National Journal of Physiology, Pharmacy and Pharmacology

RESEARCH ARTICLE
Analysis of potential risk of hearing loss among students using personal
audio devices

Abishek Srihari1, Shanmukananda P2, Lincoln S Deva Kumar3, Stanley John4

House Surgeon, Dr B R Ambedkar Medical College and Hospital, Bengaluru, Karnataka, India, 2Department of Pharmacology, Dr B R
1

Ambedkar Medical College and Hospital, Bengaluru, Karnataka, India, 3Department of Physiology, Dr B R Ambedkar Medical College and
Hospital, Bengaluru, Karnataka, India, 4Department of Otorhinolaryngology, Dr B R Ambedkar Medical College and Hospital, Bengaluru,
Karnataka, India
Correspondence to: Abishek Srihari, E-mail: srihari.abhishek@gmail.com

Received: November 04, 2020; Accepted: December 27, 2020

ABSTRACT

Background: Noise-induced hearing loss (NIHL) is on the rise, affecting nearly 1.1 billion young people as per the World
Health Organization. It is mainly due to exposure to noise in recreational settings for prolonged duration and at high intensity
resulting in unsafe listening practices. Aim and Objective: This study aims to analyze the potential risk of audio device usage
and hearing loss among the students. Materials and Methods: Hearing loss among students using personal music player with
headphones/earphones was assessed using a self-designed audiometry mobile application and followed by a questionnaire to
those found to have hearing loss asking for their preferences of personal audio devices, usage in terms of years, duration per
day, volume, content, and awareness of NIHL. Results: Among the 3000 students, 3.2% (96) of students were identified with
hearing loss and 72% of the total subjects were unaware of NIHL. About 81% (78) were headphones users as compared to
19% (18) earphones users. About 50% of the subjects with hearing loss had reported usage of a personal audio device for more
than 6 h per day followed by 30% who used it for 4–6 h, 16% who used it for 2–4 h followed by 4% who used it for 1–2 h per
day. About 90% of students used volume settings more than 60% and 10% preferred 60–40% volume settings. About 65%
of the subjects were using audio devices for more than 6 years and 16% for <3 years. About 20% of the subjects were using
audio devices of 4–6 years. About 60% used the audio device to listen to music, and 40% used it for games, videos, and others.
About 81% experienced tinnitus and 72% experienced episodes of vertigo. Conclusion: NIHL is attributed to the usage of
personal audio devices for a prolonged period and at high volumes among students.

KEY WORDS: Noise-Induced Hearing Loss; Safe Listening Practices; Personal Audio Aids

INTRODUCTION estimated to have an increased risk of developing hearing loss

because of unsafe use of personal audio devices and exposure
Loss of hearing or hearing impairment has become a to damaging levels of sound in noisy entertainment venues.[2]
significant social and public health problem affecting 6.1% of This risk is due to the growing use of smartphones and the
the world’s population.[1] In addition, more than 100 million increasingly popular practice of listening to music through
young people between the ages of 12 and 35 years are headphones.[1,3] Chronic noise exposure damages sensory hair
Access this article online cells in the cochlea, which is irreparable and is responsible for
Website: www.njppp.com Quick Response code stimulating the auditory nerve.[4] The permanence of noise-
induced hearing loss (NIHL) emphasizes the importance
of the prevention of noise damage. Damage to the auditory
DOI: 10.5455/njppp.2021.11.11301202027122020 system is a cumulative process, and injury from loud noise is
sufficiently severe enough to measure if the loss is substantial
and irreversible.[5,6]
National Journal of Physiology, Pharmacy and Pharmacology Online 2021. © 2021 Abishek Srihari, et al. This is an Open Access article distributed under the terms of the Creative
Commons Attribution 4.0 International License (http://creative commons.org/licenses/by/4.0/), allowing third parties to copy and redistribute the material in any medium or format and to
remix, transform, and build upon the material for any purpose, even commercially, provided the original work is properly cited and states its license.

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Srihari et al. Potential risk of hearing loss using personal audio devices

Several studies have reported an increasing trend of NIHL in
children and adolescents. The European Union’s Scientific
Committee on Emerging and Newly Identified Health Risks
has estimated that 5–10% of personal music player (PMP)
users are at risk of developing permanent hearing loss if they
listen to their devices at high volume for more than an hour a
day.[7] More so, the high number of sales of PMPs and of mobile
phones that play music could result in an enormous global
impact if adequate measures are not taken up at the earliest
by legislators, health caregivers, parents, and the individuals
themselves.[8] The European Union passed standards in 2011,
requiring PMPs to have a default maximum volume of 85
decibels (80 decibels for products marketed for children).
Users will still have the option of setting the volume higher
but will be reminded intermittently that their player is above
recommended limits. Manufacturers were given 2 years to
meet these standards.[7] However, it is not certain that this has
been implemented globally.
In studies conducted previously, it was found that 72 out of
110 PMP users were listening to volumes above 85 decibels,
and 25% of the users were listening to levels above the safe
threshold.[9] Evidence supporting the relationship between
uses of earphones/headphones and hearing damage is mixed.
Epidemiological data on NIHL are generally lacking in India,
and this inadequacy contributes to low awareness of the
problem. Thus, this study was taken up to identify hearing
loss using a self-designed audiometry mobile application.
The objective of the study was to assess the occurrence of
hearing loss among students and their awareness regarding
NIHL and its relation with audio device usage among students
as follows:
• Number of hours spent listening to audio devices
• Duration of usage in years they have been using audio
devices
• Volume setting preferred while using audio devices
• Choice of content heard on audio devices.
and awareness of regarding NIHL. The questionnaire also
inquired if the subject experienced any ringing, buzzing, or
roaring sounds or had vertigo or dizziness, in addition to the
difficulty of hearing. The data recorded were analyzed to
determine the occurrence of hearing loss and its relation with
the use of the audio device.
Statistical Analysis
The data collected were entered into Microsoft Excel,
and statistical analyses were performed. The results were
expressed in numbers and percentages for dichotomous data
and were represented in tables and figures.
RESULTS
A total of 3000 (N) students were screened using the mobile
application for audiometry, and 72% of the total subjects were
unaware of NIHL. About 79% preferred to use earphones and
21% preferred headphones. About 3.2% of the total students
(n = 96) of them were found to have mild hearing loss (MHL),
as depicted in Table 1. About 72% of the total subjects
(n = 3000) were unaware of NIHL, as shown in Figure 1.
Of the total of 96 (n) students with hearing loss, 81% (78)
were headphones users as compared to 19% (18) earphones
users [Table 1]. About 50% of the subjects with hearing loss
Table 1: Subject’s preference in the choice of personal
audio devices
Preference of device Earphones (%) Headphones (%)
Total screened students 2356 (79) 644 (21)
(n=3000)
Number of students with 18 (19) 78 (81)
hearing loss (n=96)

MATERIALS AND METHODS

After obtaining Institutional Ethics clearance, the study was

conducted among the college and school-going students in the
age group of 12–24 years. The students using personal audio
devices with headphones/earphones willing to give informed
consent were screened to identify sensorineural hearing
loss and its relation to noise exposure. Those students with
a history of previous ear disease and upper respiratory tract
infection were excluded from the study. An audiometry test
to identify students having hearing loss using a self-designed
audiometry mobile application that had to be downloaded
on to a mobile cell phone. The test for each ear took about
3 min. The result of the test was recorded accordingly. It
was followed by a questionnaire that asked for the student’s
preferences of personal audio devices and regarding their
usage in terms of years, duration per day, volume, content, Figure 1: Awareness regarding noise-induced hearing loss (n=3000)

463 National Journal of Physiology, Pharmacy and Pharmacology 2021 | Vol 11 | Issue 05
Srihari et al. Potential risk of hearing loss using personal audio devices

were using their personal audio device for more than 6 h per the compact size of the earphones that could be carried around
day followed by 30% who used it for 4–6 h, 16% who used easily; more affordable in the student population and invariably
it for 2–4 h followed by 4% who used it for 1–2 h. About comes free with the audio device. More so, the earphones fit
58%, 23%, 9%, 6%, and 3% of students used the volume snugly into the external auditory canal and reduce the external
settings at 90%, 80%, 70%, 60%, and 40%, respectively. noise.[10] However, in this study, it was noted that a significant
About 65% of the subjects were using personal audio devices number of headphone users, 81% (78) had hearing loss as
for more than 6 years and 16% for <3 years. About 20% of compared to earphone users, 19% (18). The smaller number
the subjects were using audio devices of 4–6 years. About of earphone users with MHL could be attributed to the snugly
81% experienced tinnitus and 72% experienced episodes of fitting earphone into the external auditory canal and reduce the
vertigo. About 60% used the audio device to listen to music external noise. Thus, the need to increase the volume is less,
and 40% used it for games, videos, and others as represented thereby causing less damage to the eardrum.[10] However, it
in Table 2. should be noted that in earphone users, the length of the canal
is reduced as the earphone is plugged into the external auditory
canal because of which the natural protection becomes less
DISCUSSION
effective and the noise level within the ear canal increases.
In the present study, among the 3000 students screened, majority Furthermore, there are no visible signs that the process of NIHL
of them (71%) were unaware of NIHL and the consequences has begun and importantly that it is irreversible as the cochlear
of using personal audio devices at high volume and long hair cells do not regenerate once damaged.[11] The preference
duration of time. Most students preferred to use earphones for earphones over headphones was also seen in the previous
(79%) over headphones (21%). The preference of earphones studies. Dobrucki et al.[11] in his study showed the influence
to headphones in the student population could be attributed to of types of headphones used and factors such as – the time of
listening, the loudness of music, and other noise exposures as
to influence the threshold of hearing in 81 young people aged
Table 2: Preferences of various parameters in the usage of
between 16 and 25 years of age. A study in Nigeria by Sunny
personal audio devices among subjects with hearing loss et al.[12] determined that the prevalence of use of earphones for
(n=96) entertainment was 95.6%, and the prevalence of subjective
Parameters Subjects n (%) tinnitus in students was 20.6% in an urban university setting,
Number of hours spent listening to audio devices and the relationship between the two was established.
>6 h 48 (50)
4–6 h 29 (30.2) In the present study, among the students with MHL, it was
2–4 h 15 (15.63) found that, as the duration of exposure to noise in terms of
1–2 h 4 (4.17)
hours and years of usage of the audio device increased, it
resulted in a significant rise in the number of students with
Volume setting (% of maximum volume)
hearing loss. This finding is comparable to the study done by
90 56 (58.33)
Ogbe et al.[13] who found that the use of headphones among his
80 22 (22.9) study population presented with MHL and it could be attributed
70 9 (9.38) to decreased sensitivity of hair cells of the ear. In our study,
60 6 (6.25) the majority of students with MHL reported high or very high-
40 3 (3.13) volume settings (more than the recommended volume setting
Number of years of using audio devices of 60%) on their music player with headphones/earphones. This
>6 years 62 (64.58) could be attributed to the early onset of deafness due to abuse
4–6 years 19 (19.79) of the personal audio devices. Among the students with NIHL,
majority of them experienced tinnitus and vertigo, which are
0–3 years 15 (15.63)
early symptoms of NIHL, a warning to the impending damage
Content type
caused by loud music/noise. The occurrence of tinnitus as an
Music 58 (60.43)
impending sign of hearing damage due to loud noise is reported
Games 22 (22.9) by Vogel et al.[14] in his study of MP3 users among adolescence.
Videos 10 (10.42) Nageris et al.[15] showed the association of tinnitus and vertigo,
Miscellaneous 6 (6.25) in his study, patients who complained of hearing loss with
Experienced episodes of tinnitus prolonged exposure to hazardous noise levels.
Yes 78 (81.25)
No 18 (18.75)
In the present study, the majority of the students with NIHL
was related to listening to music followed by games and
Experienced episodes of vertigo
videos. NIHL could be due to the continuous noise at high
Yes 69 (71.87)
decibels emitting from their personal audio device damaging
No 27 (28.13) their hearing. Many of the participants who took part in the

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Srihari et al.
study were unaware of NIHL and the adverse effects of loud
and continuous noise to the hearing system. This finding
is similar to the study conducted by Muchnik et al.[16] who
demonstrated low awareness toward loud music listening
consequences among teenagers.
The World Health Organization (WHO) has reported studies
that have shown that there is a risk of damaged hearing
because of the increased use of personal audio devices to play
loud music for an extended period of time among youngsters.
To combat this, it recommends “Rule of 60,” namely, listening
to mobile devices for a maximum of 1 h (60 min) per day and
the volume should stay around 60%. The idea is to minimize
unsafe listening practices, which depend on two factors: How
long you listen and how loud the sound is. It also notes that
headphone manufacturers and government regulators should
develop listening devices that do not irrevocably affect
listeners.[17] Thus, in 2017, the 70th World Health Assembly
adopted a resolution on the prevention of deafness and hearing
loss by calling on the member states to integrate strategies for
ear and hearing care. The WHO has recommended undertaking
several actions for the promotion of ear and hearing care at
global level, including many of those noted above.[18]
Limitations of the study were that a follow-up of the students
with MHL diagnosed with the audiometry mobile app could
not be done with conventional audiometry though they were
advised. Since a questionnaire was used regarding their use
of audio aid, there could be a recall bias.
CONCLUSION
NIHL is on the rise among youngsters and can be attributed to
the usage of audio devices for an extended period of time and
at high volumes. Intensity and duration of the audio are known
to have a deleterious effect on the hearing threshold. Safe
listening practices such as usage of snuggly fitting earphones
and at recommended volume should be adhered to prevent
NIHL. Convenient, cheap, and handy audiometry mobile
applications can be developed that could be downloaded
onto cell phones anywhere (rural-urban) and regularly used
by students to check for oncoming hearing loss.
ACKNOWLEDGMENT
The authors would like to thank Dr. Divya R.D. and Dr.
Bhavya Darshini M for their support in conducting the study.
REFERENCES
1. WHO. Estimates; 2018. Available from: http://www.who.int/
pbd/deafness/estimates/en. [Last accessed on 2020 Nov 06].
2. World Health Organization. Hearing Loss Due to Recreational
Exposure to Loud Sounds: A Review. Geneva: World Health
Organization; 2015. Available from: https://www.who.int/iris/
465 National Journal of Physiology, Pharmacy and Pharmacology
Potential risk of hearing loss using personal audio devices
handle/10665/154589. [Last accessed on 2020 Nov 01].
3. Beach E, Williams W, Gilliver M. Estimating young Australian
adults’ risk of hearing damage from selected leisure activities.
Ear Hearing 2013;34:75-82.
4. Kim J. Analysis of factors affecting output levels and
frequencies of MP3 players. Korean J Audiol 2013;17:59-64.
5. Kim MG, Hong SM, Shim HJ, Kim YD, Cha CI, Yeo SG.
Hearing threshold of Korean adolescents associated with the
use of personal music players. Yonsei Med J 2009;50:771-6.
6. Jokitulppo JS, Björki EA, Akaan-Penttiä E. Estimated leisure
noise exposure and hearing symptoms in Finnish teenagers.
Scand Audiol 1997;26:257-62.
7. EU Guidelines to Good Manufacturing Practice Medicinal Products
for Human and Veterinary Use; 2008. Available from: http://
www.academy.gmpcompliance.org/guidemgr/files/ANNEX%20
01%5b2008%5d.PDF. [Last accessed on 2020 Nov 06].
8. Khatter K. Personal music players and hearing loss: Are we
deaf to the risks? Open Med 2011;5:e137-8.
9. Williams W. Noise exposure levels from personal stereo use
nivel de expositión a ruido por el uso de estéreos personales.
Int J Audiol 2005;44:231-6.
10. Diviani N, Zanini C, Rubinelli S. Make Listening Safe, WHO;
2017. Available from: https://www.who.int/pbd/deafness/
Momograph_on_Narrative_Overview_of_Systematic_Review_
on_Listening_habits.pdf?ua=1. [Last accessed on 2020 Nov 06].
11. Dobrucki AB, Kin MJ, Kruk B. Preliminary study on the
influence of headphones for listening music on hearing loss of
young people. Arch Acoust 2013;38:383-7.
12. Sunny OD, Asoegwu CN, Abayomi SO. Subjective tinnitus
and its association with use of earphones among students of the
college of medicine, university of Lagos, Nigeria. Int Tinnitus
J 2012;17:169-72.
13. Ogbe SE, Akor-Dewu MB, Saleh MI, Eze ED, Olufunke O,
Shaibu A, et al. Effects of headphones on hearing acuity of
students of Ahmadu Bello university, Zaria, Nigeria. Ann Bio
Sci 2014;2:7-9.
14. Vogel I, Brug J, Van Der Ploeg CP, Raat H. Adolescents risky
MP3-player listening and its psychosocial correlates. Health
Educ Res 2011;26:254-64.
15. Nageris BI, Attias J, Feinmesser R. Noise-induced vestibular
dysfunction. Noise Health 2000;3:45-8.
16. Muchnik C, Amir N, Shabtai E, Kaplan-Neeman R. Preferred
listening levels of personal listening devices in young
teenagers: Self reports and physical measurements. Int J Audiol
2011;51:287-93.
17. Gopal K. Make Listening Safe WHO; 2017. Available from:
https://www.who.int/pbd/deafness/Monograph_on_current_
Practices_in_the_assessment_of_NIHL_in_recreational_
settings.pdf. [Last accessed on 2020 Nov 06].
18. WHO. Strategies for Prevention of Deafness and Hearing
Impairment; 2017. Available from: https://www.who.int/
pbd/deafness/activities/strategies/en. [Last accessed on 2020
Nov 06].
How to cite this article: Srihari A, Shanmukananda P, Kumar
LSD, John S. Analysis of potential risk of hearing loss among
students using personal audio devices. Natl J Physiol Pharm
Pharmacol 2021;11(05):462-465.
Source of Support: Nil, Conflicts of Interest: None declared.
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