference between the intervention group and the group with objective measures of hearing loss.

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Substance Antioxidants Title Noise-induced hearing loss Author Sliwinska-Kowalska. Medical Sciences-Otorhinolaryngology ISSN . Mariola. Occupational Health And Safety. Place of publication Mumbai Country of publication India Publication subject Environmental Studies--Pollution. Davis. Ltd. Adrian Publication title Noise & Health Volume 14 Issue 61 Pages 274-80 Number of pages 6 Publication year 2012 Publication date Nov 2012 Year 2012 Publisher Medknow Publications & Media Pvt.

org/10.104893 Accession number 23257577 ProQuest document ID 1267097851 Document URL http://search.doi.4103/ Copyright Copyright Medknow Publications & Media Pvt Ltd Nov 2012 Last updated 2013-04-16 Database ProQuest Medical Library .proquest.14631741 Source type Scholarly Journals Language of publication English Document type Journal Article DOI http://dx.