J Am Acad Audiol 23:824-830 (2012)

Case Report

Hearing Loss Associated with Xylene Exposure

in a Laboratory Worker
DOI: 10.3766/jaaa.23.10.7

Adrian Fuente*
Bradley McPhersonf
Linda J. Hoodt

Absfracf

Background: Xylene is an organic solvent, vi/idely used in histology laboratories and other occupational
settings. Research in animals has demonstrated that xylene induces outer hair cell damage. Evidence
regarding the effects of xylene in humans is only available from studies investigating workers exposed to
mixtures of^solvents containing xylene. These data indicate that mixtures of solvents containing xylene
may induce hearing loss and central auditory dysfunction.

Purpose: To comprehensively evaluate the peripheral and central auditory system of a histology labo-
ratory worker exposed to xylene, who had presented with bilateral mild sensorineural hearing loss at an
initial assessment.

Research Design: A case report of a male histology laboratory worker who has been exposed to xylene
for over 20 yr.

Results: A diagnosis of bilateral mild sensorineural hearing loss of cochlear origin was made on the basis
of otological, neuroimaging, and audiological examinations. Results indicating the absence of transient-'
evoked otoacoustic emissions, and auditory brainstem responses as expected for a mild cochlear hear-
ing loss, were obtained.

Conclusions: The observed bilateral mild sensorineural hearing loss was considered to have been
induced by xylene exposure, due to the absence of any other etiological factors related to the onset
of hearing loss. The results found in this patient are in agreement with animal data indicating xylene-
induced ototoxicity. Xylene-exposed individuals should be audiologically monitored on a regular basis.

Key Words: Occupational hearing loss, organic solvents, xylene

Abbreviations: ABR = auditory brainstem response; [(C)AP] = (central) auditory processing; DD = Dichotic
Digits test in Spanish; FS = Filtered speech test in Spanish; HINT = Hearing-ln-Noise test; HL = hearing level;
MRI = magnetic resonance imaging; nHL = normal hearing level; OHC = outer hair cell; PEL = permissible
exposure limit; PPS = Pitch Pattem Sequence test; RGDT = Random Gap Detection test; SNR = signal-to-
noise ratio; TEOAE = transient-evoked otoacoustic emission; TWA - time-weighted average

INTRODUCTION used as a solvent (a liquid that can dissolve other substan-

ces) in paints, varnishes, degreasers, paint thinners, and
ylene (C8H10) is an organic solvent, produced pesticides. A common form of laboratory exposure occurs

X from coal tar or by the aromatization of petroleum

hydrocarbons (Johnson and Morata, 2010). It is
during the preparation of tissue specimens for histol-
ogic examinations (Baselt and Cravey, 1989). Xylene

*School of Speech and Hearing Sciences, Faculty of Medicine, Universidad de Chile, Santiago, Chile; tCentre for Communication Disorders,
Faculty of Education, University of Hong Kong, Hong Kong; ^Department of Hearing and Speech Sciences, Vanderbilt University, Nashville TN

Jrian Fuente, School of Speech and Hearing Sciences, Faculty of Medicine, Universidad de Chile, Independencia 1027, Santiago, Chile; Phone:
Adrian
4-56i 2 978 6606; Fax:
I -1-56 2 978 6608; E-mail: afuente@med.uchile.cl
This work was supported by the National Fund for Scientific and Technological Development (FONDECYT), Chile, Project number 11080270.

is rapidly absorbed following inhalation or ingestion,
but is less well absorbed through intact skin. The highly
volatile nature of xylene makes inhalation the most
efficient route of absorption (Horowitz, 2001). Since
systematic studies on solvent-induced hearing loss com-
menced, xylene has been implicated as an ototoxic agent
(Gagnaire et al, 2001).
The effects of xylene on the human auditory system
have been studied only in populations of factory workers
exposed to mixtures of solvents containing xylene, as
factory workers are not typically exposed to isolated
agents. Human studies have found that exposure to mix-
tures of solvents is associated with hearing loss (Morata
et al, 1997; Sliwiñska-Kowalska et al, 2000) and central
auditory dysfunction (Fuente et al, 2011). Animal mod-
els, on the other hand, allow study of the adverse audi-
tory effects ofthe agents in isolation. Data from animal
models suggest that exposure to xylene in isolation is
associated with loss of outer hair cells (OHCs) and thus
peripheral hearing loss (Gagnaire et al, 2007).
In rats, a slight loss of OHCs has been observed in the
first row, with greater loss in the second and third rows
(Gagnaire and Langlais, 2005). Studies conducted in
rats exposed to xylene have found OHC damage, mainly
in the midrange (8-24 kHz) ofthe rats' audible frequen-
cies (Pryor et al, 1987; Crofton et al, 1994). It is impor-
tant to note that the ototoxicity induced by xylene is
species-dependent. Gagnaire et al (2007) have demon-
strated that rats, but not guinea pigs, are susceptible
to the ototoxic effects of xylene.
In humans, Shwinska-Kowalska et al (2000) studied a
population of 117 paint and lacquer factory workers who
were exposed madnly to a mixture of xylenes and ethyl
acetate. The research design also included two nonex-
posed control groups. The results indicated that the group
of workers exposed to xylene and ethyl acetate had worse
hearing thresholds than the nonexposed workers. A
high percentage (30%) of hearing loss was found among
exposed workers, in comparison to nonexposed workers.
The relative risk value for hearing loss in xylene-exposed
workers was greater (9.6) when compared to that for
workers only exposed to noise (4.2). Fuente et al (2011)
studied a group of factory workers who were exposed
to a mixture of solvents containing toluene, methyl ethyl
ketone and xylene, and a nonexposed control group of
subjects. A comprehensive test battery was used to inves-
tigate the central auditory system. Solvent-exposed work-
ers presented with significantly worse results for most of
the tests in comparison to control group subjects, indicat-
ing central auditory dysfunction associated with solvent
exposure. Similar results have been found in other stud-
ies investigating workers exposed to different mixtures of
solvents (Fuente et al, 2007; Johnson et al, 2006; Laukli
and Hansen, 1995; Ödkvist et al, 1987).
A case report was recently published regarding a
patient who had developed auditory neuropathy, associ-
Xylene-Induced Hearing Loss/Fuente et al
ated with xylene exposure (Draper and Bamiou, 2009).
One ofthe main symptoms was the inability to discrim-
inate speech in the presence of background noise. Diffi-
culties in understanding foreign accents and speaking on
the telephone were also reported by the patient, who was
exposed to xylene in his workplace over a period of 6 mo,
with poor ventilation. The hearing difficulties were exa-
cerbated with aging and indeed, the auditory neuropathy
was cUnically diagnosed 40 yr postexposure to xylene.
In summary, despite evidence from animal studies
that xylene induces hearing loss due to the loss of OHCs,
there is limited understanding of whether xylene in iso-
lation may also induce OHC loss in humans. As the
industrial use of xylene seldom occurs alone, but occurs
rather in combination with other solvents, study of
the ototoxicity of xylene in humans is difficult. Data
from human studies cannot differentiate whether the
adverse auditory signs observed in workers exposed
to mixtures of solvents containing xylene are due to
the ototoxic effects of xylene, to the effects of other sol-
vents, or to those solvents in combination, rather than
the organic solvents in isolation.
The aim of the present manuscript is to report an
unusual hearing loss associated with xylene exposure
in a histology laboratory worker. The patient developed
a cochlear hearing loss (pure- tone thresholds worse
than 25 dB hearing level [HL]) in the 1-6 kHz range
(based on standard pure-tone audiometry). The patient
was exposed to xylene over a long period of time. The
authors were unable to find any similar case report
in the literature, in which the exposure to organic sol-
vents had been exclusively to xylene.
METHOD
Case Report
A 46-jT-old Caucasian male visited the Audiology
Laboratory of the School of Speech and Hearing Scien-
ces, Medical Faculty, University of Chile, as a research
volunteer. He was a histopathologist, who had been
working at a histopathology and cytodiagnostics labora-
tory in a Chilean public hospital for 23 yr. He reported
working directly with xylene, on an everyday basis,
using it for human tissue processing, staining, and
cover slipping. According to the patient's report, his
most direct exposure to xylene was when samples with
human tissue had to be embedded in a receptacle with
xylene, for approximately 40 min while he remained at
the same room as the receptacle. He then had to take
the sample from the receptacle for examination under
microscope. He reported that no gloves were used when
handling the sample embedded in xylene. The level of
exposure varied according to the demand for samples
requiring examination. The higher the number of sam-
ples to be examined, the greater the amount of xylene
8S5
Journal of the American Academy of AudiologyA^olume 23, Number 10, 2012

used, and therefore the higher the expected level of air- lOCX) 2000 8000 H!

borne xylene concentration. On average, he reported 0

performing this task approximately four times per 10
day. A recent monitoring of airborne xylene concentra- 20
• ^
A
pi"" "" "'"' '"ftLi ^—*^
tion during 70% of the work shift at the site vsfhere the 30 !]__——=^
40
patient performed his duties showed a mean xylene air- I 50
borne concentration of 60 mg/m^. The permissible expo- € 60
sure limit (PEL) for xylene in Chile is 347 mg/m^ as an 70
80
8-hr time-weighted average (TWA) concentration (Min-
90
isterio de Salud de Chile, 2000) (in the United States, 100
the current Occupational Safety and Health Adminis- 110
tration (OSHA) PEL for xylene is 435 mg/m^ as an 8- 120

hr TWA concentration (US Department of Labor, 8000 Hz

Occupational Safety and Health Administration, 2011).
B
-10
Therefore, the patient's xylene exposure was below 0
Chilean and US OSHA norms for airborne xylene expo- 10
sure levels. 20 SH K

No personal protection against xylene had been uti-
lized by the patient. During the interview, he did not
complain of hearing problems; however, no previous
hearing assessment results were available. The patient
reported that the level of noise exposure at his work-
place was not high and that he did not regularly partic-
ipate in noisy activities such as attending night clubs,
live concerts, sporting events, or parties. Medically, the
patient did not report a history of diabetes, high blood
pressure, kidney dysfunction, metabolic or neurologic
diseases. The patient reported drinking alcohol and
smoking cigarettes socially. No history of past ear infec-
tions or family history of hearing loss was reported. On
the initial hearing evaluation, the patient presented
with bilateral mild sensorineural hearing loss (see Fig-
ure lA) and bilateral type A results (Jerger, 1970) for
tympanometry. The patient was referred to an otolar-
yngologist for medical assessment and management.
Four months after the first audiological assessment,
the patient was reassessed.
Otological Examination
f
40
^7^ 7
I 50
€ 60
70
80
90
100
110
120
Figure 1. (A) IniüeJ air-conduction hearing thresholds for the
right (O) and left ear (X), and bone-conduction hearing thresholds
for the right ([) and left ear (]). • denotes the expected pure-tone
thresholds for the 10% of people with worse hearing level from an
otologically screened population between 40 and 49 yr of age (Inter-
national Standards Organization 7029, 2000). (B) Air-conduction
hearing thresholds for the right (O) and left ear (x), and bone-
conduction hearing thresholds for the right ([) and left ear (])
obtained 4 mo after the initial audiogram. • denotes the expected
pure-tone thresholds for the 10% of people with worse hearing
level from an otologically screened population between 40 and
49 yr of age (International Standards Organization 7029, 2000).
ported no evidence of internal auditory canal mass.
Brain imaging was also negative for infarct, hemor-
rhage, mass, extra-axial fluid, or hydrocephalus.

The otological examination revealed normal external Audiological Assessment

ear canals and tympanic membranes bilaterally. No
abnormalities for the nasal cavity and throat were
reported. There was no history of any medical condi-
tions that could be associated with the onset of hearing
loss, with the exception of xylene exposure. The patient
did not present with any abnormal neurological signs or
symptoms. The patient was referred for a comprehen-
sive hearing assessment and for magnetic resonance
imagining (MRI) examination.
MRI
MRI of the brain and temporal bone with and without
gadolinium contrast was obtained 4 mo after the initial
hearing assessment. The supervising radiologist re-
Four months after the first hearing evaluation the
patient was reassessed. A double-wall sound-treated
audiometric booth meeting specifications for permissible
ambient noise (International Standards Organization
8253-1, 1989) was utilized for pure-tone audiometry,
transient-evoked otoacoustic emissions (TEOAEs),
auditory brainstem response (ABR), hearing-in-noise
test (HINT), and behavioral (central) auditory process-
ing [(C)AP] assessment. A clinical audiometer (Intera-
coustics AC33) delivered all stimuli via TDH-39P
headphones for air-conduction thresholds and via a
Radioear B-71 bone vibrator for bone-conduction thresh-
olds. A compact disc player (LG 73 UN), connected to
the audiometer specified above, delivered all recordings

8S6
 Xylene-Induced Hearing Loss/Fuente et al

of the (C)AP tests. The (C)AP assessment comprised
the Dichotic Digit (DD) test in Spanish (Fuente and
McPherson, 2006), Random Gap Detection test (RGDT)
(Keith, 2000), Pitch Pattern Sequence test (PPS)
(Musiek, 1994), Masking Level Difference test (MLD)
(Wilson et al, 2003) and the Filtered Speech (FS) test in
Spanish (Fuente and McPherson, 2006). The Hearing-
in-Noise Test (HINT) (Nilsson et al, 1994) utilized the
Latin American Spanish sentence module (Baron De
Otero et al, 2008). Immittance audiometry was per-
formed with an Interacoustics AZ7 middle-ear analyzer.
For TEOAE assessment, a portable Echoport plus
(Otodynamics) was used. This equipment was con-
nected to a desktop computer with ILO 88 OAE analysis
sofbware. Stimuh were delivered to the ears via an adult
B-type ILO otoacoustic emissions probe (Kemp et al,
1990). The evoking stimuh used were 80 (xs rectangular
chcks presented at 80 ± 2 dB Peak Equivalent Sound
Pressure Level (peSPL). To control for stimulus artifact,
a "nonhnear" paradigm was used for the cHck stimuli,
where every fourth stimulus was opposite in polarity
and 10 dB higher in intensity. The response time window
was set at 2.5-20 ms and the band-pass filter was set in
the range from 0.5 to 5 kHz. The TEOAE was considered
present if a response was observed above the noisefioorin
any band firom 1.0 to 5.0 kHz with whole-wave reprodu-
cibiHty equal or above 65% (Glattke and Robinette, 2007).
The ABR was recorded with an Interacoustics Eclipse
Platform (EP25) instrument, using AgCl-AgCI electrodes
placed at the scalp at the vertex (Cz) and the ipsilateral
mastoid (A 1/A2), in accordance with the International
10-20 system of EEG recordings. The amplifier band
pass was set between 0.15 Hz and 3 kHz. Two trials, each
averaging 2000 responses, were obtained for each ear
using rarefaction chck stimuh at 80 dB normal hearing
level (nHL), presented monaurally, at a rate of 27.7/sec
latency of wave I, latency of wave III, latency of wave
V, interpeak latencies I-III, I-V, and III-V, and absolute
amplitude (uV) of waves I, III, and V was examined.
Solvent and Noise Exposure Assessment
and contralateral acoustic (stapedius muscle) refiexes
in both ears (see Table 1), with negative results for ipsi-
lateral and contralateral acoustic refiex decay tests for
0.5 and 1 kHz.
TEOAEs were absent bilaterally, as the whole-wave
reproducibihty was 40% and 55% for the right and left
ear, respectively. However, in some frequency bands,
the signal-to-noise ratios [SNR] were above 0 dB. This
was the case for 2 kHz in the right ear (4 dB SNR) and 1
and 2 kHz for the left ear (3 and 5 dB SNR, respectively).
ABR showed the presence of wave III with a latency of
3.67 and 3.7 ms for the right and left ears, and wave V
with a latency of 5.8 and 5.7 ms for the right and left
ears. ABR results were observed with better wave
reproducibihty in the left ear. All the ABR values were
within the normal range (Hood, 1998), and overall phys-
iological test results were consistent with a mild bilat-
eral sensorineural hearing loss.
Behavioral Testing
Pure-tone audiometry revealed a mild bilateral sen-
sorineural hearing loss (see Figure 1). Frequencies 3, 4,'
and 6 kHz for both ears exhibited the worst hearing
thresholds. Hearing thresholds at 8 kHz were within
normal limits for both ears (equal or better than
25 dB HL). Pure-tone thresholds were similar (±5 dB
HL) to those ones obtained initially (4 mo previously).
For the HINT, the patient obtained an elevated
speech reception threshold for sentences (31.8 dB sound
pressure level [SPL]), in the binaural listening condi-
tion. For noise and speech both delivered at 0° azimuth,
the SNR obtained was —4.3 dB; for noise delivered to
the right ear and speech to the front, the SNR obtained
was —11 dB; and for noise delivered to the left ear and
speech to the front, the SNR was -11 dB. The composite
score for the three noise conditions was -7.7 dB. All the
SNR scores were within the normal range (Nilsson et al,
1994).
Results for (central) auditory function tests are shown
in Table 2. All results were within normal ranges

Noise dosimetry was conducted during a whole work Table 1. Ipsilateral and Contralateral Acoustic Reflexes,
shift (8 hr/1 day). To assess xylene exposure, methyl Pure-Tone Thresholds, and Difference between
hippuric acid (a metabolite of xylene) concentration Ipsilateral Acoustic Reflex Thresholds and Pure-Tone
per gram of creatinine in urine was analyzed. The urine Thresholds for 0.5, 1, 2, and 4 kHz
sample was taken at the end of the work shift on a Fri-. Right Ear Left Ear
day and sent to the Chilean Institute of Public Health
kHz 0.5 1 2 4 0.5 1 2 4
for further analysis.
Ipsi AR 90 100 90 80 90 90 90 80
Contra AR 90 90 90 100 100 90 90 90
RESULTS TH 25 30 35 40 25 35 35 45
A 65 70 55 40 65 55 55 35
Physiological Testing Note: Ipsi AR = ipsilateral acoustic reflex (dB HL); Contra AR =
contralateral acoustic reflex (dB HL); TH = air-conduction pure-tone
Immittance audiometry showed bilateral normal type threshold (dB HL); A = difference between Ipsi AR and pure-tone
A results for tympanometry and the presence of ipsuateral threshold in dB HL.

8S7
Journal of the American Academy of Audiology/Volume 23, Number 10, 2012

Table 2. Results of (Central) Auditory Processing Tests Age could also have affected the hearing loss. Figure 1
and Normative Values shows the expected pure-tone thresholds for the 10% of
Normative Values for people with worse hearing level from an otologically
Spanish-Speaking screened population between 40 and 49 yr of age
Adults (Fuente and (International Standards Organization 7029, 2000).
Test Results McPherson, 2006) As can be observed from Figure 1, most of the hearing
DD right ear (%) 98 '96.3 thresholds are worse than the levels expected for the
DD left ear (%) 95 96.3 patient's age. Thus, we believe that age may partially
DD both ears combined (%) 97 96.3 account for the observed hearing loss in this patient. A
RGDT 500 Hz (ms) 10 15 possible interaction between age, xylene exposure, and
RGDT 1000 Hz (ms) 2 15 smoking (Cruickshanks et al, 1998) may also account
RGDT 2000 Hz (ms) 2 15 for the hearing loss.
RGDT 4000 Hz (ms) 2 15 We conclude that this hearing loss has a cochlear ori-
RGDT clicks (ms) 2 10
gin. This conclusion relies on absent TEOAEs, absence
PPS right ear (%) 100 80
80
of consistent signs of central auditory dysfunction as
PPS left ear (%) 85
PPS both ears combined (%) 93 80
measured with behavioral auditory processing tests,
MLD (dB) 16 6.2 the presence of acoustic reflexes (ipsilateral and con-
FS right ear (%) . 48 70 tralateral), the negative acoustic reflex decay test,
FS left ear (%) 44 70 and ABR latencies within normal ranges for 80 dB
FS both ears combined (%) 46 70 nHL click stimuli. The presence of hearing loss in a per-
Note: DD = Dichotic Digits test in Spanish (Fuente and McPherson, son exposed to. solvents such as xylene is in agreement
2006); RGDT = Random Gap Detection test (Keith, 2000); PPS = with previous human cross-sectional studies (Morata
Pitch Pattern Sequence test (Musiek, 1994); MLD = Masking Level et al, 1997; Shwiñska-Kowalska et al, 2000; Sliwiñska-
Difference test (Wilson et al, 2003); FS = Filtered speech test in Spanish Kowalska et al, 2001; Chang et al, 2006), indicating
(Fuente and McPherson, 2006); ms = millisecond. the association of hearing loss with exposure to mixtures
of solvents. The cochlear type of hearing loss observed in
previously reported for Spanish-speaking adults (Fuente this patient is in agreement with previous experimental
and McPherson, 2006), with the exception of the filtered studies in rats, which have shown loss of OHCs associ-
speech test. ated with xylene exposure (Crofton et al, 1994; Gagnaire
and Langlais, 2005) and thus, cochlear-related hearing
Noise and Solvent Exposure Assessment loss induced by xylene exposure. In this patient TEOAEs
were absent, suggesting loss of OHCs.
Noise dosimetry for a whole-day work shift revealed It is important to note that the cochlear hearing loss
an equivalent noise exposure of 67.5 dBA Leq. Methyl observed in this patient is dissimilar to that noted in the
hipuric acid in urine was found at a concentration of previously mentioned case report of a person exposed
152 mg per gram of creatinine (1500 mg per gram of cre- to xylene, who had developed auditory neuropathy
atinine is the biologic tolerance limit). (Draper and Bamiou, 2009). Previous cross-sectional
human and experimental animal studies have revealed
mid- and high-frequency range hearing loss induced by
DISCUSSION solvents such as xylene (Crofton et al, 1994; Sliwiñska-
Kowalska et al, 2001; Gagnaire and Langlais, 2005;

P ure-tone audiometric results showed a mild bilat-

eral sensorineural hearing loss. Pure-tone thresh-
olds, including 8 kHz, between the first and second
assessment did not reveal differences more than 5
dB which are within the test-retest reliability previ-
ously reported (Rendell and Miller, 1983; Schmuziger
et al, 2004). According to the medical case history, the
audiological and otological assessment and the occupa-
tional history, xylene exposure appears to be the only
etiological factor for the observed hearing loss. There-
fore, the hearing impairment of this patient is most
likely associated with xylene exposure. However, no
past hearing assessments were available. Thus, the
observed hearing loss could be part of a previous hear-
ing loss of unknown etiology, plus the effect of xylene.
Chang et al, 2006). There is, however, a case report
of a painter exposed to solvents and noise who devel-
oped a hearing disorder with maximum loss at the
low- and mid-frequency range (Polizzi et al, 2003).
The.authors suggested that the unusual pattern of
hearing loss was induced by the combined effect of sol-
vents and noise. In the present case report, the patient
did not have a history of occupational or recreational
noise exposure. Noise dosimetry for a typical work
day revealed 67.5 dBA Leq. The patient in the present
case report had been exposed to xylene for over 20 jn:
and reported that, during this time, he had never worn
any protective equipment or clothing, such as masks or
gloves. He also mentioned having had frequent dermal
contact with xylene and regularly eating in the same

laboratory facilities where xylene was being used. The
laboratory facilities were visited, where it was possible
to observe the absence of ventilation systems, extractors,
and other systems that would serve to diminish airborne
xylene concentrations. Airborne xylene concentrations
and methyl hippuric acid in urine revealed rather low
levels of xylene exposure; however, this must be taken
with caution. The patient had been exposed to xylene
for more than 20 JT and the assessment of xylene expo-
sure was recent. Data regarding xylene airborne con-
centrations were available for only the last 2 yr. Data
regarding methyl hippuric acid was obtained only once,
at the time the patient was found to have a mild hearing
loss. It is likely that in the past the patient was exposed
to higher levels of xylene, due to less strict occupational
health and safety regulations. The patient also re-
ported that in the past he worked part-time on the
weekends in a private laboratory, performing the same
duties, in addition to his work at the hospital. The
patient also experienced continuous high-peak dermal
exposures to xylene when he handled slides embedded
in xylene for microscopic analysis, as he did not wear
protective gloves. The frequency of this duty varied,
depending on the demand for histological analyses.
It has been suggested that past or current peak expo-
sures, rather than minimal daily dosage, may have
contributed to the hearing losses observed in a group
of workers exposed to styrene (Morata et al, 2002).
Also, a severe sensorineural hearing loss at all fre-
quencies tested has been reported in a young male
glue-sniffer (Ehyai and Freemon, 1983). The authors
attributed the hearing loss to toluene, as it was the
main component of the glue sniffed by the individual
over a period of 5 yr.
Despite our findings of cochlear hearing loss with no
signs of auditory neuropathy in this patient, we do not
exclude the possible existence of auditory neuropathy
induced by xylene exposure in other xylene-exposed
patients (Draper and Bamiou, 2009). It has. been sug-
gested that the adverse auditory effect of solvents
depends on a combination of both oto- and neurotoxicity
(Morata and Lemasters, 1995).
Furthermore, other case studies have reported neu-
ropathy associated with hearing loss in persons exposed
to nónxylene solvents (Ehyai and Freemon, 1983;
Moshe et al, 2002). This should be taken into consider-
ation when assessing persons exposed to solvents such
as xylene.
CONCLUSIONS
T he novel aspects of the present case report are that
in humans (1) xylene exposure may induce coch-
lear hearing loss, and (2) xylene may induce hearing
loss over a wide range of frequencies (1-6 kHz) as meas-
ured by pure-tone audiometry. In view of this case
Xylene-Induced Hearing Loss/Fuente et al
report, we suggest that questions concerning history
of solvent exposure should be part of the routine patient
examination undertaken by audiologists and otolaryng-
ologists. Finally, considering thefindingsfromthe present
case report, xylene-exposed persons shoxold be audiologi-
caUy evaluated on a regular basis.
REFERENCES
Baron de Otero C, Brik G, Flores L, Ortiz S, Abdala C. (2008) The
Latin American Spanish hearing in noise test. Int J Audiol 47:
362-363.
Baselt RC, Cravey RH. (1989) Disposition of Toxic Drugs and
Chemicals in Man. 3rd ed. Chicago: Year Book Medical Publishers.
Chang SJ, Chen CJ, Lien CH, Sung FC. (2006) Hearing loss in
workers exposed to toluene and noise. Environ Health Perspect
114:1283-1286.
Crofton KM, Lassiter TL, Rebert CS. (1994) Solvent-induced
ototoxicity in rats: an atypical selective mid-frequency hearing
deficit. Hear Res 80:25-30.
Cruickshanks KJ, Klein R, Klein BEK, Wiley TL, Nondahl DM,
Tweed TS. (1998) Cigarette smoking and hearing loss. The epi-
demiology of hearing loss study. JAMA 279:1715-1719.
Draper TH, Bamiou DE. (2009) Auditory neuropathy in a patient
exposed to xylene: case report. J Laryngol Otol 123:462^65.
Ehyai A, Freemon FR. (1983) Progressive optic neuropathy and
sensorineural hearing loss due to chronic glue sniffing. J Neurol
Neurosurg Psychiatry 46:349-351.
Fuente A, McPherson B. (2006) Auditory processing tests for
Spanish-speaking adults: an initial study. Int J Audiol 45:
645-659.
Fuente A, McPherson B. (2007) Central auditory processing
effects induced by solvent exposure. Int J Occup Med Environ
Health 20:271-279.
Fuente A, McPherson B, Hickson L. (2011) Central auditory dys-
function associated with exposure to a mixture of solvents. Int J
Audiol 50:857-865.
Gagnaire F, Langlais C. (2005) Relative ototoxicity of 21 aromatic
solvents. Arch Toxicol 79:346-354.
Gagnaire F, Marignac B, Blachère V, Grossmann S, Langlais C.
(2007) The role of toxicokinetics in xylene-induced ototoxicity in
the rat and guinea pig. Toxicology 231:147-158.
Gagnaire F, Marignac B, Langlais C, Bonnet P. (2001) Ototoxicity
in rats exposed to ortho-, meta- and para-xylene vapours for 13
weeks. Pharmacol Toxicol 89:6-14.
Glattke TJ, Robinette MS. (2007) Transient evoked otoacoustic
emissions in populations with normal hearing sensitivity. In:
Robinette MS, Glattke TJ, eds. Otoacoustic Emissions. Clinical
Applications. New York: Thieme, 87-106.
Hood LJ. (1998) Clinical Applications of the Auditory Brainstem
Response. San Diego: Singular.
Horowitz RR. (2001) Aromatic hydrocarbons. In: Ford M,
Delaney K, Ling L, Erickson T, eds. Clinical Toxicology. Phila-
delphia: Saunders Company, 802-812.
ass
Journal of the American Academy of Audiology/Volume 23, Number 10, 2012
International Standards Organization. .(1989) Audiometric test
methods - part 1: basic pure tone air and bone conduction thresh-
old audiometry. No. 8253. Geneva: ISO.
Intemational Standards Organization. (2000) Statistical distribution
of bearing thresholds as a function of age. No. 7029. Geneva: ISO.
Jerger J. (1970) Clinical experience witb impedance audiometry.
Arch Otolaryngol 92:311-324.
Johnson AC, Morata TC. (2010) Occupational exposure to chem-
icals and hearing impairment (Technical Report). Gothenburg:
Arbets-Och Miljomedicin, Göteborgs Universitet.
Johnson AC, Morata TC, Lindblad AC, et al. (2006) Audiological
findings in workers exposed to styrene alone or in concert with
noise. Noise Health 8:45-57.
Keith R. (2000) Random Gap Detection Test. St. Louis: Auditec.
Kemp DT, Ryan S, Bray P. (1990) A guide to the effective use of
otoacoustic emissions. Ear Hear 11:93-105.
Laukli E, Hansen PW. (1995) An audiometric test battery for the
evaluation of occupational exposure to industrial solvents. Acta
Otolaryngol 115:162-164.
Ministerio de Salud de Chile. (2000) Decreto supremo n° 594 del
ministerio de salud. April 29, 2000. Diario Oficial de la República
de Cbile. Santiago, Chile.
Morata TC, Engel T, Durao A, Costa TRS, Krieg EF, Dunn DE.
(1997) Hearing loss, from combined exposures among petroleum
refinery workers. Scand Audiol 26:141-149.
Morata TC, Johnson AC, Nylen P, et al. (2002) Audiometric find-
ings in workers exposed to low levels of styrene and noise. J Occup
Environ Med 44:806-814.
Morata TC, Lemasters GK. (1995) Epidemiologic considerations
in the evaluation of occupational hearing loss. Occup Med 10:
641-656.
Moshe S, Bitchatchi E, Goshen J, Attias J. (2002) Neuropathy in
an artist exposed to organic solvents in paints: a case study. Arch
Environ Health 57:127-129.
830
Musiek FE. (1994) Frequency (pitch) and duration patterns tests.
J Am Acad Audiol 5:265-268.
Nilsson M, Soli SD, Sullivan JA. (1994) Development ofthe Hear-
ing in Noise Test for the measurement of speech reception thresh-
olds in quiet and in noise. J Acoust Soc Am 95:1085-1099.
Ödkvist LM, Arlinger SD, Edling C, Larsby B, Bergholtz LM.
(1987) Audiological and vestibule-oculomotor findings in workers
exposed to solvents and jet fuel. Scand Audiol 16:75-81.
Pohzzi S, Ferrara M, Pira E, Bugiani M. (2003) Exposure to low
levels of solvents and noise, ear canal volume and audiometric pat-
tern, [in Italian] G Ital Med Lav Ergon 25(Suppl 3):67-68.
Pryor GT, Rebert CS, Howd RA. (1987) Hearing loss in rats caused
by inhalation of mixed xylenes and styrene. J Appl Toxicol 7:
55-61.
Rendell RJ, Miller JJ. (1983) An evaluation of high-frequency
audiometry suitable for routine clinical use. Br J Audiol 17:
81-85.
Schmuziger N, Probst R, Smurzynski J. (2004) Test-retest rehabil-
ity of pure-tone thresholds from 0.5 to 16 kHz using Sennheiser
HAD 200 and Etymotic Research ER-2 earphones. Ear Hear 25:
127-132.
Sliwinska-Kowalska M, Zamyslowska-Szmytke E, Kotylo P, et al.
(2000) Assessment of hearing impairment in workers exposed to
mixtures of organic solvents in the paint and lacquer industry,
[in Polish] Med Pr 51:1-10.
Sliwiñska-Kowalska M, Zamyslowska-Szmytke E, Szymczak W,
et al. (2001) Occupational solvent exposure at moderate concentra-
tion increases the risk of hearing loss. Scand J Work Environ
Health 27:335-342.
US Department of Labor, Occupational Safety and Health Admin-
istration. (2011) Occupational safety and health guideline for xy-
lene. httpy/www.osha.gov/SLTC/healthguideUnes/xylene/recognition.
html.
Wilson RH, Moncrieff DW, Townsend EA, Pillion AL. (2003)
Development of a 500-Hz masking-level difference protocol for
clinic use. J Am Acad Audiol 14:1-8.
Copyright of Journal of the American Academy of Audiology is the property of American Academy of
Audiology and its content may not be copied or emailed to multiple sites or posted to a listserv without the
copyright holder's express written permission. However, users may print, download, or email articles for
individual use.