IKA YULIARTANTI BAGIAN ILMU KESEHATAN THT-KL FAKULTAS KEDOKTERAN UNPAD BANDUNG

INTRODUCTION
Sound effects organism as a whole, good and bad Excessive sound is one of the most common cause of hearing loss in the world from military, industrial, and recreational sources Noise is define in terms of its duration, frequency spectrum (Hz), intensity in measured sound pressure level (SPL) and expressed in decibels (dB) It may be continuous, intermittent, impulsive or explosive, steady-state or fluctuant

EFFECTS ON SOUND STIMULATION

ADAPTATION/PRE-STIMULATORY FATIGUE
Immediately phenomenon which occurs when a sound is presented to the ear somewhat elevating the threshold Greatest adaptation : 80dBSPL (fatiguing sounds)

EFFECTS ON SOUND STIMULATION

TEMPORARY THRESHOLD SHIFT POST-STIMULATORY FATIGUE
Degree of TTS increases progressively with stimulus duration and intensity A balance not being achieved until abnormal sound intensities are applied The higher frequency >> TTS TTS recovers within 16 hours TTS greater than 40dB pathological associated with residual PTS

EFFECTS ON SOUND STIMULATION

NOISE-INDUCED PERMANENT THRESHOLD SHIFT

Irreversible elevation of auditory threshold produced by noise exposure, associated with permanent pathological changes in the cochlea

Risk of hearing loss and injury to the ear increases with : 1. Noise level 2. Duration 3. Number of exposures 4. Susceptibility of the individual

CLASSIFICATION
1. Noise-induced temporary threshold shift 2. Noise-induced permanent threshold shift 3. Acute acoustic trauma

Noise-induced Temporary Threshold Shift

High frequency threshold shift Steep isolated audiometric dip the acoustic nocth 3kHz, 4kHz, 6kHz Early stage : temporary thereshold shift Hearing usually return to the normal level if there noise rest period

Noise-induced Permanent Threshold Shift

Most encountered hearing loss caused by noise Hearing loss at 4kHz progress rapidly at first With 100dB daily 8-hour exposure Decrease 10-20dB within 1-2 years At lower frequency the loss is least severe & grows more slowly

A typical 4-KHz notch found after exposure to noise

Adapted from Scott-Browns, 6th Edition 1997.

MECHANISM
1. NIHL involves the organ of Corti (the hair cells) 2. The outer hair cells are much more susceptible to damage
Stereocilia

Temporary Treshold Shift

Recovery normal mechanical Properties and function

TTS

Less stiff Poorly responds to the stimulation

MECHANISM
3. Increasing intensity and duration of exposure sufficient to cause NIPTS
Fusion of adjacent stereocilia in outer hair cell Loss of stereocilia Hair cell Death

NIPTS

Replaced by scar

Noise Induced Permanent Threshold Shift Noise Exposure

Damage of inner hair cell & supporting cell in organ of Corti Severe inner hair cell loss Secondary neural degeneration in auditory nerve & brainstem auditory nuclei

Stereocilial damage associated with TTS, PTS. In the former, a shortening of the supracuticular rootlet is the most obvious anatomical change. In PTS, rootlet fracture is ussualy evident Schematic diagram of outer hair cell showing various organelles. Adapted from Scott-Browns , 6th Edition 1997.

Acoustic Trauma
Is the hearing loss produced by acute noise exposure.

History and physical finding

Onset: related to a single incident or to a brief episode exposure to an intense noise with or without direct trauma to the head or ear. If examined within a few days after onset there maybe otoscopic evidence of vascular congestion or in the tympanic membrane.

 Pathophysiology
Noise swelling or twisting of the outer hair cells and pyknosis of their nuclei complete absence of organon corti and rupture of reissner membrane

Audiologic findings
Mild sensorineural hearing loss at 4,000Hz to major losses at all frequencies above 500Hz. Some instances total hearing loss (anacusis) Spontaneous nystagmus maybe present

Diagnosis and Management

DD/ sudden hearing loss
E/ of sudden hearing loss should kept in mind If accompanied by obvious damage to the TM, appropriate management of that injury is undertaken Total anacusis Following acoustic trauma, the patient should strictly avoid noise exposure while the hearing status is monitored by serial audiograms

Interactions
Aging A middle-aged, noise-exposed worker with elevated HTLs may be considered to have at least two components to his or her hearing loss: NIPTS and aging. Ward suggested that in addition to NIPTS we need to consider three other factors: presbycusis nosoacusis socioacusis

Vibration
Iki and co-workers vibration and noise may cause greater hearing loss than noise alone. Because many industrial environments combine these two factors, this interaction could be important.

Drugs and Chemicals

Combining a noise exposure and an aminoglycoside drug cause hearing loss. The ototoxic drug most likely to be combined with industrial noise exposure is aspirin, but this causes a reversible hearing loss. Carbon monoxide (CO) and toluene sensorineural hearing loss

Susceptibility
Men often display more hearing loss in noisy occupations than do women, but this may be due to different nonoccupational exposures (especially shooting) between the genders.

Factors possibly increasing susceptibility to NIHL

Blue eyes,light skin Genetic predispotition Diatebes Cochlear hydrops Iron deficiency Vit. A deficiency Aminoglycoside therapy Cisplastinum therapy Older age Arteriosclerosis Smoking Atherogenic diet prematurity

EVALUATION
Damage Risk Criteria Levels below about 80 dBA pose negligible risk to human hearing over a working lifetime. Above 85 dBA, risk grows rapidly for the high frequencies and more slowly for the low frequencies.

Nonoccupational Exposures
The most important cause is gunfire. The impulses from rifles and shotguns can range up to 170 dB at the shooters ear. The left ear of a right-handed shooter is at greater risk because the right ear is somewhat protected by the head shadow.

Diagnosis of Noise-Induced Hearing Loss

A history of occupational or nonoccupational noise exposure of hazardous intensity and duration should be sought. Sound-level measurements from the workplace, if available, are most helpful.
Other etiologies of sensorineural hearing loss (heredity, ototoxicity, head injury, and so on) are primarily excluded by history.

 Physical examination external ear and middle ear disorders and occasionally may detect cranial nerve or balance abnormalities that suggest an acoustic neuroma The pure-tone audiogram in early cases usually shows a notch at 3, 4, or 6 kHz); loss becomes more severe and as aging changes are added to NIPTS.

 A series of audiograms Laboratory and imaging tests indicated to rule out other disorders (acoustic neuroma)

Criteria for diagnosis of occupational noise-induced hearing loss

The principal characteristics of occupational noiseinduced hearing loss are as follows: 1. It is always sensorineural affecting the hair cells in the inner ear. 2. It is almost always bilateral. 3. It almost never produces a profound hearing loss. 4. Once the exposure to noise is discontinued, there is no significant further progression of hearing loss as a result of the noise exposure. 5. Previous noise-induced hearing loss does not make the ear more sensitive to future noise exposure.

6. The earliest damage to the inner ears reflects a loss at 3,000, 4,000, and 6,000 Hz. The greatest loss usually occurs at 4000 Hz. 7. Given stable exposure conditions, losses at 3,000, 4,000, and 6,000 Hz will usually reach a maximal level in about 10 to 15 years. 8. Continuous noise exposure over the years is more damaging than interrupted exposure to noise, which permits the ear to have a rest period. .

Handicap and Compensation .

The typical patient with a handicapping degree of NIHL or presbycusis can hear speech without difficulty because of the low-frequency power in vowel sounds but has difficulty discriminating among consonants

Management
Hearing Conservation (OSHA)

SOUND LEVEL (dBA) 90 95 100 105 110 115

DURATION OF EXPOSURE 8 4 2 1 0,5 0,25

Adapted from : R.F. Canalis and P.R. Lambert, The Ear: Acoustic

Trauma and Noise induced Hearing Loss.,2000

MANAGEMENT
The maximum permissible exposure (without hearing protection) under OSHA regulations is 90 dBA The essential components of an HCP are as follows:
Noise measurements Engineering or administrative controls to reduce exposure Periodic audiometry with follow-up and referral Use of personal hearing protection devices (HPDs) Education, motivation, and counseling

MANAGEMENT
The most important factors in choosing an HPD are proper fit and acceptance by the worker. Counseling and motivation are crucial.

Hearing protectors

Clinical Management
Many physicians have advocated treatments, usually based on vasodilatation or hemorrheologic effects, for acute acoustic trauma. Hearing aids are helpful when hearing loss becomes handicapping, but of course they do not restore normal hearing.

HIGHLIGHTS
Noise-induced permanent threshold shift grows rapidly in the high frequencies (3 to 6 kHz) and then decelerates after about 10 years. Within the organ of Corti, the outer hair cells are most susceptible to noise-induced damage. The most important nonoccupational cause of noiseinduced hearing loss is gunfire.

HIGHLIGHTS
Diagnosis of noise-induced hearing loss should not be made on the basis of audiometric contour alone, but must include a careful history of occupational and nonoccupational noise exposure.