An update on hearing loss in singers.
SINGERS NEED GOOD HEARING. While singers are usually careful to protect their voices, the importance of good hearing is often underappreciated. Professional and avocational singers have hearing demands that exceed those of the general public. (1) Singers need to be able to hear background music accurately, follow fellow singers, and match frequencies over a broad range that may exceed frequencies used for normal conversational speech. (2) Singers use their hearing to monitor vocal quality, provide feedback, and adjust performance. Hearing loss may lead to difficulties in singing and result in artistically unacceptable performance.
Singers may be exposed to loud noises during their musical activities. (3) Sources of loud noises in the musical performance environment include background music, accompanying instruments, loudspeakers, and the singers themselves. Studies have shown that the noise levels within orchestras range from 83-112 dBA. (4) Choir singers can produce noise levels above 110 dB separate from the music that accompanies a singer on stage or in a studio. (5) This level is equivalent to the noise in a jet engine test control room. (6)
The senior author (RTS) has published previous works on hearing loss in singers and instrumentalists. Additionally, in 1991, the senior author wrote an article for the Journal of Singing on hearing loss in singers, discussing the anatomy and physiology of the ear, and selected common causes of hearing loss. (7) The present article reviews types of hearing loss, discusses occupational hearing loss, and provides an update on hearing loss in instrumentalists and singers.
TYPES OF HEARING LOSS
There are three main types of hearing loss: conductive, sensorineural, and mixed. (8)
Conductive Hearing Loss (CHL)
CHL occurs due to the ineffective transmission of sound waves to the inner ear. (9) There may be interference in the outer ear or middle ear (Figure 1). The outer ear includes structures like the external auditory canal and the ear drum. The middle ear includes the three bones of hearing and the middle ear cavity. Causes of CHL include ear wax, foreign bodies in the external auditory canal, swimmer's ear, a hole in the ear drum, fluid in the middle ear, ear infection, fracture of the bones of hearing, and stifening of the bones of hearing (i.e., otosclerosis). Prognosis for patients with CHL is better than that for sensorineural hearing loss. CHL usually can be treated with medicine or surgery; amplification with a hearing aid is also an option.
Sensorineural Hearing Loss (SNHL)
SNHL is due to damage to the inner ear and nerves of hearing. (10) Inner ear structures include the cochlea and the first part of the nerve of hearing (Figure 1), as well as other structures. Patients with SNHL also may have tinnitus (noises in the ear) and dizziness. There are many causes of SNHL: old age, medications (e.g., some antibiotics, chemotherapy drugs), infections, loud noises, hereditary conditions, systemic diseases, tumors (e.g., acoustic neuroma), trauma, and other maladies. The prognosis for many cases of SNHL is poor with limited treatment options. Some cases of SNHL are caused by treatable conditions such as autoimmune ear disease and Lyme disease, so thorough evaluation is advisable.
Mixed Hearing Loss (MHL)
MHL patients have both a CHL and SNHL, that is, patients may have issues with the external, middle, and/or inner ear. Treatment options focus primarily on the conductive component of the hearing loss, but also on treatable causes of SNHL.
OCCUPATIONAL HEARING LOSS
Occupational hearing loss develops slowly over a long period of time (several years) as the result of exposure to continuous or intermittent loud noise in the workplace. (11) This hearing loss is always sensorineural and typically in both ears. Once the exposure is discontinued, there is no further substantial progression of hearing loss. Te earliest damage causes loss in the 3, 4, and 6 kHz range, with recovery at 8 kHz, forming a characteristic notch on the hearing test. The hearing loss usually reaches a maximal level in about 10-15 years, and is not profound. Continuous exposure over years is more damaging than interrupted exposure to noise. Common examples of jobs at risk for occupational hearing loss are factory workers and broiler room workers. Instrumentalists and singers are special examples of occupational hearing loss, as discussed below.
HEARING LOSS IN INSTRUMENTALISTS
There have been more studies examining hearing loss in instrumentalists than in singers. A recent study of German classical orchestras concluded that more than half of the instrumentalists had a mild hearing loss (greater than 15 dB). (12) String and brass players had the highest losses. Among the string players, a dominant hearing deficit in the left ear was reported. Most violin and viola players cradle their instruments in their lef hand; thus, the left ear is closer to their instrument. Two older studies examined hearing loss in music students and professional instrumentalists. (13) They also reported that string instrumentalists were at increased risk of hearing loss. Siroky et al. studied hearing loss in 76 members of a classical orchestra. (14) Sixteen instrumentalists had hearing loss, and 13 were sensorineural. The instrumentalists who had the highest incidence of hearing loss were percussionists (100%), brass (28%), wind (20%), and string (7.3%) players. Instrumentalists who had been playing for more than 20 years had a 42% incidence of hearing loss in contrast to a 0% incidence in musicians who had performing for less than 10 years. Attempts to protect the hearing of instrumentalists in classical orchestras have been made. For example, plexiglass barriers have been installed in front of the louder instruments. Seat positions have also been rotated or elevated within orchestras. (15) None of these measures have been completely satisfactory.
Particular attention has been focused on rock musicians. High intensity noise is one of the characteristics of rock music. Rock music noise levels have been documented at 90-110 dBA, (16) which is equivalent to the noise level from a furnace or a can manufacturing plant. (17) Temporary threshold shifts were identified in about half of the rock musicians they studied. A temporary threshold shift is a temporary SNHL that recovers to normal or baseline within 24 hours. (18) The temporary threshold shifts were in the high frequencies from 4,000 to 6,000 kHz. Permanent hearing losses were found in 6 of the 25 rock musicians. Another study examined the effects of rock music in humans under laboratory conditions. (19) Temporary threshold shifts of 22.5-26 dB were recorded at 4,000 Hz. Some rock musicians have developed strategies to protect their hearing; for example, some wear hearing protection (musician ear plugs) at least during practice. Some rock musicians also stand beside or behind their amplifiers, rather than in front of them. (20)
HEARING LOSS IN SINGERS
Two studies have examined hearing loss in singers. The first study examined professional choir singers. (21) The authors reported that permanent threshold shifts occur at 250 Hz and above and that the low frequency range was affected most, when compared with normative data. These findings differ from those of previous studies that consistently demonstrate hearing loss at much higher frequencies. The authors hypothesized that singing might lead to increased ear fluid pressure, that might cause low frequency hearing loss. The only subgroup to show both high and low frequency hearing loss was the youngest group consisting of 30 to 39 year olds. The authors attributed this to possible spare time activities such as personal music devices, but there was no evidence to confirm this supposition. Female singers also had better hearing at the 3000 Hz to 8000 Hz range when compared to male singers. They concluded that the hearing loss was most likely noise-induced with choir singing as the noise source. However, their study is flawed for several reasons. The control groups were not comparable. For example, all of the control subjects were under thirty, and the choir subjects ranged from thirty-four to sixty-one years of age. The controls were "noise-exposed," but they selected control patients on the basis of previous normal audiograms, and they did not have a similar bias for their experimental subjects. There is vast literature on noise-induced hearing loss (clinical and experimental), and none of it shows low frequency hearing loss such as reported in this study. The usual reason for those findings is an excessively high noise level in the test room. Their data did not show any significant association between hearing loss and voice type (e.g., baritone versus soprano). These data also are controversial and suspect because they do not conform to standard understanding of noise-induced hearing loss or meet accepted criteria for diagnosis. (22)
The second study was conducted by the authors. (23) In a retrospective chart review of 172 singers, the incidence of hearing loss was 17.5%, which was not significantly different from age and gender matched controls. Older age, male gender, longer number of years of singing, and baritone voice were associated with hearing loss. There was no association with genre of music (e.g., rock music). High frequency, bilateral SNHL was the most common type of hearing loss in singers (83.9%) and significantly higher than in age and gender matched controls (39.0%). Establishing causes of the hearing losses in these singers was beyond the scope of this study; however, bilateral SNHL is also the type of hearing loss found with occupational noise exposure.
It is extremely important for singers to protect themselves from hearing loss. There are surprisingly few studies in the literature on hearing loss in singers. This paucity of studies is an opportunity for future research and increased awareness in the singing community. Singers should avoid potentially hazardous noise exposure in avocational situations, like listening to loud music through headphones, or using power tools, chainsaws, motorcycles, and snowmobiles. Like the voice, hearing needs to be protected for a singer to enjoy a long and successful career.
(1.) Robert T. Sataloff, Professional Voice: The Science and Art of Clinical Care, 3rd ed. (San Diego: Plural Publishing Inc., 2005), 513-529.
(2.) Robert T. Sataloff, "Hearing Loss in Musicians," The American Journal of Otology 12, no. 2 (March 1991): 122-127.
(4.) Ibid. [Ed.: dBA refers to A-weighted decibels.]
(5.) Martin Steuer, Susanne Simak, Doris Maria Denk, and Michael Kautzky, "Does Choir Singing Cause Noise-Induced Hearing Loss?" Audiology 37, no. 1 (January/February 1998): 38-51.
(6.) Robert T. Sataloff and Joseph Sataloff, Occupational Hearing Loss, 3rd ed. (Boca Raton: Taylor & Francis Group, 2006).
(7.) Robert T. Sataloff, "Hearing Loss in Singers," Journal of Singing 57, no. 3 (January/February 1991): 35-39.
(11.)Sataloff and Sataloff; D. Bruce Kirchner, Col. Eric Evenson, Robert A. Dobie, MD, et al., "Occupational Noise-Induced Hearing Loss. ACOEM Task Force on Occupational Hearing Loss," Journal of Occupational and Environmental Medicine 54, no. 1 (January 2012): 106-108; OCOEM Noise and Hearing Conversation Committee, "ACOEM Evidence-Based Statement: Noise-Induced Hearing Loss," Journal of Occupational and Environmental Medicine 45, no. 6 (June 2003): 579-581.
(12.)Edeltraut Emmerick, Lars Rudel, and Frank Richter, "Is the Audiologic Status of Professional Musicians a Refection of the Noise Exposure in Classical Orchestral Music?" European Archives of Oto-Rhino-Laryngology 265, no. 7 (July 2008): 753-758.
(13.)M. Flach and E. Aschoff, "[On the Question of Occupationally Related Hearing Difficulties in Musicians"], Z Laryngology, Rhinology, Otolaryngology 45, no. 9 (September 1966): 595-605; M. Flach, "[Hearing of the Musician Seen from the Otologic Viewpoint"], Monatsschrif fur Ohrenheilkunde und Laryngo-Rhinologie 106, no. 9 (September 1972): 424-432.
(14.)J. Siroky, L. Sevcikova, A. Folprechtova, and O. Miksovska, "[Audiological Examination of Musicians of a Symphonic Orchestra in Relation to Acoustic Conditions"], Cesk Otolaryngol 25, no. 5 (October 1976): 288-294.
(15.)Sataloff, "Hearing Loss in Singers."
(16.)Charles Speaks, David Nelson, and W. Dixon Ward, "Hearing Loss in Rock-and-Roll Musicians," Journal of Occupational Medicine 12, no. 6 (June 1970): 216-219.
(17.)Steuer et al.
(18.)J. Byron, B. Bailey, and Jonas T. Johnston, Head & Neck Surgery: Otolaryngology, 4th ed. (Philadelphia: Lippincott, Williams & Wilkins, 2006), 2190-2199.
(19.)William F. Rintelmann, Robert F. Lindberg, and Ellen K. Smitley, "Temporary Threshold Shift and Recovery Patterns from Two Types of Rock and Roll Presentation," Journal of the Acoustical Society of America 51, no. 4B (April 1972): 1249-1255.
(20.)Sataloff, "Hearing Loss in Singers."
(21.)Steuer et al.
(22.)Sataloff and Sataloff; Kircher et al.; ACOEM Noise and Hearing Conversation Committee.
(23.)Amanda Hu, Erik Hofmann, John Davis, Joseph Capo, Natalie Krane, and Robert T. Sataloff, "Hearing Loss in Singers: A Preliminary Study," Journal of Voice 29, no. 1 (January 2015): 120-124.
Dr. Amanda Hu is a voice doctor working with Dr. Robert Sataloff. She is an Assistant Professor at Drexel University College of Medicine. Dr. Hu graduated from medical school at the University of Toronto. She completed her Residency in Otolaryngology--Head & Neck Surgery (ENT) at the University of Western Ontario. She pursued a Fellowship in Laryngology (the care of the professional voice) at the University of Washington with Drs. Albert Merati, Albert Hillel, and Tanya Meyer. She joined Dr. Sataloff's practice as an ENT surgeon.
Robert T. Sataloff, Associate Editor
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|Title Annotation:||Care of the Professional Voice|
|Author:||Hu, Amanda; Sataloff, Robert T.|
|Publication:||Journal of Singing|
|Date:||May 1, 2015|
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