29 Volume 59 October 1966 957

Section of Otology
President A Brownlie Smith MD FRCS

Meeting February 4 1966

Papers
Acoustic Trauma - considered that the present knowledge of this
Clinical Presentation complex problem did not provide a sufficient
basis for legislation. Noise-induced hearing loss
by Denis L Chadwick MD FRCS is not a prescribed disease under the provisions of
(Department of Otolaryngology, the National Insurance (Industrial Injuries) Act,
University of Manchester) 1946. It is a sad reflection on the state of our
national legislative conscience that the United
Noise and its harmful effects on hearing are Kingdom is one of the few remaining countries
attracting increasing attention. This communica- which still do not recognize noise deafness as a
tion, based on a study of 160 patients who disabling occupational disease. The fact that the
attended with symptoms attributable to acoustic author has seen an average of one new patient
trauma, attempts to indicate the degree to which each week complaining of symptoms directly
the disabilities caused by noise are permeating the arising from acoustic trauma surely underlines
everyday life of the individual. the magnitude of the problem and stresses the
This review was largely prompted by a con- vast amount of damage to hearing which must be
sideration of some of the recommendations in the taking place in industry each year.
final report (1963) of the Committee on the There have been many audiometric surveys on
Problem of Noise (Wilson committee), which was people employed in selected noisy industries. The
appointed by the Government to examine the early occurrence of an 'acoustic dip' in the region
nature, sources and effects of noise and to advise of 4,000 cycles per second has long been recog-
what further measures could be taken to mitigate nized; downward spread of this noise-induced
the problem. It surveyed many aspects of noise; damage to involve the conversational speech
of particular interest to the otologist are the frequency range may appear later; an impression
sections dealing with industrial noise and occupa- often given is that this occurs only rarely and does
tional exposure to high levels of noise. Professor not necessarily cause any notable disability. The
W Burns, Dr T S Littler and Air Vice-Marshal thesis of this report is that noise-induced damage
E D D Dickson were among those who gave to the inner ear is commoner than is generally
evidence. One important conclusion of the com- supposed and that symptoms produced by it are
mittee was that industrial research should be more frequent than is thought.
undertaken, and the lines of the Government It seemed pertinent to approach this problem
research programme were indicated in some from the clinical aspect. An analysis has been
detail. made of a series of patients with symptoms asso-
The Wilson committee has been criticized for ciated either with the effects of industrial noise or
failing to lay sufficient emphasis on the causal more rarely with acute acoustic trauma.
relationship between noise and deafness, notably
by Philip Beales (1965) who strongly attacks the Definition of Terms
suggestion, made in the report, that the effects of In this context the description 'acoustic trauma'
noise may be more psychological than physical. is used to cover both the acute (explosive) variety,
Feeling on this subject was summed up admirably and the chronic (noise-induced) form. Temporary
by a comment in the Sunday Times in 1963: threshold shift (TTS) is the extent to which the
'There is mounting evidence that one person in threshold of hearing is raised as a result of noise
ten becomes deaf or partly deaf as a result of exposure and is reversible. The length of time
working in noisy surroundings. This is an aspect during which recovery can continue to take place
of noise which the Wilson committee hardly is still in doubt; for practical purposes it is fre-
touched upon.' It is also a pity the committee quently assumed that complete recovery occurs
958 Proceedings of the Royal Society ofMedicine 30
within forty-eight hours. Most determinations of 6tr MILITARY TRAUMA
TTS have been made by a comparison of
audiograms at the beginning and end of a
working week. The work of Atherley (1964) on a '0
group of weavers in whom he compared the vxc
'Monday morning thresholds' with the thresholds
after a sixteen-day holiday indicates that the 20
process of complete recovery may occur over a
much longer period. It is considered probable
that the degree of TTS is an indication of the 20 40 60 80
eventual extent of any permanent threshold shift AGE (years)
which will occur after prolonged or repeated
noise exposure. Fig 1 Acoustic trauma, 160 cases
Permanent threshold shift (PTS) may be so
slight that no subjective symptoms are produced 20s; there was an appreciable increase in the 30s
but, with excessive noise exposure, noise-induced (21 cases) and 40s (35 cases) to a maximum of
deafness known also as chronic acoustic trauma 53 cases in the 50s, with a decline to 31 cases in
becomes apparent. the 60s and only 7 in their 70s.
Sudden bursts of abnormally intense sound or In this series deafness began at an earlier age
single explosive incidents may cause permanent than would have been seen in a comparable study
inner ear damage and constitute acute acoustic of presbycusis. Particular attention was paid to
trauma. the hearing losses over the generally accepted
Mixed acoustic trauma occurs when the working speech range of 512, 1,024 and 2,048 cycles per
noise environment contains intense steady state second. Hinchcliffe (1958) obtained smoothed
noise interspersed with impulsive peaks of even presbycusis curves derived from the data of a
greater intensity, the jet engine being the most random sample population. These demonstrated
notorious offender in this respect. an average loss of less than 15 dB at 2,000 c/s at
In the cases under review, the effect of tem- the age of 70. Littler (1962) considered that, since
porary threshold shift was minimized as far as the exact mechanism of presbycusis loss is still
was practicable, the majority of audiograms being undecided, presbycusis corrections should not yet
carried out on a Monday morning before the be introduced: no such corrections have therefore
start of the week's work. been applied to the present series.
The commonest complaint was deafness.
Almost 90 % showed a hearing loss of 30 decibels Symptoms
or more at or below 2,000 cycles per second. The frequency with which the various symptoms
occurred and the multiple combinations in which
Sex Incidence they presented are shown in Table 1. By far the
As expected, there was a marked preponderance greatest number complained only of deafness; in
of men: of the 160 patients, 136 were men and 24 association with other symptoms, deafness was
were women (a ratio of almost 6:1), since more reported in almost 90 % of all cases. Tinnitus was
men than women are employed in the noisier present in some 30 % and disturbances of balance
industries. The investigations of Ward et al. (1959) in about 20 %.
into susceptibility and sex support the view that Deafness: The majority of cases seen were of the
differential exposure, not differential suscep- noise-induced type (122 patients); acute acoustic
tibility, accounts for the observed differences. trauma accounted for a further 13 and the re-
Certain investigations, however, seem to show maining 25 showed associated ear pathology in
that women are more resistant to the effects of
acoustic trauma than men; and Rosen et al. Table 1
(1962) in studies of a noise-free population found Symptoms
that the hearing of men deteriorated more with No. of cases
age than did that of women. Deafness 86
Deafness + tinnitus 21
Tinnitus 15
Age at Presentation Deafness, tinnitus, unsteadiness 13
The age at which patients first came for examina- Deafness+unsteadiness II
Unsteadiness 4
tion is shown in Fig 1. The two children aged Tinnitus + unsteadiness 2
under 10 years were both involved in acute Deafness+ distortion 2
explosive episodes. The proportion of cases asso- Deafness+irritation
Numbness: stuffiness 2
ciated with service in the armed forces is indicated. Pressure + irritation I
Ten patients became aware of deafness in their Earache I
.31 Section of Otology 959

addition to the effects of noise: the one person Table 2

with a history of prolonged exposure to jet engine Occupations
noise, with its risk of mixed acoustic trauma, No. of No. of
came into this last category but several subjects cases cases
Engineering 32 Weavers 10
detailed both explosive incidents and many years' Armed forces 22 Printers 6
continuous work in noisy industry. Diesel engine Machinists 6
workers 17 Sheet metal workers 5
A leading article in the Lancet (1960) stated: Spinners 15 Riveters 4
'It is surprising how indifferent a man will be to Boiler-makers 14 Circular saw workers 4
the incessant rattle of machinery, to the high-
pitched whine of a saw, or to the affront from a pure tones in narrow bands such as the whine of
nearby pneumatic tool or panel-beater.' This was a circular saw, is especially to be noted: as HM
evident in the present survey: only 4 of the 122 Factory Inspectorate points out (Ministry of
patients with noise-induced deafness said they Labour 1963), noises emitted from such sources
considered noise to be responsible. The Lancet may be damaging to hearing at levels 10 dB lower
further remarked that 'only by direct inquiry is than steady state industrial noises.
the physician who suspects early deafness likely Diesel engine noise: The large number of cases
to learn that the patient is subjected to intense (17) in this category was surprising; it was third in
noise at work'. the list of individual noisy occupations and came
'Dizziness': This symptom was often described before the traditionally better known deafening
vaguely: 'slightly off balance', 'maziness', 'dizzy industries of boiler-making, weaving and riveting.
do's' and 'unsteadiness', as opposed to anything It included men engaged in the manufacture,
approaching true rotatory vertigo, were the terms testing, maintenance and operation of both com-
commonly used. It is interesting to note that John mercial diesel vehicles and diesel locomotives. In
Fosbroke's classical description of blacksmith's a table of noise levels of some typical sounds in
deafness in 1831 included 'slight vertigo' as a the Wilson committee's report, levels of 92 dBA'
symptom once deafness became established. were recorded at a distance of 25 feet from a
In 4 cases dizziness was the only symptom com- heavy diesel propelled vehicle. Several authors in
plained of. Two of these patients gave very the National Physical Laboratory's Symposium
accurate descriptions of the Tullio phenomenon. on the Control of Noise (1962) drew specific
One was a vertical borer, 57 years of age, who attention to diesel engines. T Priede stated (p 97)
stated that high-pitched noises made him dizzy; that 'one of the major objections to diesel engines
he was one of the few who did not complain of which tends to prevent their wider use is that they
clinical deafness but his audiogram showed a are noisier', having found that their noise spectra
bilateral acoustic dip of 55 dB at 4,000 c/s. The showed a broad peak in the frequency range from
other was a man of 46 who had been staying at a 800-2,000 c/s, i.e. in the frequency range to which
house in France alongside a fast stretch of railway the ear is most sensitive. Coles & Knight (1965)
line: dizziness had been provoked by the screech noted overall sound levels in the region of 120
of whistles as trains speeded past his bedroom; he decibels in diesel propelled ships and although
too was unaware of deafness but audiograms continuous in character the noise had impulsive
showed an acoustic dip of 25 dB at 4,000 c/s. components.
A third man, aged 38, gave a vague history of
unsteadiness and at times felt as though he were Occupational History
veering to one side or the other; he had worked The importance of taking a complete history of
in railway engineering shops since leaving school all occupations followed since leaving school was
and for the last fourteen years was employed in a very evident. For instance, one man, aged 52,
riveting shed; while his Hallpike caloric responses gave his occupation as a joiner, a pursuit which
were normal, his audiogram showed a dip at one might consider comparatively innocuous as
4,000 c/s of 45 and 40 dB respectively in the regards noise: on being questioned about the
right and left ears. details of his job, however, he said that he worked
continuously with extremely noisy circular saws
Occupation and, perhaps even more significant, that ten years
The main occupations involved were as shown in previously he had been engaged in a curious
Table 2. Among less frequent sources of occu- process involving the use of a pneumatic hammer
pational noise were pneumatic drills, an air com- for firing nails into concrete walls; he 'felt his ears
pressor, a dental surgeon's ultrasonic drill and a sting' was how he described the sensation at that
blacksmith's forge. time. Another man, aged 39, gave his occupation
The high proportion of occupations in which
impact noises such as hammering or riveting are 'dBA is a specific unit measuring sound level, using frequency
network A incorporated in the amplifying circuit ofthe sound level-
produced, compared with those producing intense meter. Three such networks, A, B and C; are now commonly used
960 Proceedings ofthe Royal Society of Medicine 32
as painter and decorator; referred on account of 4,000 c/s when he was first seen and an improve-
'defective hearing' he had a bilateral high-tone ment after wearing ear muffs. It also illustrates the
deafness. Inquiry into previous occupations fact that most ear protectors give better attenua-
revealed that for 14 years he had been firing tion for high frequencies than low; there is slight
harpoons with an Antarctic whaling fleet. A deterioration in hearing at the lower end of the
'kennel man' had been a boiler-maker for six frequency scale.
years; a gardener had been a diesel-engine fitter In the other 3 cases the hearing in the right ear
for thirty-five years. was affected more than in the left. This finding is
Some complexities involved in unravelling a particularly interestingsince usually, as Ballantyne
history of previous noise exposure are demon- (1960) has noted, 'the deafness of rifle shooting is
strated by the following case, a man of 43 more marked in the left ear in the right shouldered
presenting with 'deafness': from the age of 14 shot' (as these men were), 'since the butt of the
until he was 20 he had worked in a noisy cotton rifle is nearer to this ear.' The rifle shot was only
mill; he had then entered the army where he was 25 years old and showed a dip beginning with a
exposed to a good deal of gunfire and exploding loss of 15 dB at 1,000 c/s, dropping sharply to
mortar bombs; on demobilization he returned to 65 dB at 2,000 and a maximum of 75 dB at 4,000
cotton spinning which he then found very noisy; c/s.
following this he had a spell as a sheet metal Motor cycles and mini-sports cars are particu-
worker and, for the last six years, had been larly offensive noise weapons when it is consid-
engaged as a fitter in what he considered his ered that they can emit sound pressure levels of
noisiest job to date, working on heavy castings. over 100 dB. It is particularly disquieting to read
In addition there was evidence of past middle ear in the Wilson committee's report 'that for motor
disease. He had a 55 to 60 dB air conduction loss cycles a limit of 90 dB was the lowest that could
over the speech frequencies, with correspondingly be achieved at present.'
poor bone conduction. Another man, aged 50,
described himself as an electrical fitter's mate but, Acute Acoustic Trauma
at his place of employment, his actual working There were 13 cases of acute acoustic trauma,
space was bounded on one side by a bank of 2 children and 11 men. In only 4 patients was there
printing machines and on the other by a circular evidence of healed perforations, 2 bilateral,
saw; audiograms showed a bilateral perceptive making a total of only 6 perforations in 26 drums:
hearing loss. 4 of them were typically in the posterior segment
It was interesting to note how frequently of the drumheads; in the youngest, a girl aged 7,
patients seemed to become aware of their deaf- there were bilateral healed anterior perforations,
ness only when changing from one noisy occupa- with no past history of ear disease, but bleeding
tion to another: for example a boilermaker for occurred at the time of the explosion.
thirty years changed to work with power station Of the 11 adults, only 4 gave a clear-cut history
turbine generators and found this new noise of acute acoustic trauma alone. In 6 of the 7 other
environment upsetting. cases the acute acoustic trauma was complicated
by a history of many years working in high
Noisy Pastimes intensity noise. Their individual case histories all
Careful inquiry should be made into any hobbies demonstrated the complexities which beset
of a noisy nature: 4 cases in this series had symp- attempts to introduce satisfactory legislation and
toms related entirely to spare time pursuits. Two workman's compensation for noise induced
of them were associated with game shooting, one hearing loss. To quote just one illustrative
with clay-pigeon shooting, all these using 12-bore example, a 57-year-old fitter currently employed
shot guns. The fourth fired small arms with a rifle in a forge: on leaving school he had worked for
club two nights a week. seven years as a boiler-maker's apprentice; for
The clay-pigeon shot was a man aged 54 who the next thirteen years he had been a steel plater;
presented within a few months of taking up his during the war he had served in the Home Guard
hobby, giving no history of any previous noise and had experienced increased deafness and dis-
exposure; he complained only of a feeling of tortion of hearing when on the firing range. His
slight stuffiness in his ears. He showed a bilateral reason for attending hospital was that these sym-
acoustic dip of 55 dB at 4,000 c/s. Suitable ear ptoms had again been precipitated, with increased
defenders were fitted and have been worn con- intensity, four months earlier and had shown no
scientiously ever since. Audiograms have been signs of abating: the incident which provoked
repeated annually during the past four years. them had occurred whilst he was watching a yacht
The dip in the left ear has remained stationary at race; he was standing four feet from two starting
55 dB but that in the right has improved to 25 dB. cannons and as soon as they fired he experienced
An audiogram of the right ear showed a dip at deafness and distortion. His audiogram showed a
33 Section ofOtology 961

sudden drop in hearing in the right ear of 45 dB at showed considerable impairment of bone con-
1,000 c/s and of 65 dB in the left ear at 2,000 c/s. ducted hearing, 40 dB loss at 500 c/s and 55 dB at
Of the children, one had been sitting in front of 1,000 c/s but with an air-bone gap of 35 dB. A
the fire when an explosive mixed with the coal similar picture was seen in one of the other
blew the fireguard, the fire and the fire grate out women who had been a ring spinner since the age
into the room. of 14.
The other, a healthy boy aged 9 with a com- Were the bone conduction losses those fre-
pletely negative medical and family history, who quently encountered in otosclerosis or was
had even escaped mumps, had been discovered to cochlear damage induced by noise before the
have a severe unilateral perceptive deafness on stapes became fixed? Steffen et al. (1963), dealing
routine school audiometric testing. Having ex- with stapedectomy and noise, noted the difficulty
hausted all other likely possibilities and having of separating the labyrinthine element in
recently read Glorig & Ward's (1961) report of otosclerosis from the effects of noise and
a case of fire-cracker-induced hearing loss, I presbycusis.
inquired whether this child had ever been in- Of the 4 men 3 had been accepted for and
volved in a firework explosion. The parents were served their full time during World War II in the
astonished at this question; at the age of 5 the boy armed forces; presumably their hearing had been
had dashed to the front door in answer to a loud sufficiently acute on entry to pass normal routine
knock, a lighted firework of the 'banger' variety hearing tests. One of them had in fact worked for
had been thrust through the letter box and ex- seven years in a cotton mill before being enlisted
ploded in his face; he had complained of deafness and returned to even noisier industrial activities
for some time afterwards but both he and his when demobilized. The fourth man had worked
parents had since completely forgotten this as an engineer in a noisy machine shop all his life.
incident. In only 1 of these 7 cases was bone conduction
normal in the speech frequencies - surely a much
Cases with Associated Ear Disease higher proportion of perceptive hearing loss than
Otitis media: 16 patients (10% of all the cases) would be encountered in a group of non-noise-
showed evidence of otitis media; 10 cases were exposed otosclerotics. The average age of this
bilateral, 6 unilateral, making 26 ears out of a group was 44.
total of 320 ears (just over 8 %). Twenty-one of What advice should these patients be given? If
the perforations were healed, 5 were patent, 3 of surgical correction of their otosclerotic deafness
these showing active suppuration. No cases of is contemplated it seems clear that they should be
cholesteatoma, polyposis or granulations were warned of the subsequent increased risk of noise-
seen. induced hearing loss should they continue to work
There was a much higher incidence in this group in noise. Either they should be encouraged to.
of subjective vertiginous symptoms: almost half, change to a quiet occupation or the operative
7 out of the 16, described such symptoms, whereas technique of any surgical procedure should ensure
of all those without evidence of otitis media at any preservation of function of the stapedius muscle
time only 21, about 1 in 7, described some dis- and its protective reflex.
turbance of balance. This problem was considered by Sagardia
The 4 patients who sustained acute acoustic (1963) who studied patients, who had undergone
trauma and showed healed traumatic perfora- stapedectomy, working in noisy surroundings not
tions did not complain of any balance disturbance exceeding 85 dB, that is, within the limits of the
nor did the 7 patients with otosclerosis. damage risk criteria suggested by Burns and
It has been suggested by Glorig (1958) that Littler for people with normal ears. These ears,
scarring from otitis media may protect the inner deprived of their stapedius muscle reflex showed
ear from the effects of noise by acting as a built in irreversible deterioration from 1,000 to 6,000 c/s.
ear plug. This was not evident in the present A similar series not exposed to noise showed no
series, 6 cases showing perceptive losses between such deterioration, neither did noise affect other
85 and 100 dB. The protective effect of the operated cases in which the ossicles and the
stapedius muscle reflex may be less as a result of stapedius muscle were preserved.
middle ear suppuration and the effects of acoustic Kos (1962) described severe inner ear changes
trauma greater. following stapedectomy in ears subsequently ex-
posed to intense noise.
Otosclerosis: 7 patients had otosclerosis, 4 male
and 3 female; the women all in their 40s and all Streptomycin deafness: A severely deaf man aged
cotton mill workers. One of them had worked 32 had been treated with very large doses of
from 14 only until 21; soon after this she first streptomycin for tuberculous meningitis ten years
became aware of deafness. Her audiograms previously; during the past 18 months he had
962 Proceedings of the Royal Society of Medicine 34
been working about twenty yards from jet-engine 120r
test beds which operated for about three hours
daily. He had experienced a considerable increase
in his deafness during this period: his audiograms
100
kl,__ e-
! - - - il
taken before exposure to jet-engine noise showed
80
the expected severe perceptive deafness; the
further marked deterioration after eighteen
months of such noise exposure was very evident. 60
* NOISE LEVEL
There was a bilateral increased hearing loss of * DAMAGE CRITERION (I)
O DAMAGE CR ITER ION (2)
20-40 dB at all frequencies. - -MANUFACTURERS ADVERTISED LEVEL

Presbycusis: In only one case was there clear-cut C/S'

106
.
212
..
'425 850 1700 3400 6800
evidence from the history that the effects of age Fig 2 Spinning mill noise
change were complicating previous acoustic
trauma. This occurred in a retired man aged 64, was that the new machines had been advertised
who had been noticeably deaf in one ear following as having a noise level of about 92 dB.
an episode of acute acoustic trauma in World Fig 2 illustrates some of these findings and
War I. Recently he had become increasingly compares them with two suggested damage risk
aware of deafness in the opposite ear and had also criteria. The upper one is that proposed by Rosen-
found that in the presence of noise his hearing blith et al. (United States Air Force 1953). The
became confused. original machine noise was below this level. The
lower one is in keeping with the levels suggested
Mastoid pneumatization: Routine temporal bone by Burns and Littler and quoted in the Wilson
X-rays are now included as one of the standard committee's report. It is in agreement also with
investigations in any case of suspected noise- the British Medical Association's view that 'work-
induced deafness. The earlier cases in this series ing conditions involving continuous exposure
were not, however, all examined in this way. throughout working hours for a prolonged period
Results to date suggest that there may be a higher to noise where intensity exceeds 85 dB in the
proportion of poorly pneumatized mastoid pro- speech frequency range may cause permanent
cesses in patients showing severe acoustic trauma damage to hearing.' Both the old and the new
than one would find in an unselected group of the equipment showed sound intensities above these
normal population. In this respect the observa- recommended safety levels.
tions of Ottaviani & Mazzoleni (1959) are to be In view of the findings of an overall sound
noted: in a study of the relationship between pressure level of some 110 dB, recommendations
mastoid pneumatization and loss of hearing in in line with current practice to reduce the noise
187 boiler-makers, they found that the progress of were made. These included reduction of the noise
noise-induced deafness was more rapid in cases level at source by modifying the machine bear-
showing no pneumatization. ings, the fitting of baffles and treatment with
sound absorption panels. Protective ear-muffs
A Typical Noise Problem were made available to the workers.
Illustrating some of the difficulties encountered in
dealing with industrial noise a case in point arose Conclusions
recently. A spinning mill was in process of Noise problems similar to the one just outlined
modernization; equipment some fifty years old can be found in many industries. That a noise
was being replaced by new high speed automatic hazard exists in many factories is still often
machinery. Complaints were made by spinners ignored, the introduction of satisfactory hearing
transferred to these new machines that the noise conservation programmes tardy and effective
levels were much higher. Many of them had noise reduction expensive.
worked in this mill for over forty years. It was In this country at the present time occupational
possible to walk directly from a shop containing deafness is still not a prescribed industrial disease.
the original machinery into another shop housing This disability is not eligible for compensation
the new. Even without taking recordings of sound under the National Insurance (Industrial Injuries)
pressure levels it was immediately evident that Act. Nevertheless it seems clearly evident, judged
much higher and more obtrusive noise intensities by the numbers seeking relief for this defect, that
were being emitted from the new machines. a considerable proportion of the community do
Octave band analyses showed an overall sound suffer directly from the effects of industrial
pressure level of about 95 dB from the old deafness. It is to be hoped that more just and
machines but the noise environment of the new effective legislation for this condition will not
was in the region of 110 dB. An interesting point long be delayed.
35 Sectioni of Otology 963
REFERENCES
Atherley G R C (1964) Brit. J. industr. Med. 21, 150
cochlea was excited by sound in a given band of
Ballantyne J C (1960) Deafness. London; p 189 frequencies, regions of the basilar membrane
Beales P 1 (1965) Noise, Hearing and Deafness. London; p 143 specific to higher frequencies were excited as well,
Coles R R A & Knight J J (1965) J. Laryng. 79, 131 whereas regions of lower frequency specificity
Committee on the Problem of Noise
(1963) Noise. Final Report. Cmd 2056. HMSO, London were not. Another important characteristic was
FosbrokeJ (1831)Lanceti, 645 that transmission of excitation to regions of low
Glorig A (1958) Noise and Your Ear. New York; p 102
Glorig A & Ward D W (1961) Laryngoscope 71, 1590 frequency specificity took a time which was
Hincheliffe R (1958) Gerontologia 2, 311 greater the lower the frequency. Laboratory
Kos C M (1962) In: Otosclerosis. Ed. H F Schuknecht. London;
p497 studies as well as industrial surveys had demon-
Lancet (1960) ii, 417 strated that there were appreciable differences in
Littler T S (1962) In: Control of Noise. National Physical individual susceptibilities.
Laboratory Symposium No 12. HMSO, London; p 285
Ministry of Labour (1963) Noise and the Worker. Safety, Health For many years a sound pressure level of 90 dB
and Welfare Booklet No. 25. HMSO, London overall had been looked upon as that at which, on
National Physical Laboratory (1962) Control of Noise, NPL
Symposium No 12. HMSO, London the average, the normal phenomenon of adapta-
Ottaviani A & Mazzoleni G F (1959) Riv. Audiol. prat. 9, 1 1
Rosen S, Bergman M, Plester P, El-Mofty A & Satti M H
tion changed to that of aural fatigue, which if
(1962) Ann. Otol. Rhin. Laryng. 71, 727 maintained for prolonged periods resulted in
Sagardia J R M (1963) Int. Audiol. 2,247 permanent threshold shift; but later work showed
Steffen T N, Nixon J C & Glorig A (1963) Laryngoscope 73, 1044 that the level was a function of frequency. The
United States Air Force (1953) Handbook of Acoustic Noise
Control. Vol 2: Noise and Man. By W A Rosenblith et al. WADC overall level then lost favour and was replaced by
Tech. Rep. 52-204. Wright-Patterson Air Force Base, Ohio damage risk criteria in which noise levels were
Ward D W, Glorig A & Sklar D L
(1959) J. acoust. Soc. Anzer. 31, 1138 specified in octave bands. In these criteria it was
considered that higher noise levels could be per-
mitted in the lower frequencies than in the higher.
At the present time a consensus of opinion
believed the following could be considered the
limit for continuous exposure of 8 hours per day:
DISCUSSION
Centre of octave band cls 125 250 500 1,000 2,000 3,000 4,000
Dr T S Littler (Medical Research Council, London) Sound pressure level in dB 98 93 89 87 85 85 85
said that traumatic and industrial deafness as well
as hearing conservation were now receiving much An alternative method which had many attrac-
attention, although the subject had been debated tions was to use a noise level reading on a meter
frequently over the last thirty years. There had which gave appropriately less weighting to low
been a number of discussions in the Section of frequencies and for this the A scale on a sound
Otology and a presidential address by Air Vice- level meter was suitable. The above criterion was
Marshal Dickson fourteen years ago (Proc. R. approximately covered by a reading of 90 dB on
Soc. Med., 1953, 46, 139). the A scale.
Many national bodies were endeavouring to For intermittent exposures somewhat higher
bring out standards for hearing conservation: all levels, based at present on temporary threshold
the viewpointswere to be put forward at a meeting shift experiments, could be accepted. In the field
of the International Standardizing Organization studies in which Dr J J Knight and Dr Littler had
in Prague in April 1966, with the hope of progress been co-operating, the nature of the TTS had
towards one international standard of acceptable been found not to be the same as that of per-
levels of continuous and intermittent noise. manent hearing loss, and much further work
Mr Chadwick had dealt with a number of topics would need to be done in the actual factory
associated with occupational noise and had situation.
described some interesting cases in which noise of The joint MRC/NPL investigation of occupa-
one kind or another had been blamed for the tional deafness was originally put forward by the
complaint. Asaresult of attention now being given DSIR in 1957 and sponsored by the Ministry of
to the matter by many industrial firms, improve- Pensions in 1962. There were very considerable
ment could be expected in the future. difficulties and complexities in such an investi-
Indications of the nature of the mechanism of gation. The problem could be approached in two
industrial deafness were derived from a number of different ways, both with their own limitations.
investigations. The evidence came from the The retrospective method studied a group of
hydrodynamics of cochlear behaviour, masking noise-exposed workers and attempted to relate
phenomena, temporary threshold shift and other the degree of deafness to the duration and
laboratory studies. All these investigations as well severity of the noise exposure. The advantage was
as surveys under actual conditions of industry had that all the subjects were immediately available.
indicated the asymmetrical nature of excitation ol The disadvantage was dependence on the subject's
the end organ of hearing, namely that, when the evidence for assessing his noise exposure, and this
964 Proceedings of the Royal Society ofMedicine 36

was scientifically unacceptable. In the prospective a remote area of the Sudan. It was of interest to
method a group of young people with normal compare the loss of hearing found among the
hearing were chosen before they entered a noisy Mabaans with increasing age with the hearing
situation, and their hearing was tested at intervals. acuity at various ages of a healthy population
This had the advantage that the noise level in living in the USA. The figures of Rosen et al.
which they were working could be monitored at showed that a Mabaan at the age of 70-79 years
will. The difficulty was that of every 100 suitable had a hearing acuity rather better than that of the
subjects 60 or 70 might be lost during the survey. age group 30-39 in the sample from the USA.
For obvious reasons the second method was Presbycusis had been attributed to many factors
chosen, but as it had become apparent that the such as hereditary predisposition, smoking,
yield of suitable subjects was sparse the survey arteriosclerosis and hypertension, anemia, vita-
was supplemented by studying an extra group of min deficiency, acoustic trauma; but of these only
workers who had already sustained a few years of acoustic trauma had a constant bearing on pres-
noise exposure. The plan was to determine how bycusis. Mr Beales hoped it would before long be
much further deterioration occurred in a given appreciated that all loud noise was potentially
time. By this method it was hoped to compare the damaging to hearing, and that this applied not
initial hearing loss sustained with the later one only to the extreme noise met within industry but
observed after further exposure. to all loud noises.
The investigation depended very heavily on the
validity of the criteria, on the stability of the REFERENCE
Rosen S, Bergman M, Plester P, El-Mofty A & Satti M H
apparatus and on the accuracy of information (1962) Ann. Otol. Rhin. Laryng. 71, 727
regarding the individual's noise exposure. The
clinical criteria were laid down by Mr I A Dr R Hinchcliffe (London) asked Mr Chadwick:
Tumarkin, who was a member of the working (1) Had he not met any cases of acoustic accident
group. The hearing was measured by self- of the type described by Antoli-Candela (1959),
recording Bekesy fixed frequency audiometers Boenninghaus (1959) and Becker & Matzker
which were calibrated daily to ensure that no (1961), or did he not recognize such an entity?
drift occurred. (2) Was his classification of his cases of noise-
The assessment of noise exposure was a com- induced hearing loss based on a taxonometric
plex matter. The plan in a given factory was to procedure or was it based merely on a clinical
assess by noise measurement not only the intensity impression? (3) Were personality data obtained
of the noise but also its distribution throughout on the cases of 'unsteadiness'? (4) Had Mr Chad-
the different frequencies. It was essential to know wick considered whether, in the cases with con-
how much time each worker spent in each ductive deafness who showed a greater than
different noise locus. The survey was therefore expected degree of noise-induced hearing loss, this
concentrated on large factories with a large labour was due not to the absence of a functioning
force of stable employment with reasonably con- stapedius muscle but to the absence of the dam-
stant levels of noise exposure. Work was also pening effect on the tympanic membrane at
proceeding on temporary threshold shift studies. 4,000 c/s of a poorly pneumatized mastoid, as
It was expected that the investigation would indicated by Onchi (1966)?
continue for another two or three years, by which Regarding the study by Rosen et al. Dr Hinch-
time it should be possible to reach an internation- cliffe commented that the Mabaans had no birth
ally acceptable damage risk criterion. It must be certificates. Absence of valid data on date of birth
emphasized, however, that this was still only a was a notorious source of error in determining
statistical concept and did not answer the biological changes as a function of age.
question of what would happen to a given Preliminary results on a similar non-noise-
individual in a given factory. exposed ethnic group living in a tropical climate,
but where there was valid evidence of the age,
Mr P H Beales (Doncaster) said it was still too indicated that the particular sample had worse,
widely assumed that to be harmful to hearing not better, hearing than comparable British
noise must be very loud, only met with in certain populations (Hinchcliffe 1964).
factories, and so on. This was a facile assumption Dr Hinchcliffe endorsed Mr Chadwick's finding
and Mr Beales believed that the everyday noise regarding the cochlear-damaging effects of 12-
met with by all who lived in towns had by now bore guns. Five years ago a significant correlation
reached a harmful intensity. Various studies had had been shown between the hearing level at
been made on the hearing acuity of people living 2,000 c/s and the stated number of round of
in a relatively noise free environment. Rosen et al. 12-bore ammunition that had been fired (Hinch-
(1962) had studied the hearing acuity of the cliffe 1961).
Mabaans, a tribe living in such an environment in With regard to deaf people being cited as more
37 Section ofOtology 965
susceptible to noise-induced hearing loss, Burns found that TTS did in fact vary inversely with
et al. (1964) had shown that, in a factory popula- existing hearing loss and if so did he agree that
tion, the degree of deterioration in auditory two differing processes were involved in con-
threshold at 4,000 c/s was inversely related to the ductive and perceptive deafness respectively? (2)
initial hearing level. Working at the Institute of Had he done any work on impulse noise and
Laryngology and Otology, Ferris (1965) had also could he give any information on the relative
shown that stapedectomized individuals were less, importance of peak impulses of short duration
not more, prone to temporary noise-induced versus steady state noise? (3) Had he any evidence
hearing loss. that there were tough and tender ears?
REFERENCES REFERENCES
Antoli-Candela F (1959) Proc. IV int. Congr. Acoust. p 174 Kryter K D & Garinther G R (1965) Acta otolaryng. Suppl. 211
Becker W & Matzker J (1961) Z. Laryng. 40,49 Nixon J C, Glorig A & Bell D W (1965) Arch. Otolaryng. 81, 250
Boenninghaus H-G (1959) Z. Laryng. 38, 585
Burns W, Hinchcliffe R & Littler T S (1964) Ann. occup. Hyg. 7, 323
Ferris K (1965) J. Laryng. 79, 881 Mr Ian G Robin (London) said it was obvious that
Hinchcliffe R with an improvement in hearing conservation
(1961) Brit. J. prev. soc. Med. 15, 128
(1964) Ann. Otol. Rhin. Laryng. 73, 1012 programmes and the probability of an increase in
Onchi Y (1966) Proc. II extraord. Congr. int. Soc. Audiol. Kyoto, medicolegal cases, the reliability of audiometric
1965 (in press)
readings must be ensured. This meant that
technicians must be adequately trained, as well as
Mr Harold Zalin (Liverpool) said it was a matter audiometers properly calibrated.
of regret that the problem of acoustic trauma, The new scheme of the Ministry of Health for
which was international and involved such com- the regional training of technicians made otolo-
plexities, could not be tackled by international gists fully responsible for their efficiency. It was
co-operation. to be hoped that proper standards would be
Nixon and Glorig had encountered the same maintained.
problems and had reached certain interesting con-
clusions (Nixon et al. 1965): (1) That TTS was Mr Colin C Wark (Brisbane) said that the problem
inversely related to hearing loss. They made no of assessing percentage of hearing loss for calcu-
attempt to explain the mechanism which must lation of compensation was yet to be solved.
involve consideration of conductive and percep- Speech audiometry, while theoretically good, was
tive deafness, which surely behaved differently. unsatisfactory because of differences in language
Conductive deafness implied attenuation at all and dialect. Pure tone audiometry was now the
times whilst the effect of perceptive deafness was basis of work, but the method of calculation left
not so obvious since there was no protection. much to be desired.
Presumably antecedent damage resulting in high
tone perceptive deafness had already eliminated Mr Chadwick, in reply, thanked Dr Littler for opening
those nerve elements which might have suffered. the discussion. He was heartened to hear that im-
(2) That TTS was, in fact, a valid measure of the provements in the industrial field could be expected in
individual's liability to PTS and they offered an the near future, and of the progress of the MRC/NPL
equation by means of which the hearing loss a investigations. That Dr Knight and Dr Littler had
year later could be calculated on the basis of the found the TTS to differ from permanent hearing loss
existing hearing level and the TTS. was most interesting since it accorded with his own
According to these authors the only practical views, that to be able directly to predict one from the
method of determining whether an individual was other was an unjustifiable assumption.
In answer to Dr Hinchcliffe, while he recognized the
susceptible to a particular noise was to put him in low-tone incidents described, none had been observed
that noise and observe what happened. This was in the cases under discussion; as indicated in the title
something of a blow to prospects of establishing of the paper, the approach was essentially a clinical
definite damage risk criteria for noise. The reason one. Mr Chadwick was well aware of Dr Hinchcliffe's
was twofold: (1) Individuals seemed to vary con- particular interest in the relationship between vertigo
siderably in their sensitivity and it was even and the patient's psychological make-up. Disturbances
suggested that there were tough and tender ears. of balance had been noted in only about 20% of the
(2) It was extremely difficult to measure noise cases, and in most of these there had been nothing to
objectively. A steady state noise could easily be suggest any obviously abnormal psychological factors.
analyzed but there was the almost insuperable It had, however, not been practicable to investigate
patients in detail with regard to personality data, but
problem of impulse noise. Kryter & Garinther this aspect would be borne in mind in future studies.
(1965) in fact said: 'It is quite possible that PTS Mr Chadwick agreed that the exact reason why
from impulse noise follows a much different some cases of conductive deafness showed excessive
pattern from PITS due to steady state noise.' perceptive losses was unknown and that there were
Mr Zalin therefore asked Dr Littler (1) Had he several possible alternative hypotheses.
966 Proceedings ofthe Royal Society of Medicine 38
Mr Robin and Mr Wark had both stressed the need Since the middle ear muscles respond to such a
for reliable audiometry and the necessity for devising a variety of motor patterns and sensations, it is not
formula for accurate assessment of hearing loss, and clear whether activity would be recordable in the
Mr Chadwick expressed the hope that a suitable absence of any activating factors. The term
method would be evolved in the near future. He
pointed out, however, the widespread variations 'spontaneous' implies only that activity seemingly
which existed at present in different States in the unrelated to any particular factor present can be
USA, and also considered that the possibilities of recorded.
speech audiometry should not be ruled out, but Using impedance techniques in man, several
should be carefully explored, since this gave the investigators have shown that subliminal acoustic
nearest approximation to a person's actual disability. stimulation was facilitated by simultaneous subli-
minal non-acoustic stimulation and vice versa
Dr Littler, in reply to Mr Zalin, stated that the term (Jepsen 1963). Electromyographic (EMG) studies
'tough and tender ears' had been used to express what of the middle ear muscles in cats have shown not
had been repeatedly observed in a number of in-
vestigations, namely that in response to approximately only facilitatory interaction but also inhibitory
the same quantified noise exposure different subjects interaction. Furthermore, interaction is present
showed different degrees of permanent threshold between successive stimuli with time intervals of
shift. Experimental work had shown that, on average, up to 0-1 sec (Salomon & Starr 1965).
TTS varied inversely as existing PTS and this would be Studies of the middle ear muscles in relation to
expected considering that the progress of PTS slowed a single activating factor are therefore much too
up asymptotically with years of exposure to a final limited. Experiments must be designed to tell us
value achieved in the first few years of exposure. He how successive stimulating factors are integrated
agreed with Mr Zalin that there should be some from moment to moment. A technique for this
qualification of this observation according to whether type of investigation has been established.
an existing deafness was conductive or perceptive. A
conductive deafness was a protection as far as noise
exposure was concerned and equivalent to a reduction Techniquie
of the noise exposure by the magnitude of the hearing Electromyographic activity (DISA myograph) in
loss. In general, industrial noise investigations were the middle ear muscles of cats was recorded via
concerned only with perceptive deafness and subjects two chronically implanted bipolar stainless steel
with conductive deafness were not usually included in electrodes. In response to a loud click both
the statistics. It had been his experience that impulsive muscles give a response pattern consisting of an
noise environments of high intensity such as weaving, initial burst of activity (latency 4 5-10 msec), a
chipping, boiler-making, gunfire, &c., were more pause and then a later and more sustained period
damaging to hearing than steady state noises such as of activity (latency 34-56 msec, duration up to
spinning and rotating machinery but there was, at 1 sec) (Salomon & Starr 1965). By decreasing the
present, no universally acceptable definition or
criterion regarding the characteristics of impulsive intensity of the click or by repeating the click, the
noise. The peak levels of the impulsive noise en- late response disappears. The integrated electrical
vironments that were so damaging to hearing were activity of the electromyogram is proportional to
much higher than the average levels indicated on a the muscle force of the contraction (Bigland &
noise level meter whereas for the so-called steady Lippold 1954, Rosenfalck 1959).
noises peak and average levels were closer in mag- A quantitative measure of the middle ear
nitude. muscle contraction could therefore be obtained
by integrating the EMG response of these
muscles. As it was our aim to measure responses
to successive stimuli with inter-stimulus intervals
of as little as 8 msec, the integration time for a
Middle Ear Muscle Activity suitable integrator had to be so short that each
response maximum was separately recognizable.
by G Salomon' cand.Med. Therefore the integration time had to be less than
(Institute ofLaryngology and Otology, London) 4 msec. In addition, the pulse response from the
integrator had to be so near to a rectangle that
The middle ear muscles are activated not only by the output from one response did not contribute
sounds but also by a great number of non-acoustic to the integration of the output from the following
stimuli (Salomon & Starr 1963). In addition to response (less than 8 msec total duration of the
activity in response to discrete stimuli, the stape- pulse response). Fig 1 shows the circuit with
dius muscle shows spontaneous activity both in alternative integration times for the integrator
man (Salomon & Starr 1963) and in animals that was developed. The first two valves amplify
(Salomon & Starr 1965, Wigand & Brauer 1964). the myographic activity so that rectification can
'Present address: Copenhagen County Hospital, Gentofte, be later obtained in a linear way by the two
Copenhagen, Hell., Denmark germanium diodes. The first half of the last valve