International Journal of Pediatric Otorhinolaryngology 93 (2017) 117e122

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International Journal of Pediatric Otorhinolaryngology

journal homepage: http://www.ijporlonline.com/

Amplified music exposure carries risks to hearing

ria Gomes da Silva*, Carlos Augusto Costa Pires de Oliveira, Pedro Luíz Tauil,
Vale

Luiz Lopes Sampaio
Isabella Monteiro de Castro Silva, Andre
University of Brasília, Brazil

a r t i c l e i n f o a b s t r a c t

Article history: Objective: To investigate the association between changes in the outer hair cells and exposure to
Received 23 September 2016 amplified music in a group of high-school students.
Received in revised form Materials and methods: In this retrospective, case-control study, 86 subjects underwent audiometry,
18 December 2016
immittance audiometry, and distortion-product otoacoustic emission tests. The subjects were questioned
Accepted 21 December 2016
Available online 27 December 2016
about their listening habits and divided into 2 groups: exposed and unexposed.
Results: Most of the subjects had reduced function in their outer hair cells, mainly beginning at 8 kHz.
Among 60 subjectsd30 cases and 30 controlsd75% were considered exposed and 25% unexposed. The
Keywords:
Adolescents
exposed subjects were 9.33 times more likely to have altered outer hair cells than the unexposed subjects
Amplified music were.
Leisure Conclusion: Exposure to amplified music is associated with reduced function in the hair cells.
Hearing loss © 2016 Published by Elsevier Ireland Ltd.
Cochlear hair cells

1. Introduction discomfort and pain. Moreover, sounds approaching 130 dB SPL

Concerns have been increasing regarding hearing impairment
caused by noise exposure among young adults; indeed, many
studies have been published on this subject [1e3]. Noise-induced
hearing loss (NIHL) is the second-most common cause of sensori-
neural hearing loss; it is considered an irreversible chronic disease
that damages the inner hair cells.
Young people, especially adolescents, are increasingly exposed
to amplified music, especially during their leisure activities. Spe-
cifically, they visit concerts, which can reach volumes of
100e115 dB (dB), listen to automobile sound systems, whose in-
tensity can measure up to 120 dB, and use portable music devices,
such as MP3 players [1,4e6]. The American Speech-Language-
Hearing Association has stated that these music players reach up
to 125 dB, depending on their brand and type of earphone [7]. In
addition, young people often attend parties, bars, and nightclubs, in
which, the sound intensity varies according to country. In Brazil and
USA, these types of stimulus can reach volumes of 93e109.7 dB; in
Argentina, the sound intensity is even higher: 104e112 dB. The
human auditory system is able to withstand sounds up to 90 dB
sound-pressure level (SPL), and sounds exceeding this limit cause


* Corresponding author. Qd.201 Resid. Imprensa I, Apto1203 Bl-D, Aguas Claras,
Brasília-DF, Brazil CEP: 71937-540.
E-mail address: valeriafga@gmail.com (V.G. da Silva).
may cause damage to the auditory system [8,9].
A recent study carried out by Silva et al., 2012 [1] using otoa-
coustic emissions (OAE) tests showed that, in a sample of 134
students from Brasília, Brazil aged between 13 and 18, the preva-
lence of injury in the otic sensory cells was 79.9%. Concerning the
students' history of exposure to amplified music, 94.0% reported
using earphones, and 82.8% reported attending places with
amplified music [1].
The evaluation and monitoring of hearing loss in general are
done through threshold tone audiometry, but the audiometric
evaluation is insufficient to determine the functional status of the
outer hair cells (OHC), since lesions of up to 30% of OHC with
normal hair cells (IHC), may occur before any hearing loss is
detected. Therefore, OAE are efficient for early assessment of
cochlear function in subjects exposed to noise, without hearing loss
being diagnosed [10]. The OAE are sounds produced by the physi-
ological activity of the OHC of the Corti organ and are observed in
individuals with cochlear integrity [11]. Due to the capability of to
OAE demonstrate the functioning status of these cells, this test has
been adopted as a procedure of auditory investigation in several
clinical situations, including the monitoring of hearing of subjects
exposed to high sound intensities. The literature indicates that
exposure to intense sounds with a headset for about 15 min is
sufficient for auditory changes to accur [12]. The amplitude and
signal-to-noise ratio of otoacoustic emissions, will detect these

http://dx.doi.org/10.1016/j.ijporl.2016.12.023
0165-5876/© 2016 Published by Elsevier Ireland Ltd.
118 V.G. da Silva et al. / International Journal of Pediatric Otorhinolaryngology 93 (2017) 117e122
changes.
Evoked otoacoustic emissions (EOAEs) can be used to detect
cochlear alterations before they are detectable by pure-tone audi-
ometry (PTA), since EOAEs are more sensitive to OHC damage. They
also allow specific assessment of functionality in the outer hair cells
(OHCs) [13,14]. A 1998 ordinance in Brazil [15] recognized that
cochlear alterations caused by noise exposure primarily affect high-
frequency ranges. Thus, in occupational monitoring, it is appro-
priate to carry out a hearing test that mainly investigates the
integrity of cochlear tonotopy at high frequencies. Hence, in-
vestigators frequently use distortion-product otoacoustic emissions
(DPOAE) as an OAE test in studies related to noise exposure
[4,15e20].
Hearing impairment in young people, and its association with
excessively intense listening habits, is well documented, especially
in young adults aged >18 years [1e4]. Nonetheless, further evi-
dence is required regarding hearing impairment associated with
risky listening habits, such as exposure to amplified music. A pre-
vious study [3] found a high prevalence of OHC alterations in high
school students, indicating that a case-control study should be
carried out in order to (1) verify whether the hearing impairment
observed in the case group was associated with exposure to noise
from amplified music, and (2) to assess, if possible, whether this
damage was caused by exposure to noise. The latter was the
objective of the present study.
2. Materials and methods
This was a retrospective, case-control study carried out in three
high schools in the Federal District, Brazil, from August 2013 to
December 2014. The study was approved by the Research Ethics
Committee of the Faculty of Medicine, University of Brasília, under
protocol number 059.058.
2.1. Sample
The study included 86 randomly selected participants of both
genders. Schools were selected according to the convenience of the
researchers, upon approval of their board of directors.
To qualify for the study, the subjects had to (1) be between 13
and 18 years old, (2) have not used ototoxic drugs and/or personal
sound-amplification products (PSAP), (3) have no complaints and/
or symptoms of ear disease, and (4) provide an informed consent
for signed by their legal representative, indicating acknowledge-
ment and agreement with the procedures. The exclusion criteria
were as follows (1) history of outer or middle ear disorders, (2) PTA
results above 25-dB hearing level in any frequency evaluated, (3)
absence of acoustic reflexes at all frequencies in immittance audi-
ometry, and (4) tympanometry results with type “B” or “C” curve
corresponding to these alterations.
In this case-control study, the sample comprised 60 subjects, 30
with abnormal OAE tests, allocated to the case group, and 30 with
normal OAE tests in the control group. The exposed and unexposed
groups were determined using a self-administered questionnaire
that identified behavior that is risky for auditory health. Subjects
who responded to all alternatives indicating high-risk listening
behavior were considered exposed, while subjects who answered
all alternatives indicating low-risk listening behavior were
considered unexposed. In this manner, the possible association
between evidenced hearing loss and exposure to amplified music
was studied.
2.2. Procedures and materials
The subjects included in the study underwent anamnesis,
otoscopy, PTA, and immittance audiometry to meet the inclusion
criteria in the study, as well as DPOAE to define the case (with al-
terations) and control groups (no alterations). Before the study, to
profile participants regarding their listening habits and classify
them as either exposed (high-risk) or unexposed (low-risk), sub-
jects responded to a questionnaire (Appendix A) regarding time
spent using earphones and attendance in places with amplified
music.
PTA was used to determine air-conduction thresholds in a
soundproof booth model VSA-40, a Vibrassom audiometer model
AVS-500, and a supra-aural headphones model TDH39, at fre-
quencies between 0.25 and 8 kHz. Immittance audiometry,
including tympanometry and the acoustic reflex of the stapedius
muscle, was assessed using a manual mode, Interacoustics™ mid-
dle ear analyzer model AZ-7, as well as the ipsilateral acoustic reflex
at 1 and 2 kHz and the contralateral acoustic reflex at 0.5, 1, 2, and
4 kHz.
DPOAEs were assessed using a MAICO™ model ERO-SCAN, with
a bandwidth near 2, 4, 6, 8, 10, and 12 kHz, intensity of 65 dB SPL in
L1, and of 55 dB SPL in L2. Two pure tones (F1 and F2) were used as
acoustic stimuli; they were simultaneously paired so that F1/
F2 ¼ 1.22 (ratio).
2.3. Data analysis
The PTA used bilateral hearing thresholds 25 dB as normal
criteria at all frequencies. For immittance audiometry, the criteria
were: (1) presentation of A-type, As-type, or Ad-type of tympa-
nometric curves in both ears, and (2) acoustic reflexes in up to 3 of
the 6 frequencies evaluated.
To evaluate the DPOAE, the criterion used to signal amplitude
values 5 dB and a signal-to-noise (S/N) ratio <6 dB in 5 of the 6
frequencies evaluated was “pass”. The subjects who met this cri-
terion in both ears were allocated to the control group. Others were
deemed “fail” and allocated to the case group. The OEA analyzer
used in this study automatically monitored the noise level, linearity
stimulus, and appropriate positioning of the probe during the test.
The listening habits survey considered the responses of the
questionnaire. Subjects who answered “A” to the first 2 questions of
the questionnaire were considered high-risk, i.e., exposed. The
other subjects who answered “B” were considered low-risk or
unexposed.
The necessary sample size in this case-control study was
calculated using a 95% confidence interval (CI), 0.05 a-level, 0.20 b-
level, and a 1:1 control-case ratio, resulting in 13 subjects in the
case group and 13 in the control group.
Regarding statistical analysis, the dependent variables were the
following: signal amplitude, sound/noise ratio, which verified the
existence or lack of an association with the independent variable
(exposure to amplified music). Pearson's chi-square test and 95%
CIs were used to evaluate the significance of the calculated odds
ratio. The level for statistical significance was set as 5% (p < 0.05).
Epi-Info software, version 3.5.1, was used.
3. Results
3.1. Selection of groups
Initially, 26 of the 86 subjects were excluded from the study: 12
had a middle-ear condition, 4 had increased thresholds in audio-
metric tests, 3 showed abnormal results in tympanometry, and 7
responded inconsistently to the questionnaire. Therefore, this case-
control study was carried out using 60 subjects. Thirty presented
abnormal results (“fail”) and were allocated to the case group, and
30 presented normal results (“pass”) and were allocated to the
 V.G. da Silva et al. / International Journal of Pediatric Otorhinolaryngology 93 (2017) 117e122 119

control group. right ear (p < 0.005).

3.2. Assessment data
All subjects showed thresholds within normal limits and 95%
(n ¼ 57) showed a type “A” tympanometric curve. Acoustic reflexes
were more “frequent” than “absent”: 83.3% (n ¼ 50) in the left ear
compared to 88.3% (n ¼ 53) in the right ear. Concerning gender and
age, 56.7% (n ¼ 34) of the subjects were girls and 43.3% (n ¼ 26)
were boys; the mean age was 15.1 ± 1.2 years. Regarding the OAE
tests, “pass” was more common in the right ear (70%; n ¼ 42) than
in the left ear (65%; n ¼ 33).
The listening-habits survey showed that most subjects (75%;
n ¼ 46) were exposed to amplified music and only 25% (n ¼ 14)
were considered unexposed (Table 4).
An association was found between exposure to amplified music
and whether the subject was in the case or control group
(OR ¼ 9.33; 95% CI ¼ 1.65e68.78; p ¼ 0.006), indicating an asso-
ciation between exposure and alterations in OAE tests. Thus, a
causal relationship was found between OAE alterations and expo-
sure to amplified music.
4. Discussion

3.3. Association analysis
In terms of sex, no significant differences (p ¼ 0.795) were found
between the case and control groups. The subjects were signifi-
cantly older in the case group: their average age was 15.4 ± 2.3
years in the case group and 14.8 ± 1.1 years in the control group
(p ¼ 0.017).
Over 60% (60.9%) of subjects who were exposed to noise were
girls; 57.1% of those unexposed were boys. There were no signifi-
cant sex-specific differences in terms of auditory exposure
(p ¼ 0.377). The average age of the participants in the exposed
group was 15.3 ± 1.3 years, whereas that of the subjects in the
unexposed group was 14.4 ± 0.9 years; therefore, participants in
the exposed group were significantly older than those in the un-
exposed group (p ¼ 0.017).
In Table 1, when observing the amplitude responses and left ear
S/N ratio between the exposed and non-exposed individuals of the
case group, it can be seen that the best responses were those of the
non-exposed individuals. Although they did not have statistically
significant differences, the absolute values in the majority of fre-
quencies evaluated, evidenced relatively better answers among the
non-exposed individuals. The same occurred in the control group,
except for the frequency of 8 and 10 kHz in the S/N ration and
12 kHz in the AMP.
In the right ear, we observed better S/N ratio results among the
non-exposed subjects in the majority of frequencies evaluated,
except for the 12 kHz frequency in S/N ration for the control group
(Table 2).
In Table 3, we observed that the absolute values of amplitude
and S/R ratio in the unexposed individuals of the control group
were higher than those exposed in the case group. These responses
were observed at all frequencies of both ears except at 8 kHz in the
S/N ration in LE However, there were statistically significant dif-
ferences in the mean S/N ratio responses for both the left ear
(p ¼ 0.001) and the right ear (p ¼ 0.004) and the selective fre-
quencies of 2, 4 and 8 kHz in the left ear and 4 and 12 kHz In the
This study was prompted by the results of a previous investi-
gation [1] that found significant alterations in OAE tests among
teenagers who were frequently exposed to amplified music. Spe-
cifically, Silva et al. [1] found that 79.9% of their sample showed
alterations in OAE tests, and 94.0% used earphones. Nonetheless,
the authors stipulated that more detailed study was necessary to
assess the subjects' hearing using the OHC and relate these findings
to the participants' listening habits and to verify whether high rates
of abnormal results are associated with a high prevalence of ear-
phone use and/or exposure to amplified music.
4.1. Analysis of OAE
In the present study, a higher proportion of the subjects were in
the case group: those who were given a “fail” in the DPOAE. In our
other studies [1], which used parameters similar to those of this
study, when the occurrence of DPOAE in subjects exposed to loud
music was considered, a higher proportion of tests were awarded a
“fail” than were given a “pass.” Another study found higher rates of
normal results than those in this study. However, the authors did
not describe accurately the evaluation criteria used. Furthermore,
the study considered higher frequencies than in this work thus,
more alterations were found, mainly in the other bandwidths [3,5].
According to the “pass/fail” criterion used in this study to divide
the subjects into the case or control group, more were deemed a
“pass” in the right ear (70%) than in left ear (65%). A similar pattern
was found in the average absolute amplitude and S/N ratio when
the right and left ears were compared. The average S/N ratio of the
right ear varied between 13.3 and 26.0 dB SPL; that of the left ear
fluctuated between 12.5 and 25.1 dB SPL; a higher average was
found in the unexposed group. Comparing our results with those of
other studies [6,16], previous averages have been lower than our
own, with a bandwidth between 10 and 15 dB SPL in unexposed
participants, and between 5 and 15 dB SPL in exposed groups.
This finding may be related to what occurs during transient
emissions in the right ear of women whose amplitudes are higher

Table 1
Average amplitude and signal-to-noise ratio in the exposed and unexposed left ears of the case and control groups.

Frequency (kHz) Group

Case Control

Exposed Unexposed P-value Exposed Unexposed P-value

Ampl. S/R Ampl. S/R Ampl. S/R Ampl. S/R Ampl. S/R Ampl. S/R

2 5.3 14.2 11.5 21.5 0.80 0.30 8.1 16.7 10.8 16.1 0.07 1.00
4 2.2 18.8 4.5 24.0 0.35 0.07 4.7 21.2 5.9 22.4 0.61 0.51
6 3.9 20.9 4.0 19.0 0.58 0.63 5.7 25.1 4.3 21.9 0.39 0.19
8 10.4 17.9 6.5 21.0 0.88 0.53 6.1 24.8 3.7 16.3 0.42 0.01
10 3.7 17.5 7.0 22.0 0.30 0.68 7.7 24.4 7.1 18.6 0.76 0.02
12 4.2 12.9 3.5 12.5 0.56 1.00 6.7 17.8 1.3 12.9 0.01 0.13
General 4.7 17.5 6.1 19.8 0.36 0.24 6.5 21.7 5.7 18.0 0.40 0.00

Amp: Amplitude, S/R: signal-to-noise ratio; p < 0.05 by ManneWhitney test.

120 V.G. da Silva et al. / International Journal of Pediatric Otorhinolaryngology 93 (2017) 117e122

Table 2
Average amplitude and signal-to-noise ratio in the exposed and unexposed right ears of the case and control groups.

Frequency (kHz) Group

Case Control

Exposed Unexposed P-value Exposed Unexposed P-value

Ampl. S/R Ampl. S/R Ampl. S/R Ampl. S/R Ampl. S/R Ampl. S/R

2 8.6 16.9 8.5 19.5 0.23 0.28 9.3 15.8 9.6 17.4 0.78 0.48
4 3.2 19.7 1.0 21.0 0.27 0.75 6.0 21.7 5.7 23.9 1.00 0.25
6 4.8 23.4 1.0 20.5 0.82 0.57 6.2 23.9 6.2 24.5 0.85 1.00
8 6.0 19.3 6.0 16.5 0.62 0.86 4.4 20.9 5.0 20.3 1.00 0.59
10 6.6 18.5 11.0 26.0 0.49 0.32 8.0 23.8 10.6 20.8 0.28 0.30
12 1.8 13.3 2.0 14.0 0.94 0.78 5.3 19.7 3.2 14.3 0.51 0.03
General 5.4 18.8 4.0 19.5 0.60 0.67 6.5 20.9 6.7 20.2 0.86 0.40

Amp: Amplitude, S/R: signal-to-noise ratio; p < 0.05 by ManneWhitney test.

Table 3
Mean amplitude and signal-to-noise ratios for subjects “case exposed” and unexposed.

kHz LEFT EARS RIGHT EARS

Case exposed Control P-value AMP P-value S/N Case exposed Control P-value AMP P-value S/N
unexposed unexposed

AMP S/N AMP S/N AMP S/N AMP S/N

2 5,3 14,2 10,8 16,1 0,007 0,156 8,6 16,9 9,6 17,4 0,80 0391
4 2,2 18,8 5,9 22,4 0,04 0,729 3,2 19,7 5,7 23,9 0,34 0033
6 3,9 20,9 4,3 21,9 0,65 0707 4,8 23,4 6,2 24,5 0,57 0273
8 10,4 17,9 3,7 16,3 0,03 0,211 6,0 19,3 5,0 20,3 0,87 0,16
10 3,7 17,5 7,1 18,6 0,18 0559 6,6 18,5 10,6 20,8 0,30 0383
12 4,2 12,9 1,3 12,9 0,20 0,26 1,8 13,3 3,2 14,3 0,56 0,03
General 4,7 17,5 5,7 18,0 0,19 0001 5,4 18,8 6,7 20,2 0,12 0004

Amp: Amplitude, S/R: signal-to-noise ratio; p < 0.05 by ManneWhitney test.

Table 4 exposure to non-occupational noise has been a source of increasing

Continuity between groups and subgroups.
Subgroup/group Case Control
Exposed 28 18
Unexposed 2 12
Total 30 30
Yates's continuity correction ¼ 7.55; p ¼ 0.006.
because of the influence of spontaneous emission [11]. When both
subgroupsdexposed and unexposeddwere compared in our study
(Tables 1 and 2), the right ear showed superior responses, espe-
cially in the unexposed group.
Comparing the results between the exposed and unexposed
groups in Tables 1 and 2, a tendency towards lower amplitude was
observed as frequency increased, although no significant difference
(p > 0.05) was found. This corroborated the findings of previous
studies, using different equipment that associated higher fre-
quencies with smaller amplitude found [1,4].
The results found between the groups studied were not signif-
icant in all bandwidths evaluated. However, they highlight, to a
greater or lesser extent, a prognosis of susceptibility to hearing loss.
Low amplitude values were likely to suggest subclinical cochleop-
athy, since smaller amplitudes and S/N ratios were mainly found at
high frequencies. One could also hypothesize that these cochlear
regions had already been affected by noise [15].
4.2. Exposure to amplified music
Previous studies have shown that individuals who have already
used earphones, or who have been more exposed to noise, have
higher hearing thresholds than those who have not used earphones
or who have been less exposed to noise [7,21,22]. In this regard,
concern. For instance, one study [23] indicated that non-
Total occupational noise is less likely to cause injury, although the
number of young people exposed to such noise, especially using
46
14 earphones, is considerable.
60 The subjects in the case group had a higher mean age than those
in the control group (p ¼ 0.017), indicating that older people may
be more likely to show alterations in cochlear function. Further-
more, our results clearly showed that the odds of individuals
developing cochlear alterations were 9.33 times (OR) greater when
they were exposed to amplified music than when they were
unexposed.
In the present study, the survey carried out to evaluate the
exposure of adolescents to amplified music suggested that they do
not currently consider the harmful effects of loud music. When
subjects responded to a questionnaire regarding earphone use and
exposure to amplified music, most young people indicated that this
was frequent behavior; therefore, most were included in the
exposed group (Table 3). It seems that young people are not con-
cerned about excessive sound volume or prolonged exposure to
noise, both of which increase their risk of early and irreversible
cochlear lesions [24]. In the Netherlands, 70% of young people have
reported attending nightclubs, and 24.6% are at risk of hearing loss
due to exposure to 100-dB noise levels >60 h a week without
hearing protection [25].
Music is pleasant to human beings; however, it may also be
injurious. Sounds linked to leisure, such as music, although less
harmful, are, nevertheless, currently a risk factor for hearing loss.
According to a World Health Organization (WHO) document,
Guidelines for Community Noise [23], investigators are concerned
about young people in environments like parties, nightclubs, con-
certs, cinemas, and outdoor events, because exposure to high-
intensity noise (>100 dB) may lead to hearing impairment. The
 V.G. da Silva et al. / International Journal of Pediatric Otorhinolaryngology 93 (2017) 117e122 121

present study only questioned participants about whether they A- ( ) to more than 1 year? B- ( ) at least 1 year?
used earphones or attended places with amplified music. Other
studies addressing the other listening habits of young people have 5 How often do you listen to music using headphones?
indicated that young people listen to music using earphones more
often than older people do [26,27]. Our results may indicate that A- ( ) every day? B- ( ) less than 3 days per week?
young people are not aware of the problems this kind of noise can
cause. 6 On average, what is the daily time you usually listen to?
NIHL is an invisible condition, and evidence from the listening
habits of young people indicates that they may be ignoring NIHL. A- ( ) over 2 h per day B- ( ) less than 1 h per day?
Therefore, the condition could be minimized with the support of
schools and educational programs. In addition to the minimal 7 As for where you go, how long to began attending these
cochlear alterations shown in this study, other hearing damage may environments?
occur in this population. For instance, tinnitus is a very common
complaint among the population in general [28e30]. Young people A- ( ) to more than 1 year? B- ( ) at least 1 year?
should be informed at an earlier age about the risks of hearing loss
from exposure to high-intensity sound [30], which can occur via 8 How often do you go to these places?
headphone use or through leisure activities involving loud music.
Some actions that could minimize these bad habits include the A- ( ) more than 1 per month B- ( ) 1 per month
following: monitoring the intensity levels of environments with
music, addressing issues related to healthy listening behavior in the
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