Tinnitus and hearing

    The function of the ear

    How is the ear canal affected by sound?
    How do hair follicle cells react to sound and how do tinnitus/extreme sound sensitivity and distortion occur? 

    Tinnitus and hearing impairment

    Hearing impairment, tinnitus and changes in sound sensitivity are symptoms of injury to the inner ear. Tinnitus often occurs without hearing impairment. Sound disorientation and a sense of a closed hearing canal can also be experienced during or after overexposure to sound. Sensitivity to sound may be accompanied by ear pain and dizziness. Temporary hearing problems like impairment and tinnitus, that occur after an orchestral rehearsal or concert should be considered a temporary noise injury, as well as a warning sign of permanent damage.

    In many cases tinnitus and hearing impairment disappear after about 24 hours. Sometimes tinnitus continues and is a sign of a definite hearing injury.

    Tinnitus can occur in one or both ears, and sometimes inside the head. If tinnitus occurs, the ears should be examined to eliminate the possibility of wax build up and inflammation – both of which can cause tinnitus temporarily. A hearing test is also recommended to confirm possible hearing impairment and to provide a prognosis for the tinnitus.

    Tinnitus becomes more pronounced and difficult during fatigue, pain, stress and anxiety. A negative spiral is created which disturbs sleep. The degree of discomfort depends often on the brain’s ability to filter out the tinnitus. This ability can be weakened during times of worry and negative thinking. In a calm and healthy brain, tinnitus is lessened and only a problem when attention is turned to it. The prognosis for tinnitus is usually good, but after treatment it may still be more or less noticeable.

    Tinnitus can be treated. There are treatment methods to fit everyone, but none of them removes the tinnitus completely. Sound treatment can be one way. Hearing aids can be used when there is hearing impairment, and sound stimulators can be used to train the brain to handle sound. There are psychological treatments to lessen the mental influences that worsen tinnitus, and pain relief with the help of a physiotherapist can also be effective.

    Musicians need to have stretches of quiet after times of intense sound exposure that can cause tinnitus. Resting from sound should be done as long as discomfort from tinnitus and sound sensitivity is apparent. This often takes about one to two weeks.

    Medication may also be considered to treat inner ear injury. Musicians also need to analyze their playing, weekly practice and rehearsal schedules, as well as where they sit in the orchestra, how often they play in very loud compositions. Implementation of hearing protection aids should be done as much as possible.

    Artist- och Musikerhälsan can, through the expertise of their audiologists, physicians, physiotherapists, psychologists, etc provide ear and hearing examinations, and give advice on how to minimize problems with tinnitus and other hearing difficulties.
    Per Broms, physician

    How much can the ear take before hearing impairment may occur?

    Decibel, dB is a mathematical measure, where the relation to the actual loudness of a sound and its comparable strength is expressed as an algorithm.

    An increase/decrease of dB levels by 10, means a 10 times higher/lower sound level. +/- 20 dB means 100 times higher/lower sound level. An increase/decrease of 3 dB means a doubling or halving of the sound level.

    Our ears cannot discern smaller variations in dB levels. An increase of 10 dB is needed for a sound level to be heard as twice as loud.

    According to “Arbetarskyddsstyrelsen’s” (the Swedish Work Environment Agency) regulations, most people can handle levels of around 85 dB for 8 hr/day, five days a week. Tolerance is individual, so that this level of sound may be too great for some people. Considering that an increase of 3 dB means a doubling of the sound level, the double level acceptable would be 88 dB for 4 hr/day, etc according to the table below.

    The effect of different sound levels, how much people in general can tolerate:

    Sound level      Time
    85 dB                – 8 h
    88 dB                – 4 h
    91 dB                – 2 h
    94 dB                – 1 h
    97 dB                – 30 min
    100 dB              – 15 min
    103 dB              – 7 min
    106 dB              – 3 min
    109 dB              – 1,5 min 

    Time limits for exposure to sound after which the risk of hearing injury is high.

    dB – How is a change in sound level experienced?

    An increase/decrease of the sound level by 3 dB means it becomes twice as loud/half as loud, but for the ear to notice twice the difference in a sound level, the increase/decrease needs to be 10 dB!

    What do employers and musicians need to know about the effects of sound levels?

    88 4 tim
    91 2 tim
    94 1 tim
    97 30 min
    100 15 min
    103 7,5 min
    106 4 min
    109 2 min
    112 1 min

    Tabel 8.3. The amount of time it takes to reach an 85 dB daily harmful exposure at various sound levels.

    In the Swedish Work Environment Law there are recommendations to help prevent hearing loss and impairment. This includes the usual injuries of tinnitus, sound sensitivity and disorientation. For those who are regularly exposed to high levels of noise and sounds in their work environment, employers are required to provide regular hearing tests, including an examination of both air and bone structures, so that it is possible to identify where in the “hearing chain” a possible injury has occurred.

    In order to know just how many decibels of sound musicians are exposed to, one needs to consider the entire amount of exposure during a single day. This includes practice sessions, passive listening to music, rehearsals and concerts. Individuals vary in how sensitive they are to various levels of sound, just as everyone’s sense experiences are unique. This is why it is important to measure sound levels. How much various instrumentalists are exposed to higher levels should also be measured, as it is well known that those located close to loud instruments, such as percussionists, and wind players, can be protected. Musicians who play very loud instruments, are placed 0.5 – 1 meter up on a platform.

    If the distance between musicians is increased, the sound level heard can be decreased (if the distance is doubled, the effect will be minus 6 dB, that is, sound levels are lowered by a 25%).

    For example, if a horn player has a shield placed behind her/him at a 45° angle, the sound will travel forward better. Acoustic screens of acrylic with sound absorbing material on both sides are used to lower sound levels. For string instruments, sound should be helped to spread out to the audience, so it is important to have about 2 meters of free floor space in front of the string sections. These are just two of the many ways of handling the acoustics of an orchestra or ensemble.

    Quiet breaks have a major preventive function. The order of the concert program – ensuring that louder pieces are alternated with quieter ones – contributes to protecting the hearing of musicians.

    How can sound levels be adjusted in an ensemble?

    In order to set up protective measures, knowledge of the sound levels is necessary. The space of any given facility, including ceiling height, determines how many can play together at one time. Each musician should have 2 x 2 meters as a minimum. If the ensemble plays in a smaller room, sound levels must be lowered accordingly.

    For electronic music, levels can be lowered by placing parts of the sound production equipment higher than floor level. It is also important to consider the distance between players. A set of drums should have acoustic screens around it.

    References from various international studies

    1. In an article review, it was shown that 38.6 % of those with hearing injuries are musicians. These injuries include tinnitus, sound sensitivity, hearing impairment and diplacusis. Pop/rock musicians are more often injured (63.5 %) than classical musicians (32.8 %).
    Tinnitus was just as common in both groups, but sound sensitivity was more common among pop/rock musicians and diplacusis more common among classical musicians. Hearing impairment in pop/rock players was symmetrical to classical players (68 % to 44.5 %). Hearing injuries were most common in the range of 3000 Hz – 6000 Hz. Tinnitus occurred in 26.3 % compared to 17 % in the population at large.

    2. In Denmark digital sound measurements have been made in two different orchestras by placing microphones in both ears of the musicians. This was done for practice sessions, rehearsals and concerts. Brass players showed a level of 86–98 dBA. Trumpet players were always above 93 dBA. Woodwinds were in the range of 80-97 dBA. Smaller strings reached 82–98 dBA and had a higher exposure by 4.6 dBA in their left ears. The peak for woodwinds was lower than for smaller strings. Viola players and second violinists are more exposed than first violinists. Cello and bass players have a much lower level of exposure. Percussionists often peak at more than 115 dBA and brass players can reach peaks of more than 133 dBA. The study concluded that measurement of exposure during practicing was important to include. Second violinists and violas sat in the middle of the orchestra.

    3. I the Finnish study, exposure was measured with a dosimeter and hearing tests were performed. The study shows that hearing impairment occurred at levels over 3000 Hz, more often than in the population at large. 30 % of the musicians had tinnitus and a few more had chronic problems with sound sensitivity. The highest exposure levels were found among trumpet, piccolo and horn players with levels above 90 dBA.

    4. Queensland Symphony Orchestra has a program to protect the hearing of their musicians since 2005. This program has continued to develop and evolve in order to prevent hearing injuries. They have built up a very comprehensive database of exposure measurements during the various orchestral productions, showing how likely exposure levels are to occur in various compositions. This is also done in order to compile knowledge of exposure during new compositions and exposure variations due to seating positions in the orchestra. The data can be used as a foundation for risk evaluation when an orchestral production is planned. Repeated hearing tests and follow up are important. The person who administrates all of this is the project coordinator. The program committee is composed of managers, artistic leaders, musicians and program administrators. This group ensures that preventive measures such as using earplugs, acoustic screens and sitting positions are taken care of. A specialist in hearing protection and sound exposure educates the others and is available on a regular basis to teach musicians and technicians how to prevent injury.

    References

    Arbetsmiljöverkets Rapport 2009:1 om Musik och höga ljud - praktiska riktlinjer för musik- och underhållningsbranschen. (“On music and loud noise levels – practical guidelines for the performance and entertainment industry.”)
    1. Hearing Loss, Tinnitus,Hyperacusis, Diplacusis in Professional Musicians: A Systematic Review (41 artiklar). Ariana di Stadio et al.
    2. Sound Exposure of Symphony Orchestra Musicians. Jesper Hvass et al; Odense University Hospital
    3. Hearing Loss in Classical-orchestra Musicians. Esko Toppila et al.
    4. Description and Evaluation of a Hearing Conservation Program in Use in a Professional
    Symphony Orchestra. Ian O`Brien et al.

    / Karin Engquist, physician

    Karin Engquist och Ing-Marie Olsson
    Artist- & Musikerhälsan
    Östra Rönneholmsvägen 9B
    211 47 Malmö
    Phone: +46 (0)708 670 647

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