A 17-year-old female came to clinic for her health examination visit. Her mother basically didn’t have any concerns except that she seemed to not be listening to her as much. “I can’t tell if it’s typical teenager, she’s paying too much attention to all the stuff she’s doing online, or she’s having a hearing problem,” the mother said. The teenager disagreed with her mother and said that she was paying attention to her mother. The teen said she didn’t have any hearing problems, could hear noises and voices just fine, and had no tinnitus or dizziness. The pertinent physical exam showed a healthy female with growth parameters in the 75-90% with normal vital signs.

The diagnosis of a healthy teenager was made. The teenager said that she turned her computer or phone on before putting her earbuds into her ears. “I’ve had a couple of times where I put them in and then got blasted because the volume was turned up. That hurt,” she said. She also said she usually didn’t listen to the radio when she was driving or if she did it was turned to a low volume because she needed to pay attention to the traffic. The pediatrician recommended that the teen did take frequent breaks from the earphones or earbuds in addition to what she was already doing. He also recommended that if the mother wanted to get her daughter’s attention to make sure the teen could see her and not just hear her. “She may not be able to hear you over the earbuds so make sure she can see you. That way both of you won’t be frustrated,” he offered.

Discussion
Hearing loss due to occupational or recreational exposure are problems in our current society. The increased ambient noise in many locations is above recommended thresholds such as street noise, inside communal activities such as sports/music practice or events, or even lunch in a noisy cafeteria, etc. Equipment can be sources of unrecognized exposure including air compressors, gardening tools such as leaf blowers, trimmers, lawn mowers, and snow blowers, and even loud home appliances such as vacuum cleaners, washers/dryers, and dishwashers. This can be worsened by the concurrent need to increase the volume of other appliances such as a TV or stereo to overcome the dishwasher noise in the background.

Additionally, with the increased use of portal listening devices (PLDs) including mobile phones, and the increase of time spent online, there is an increased use of amplified sound through earphones and ear buds. Harmful sound depends on the volume/intensity and the duration. Overall, “…a sound level above 75 dBA can potentially harm hearing, and a sound level above 85 dbA can induce hearing damage if the daily exposure duration is more than 45 min.” Studies of youth using PLDs have found that these devices are often used daily, for multiple hours/day and “… that PLDs can easily reach sound pressure levels … that are considered to impair hearing.” A “maximum exposure to noise of 85 dB(A) for 8 h per day for a 40-h working week and are commonly [cited] when assessing risky leisure noise exposure.”

Increased risk is due to increased exposure. A longitudinal study of German youth over 5 years found that auditory noise exposure did not change over time and that up to 73% of students exceeded these noise levels at one or more sampled time periods. Using PLDs increased the exposure compared to listening to music via a loudspeaker. The type of music also made a difference with listening to “charts, rock, and pop” more likely to exceed thresholds than “oldies and jazz” or “classic” music. In this study listening to audiobooks, movies, or playing videogames was less likely to exceed the threshold. However the use of PLDs has increased overtime, particularly with the need for online educational activities due the COVID-19 pandemic. Use of PLDs particularly in the setting of other ambient noise and the duration of the activities may have changed since this and other studies were published.

Problems associated with increased noise aren’t just hearing loss but other aural problems including tinnitus, sound distortion, difficulty understanding speech, dizziness, and earache. Other “extra-auditive damage, [includes] sleep disorders, cardiovascular disorders, stress, fatigue, tension, irritability, inattention, tiredness, nervousness, headache and arterial hypertension.”

Noise canceling headphones and ear buds can help by reducing unwanted ambient noise and helping to increase the listening experience. Active noise canceling devices work by creating sound waves in the opposite phase of the incoming noise waves thus canceling the noise waves. Additionally, the actual device also offers physical protection and thus is a passive noise reducer. Even well-fitting over-the-ear or in the ear noise canceling headphones block less noise than noise canceling headphones with a circumaural cushion (i.e. ear-muff style).

As a comparison, water dripping is 0 dB of sound and this is normal hearing. A clock ticking is 20 dB of sound, and a person with this hearing loss may miss some speech consonants. A whisper is 30 dB of sound and a person with this hearing loss may hear only louder noises or have mild speech problems. Conversational speech is 40 dB and a person with a loss may hear speech only as a whisper. A baby crying is 55 dB and a person may only be able to hear loud speech at a few feet with this degree of loss. Other common environmental sounds are telephone ringing (90 dB), lawn mower (100 dB) and an airplane (110 dB). Deafness is defined as a hearing loss > 90 dB. The person will not be able to distinguish between different speech elements. Hearing aids are often recommended for losses > 25 dB. They may also be useful for certain patients with less loss.

Learning Point
Some recommendations for use of PLDs include:

• Decrease overall use of PLDs as much as possible – frequent aural breaks (at least hourly), use of other auditory devices such as the built-in computer speaker set at a low or normal volume, foregoing using PLDs during various activities such as exercise, cleaning etc. Longer breaks after longer use, such as school work, are also recommended.
• Properly fitted headphones and ear buds – check fitting when initially purchased and over time
• Use PLDs with the lowest volume setting or purchase ones that have volume limitations. Some of the volume limiting products may still exceed recommended thresholds though.
• Keeping the volume at half of the maximum setting is a good general rule but the volume need may change over a day’s use and need to be readjusted downward if it was adjusted upward for a particular reason.
• Turn the device on first, and then put on the headphones or ear buds – this decreases the chance the initial volume is too loud, and makes the person adjust the level needed for the current listening session.
• There may be “parental” controls for some devices that can be set.
• Use of active noise canceling headphones and ear buds can also help

The American Speech-Language-Hearing Association also recommends youth and parents are aware of hearing damage symptoms which can be subtle such as hearing discomfort, difficulty hearing soft or faint sounds, or tinnitus.

Questions for Further Discussion
1. What are causes of sensorineural and conductive hearing loss? A review can be found here
2. How much time do you use a portable listening device daily or weekly and what volume is it set to?
3. What loud noise is in your and your patient’s daily environment?

Related Cases

Disease: Hearing Disorders and Deafness | Hearing Problems in Children | Noise

Symptom/Presentation: Hearing Problem

Specialty: Otolaryngology | Speech and Hearing

Age: Teenager

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Hearing Disorders and Deafness, Hearing Problems in Children and Noise.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Liang M, Zhao F, French D, Zheng Y. Characteristics of noise-canceling headphones to reduce the hearing hazard for MP3 users. J Acoust Soc Am. 2012;131(6):4526-4534. doi:10.1121/1.4707457

Herrera S, Lacerda ABM de, Lurdes D, Rocha F, Alcaras PA, Ribeiro LH. Amplified music with headphones and its implications on hearing health in teens. Int Tinnitus J. 2016;20(1):42-47. doi:10.5935/0946-5448.20160008

Widen SE, Moller C, Kahari K. Headphone listening habits, hearing thresholds and listening levels in Swedish adolescents with severe to profound HL and adolescents with normal hearing. Int J Audiol. 2018;57(10):730-736. doi:10.1080/14992027.2018.1461938

Dreher A, Weilnhammer V, Gerstner D, et al. Longitudinal analysis of leisure noise exposure among adolescents with special focus on portable listening devices: the OHRKAN cohort study. International Journal of Audiology. 2018;57(12):889-897. doi:10.1080/14992027.2018.1510187

Giving the Gift of Hearing Protection: ASHA Offers Tips for Smart Shopping, Safe Listening When Headphones Are on a Child’s Holiday Wish List. Accessed January 11, 2021. https://www.asha.org/news/2020/giving-the-gift-of-hearing-protection-asha-offers-tips-for-smart-shopping-safe-listening-when-headphones-are-on-a-childs-holiday-wish-list/

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa