GENERAL ARTICLE

Noise and Hearing Loss: A Review

ABSTRACT
EILEEN DANIEL, DEd
BACKGROUND: Noise-induced hearing loss is a major cause of deafness and hear-
ing impairment in the United States. Though genetics and advanced age are major
risk factors, temporary and permanent hearing impairments are becoming more
common among young adults and children especially with the increased exposure to
portable music players. Though treatment options are limited for most people with
noise-related hearing loss, several modifiable health behaviors that should begin in
childhood might prevent or delay the onset of hearing impairment. The purpose of
this article is to review modifiable and nonmodifiable risk factors, comorbidity, and
the role of health education in the prevention of noise-induced hearing loss.
METHODS: Review of current literature in the etiology, prevention, and treatment of
noise-induced hearing loss as well as the role of health education.
RESULTS: Nonmodifiable risk factors related to noise-related hearing loss include
increasing age, genetics, male gender, and race. Modifiable risk factors are voluntary
exposure to loud noise, nonuse of hearing protection, smoking, lack of exercise, poor
diet, tooth loss, and the presence of diabetes and cardiovascular disease.
CONCLUSIONS: As hearing impairment among children and teenagers rises due to
mostly voluntary exposure to loud noise, there are many implications for health
education. Health educators need to address barriers to the use of hearing protection,
deliberate exposure to loud music, and other modifiable risk factors, which cause and
exacerbate hearing loss among those exposed to loud noise.
Keywords: noise-induced hearing loss; hearing protection; hearing conservation;
tinnitus.
Citation: Daniel E. Noise and hearing loss: a review. J Sch Health. 2007; 77: 225-231.

Professor, ([email protected]), Department of Health Science, SUNY College at Brockport, Brockport, NY 14420.
Address correspondence to: Eileen Daniel, Professor, ([email protected]), Department of Health Science, SUNY College at Brockport, Brockport, NY 14420.

Journal of School Health d May 2007, Vol. 77, No. 5 d ª 2007, American School Health Association d 225
W hile noise-induced hearing loss is most preva-
lent among individuals over the age of 65 and
the incidence is expected to rise as the population
Table 1. Decibel Chart*

Typical Physical
Decibel Level (dB) Source Response
ages, the number of children and young adults with
hearing loss is increasing.1,2 This appears to be corre- 0 Softest sound that
lated to the increase in the amounts of hazardous can be heard
10 Normal breathing Barely audible
levels of noise exposure from infancy through early 30 Whisper Very quiet
adulthood. 50-65 Normal conversation Quiet
Approximately 28 million Americans have im- 80-85 City traffic noise Annoying
paired hearing and about half of these cases are at 95-110 Motorcycle Very annoying
least partly related to damage from short-term or 100 School dance, Very annoying
boom box
chronic exposure to loud noise.1 The National Insti- 110 Busy video arcade Very annoying
tute of Occupational Safety and Health (NIOSH) 120 Nightclub Can damage hearing
reports that approximately 30 million Americans are after 15 minutes
exposed to daily noise levels that will likely lead to exposure per day
hearing loss. Adults are going deaf at earlier ages 110-125 Stereo, personal Can damage hearing
music player after 15 minutes
than in the past while 1 in 8 children and teenagers exposure per day
between the ages of 6 and 19 already have some 110-140 Rock concerts Noise may cause pain
level of hearing loss.2 Hearing loss, whatever the and brief exposure
cause, can give rise to a number of handicaps. Stud- can injure ears
ies have shown that children and adults with 150 Firecracker Noise may cause pain
and brief exposure
impaired hearing have a poorer quality of life related can injure ears
to reduced social interactions, isolation, a sense of
exclusion, depression, and possibly impaired cogni- *American Tinnitus Association, http://www.ata.org/about_tinnitus/consumer/healthy_
hearing1.htm
tive function.3
The mechanism of noise-induced hearing loss
involves the destruction of hair cells in the Organ of experience tinnitus to the extent that it interferes
Corti within the cochlea of the inner ear. Chronic with their daily lives. While constant exposure to
exposure to loud noise initially damages the hair loud noise exacerbates the risk of hearing loss, single
cells, which are responsible for high-frequency exposures can also cause auditory changes. A recent
sounds. Over time, continued contact with excessive study determined that children and teenagers exposed
noise may lead to impaired transmission of both to a single intense sound event experienced both
low- and high-frequency sounds to the brain. While hearing loss and tinnitus.5 These individuals, who
the average person is born with approximately ranged from 1 to 16 years, maintained a slight hear-
16,000 hair cells, up to 30-50% can be damaged or ing loss and a hypersensitivity to sound after 1 year.
destroyed before any measurable level of hearing Loud noise has other effects on the body unrelated
loss is detected.4 There is, unfortunately, limited to hearing. Nonauditory effects may include elevated
ability to detect the beginning stages of noise- blood pressure, loss of sleep, changes in brain chemis-
induced hearing loss. By the time a sufficient num- try, and increased heart rate.6 Other effects include
ber of hair cells are destroyed to be noticeable, the impaired early development and learning disabilities
damage has been done. Hearing loss related to hair among children. Noisy homes and environments may
cell destruction is not reversible and cannot typically impede cognitive and language development and psy-
be restored by the use of a hearing aid. chomotor tasks. There are many studies demonstrat-
Sound intensity is measured in decibels (dB), ing that children living and attending schools near
which is used to indicate how humans hear a given areas of loud noise such as airports have lower read-
sound. A dB of 0 is considered the point at which ing scores.4 To perform well academically, students
a person starts to hear sound while a whisper at 3 need quiet places to learn and study.
feet is equal to 30 dB and an average rock concert While involuntary contact with loud noise puts
can measure up to 140 dB (Table 1). NIOSH defines children and adults at risk for hearing loss and other
hazardous noise as sound that exceeds 85 dB over noise-induced health problems, much noise expo-
a typical 8-hour day1. The agency’s data also indicate sure is voluntary. Loud music, particularly portable
that prolonged exposure to noise over 85 dB can music players, can expose listeners to potentially
change the structure of hair cells, resulting in often harmful sound for many hours of the day. Portable
irreversible hearing loss. It can also cause tinnitus, music players can store thousands of songs and can
a ringing or buzzing in the ears, which affects an esti- play for hours. Industrial regulations require
mated 12 million Americans, many of them are chil- employers to take action whenever their workers are
dren and teenagers.4 Of those, at least 1 million exposed to noise over 85 dB for 8 hours a day.

226 d Journal of School Health d May 2007, Vol. 77, No. 5 d ª 2007, American School Health Association
Either ear protection has to be provided or the noise NONMODIFIABLE RISK FACTORS
must somehow be reduced. Listeners using portable
Nonmodifiable risk factors for noise-induced hear-
music players can expose themselves to the same
ing loss include age, genetics, gender, and race. Of
level of loudness in 15 minutes of music at 100 dB
these factors, age plays the most significant role. The
that an industrial worker gets in an 8-hour day at
risk of developing noise-induced hearing loss typi-
85 dB. The typical listener has the volume at a range
cally increases with advancing years. Among individ-
between 75 and 105 dB.7
uals between the ages of 65 and 75, approximately
In addition to portable music players, there are
23% suffer from partial or full loss of hearing. Over
other recreational exposures that can negatively
age 75, about 40% are hearing impaired or deaf.1
affect hearing. Playing with loud toys and games and
However, studies have shown that increasing numbers
attending rock concerts can contribute to sounds
of children and teens are showing signs of tinnitus,
high enough to negatively affect hearing or cause
temporary threshold shift, and hearing impairment.
tinnitus. A recent study found that in a typical
In a large, national population-based study, re-
nightclub, the sound intensity ranged from 104 to
searchers estimated that approximately 12% of 6- to
112 dB.2 Researchers determined that exposure to
12-year-old children had experienced noise-induced
loud leisure noise is correlated with hearing loss
threshold shifts.9 Chung et al10 determined that
and tinnitus and the risk rises as noise exposure
a majority of teenagers and young adults in their
increases.5 Whatever the source, unlike workers
study suffered from tinnitus and impaired hearing
who may have limited choice regarding noise expo-
after exposure to loud music.
sure, young people often choose to expose them-
Although age is correlated with hearing loss,
selves to loud sounds.
genetics and gender also have been linked. Studies
Mercier and Hohmann studied over 700 teenagers
have shown that there are considerable differences
and young adults and determined that the majority
in susceptibility to noise damage between individu-
regularly attended discotheques and rock concerts.
als, between the left and the right ear, and at differ-
The researchers found that while the subjects typi-
ent times of day within the same person, indicating
cally were exposed to sounds exceeding 87 dB,
the possibility of genetic variability to response to
approximately 60% did not consider the noise to be
noise exposure.11 Dogru et al12 determined that
too loud.8 While these individuals did not perceive
there may be a correlation between blood group and
the music as too loud, 71% suffered from tinnitus
noise-induced hearing loss. The researchers found
and 11% had hearing loss following attendance at
that noise-induced hearing loss was significantly more
a music event.
frequent among subjects with blood group O who
Takayuki Kageyama identified several psychologi-
may be more prone to noise-related hearing impair-
cal characteristics of young people who keep their
ments. A recent National Health and Nutrition Study
volume high while listening to music with portable
III indicated that boys were more likely to show
headphones.7 These included anxiety and sensation-
signs of early hearing loss than girls, possibly due to
seeking tendencies. Overall, those who turned up
the kinds of activities in which they engage.9 Finally,
the volume the highest were males regardless of the
researchers found a positive association between
type of music though rock and heavy metal was
hearing loss and short stature.13 While genetics or
played the loudest by both males and females.
other variables may play a role, they theorized that
Recent studies have shown prevention measures,
mechanisms linked to prenatal growth retardation
including consistently using hearing protection, can
during fetal life may have caused both the short
minimize the negative effects of exposure to loud
stature and the damage to the development of the
noise. Avoiding tobacco, getting regular exercise,
cochlea.
and eating a healthy diet and/or nutritional supple-
A racial difference in hearing loss when exposed
ment use may also decrease an individual’s risk of
to loud noise has been observed in the workplace.
developing noise-induced hearing loss or delay its
Researchers determined that non-whites suffered
onset even if exposed to consistent levels of noise
a greater degree of hearing loss after adjusting for
loud enough to damage hearing. The presence of
years of employment.14 Helzner et al15 found that
diabetes, heart disease, and tooth loss may increase
other variables were better predictors than race and
the risk of deafness following noise exposure. Under-
included concomitant high blood pressure, diabetes,
standing the risk factors is especially important, as
and smoking.
there are limited effective treatments or cure for
most sufferers once a noise-induced hearing loss
occurs. The purpose of this article is to review modi-
MODIFIABLE RISK FACTORS
fiable and nonmodifiable risk factors, comorbidity,
and the role of health education in the prevention Several modifiable risk factors relate to noise-
of noise-induced hearing loss. induced hearing loss. These include the nonuse of

Journal of School Health d May 2007, Vol. 77, No. 5 d ª 2007, American School Health Association d 227
hearing protection, cigarette smoking, lack of exer- gators found similar results in a study involving male
cise, low dietary intake of foods rich in antioxidant metal factory workers. They determined that there
vitamins and minerals, the presence of diabetes or was a synergistic effect of smoking and noise expo-
heart disease, and poor oral health. sure on hearing loss.21

Nonuse of Hearing Protection Exercise and Nutrition

While ear protection has been found to reduce A limited number of studies were identified,
the risks associated with loud noise, many people do which linked physical fitness and prevention of
not wear them, especially teenagers. Several studies hearing loss. Cristell et al22 found that after 2
have shown that even when individuals are aware months of fitness training, teens and young adults
of the risks of noise exposure, they are reluctant to improved both their level of cardiovascular fitness
use hearing protection.16,17 Reasons include discom- and their hearing. Kolkhorst et al23 determined that
fort, safety concerns, design, lack of knowledge there was an association between physical fitness
related to noise-induced hearing loss, and peer pres- and diminished temporary hearing loss experienced
sure. These barriers exist even when individuals per- after noise exposure. The researchers theorized that
ceive themselves to be at risk for hearing loss.16 exercise training causes the inner ear to receive
Olsen and Erlandsson17 found that teenagers with more oxygen-rich blood, which enhances hearing.
a high socioeconomic status were more likely to use In addition to exercise, diet may also play a role
hearing protection and were more concerned about in mitigating the effects of noise exposure. Research-
hearing loss related to exposure to loud noise. ers believe that exposure to loud noise can damage
Peters18 determined that most people were not suffi- inner ear hair cells via processes related to free radi-
ciently aware of the dangers of noise, which contrib- cals, unstable oxygen compounds, which can attack
uted to their not using hearing protection. A Web or react with healthy body cells. Antioxidants such
site survey conducted by Chung et al10 found that as vitamins A, C, and E and the mineral selenium
most teens responding to questions about general protect the body against damage caused by free radi-
health did not consider hearing loss a major con- cals.24 Kopke et al25 similarly found that antioxi-
cern. This was despite the fact that about 60% had dants helped reduce hearing damage after exposure
experienced temporary hearing loss or tinnitus while to loud noises. The mineral magnesium has also
attending loud concerts or clubs. Many of these re- been shown to lessen the damaging effects of noise
spondents claimed they might consider hearing exposure. Two studies have demonstrated the pro-
protection if they believed they were at risk for phylactic effects of magnesium on noise-related
permanent as opposed to temporary hearing loss hearing damage in humans.26,27
(66%). Peters18 found that individuals who expose In addition to magnesium, the mineral zinc and
themselves to loud noise during their leisure time two B vitamins may also play a role in lessening the
were unlikely to consider the need for hearing impact of noise exposure and resulting hearing loss.
protection. Vitamins B9 (folate) and B12 have been studied in
relationship to hearing loss. Data indicate that while
further studies are needed, there may be some ther-
Smoking
apeutic value in the use of these two vitamins.28
Cigarette smoking is a major risk factor for many
health problems, including hearing loss. Smoking
exposes smokers to distinct toxic substances in Comorbidity
mainstream smoke, which may synergistically affect There is a well-established relationship between
hearing when combined with loud noises. Non- hearing loss and tooth loss, diabetes, and heart dis-
smokers exposed to both noise and secondhand ease.6,29 Lawrence et al29 observed nearly twice as
smoke are also more likely to have hearing loss. much hearing loss among patients shifting from
Researchers tested the hearing of over 3700 adults greater than 17 to less than 17 teeth. Schell et al30
who began smoking in their teens and found they found that hearing loss was more pronounced
were more likely to have hearing loss than non- among those with the highest number of teeth lost.
smokers. Nonsmokers who were exposed to second- The authors suggested that tooth loss causes hearing
hand smoke were also more likely to experience loss impairment because of a lack of muscle activity of
of hearing.19 the palate on the auditory tube.
A study involving steel workers found that smok- Among individuals with diabetes, there appears to
ing was associated with increased odds of having be an increased risk of hearing loss and loss of hear-
high-frequency hearing loss. Researchers determined ing at an earlier age. High blood sugar may cause
that there was a synergistic effect on hearing with blood vessels in the inner ear to narrow, which dis-
exposure to smoking and industrial noise.20 Investi- rupts the normal transmission of sound.31,32 Diabetes

228 d Journal of School Health d May 2007, Vol. 77, No. 5 d ª 2007, American School Health Association
is of particular concern since its incidence has important effects on the numbers of Americans who
been increasing significantly among young children develop noise-induced hearing loss. These strategies
and teens.31 Similarly, cardiovascular disease can may include the integration of hearing conservation
also increase the risk of hearing loss. People with into existing health education and science classes,
cardiovascular-induced circulatory problems are raising awareness of the relationship between other
more likely to suffer hearing loss due to diminished modifiable risk factors and hearing loss, and mandat-
circulation and narrowing of the blood vessels in the ing hearing conservation instruction during elemen-
inner ear.33 tary and secondary schools.
Though knowledge of the relationship between
noise and hearing loss is an important component of
IMPLICATIONS FOR HEALTH EDUCATION
health education, it does not always facilitate change.
While age and hearing loss is linked, there For over half a century, the Health Belief Model
appears to be a rise in hearing impairment among (HBM) has been used to better understand health
children and teenagers, usually related to recrea- behavior and factors related to compliance and non-
tional noise exposure. Unlike industrial contact, compliance with recommended health behaviors.36
many young people voluntarily expose themselves The model offers guidelines for the development of
to loud noise via headphones, car sound systems, programs, which address compliance issues. For
loud concerts, and nightclubs. The most effective instance, this model suggests that young people vol-
way to lower the incidence of noise-induced hearing untarily exposed to loud noise are more likely to
loss among this population is to reduce the exposure take action (ie, use hearing protection or turning
to loud noise by having them turn down the vol- down the volume) if they believe they are suscepti-
ume, avoid the source of the loud noise, or the con- ble to permanent hearing loss. In addition, if they
sistent use of hearing protection. Unfortunately, are aware that developing a hearing impairment
many listeners who deliberately expose themselves could negatively affect their quality of life and may
to loud noise appear unwilling to do any of these. It not be treatable, that would increase their sense of
has been determined that many young people be- susceptibility. Next they must perceive the benefits
lieve music is enhanced when played very loudly.8 of taking action (avoiding loud noise or the use of
There also appear to be barriers to the use of ear protection) as outweighing the barriers (ie, peer
hearing protection. Major limitations to the consis- pressure).
tent and effective use is discomfort, the lack of easily Hearing conservation programs based on the
accessible health information, advice and guidance HBM and administered in school-based settings
on the risk from loud noise during leisure activities, could be designed with two components: knowledge
lack of knowledge of the function of the ear, the (ear anatomy, relationship between noise and hear-
need for regular hearing assessments, and lack of ing loss, and hearing loss and modifiable risk fac-
hearing conservation programs.18 Hearing conserva- tors) and skill building (turning down the volume,
tion programs focusing on the prevention of hearing proper use of ear protection, ways to add vitamin
loss have traditionally been offered in the workplace and mineral-rich foods to the diet, exercise programs,
but are also offered in some school districts.34 School- and good oral hygiene). If available, hearing testing,
based hearing conservation programs are designed particularly before and after exposure to loud noise,
for children and teens to emphasize consequences of could provide a strong illustration of the relation-
hearing loss and the types of noise that are most ship between noise and temporary hearing loss.
likely to cause temporary and permanent impair- Program evaluation should address knowledge of
ment. Numerous studies have evaluated the efficacy ear anatomy, the effects of loud noise on ear cells,
of hearing conservation programs and determined and behaviors (use of hearing protection, turning
that they significantly improve knowledge and have down the volume, diet, exercise, and dental care).
measurable, positive effects on behavior.10,34 While Most school-based hearing conservation programs
the benefits of hearing conservation programs are conclude that compared to pretest responses, stu-
clear, there are too few school districts including dents’ performance on knowledge and awareness
them in their curricula.35 That may be related to questionnaires improves significantly as measured
lack of public awareness about how excessive sound by posttests.34 In addition, several studies have
exposure damages hearing and the impact of hearing determined that a significantly larger number of
loss. Both children and parents should be educated students used hearing protection following conser-
on the various means to prevent noise-induced vation instruction than among control groups.35
hearing loss at home, school, and during recreational This is significant since personal hearing protection
activities. devices are one of the most important behavioral
Identifying education strategies to prevent or changes that can be made to prevent noise-induced
delay onset of noise-induced hearing loss will have hearing loss.18

Journal of School Health d May 2007, Vol. 77, No. 5 d ª 2007, American School Health Association d 229
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to reach children and help them develop the knowl- health effects? Nutr Health Rev. 1996;78(78):2-7.
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cardiovascular disease and tooth loss, which are also loud?: what do young people think? Noise Health. 2002;4(1):
correlated to hearing impairment.29,30,33 School- 47-55.
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11. Klein BEK, Cruickshanks KJ, Nondahl, et al. Cataract and
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NOTICE
General Recommendations on Immunization
Recommendations of the Advisory Committee on Immunization Practices (ACIP)

This report is a revision of General Recommendations on Immunization and updates the 2002
statement by the Advisory Committee on Immunization Practices (ACIP) (CDC. General
recommendations on immunization: recommendations of the Advisory Committee on Immuniza-
tion Practices and the American Academy of Family Physicians. MMWR 2002;51[No. RR-2]). This
report is intended to serve as a general reference on vaccines and immunization. The principal
changes include 1) expansion of the discussion of vaccination spacing and timing; 2) an increased
emphasis on the importance of injection technique/age/body mass in determining appropriate
needle length; 3) expansion of the discussion of storage and handling of vaccines, with a table
defining the appropriate storage temperature range for inactivated and live vaccines; 4) expansion
of the discussion of altered immunocompetence, including new recommendations about use of
live-attenuated vaccines with therapeutic monoclonal antibodies; and 5) minor changes to the
recommendations about vaccination during pregnancy and vaccination of internationally adopted
children, in accordance with new ACIP vaccine-specific recommendations for use of inactivated
influenza vaccine and hepatitis B vaccine. The most recent ACIP recommendations for each
specific vaccine should be consulted for comprehensive discussion. This report, ACIP recommenda-
tions for each vaccine, and other information about vaccination can be accessed at CDC’s National
Center for Immunization and Respiratory Diseases (proposed) (formerly known as the National
Immunization Program) website at http//:www.cdc.gov/nip.
Reference: Kroger AT, Atkinson WL, Marcuse EK, Pickering LK. General Recommendations on
Immunization: Recommendations of the Advisory Committee on Immunization Practices (ACIP).
MMWR Recommendations and Reports 2006; 55(RR15);1-48. Errata to Table 9, MMWR 2006;
55(48); 1303-1304.

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