Cory Portnuff, AuD, PhD, CPS/A Board Certified, Clinical Audiologist - - PDF document

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Cory Portnuff, AuD, PhD, CPS/A Board Certified, Clinical Audiologist - - PDF document

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10/17/2018 Cory Portnuff, AuD, PhD, CPS/A Board Certified, Clinical Audiologist UCHealth Assistant Clinical Professor Department of Otolaryngology, School of Medicine University of Colorado Denver Following this presentation, learners

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10/17/2018 1

Cory Portnuff, AuD, PhD, CPS/A

Board Certified, Clinical Audiologist UCHealth Assistant Clinical Professor Department of Otolaryngology, School of Medicine University of Colorado Denver

 Following this presentation, learners should

be able to explain the factors which contribute to music-induced hearing loss and describe the state of the science in this field.

 Following this presentation, learners should

be able to implement a program of hearing conservation for musicians with a focus on reducing the risks of music on the auditory system.

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10/17/2018 2  This presentation will discuss

commercially available and some not commercially available products.

 Endorsement of any products is mine

alone and does not necessarily reflect the

  • pinions of UCSF, the University of

Colorado School of Medicine, UCHealth, ASHA, AAA or anyone else.

 Metabolic “overload”

  • Glutamate ototoxicity
  • Cellular apoptosis/necrosis is induced

▪ Heat shock proteins ▪ Oxidative stress

 Mechanical hair-cell damage

  • Stereocilia damage
  • Supporting cell damage

 Micro-structural damage to stria vascularis

  • Vascular break-down leads to cochlear hypoxia

▪ Decreased vasodilators, disruption of endothelial cells

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10/17/2018 3  Acoustic trauma

  • Stereocilia sheared off
  • TM perforations
  • Separation of organ of Corti from basilar

membrane (>132 dB SPL)

Uncommon with music exposure!

 Few studies of music effects on auditory

pathophysiology

 Most studies use auditory biomarkers

  • Hearing loss
  • Tinnitus
  • OAEs
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10/17/2018 4

“Temporary” effects of music

  • TTS
  • Amplified music (Opperman et al, 2006)
  • Dance clubs (Gunderson et al, 1997; Meecham & Hume, 2001)
  • Temporary OAE change
  • Aerobics classes (Torre & Howell, 2008)
  • PLD use (Keppler et al, 2010; Bhagat & Davis, 2008)

“Temporary” effects of music

  • Tinnitus
  • Dance clubs (Holgers & Pettersson, 2005)
  • Concerts (Chung, et al., 2005; Quintanilla-Deck, et al., 2009).
  • MP3 player use
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10/17/2018 5

Permanent effects of music

How do we quantify effects?

  • Cross-sectional research with large study

groups

  • Can see changes between groups
  • Longitudinal studies
  • Can see changes within a group

Permanent effects of music

  • Hearing thresholds
  • Classical musicians – 52.5% have “notch”

(Royster, Royster & Killion, 1991; Emmerich, Rudel, and Richter. 2008)

  • Amplified musicians
  • PLD users have worse hearing thresholds

than non-users (Meyer-Bisch, 1996, Kim et al, 2009)

  • Differences are typically small in teenagers
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10/17/2018 6

Permanent effects of music

  • OAEs
  • “Heavy” PLD users have significantly lower

OAE levels than non-users (LePage & Murray,

1998; Santollala Montoya et al, 2008)

 Tinnitus

  • Significant tinnitus can reduce the ability to

match pitch, control timbre

 Hyperacusis / recruitment  Diplacusis

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10/17/2018 7  “Notch” in audiogram

  • Typically at 4000, 6000 Hz

 Notch definitions…

  • No standardized definition of “notch”
  • Research varies

10 20 30 40 50 60 70 80 90 100 110 AC (AIR)

UNMASKED MASKED

BC (BONE)

UNMASKED MASKED

125 250 500 1000 2000 4000 8000

750 1500 3000 6000

FREQUENCY IN HERTZ (Hz) HEARING LEVEL (HL) IN DECIBELS (dB)

KEY R L SOUND FIELD

S

15 year old male following right earwax removal daily PSS use “all the way up”

  • 10
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10/17/2018 8

AC (AIR)

UNMASKED MASKED

BC (BONE)

UNMASKED MASKED

125 250 500 1000 2000 4000 8000

750 1500 3000 6000 10 20 30 40 50 60 70 80 90 100 110 120

FREQUENCY IN HERTZ (Hz) HEARING LEVEL (HL) IN DECIBELS (dB)

KEY R L SOUND FIELD

S

  • 10

14-year-old male (seen 4/09) Did not pass school hearing screen Max volume on iPod, 60 min/day

DPOAEs, 14-year-old iPod users (1 ½ years),

notched audiogram

  • Reduced or absent DPOAEs at frequencies 4000 Hz and above re: 95%

normals (Gorga, et al., 1997)

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10/17/2018 9

  • 62 year old Cellist

62 year old flutist

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10/17/2018 10 29 year old bassist – Intermittent use of

HPDs, c/o tinnitus

 Distortion Product Otoacoustic Emissions

  • Present & robust at 1500, 2000 Hz
  • Present at low levels at 3000 Hz
  • Absent 4000-10000 Hz
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10/17/2018 11

Does a “Notch” mean NIHL?

  • Osei-Lah & Yeoh (2010)
  • 62 patients with “high-frequency notch”

(39% of clinic patients)

  • 40% had no history of noise exposure
  • 25% bilateral, 50% left, 25% right
  • Must consider actual exposure
  • Unilateral vs. bilateral

Damage risk criteria (DRC):

  • A model for understanding the dose-response

relationship between noise and hearing loss.

  • Function of time of exposure and the level

(dBA) of the exposure

  • “Acceptable” risk is a judgment call

Population Fractiles of susceptibility:

0.1 0.5 0.9 “Tender” “Average” “Tough” (10% most) (10% least)

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10/17/2018 12

NIOSH

 85 dBA as an 8 hour

TWA

  • Exposures at or above this

limit are hazardous  Calculate:

  • T(min) = 480/2^(L-85)/3
  • L = level, 3 = exchange rate

OSHA

 90 dBA as an 8 hour

TWA

 5 dB exchange rate  NIOSH

  • 85 dBA
  • 3 dB Exchange

rate 85 dBA | 8 hrs 88 dBA | 4 hrs 91 dBA | 2 hrs 94 dBA | 1 hr

 OSHA

  • 90 dBA
  • 5 dB Exchange

rate 90 dBA | 8 hrs 95 dBA | 4 hrs 100 dBA | 2 hrs 105 dBA | 1 hr LIBERAL

  • EU

– 80 dBA – 3 dB Exchange rate 80 dBA | 8 hrs 83 dBA | 4 hrs 86 dBA | 2 hrs 89 dBA | 1 hr CONSERVATIVE

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10/17/2018 13

Organization 8hr Noise Exp Estimated % at Risk

OSHA 90 dBA 21% 85 dBA 10% 80 dBA 3% NIOSH 90 dBA 29% 85 dBA 8% (NIOSH/EU) 80 dBA 3%

Damage-risk Criteria choice

 100% noise dose = 8 hours at recommended

exposure level of a damage risk criteria

 NIOSH:

  • 85 dBA for 8 hours = 100% dose
  • 88 dBA for 4 hours = 100% dose
  • 91 dBA for 2 hours = 100% dose

 Dose is cumulative

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10/17/2018 14

So… what criteria do we use?

  • Damage-risk Criteria
  • OSHA (90 dBA, 5 dB exchange ratio)
  • NIOSH (85 dBA, 3 dB exchange ratio)
  • EU (80 dBA, 3 dB exchange ratio)
  • Percentage of noise dose?
  • 50%
  • 100%
  • Some other percentage?

Who is at risk for MIHL

  • Musicians
  • Amplified musicians
  • Stage levels can exceed 110 dBA
  • Classical musicians
  • Levels may be lower, but exposure time is

greater (200% dose per rehearsal)

  • Music students & teachers
  • Long exposure time
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10/17/2018 15

Who is at risk for MIHL?

  • Listeners
  • Amplified music
  • Dance clubs
  • Concerts
  • Classical Music
  • Portable listening devices

Mean Minimum Maximum Nightclub / discotheque 98 80 106 Personal cassette player 80 75 92 Rock / pop concert 104 80 120 Jazz concert 91 77 100 Symphony concert 90 80 100

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10/17/2018 16

Does recreational exposure cause hearing loss?

  • It is difficult to show a causal relationship

between recreational exposure and hearing loss

  • A noise notch is suggestive, not definitive
  • Only way to show cause is to document

exposure

 Musicians

  • Support staff

 Workers exposed to music

  • In music-filled environments
  • Their own PLDs
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10/17/2018 17

Output Levels of PLDs

Music players can produce high outputs levels

70% = 83 dB 80% = 89 dB 90% = 95 dB 100% = 101 dB

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10/17/2018 18

Portnuff, Fligor & Arehart (2011)

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10/17/2018 19

NIOSH 85 dBA 3 dB Exchange rate 85 dBA | 8 hrs 88 dBA | 4 hrs 91 dBA | 2 hrs 94 dBA | 1 hr OSHA 90 dBA 5 dB Exchange rate 90 dBA | 8 hrs 95 dBA | 4 hrs 100 dBA | 2 hrs 105 dBA | 1 hr LIBERAL European Union 80 dBA 3 dB Exchange rate 80 dBA | 8 hrs 83 dBA | 4 hrs 86 dBA | 2 hrs 89 dBA | 1 hr CONSERVATIVE  Damage-risk Criteria

  • 90 dBA, 5 dB exchange ratio (OSHA)
  • 85 dBA, 3 dB exchange ratio (NIOSH)
  • 80 dBA, 3 dB exchange ratio (WHO)

 Percentage of noise dose due to music?

  • 50%
  • 100%
  • Some other percentage?
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10/17/2018 20

Listening Time Guidelines

  • As people are exposed to more than just

their MP3 player… time to 50% noise dose

NOTE: Do NOT over-interpret this table to suggest “isolator” headphones are more dangerous!

Listening Behavior

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10/17/2018 21

Portnuff, unpublished dissertation (2011)

Background noise (dBA)

10 20 30 40 50 60 70 80 90

Chosen listening level (dBA)

50 60 70 80 90 100 110

CLLs and SNR

Noise Mean CLL (Std. Dev) Mean SNR (Std. Dev) % of listeners >85 dBA Quiet 74.1 dBA (14.2 dBA) 25% 50 dB 76.0 dBA (12.2 dBA) 30.5 dB (12.7 dB) 23.1% 60 dB 82.0 dBA (10.3 dBA) 24.7 dB (10.9 dB) 28.9% 70 dB 87.0 dBA (9.0 dBA) 19.7 dB (9.5 dB) 53.9% 80 dB 93.1 dBA (7.8 dBA) 15.8 dB (7.9 dB) 84.6%

Portnuff, unpublished dissertation research

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10/17/2018 22  Manikin measures in public places

Study % of subjects exceeding 100% noise dose (NIOSH) Location Levey, Levey & Fligor (2011) 51.9% Urban university campus, New York City, NY Williams (2005) 25% Busy streets, Melbourne and Sydney, Australia Williams (2009) 17% Busy streets, Brisbane, Canberra, Australia Keith et al (2011) 3.2% Quiet classrooms, Ottawa, ON Epstein, Marozeau & Cleveland (2010) 0% Various locations, Boston MA

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10/17/2018 23  Young Adults (18-29 y.o.)

  • 16.7% exceed 100% noise dose
  • 20.8% exceed 50% noise dose

 Self-reports reflect similar results!

Portnuff, Fligor & Arehart 2013

 Most accurate question:

  • “When you listen to your MP3 player, what

volume setting do you usually listen at?”

▪ Combined with listening duration, can calculate Dose

Average % Over 50% daily dose Over 100% Daily dose Dosimetry (% Dose) 518.0 32.1% 14.3% Self-report (% Dose) 1710.9 20.8% 16.7%

Portnuff et al (2013)

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10/17/2018 24

 Time to 50% noise dose, NIOSH damage-

risk criteria

NOTE: Do NOT over-interpret this table to suggest “isolator” headphones are more “dangerous”!  Is PLD overuse going to cause an

“epidemic” of hearing loss?

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10/17/2018 25  Environment dependent

  • In quiet, accurate 9% of the time
  • In 60 dB, accurate 16% of the time
  • In 75 dB, accurate 42% of the time

 Earphone dependent

  • Isolating earphones would decrease sound

“leakage” from ear canal

Weiner, Kreisman & Fligor (2009)

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10/17/2018 26  Damage-risk Criteria

  • 90 dBA, 5 dB exchange ratio (OSHA)
  • 85 dBA, 3 dB exchange ratio (NIOSH)
  • 80 dBA, 3 dB exchange ratio (WHO)

 Percentage of noise dose due to music?

  • 50%
  • 100%
  • Some other percentage?

“Musicians need an audiologist like everyone needs a dentist” Benj Kanters, M.M.

Professor, Audio Engineering Columbia College Chicago

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10/17/2018 27

When do musicians or PLD users see an audiologist?

 Survey measures to identify extent of music

exposure

  • Instruments, live music, PLD use

 Audiometric Evaluation

  • Pure-tone monitoring
  • OAE monitoring

 Noise exposure measurements  Counseling

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10/17/2018 28  Consider Noise Dose

  • Dose is cumulative through the day
  • Music/PLDs are only one part of the daily

exposure

▪ Occupational exposure ▪ Recreational exposure

  • Consider variations in exposure level

▪ Are there times when the level is significantly lower

  • r higher?

 Consider listening environment

  • Always higher listening in background noise
  • Average preferred SNR +4 to +13 dB

 Consider earphones

  • Earphone sensitivity affects output level
  • Isolation affects SNR & chosen level
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10/17/2018 29  Consider susceptibility

  • Usually unknown, unless you can document

hearing loss due to sound exposure

  • Hearing loss due to PLD use suggests

enhanced susceptibility

 Consider effects of hearing loss

  • Pre-existing hearing loss
  • Cumulative effects of hearing loss on

perception

 Noise Survey (Measurement)  Noise Controls  Hearing Protection  Audiometric Monitoring  Training and Education

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10/17/2018 30  How do you know what the musician is

exposed to?

 Music is NOT stochastic

  • Music is variable across time
  • Music levels may increase and decrease

 Music CANNOT be measured well with a

sound level meter – dosimetry is always a better choices

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10/17/2018 31

 103 dBA (single piper), 110 dBA (7 pipers)

 Exposure is Level + Time  Reduce playing level  Reduce playing time  Reduce exposure from other instruments

  • E.g. highly directional instruments on risers
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10/17/2018 32

HCP: Noise Controls

  • Performance location
  • Stage levels
  • What speakers are being used?

Monitors? Where are they aimed?

  • Control by sound engineer
  • Rehearsal areas
  • Individualized level changes
  • In-ear monitors with sound isolation
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10/17/2018 33  Earplugs  In-Ear Monitors

  • Both HPDs and Noise Controls

More on this tomorrow!

 Noise Survey (Measurement)  Noise Controls  Hearing Protection  Audiometric Monitoring  Training and Education

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10/17/2018 34

 MIHL is ENTIRELY preventable  Portable listening devices are not inherently

dangerous – most people use them safely!

 Audiologists are uniquely suited to be the

experts of clinical noise exposure assessment and hearing loss risk Questions? cory.portnuff@uchealth.org