Make a Joyful Noise
(More Quietly)

by Kayte Deioma

If you’re a musician, you know that music is awesome. You nod your head every time you read a headline about the benefits of music. You know that playing an instrument is good for the brain, that singing is good for your lungs and heart, and singing in groups promotes socialization. Music has a variety of profound impacts on the highly plastic brains of children, and it’s our joy to share music with them. Nothing beats seeing the happy faces of children dancing and singing along to music you are creating live.

Then you ask a child for her name, and find that understanding the answer is harder than it used to be. You have trouble hearing what people are saying against a noisy background. You feel like people are always mumbling and you must ask them to repeat what they said. You notice that you turn up the dials on the higher frequencies on the soundboard more than you used to. People around you ask, “Why do you have the music up so loud?” or “Didn’t you hear what I just said?” You might also have the constant ringing or buzzing of tinnitus in your ears.

All of these are common complaints among musicians and sound engineers, but audiologists are finding this type of noise-induced hearing loss more and more among young adults, teens, and even young children.

The House Ear Institute in Los Angeles, California conducted nearly 7,000 hearing tests of sound engineers and musicians attending the National Association of Music Merchants (NAMM) Show over more than a decade. Mix editor Sarah Jones writes, “In one of the most striking findings, all tested groups shared a characteristic ‘noise notch’—a distinct loss in sensitivity—in the 4 to 6 kHz range. What’s more, the notch grew deeper with results taken from trade shows dedicated to live sound, suggesting higher job-specific risks” (Jones 2007).

Andy Vermiglio, AuD, Director of the Speech Perception Laboratory at East Carolina University in Greenville, North Carolina, and longtime drummer, was one of the researchers on the project when he was at the House Ear Institute. During a phone interview for this article, he stated, “I saw guys who were like, twenty-one years of age that looked like they’d been in a factory all their lives and were seventy-five years old. I’d look at these guys at the NAMM show and say, yeah, according to your audiogram, you qualify for a hearing aid. They’d look at me with complete disbelief, because the thing is with hearing loss, you can’t hear what you can’t hear. So you don’t know the extent of your hearing loss.”

According to data from the Penn State School of Music in University Park, Pennsylvania, classical musicians show an even greater prevalence of hearing loss by college age than rock musicians (44–52% versus 32%). String students and brass musicians are even more likely to have sustained hearing damage than percussionists, who come in third, followed by vocalists, wind instruments, and keyboard (PSU School of Music 2017).

Statistics for the Decibel (Loudness) Comparison Chart were taken from a study by Marshall Chasin, MSc, Aud(C), FAAA, Centre for Human Performance and Health, Ontario, Canada. There were some conflicting readings, and in many cases authors did not specify at what distance the readings were taken or what the musician was actually playing. In general, when there were several readings, the higher one was chosen.

Some high-profile rock musicians, like Pete Townshend, Neil Young, Ozzy Osbourne, Phil Collins, AC/DC vocalist Brian Johnson, Dave Matthews, Chris Martin of Coldplay, and will.i.am have publicly shared their struggles with hearing loss and tinnitus, leading the Recording Academy’s Producers and Engineers Wing to partner with MusiCares on the GRAMMY Hearing Health Initiative to “do all we can to help reduce or eliminate hearing loss,” according to Debbie Carroll, Senior Executive Director of MusiCares (Recording Academy 2016). This initiative focuses on educating musicians and the concert-going public about using ear protection, but doesn’t address the underlying issue that the music itself is dangerous to both musicians and audiences at the levels commonly produced at live music events.  

Who Makes the Rules?

Since the 1970s, the Environmental Protection Agency (EPA), the Occupational Safety and Health Administration (OSHA), the National Institute for Occupational Safety and Health (NIOSH), and the World Health Organization (WHO) have set guidelines for workplace noise. OSHA, the only agency whose regulations are actually enforceable, has the least stringent limits, requiring hearing protection or noise abatement when levels reach 90 decibels (dB) for an eight-hour day. NIOSH sets the eight-hour threshold at 85 dB. WHO agrees with the old EPA guidelines recommending that “noise exposure levels should not exceed 70 dB over a 24-hour period, and 85 dB over a one-hour period to avoid hearing impairment” (CDC 2017).

The general idea is that your ears can tolerate a certain cumulative daily dose of sound. As long as you don’t exceed the maximum, your ears should be able to recover from short exposure to loud noise. The daily dose is calculated based on noise intensity and duration. So you may be able to tolerate a whole day of moderate noise, but only a few minutes of very loud noise. OSHA and NIOSH measures assume that outside of work time, you will be surrounded by relative quiet and that your entire dose of noise comes from your eight-hour work day. It’s also calculated based on a career of forty years in a noisy work environment, assuming you don’t have significant levels of noise exposure in your leisure time or over your childhood and teen years before beginning this career. Since even playground noise is commonly over 90 decibels, that assumption is overly optimistic.

Some workers who should be protected by OSHA include musicians, sound engineers, and venue staff. According to OSHA, these workers should not be subjected to 95 dB for more than four hours, or 100 dB for more than two hours without ear protection (reducing the time by half for every 5 dB of noise increase). Since the 1970s, lobbyists for big corporations have succeeded in weakening OSHA standards by getting them to dial back the requirement for expensive engineering solutions to prevent excessive noise in favor of cheaper hearing protection, which OSHA previously considered only an interim and last resort solution. Industrial lobbyists have also succeeded in preventing OSHA from lowering recommended maximum noise thresholds, even though OSHA admits they’re out of date. For example, OSHA used the 5 dB measure for convenience, but NIOSH uses a more mathematically accurate 3 dB (10 log 2 = 10 x 0.3 = 3 dB for you math geeks), A-weighted increment to calculate the maximum noise dosage after which hearing damage is likely.

(NIOSH 2015)

If you look at those numbers, you’ll realize that every rock, pop, electronic dance music (EDM), and many children’s music concerts you’ve played or attended were well beyond a safe sound dosage. According to the CDC website, “Limits are not set to protect all workers, nor sensitive populations, such as children and people with certain diseases. When setting this limit, NIOSH acknowledged that about 8% of workers could still develop a material hearing impairment. For this reason, NIOSH recommends that noise levels be reduced or hearing protection used whenever a noise level exceeds 85 dB for any length of time” (CDC 2017).

As an audiologist and drummer, Vermiglio had a unique opportunity to test the level of sound hitting his ear while he was playing. “I clocked myself playing a church gig with these things called Hot Rods, which are like these little bundles of sticks that are supposed to be softer than regular drumsticks. The level was 140 dB peak equivalence sound pressure level (SPL) at my ear. It’s like the sound of a pistol shot going off over and over,” he says. “My jaw hit the floor. It wasn’t that loud for my perception, but oh my gosh, all the damage I was causing, and the damage to my fellow musicians!”

At 140 dB, there’s no safe time without protection, and ear protection can only attenuate a small percentage of the sound, so even with earplugs or headphones, you’re only knocking the level down to maybe 120 dB, which won’t prevent hearing loss.

“I struggle to hear speech in noise,” reports Vermiglio. “I knew about that when I was in high school. I had started studying drums formally around age seven or eight. By the time I was in high school, I realized, wow, I really struggle to hear when people are talking and there’s background noise. I remember in high school being told by a math teacher when I asked him to repeat the instructions, ‘Oh, we have a slow student in the class,’ referring to me, and I remember thinking, I don’t think I’m slow. I just need to hear what he said. The classroom was especially noisy. There was a heating and air conditioning system and I was struggling to hear his instructions. My audiograms were all normal until I hit my thirties, so there was clearly damage going on way before the audiogram showed it” (Vermiglio, interview with author, 2017).

Beyond Traditional Understanding of Hearing Loss

Ben Stanley, AuD from Northwestern University, who presented at the 2015 CMN Conference, points to the deeper underlying damage not caught in an audiogram: “We used to think, you go to a concert, it’s real loud and your ears are ringing overnight and then two days later, boom, you’re right back to normal,” he says. “That made sense, and what people always just assumed was that whatever damage you did there fixed itself. What’s really interesting about that is that although sensitivity returns, we are finding out more that there may be lasting damage to the neural structures of the auditory system” (Stanley, interview with author, 2017).

Stanley points to an animal study by Harvard researchers Sharon Kujawa and Charles Liberman reporting that even though hearing levels—called temporary threshold shifts (TSS)—may return to normal after noise exposure, there is permanent neural damage. “We show rapid, extensive, and irreversible loss of synapses within 24 hours postexposure, and delayed and progressive loss of cochlear neurons over many months, although hair cells remain and recover normal function” (Kujawa and Liberman 2017).

Another body of research is looking at how excessive loud noise or chronic low noise affects the organization of the auditory cortex in the brain where sound is processed, so the brain’s response to sound does not proceed in a normal pattern. The combination of neural damage and brain disorganization from noise exposure can lead to a whole host of additional auditory problems like tinnitus, frequency perception, timing issues, inability to locate where sound is coming from, and many other disorders that don’t show up on the standard pure tone threshold audiogram.

One of the most common ­­­complaints is the difficulty of hearing speech in noise, which Vermiglio reported he was already experiencing in high school. He went on to help develop commercial versions of the Hearing in Noise Test (HINT) that can now be used to diagnose this specific auditory challenge.

According to Marshall Chasin, AuD, Director of Research and Chief Audiologist for the Musicians’ Clinics of Canada, and author of Hear the Music: Hearing Loss Prevention for Musicians, one of the most serious problems for musicians is pitch distortion. Pete Townshend is one musician who suffers from distortion in pitch perception, where a C note, for example, sounds like a B flat, so nothing sounds correct. Both pitch distortion and tinnitus are thought to be caused by altered input to the auditory cortex from the damaged auditory nerve, which can begin after one night of excessively loud music and gets worse over time.

One of the mechanisms behind TSS, or temporary hearing loss after a loud event, is the production of toxic levels of a substance called glutamate. “Glutamate is the main neurotransmitter substance in the cochlea and auditory system that make it work,” writes Chasin, “but high levels of glutamate can be toxic to the ear” (Chasin 2017). Loud music or noise and general stress both cause glutamate levels to rise. When the two are combined, researchers have found that having negative emotions about the loud noise or music causes even greater TSS than if you’re enjoying the music. So although loving the music doesn’t protect you from hearing loss, disliking it may increase your degree of hearing loss. This seems to be a greater risk for classical musicians, who don’t get to choose what they play.

Chasin says that while repeated episodes of TSS will most likely eventually result in permanent hearing loss over time, they are not a predictor of future hearing issues. Many musicians who don’t commonly experience TSS or tinnitus right after noise exposure still develop the symptoms related to auditory nerve damage and brain map disorganization from extended exposure to loud music (Chasin 2010).

How Are Children Affected?

According to the 2005–2006 CDC National Health and Nutrition Examination Survey (NHANES), 12.5% of American six- to nineteen-year-olds already have noise-induced hearing loss (NIHL). A comparison of 1988–1994 research data to 2001–2006 research data on hearing loss in twelve- to nineteen-year-olds shows that all forms of hearing loss increased from 14.9% in the earlier group (already bad) to 19.5% in the more recent group, a 33% increase. The degree of hearing loss is also greater in the second study group, with 77% more youth having mild or worse hearing loss (Shargorodsky et al 2010). And the NHANES figure of 12.5% of children and adolescents with measurable pure tone hearing loss doesn’t include all those who measure normal on the pure tone audiogram, so the actual number of six- to nineteen-year-olds having hearing difficulty is even greater.

Children are at higher risk than adults for developing hearing damage at the same volume levels. This is partially due to early impact of damage to cochlear hairs having longer and cumulative effect, and partially due to developmental issues.

The outer ear is mostly developed at birth, although parts of the ear continue to grow and develop through childhood. However, the auditory cortex in the brain, which is largely responsible for the perception, organization, and identification of sounds, is heavily influenced by the input it receives in the early years of development and even before birth. While the brain is still developing its ability to process sound, excessive input (or not enough input) disorganizes the brain’s auditory map even more than it does for adults.

As a baby, you map your mother’s voice, your father’s voice, your own cry, the sounds of words and music, and dogs barking. You learn to distinguish sounds coming from left and right and near and far. Your brain learns to distinguish the sound of one person talking versus another person talking, a person in the room versus a person on TV. You learn to modulate your own vocalizations to create words and language. Your brain’s ability to perceive volume and pitch differences and to process the auditory scene around you continues to develop until you’re sixteen to eighteen years old. 

The plasticity that allows you to develop this comprehensive auditory map also allows that map to be more easily misprogrammed by excessively loud sounds and sensory stressful auditory experiences. Additionally, the neural damage done by high-level noise exposure has a much greater lifetime impact when experienced at an early age. The two-year-old dancing in front of a speaker peaking at 100 dB can sustain permanent damage in a few short minutes that may not be caught until they get their first hearing test or when some developmental milestone is missed. The good news is that if identified early, there’s some hope that neural function can be restored (Kujawa and Liberman 2017).

The epidemic of ADD and ADHD diagnoses have also come under examination as potentially linked to coexisting or missed diagnoses of low-level hearing loss or other auditory dysfunction in children, since ADD and minor hearing loss present with similar behaviors. A study found that 43% of children who presented with “learning difficulties” had some kind of auditory dysfunction (Iliadou et al 2009).

Fortunately, from what Ben Stanley is seeing in his practice, more pediatricians and school psychologists are becoming aware of the issue and sending kids for a complete auditory workup before pronouncing another diagnosis that might result in unnecessary medication. However, noise-induced hearing and auditory issues are completely preventable. While we can’t move all the kids who live next to airports, trains, and farm machinery, there are actions we as musicians can take to make sure that we’re not harming the ears of our audiences—or further harming our own.  

What Can We Musicians Do About It?

1. Get your hearing tested. It’s always good to have a baseline, and knowing your own weaknesses will allow you to use technology rather than your ears. Vermiglio recounts going to a concert that was really shrill, with massive amounts of high frequency. “The sound guy was using this beautiful system as his hearing aid. The poor guy was mixing to his hearing loss” (Vermiglio, interview with author, 2017).
   
   If you know you have an overall loss, you can use technology rather than your ears to set the levels. If you know you have a high frequency hearing gap or “notch,” you can be aware that not enough treble for you may be just right for your audience.
2. Set a lower overall volume for your show. Don’t amplify already loud instruments in a small space. Use a decibel meter to set your levels and aim for an overall level around 75 dB, keeping peaks at 85 dB or below. There are NIOSH-approved decibel meter apps available for iPhones and iPads. Many of the same apps are available for Android, but there was not enough consistency in Android-based phones for NIOSH to do a comparison (Kardous and Shaw 2014).
3. Back away from your audience. In a classroom, an acoustic guitar played enthusiastically with a pick can be excessively loud to a child sitting three or four feet away, especially when that sound hole is at ear level.
4. Talk to venues about keeping the volume down so you’re on the same page. If you’re performing in a space that has other loud activities going on at the same time, discuss ways you can reduce sound bleed so you’re not trying to play over a museum full of screaming children on the other side of the partition.
5. Get parents on your side. If you think you might have chatty adults in the room, tell parents and teachers in the audience that you’re keeping the sound levels down to protect the children’s hearing and you’d appreciate their cooperation in not talking to each other during the show, since that contributes to the children not being able to hear optimally. 
6. Don’t encourage audience screaming competitions. In addition to the potential for hearing damage to the ears next to the screamers, children can damage their vocal chords screaming.
7. Mix up your set. Play quiet songs between the loud songs to prevent ear fatigue for the audience and yourself.
8. If you don’t have control of the volume, educate your audience. Tell parents at the top of the show, and any time you notice it happening, to keep their children away from the speakers for their own safety. Make child-sized earplugs available. If you know in advance that it will be loud, suggest that parents bring earmuffs for everyone, especially for sensitive kids. Stress that damage happens without pain or discomfort.
9. Protect yourself! Wear hearing protection. It will protect the hearing you have left from getting worse and sets a good example for others. Send the message that protecting your hearing is cool. For bands, in-ear monitors with personal mix control let you monitor the whole band at your preferred listening level.
10. Stay fit! “There is evidence that cardiovascular function and overall physical fitness can affect the propensity for hearing loss” (Chasin 2010).
11. Keep making music! The joy of music making far outweighs the risk, and a little caution can keep you and your audience enjoying music for years to come.