Predictive factors of occupational noise-induced hearing loss in Spanis... https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4900496/?

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Noise Health. 2015 Sep-Oct; 17(78): 343–349. PMCID: PMC4900496

doi: 10.4103/1463-1741.165064: 10.4103/1463-1741.165064 PMID: 26356377

Predictive factors of occupational noise-induced hearing loss in Spanish workers:

A prospective study
Armando Carballo Pelegrin,1,2 Leonides Canuet,3 Ángeles Arias Rodríguez,2 and Maria Pilar Arévalo Morales2

1
MGO Group, SA, Department of Occupational Risk Prevention, Tenerife, Spain
2
Department of Preventive Medicine and Public Health, University of La Laguna, Tenerife, Spain
3
Center for Biomedical Technology, Madrid Complutense University, Madrid Polytechnic University, Madrid, Spain
Address for correspondence: Dr. Armando Carballo Pelegrin, Territorial Delegation of MGO, Santa Cruz de
Tenerife, Spain. E-mail: [email protected]

Copyright : © 2015 Noise & Health

This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-
ShareAlike 3.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as
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Abstract

The purpose of our study was to identify the main factors associated with objective noise-
induced hearing loss (NIHL), as indicated by abnormal audiometric testing, in Spanish workers
exposed to occupational noise in the construction industry. We carried out a prospective study in
Tenerife, Spain, using 150 employees exposed to occupational noise and 150 age-matched con-
trols who were not working in noisy environments. The variables analyzed included sociodemo-
graphic data, noise-related factors, types of hearing protection, self-report hearing loss, and au-
ditory-related symptoms (e.g., tinnitus, vertigo). Workers with pathological audiograms had sig-
ni icantly longer noise-exposure duration (16.2 ± 11.4 years) relative to those with normal au-
diograms (10.2 ± 7.0 years; t = 3.99, P < 0.001). The vast majority of those who never used hear-
ing protection measures had audiometric abnormalities (94.1%). Additionally, workers using at
least one of the protection devices (earplugs or earmuffs) had signi icantly more audiometric ab-
normalities than those using both protection measures simultaneously (Chi square = 16.07; P <
0.001). The logistic regression analysis indicates that the use of hearing protection measures
[odds ratio (OR) = 12.30, con idence interval (CI) = 4.36-13.81, P < 0.001], and noise-exposure
duration (OR = 1.35, CI = 1.08-1.99, P = 0.040) are signi icant predictors of NIHL. This regression
model correctly predicted 78.2% of individuals with pathological audiograms. The combined use
of hearing protection measures, in particular earplugs and earmuffs, associates with a lower rate
of audiometric abnormalities in subjects with high occupational noise exposure. The use of hear-

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ing protection measures at work and noise-exposure duration are best predictive factors of
NIHL. Auditory-related symptoms and self-report hearing loss do not represent good indicators
of objective NIHL. Routine monitoring of noise levels and hearing status are of great importance
as part of effective hearing conservation programs.

Keywords: Audiometry, hearing loss, hearing protection devices, occupational noise, predictors

Introduction

It is well documented that occupational noise exposure is associated with permanent hearing
loss. Noise-induced hearing loss (NIHL) represents a major occupational health hazard world-
wide.[1,2,3,4,5,6,7] In fact, hearing loss is the third most prevalent condition among older adults,
with over 11% of the population being affected.[8] NIHL is particularly common in several sec-
tors with exposure to high noise levels including the construction and manufacturing industries.

NIHL has an insidious onset and may be well advanced by the time that it gives rise to apprecia-
ble disability.[9] Pure-tone audiometric testing is used to detect and quantify the degree of NIHL.
This provides an objective measure of hearing impairment in individuals exposed to occupa-
tional noise.[10] Self-report hearing problems and a physical examination are sometimes used
for detection of NIHL at the workplace. However, hearing complaints do not always seem to be
associated with early hearing impairment.[11] In addition, although auditory or vestibular
symptoms such as tinnitus and vertigo are thought to be related to early NIHL, these symptoms
often represent a heterogeneous group of underlying disorders.[12] Furthermore, long-term ex-
posure to noise may cause vestibular symptoms before clinically detectable hearing loss occurs.
However, the symptoms are subtle and mostly neglected and do not affect the functional ability
of workers.[13] Thus, the use of audiometric testing is of great value for an early diagnosis of oc-
cupational hearing loss, especially in high-noise environments.

Although noise controls are regarded as the best strategy for NIHL prevention, many hearing
conservation programs rely on the use of hearing protection devices to reduce noise expo-
sure.[13] Nevertheless, hearing conservation programs often fail in the construction indus-
try,[14] and underuse of protection has been partly attributed to inadequate company ef-
forts.[15] In fact, in some workplaces with high noise levels in Spain many workers have been
found to be reluctant to use hearing protection devices.[16] Recent evidence raises concern
about the effectiveness of hearing protection as a substitute for noise control to prevent occupa-
tional NIHL. For instance, Groenewold et al. assessed the association between self-reported
hearing protection use at work and incidence of hearing shifts in 19,911 workers over a 5-year
period. The measures used suggested a marginally signi icant difference for hearing shift be-
tween workers who reported rare versus frequent use of hearing protection devices.[17]

The purpose of our study was to assess objective occupational NIHL, as measured by audiomet-
ric testing, and determine its relation to subjective sensation of hearing loss as well as to audi-
tory and vestibular symptoms in Spanish workers exposed to occupational noise in the construc-
tion industry. In addition, we aimed to determine whether the use of hearing protection devices

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such as earplugs and earmuffs, alone or combined, offer a differential bene it to prevent NIHL in
noise exposed workers. We were also interested in identifying main predictive factors of NIHL in
this sample controlling for confounding variables.

METHODS

Subjects

We carried out a prospective study using 150 employees exposed to occupational noise (mean
age: 40.9 ± 10.3 years) in Tenerife, Canary Islands, Spain, from September 2009 to August 2010,
who were seen at the Health Surveillance Center of Adeje district. For comparison, we also re-
cruited 150 subjects (mean age: 41.2 ± 11.4 years) who were not working in noisy environ-
ments. The occupational sectors that the workers belonged to are shown in Table 1. Subjects
working in the construction industry were included in the exposed group, whereas those work-
ing in hotel/restaurant's of ices were included in the unexposed group. All subjects signed a
written informed consent to participate in the study. We excluded workers with a personal or
family history of congenital deafness, ear surgery, prolonged exposure to ototoxic agents (e.g.,
antituberculosis agents, salicylates, aminoglycoside antibiotics, carbon monoxide, lead, and ben-
zene), a history of hypertension for more than 5 years with poor control or blood pressure val-
ues higher than 140/90 mgHg at the time of the assessment. Subjects with a history of poorly
controlled diabetes mellitus for more than 5 years, alcoholism, moderate or severe head trauma,
mumps and measles, and typhoid fever were also excluded. Based on these criteria, a total of 27
workers were excluded from the study (exposed, n = 15; unexposed, n = 12).

Data collection

For each subject, data of audiometric tests were collected. We also applied a questionnaire with
sociodemographic information, smoking and alcohol habit, employment history, current noise
exposure, hearing protection use, auditory-related symptoms (e.g., tinnitus, vertigo), and self-
assessment of hearing loss. The questionnaire is derived from the protocol for health surveil-
lance of workers exposed to noise of the Spain Ministry of Health.[18]

Audiometric test

Hearing ability was measured using pure-tone audiometry. This test was performed with a stan-
dard, calibrated audiometer (Redus 75®, Eymasa, Barcelona, Spain). Air-conduction hearing
thresholds were explored at 1,000 Hz, 2,000 Hz, 3,000 Hz, 4,000 Hz, 6,000 Hz, and 8,000 Hz fre-
quencies in both ears, in 5 dB increments. To diagnose NIHL, we used the Klockhoff-modi ied
criteria.[19] Based on these criteria, NIHL was de ined as having a history of occupational noise
exposure, bilateral hearing impairment, and a threshold level higher than 25 dB at frequencies
between 1,000 Hz and 8,000 Hz in the absence of other conditions affecting hearing.
Environmental noise levels were not measured.

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The self-assessment of hearing loss was determined if the subjects answered af irmatively to
three out of the ive questions included in the questionnaire recommended by the Protocol for
health surveillance of workers exposed to noise of the Spain Ministry of Health.[18] Similar
questionnaires have been used in other studies.[20] The questions cover the following areas:

1. Subjective hearing disturbance,

2. Dif iculties in hearing in a crowd or in a noisy environment,
3. Need to ask others to repeat frequently during a conversation,
4. Need to turn the volume up of the TV higher than that others would prefer,
5. Trouble knowing where sounds are coming from.

Statistical analysis

Descriptive statistics for categorical variables was performed by frequency analysis. To analyze
the distribution and percentages for categorical variables in relation to noise exposure (exposed
or unexposed) or type of audiometry (normal or pathological), contingency tables were used,
and statistical signi icance was determined with the Chi-square test. The difference in continu-
ous variables (age, duration of noise exposure) across groups was determined by the Student's
t-test.

To identify predictors of hearing loss, a logistic regression analysis was conducted, with “au-
diometry” as the dependent variable. The independent variables included demographic data,
factors relevant to hearing loss, and possible confounding variables (e.g., smoking, alcohol con-
sumption). For the regression analysis, continuous variables became ordinal variables (e.g., age
groups). OR with 95% CIs were obtained. All statistical analyses were performed using
Statistical Package for the Social Sciences (SPSS) 19 software (IBM, Armonk, NY).

Results

The demographic and clinical data of the workers in our sample are given in Table 1. We noted
that there was no signi icant difference in age across exposed versus unexposed groups. The as-
sessment of audiometric tests revealed a predominance of pathological audiograms in the group
of workers exposed to occupational noise compared to those who were unexposed. This differ-
ence was statistically signi icant (Chi square = 43.81, P = 0.00).

The relationship between auditory symptoms (e.g., tinnitus and vertigo) and the exposure to oc-
cupational noise was explored. The number of subjects exposed to noise reporting tinnitus (n =
16; 10.7%) was signi icantly higher compared to those who were unexposed (n = 4; 2.7%) (Chi
square = 7.71; P = 0.005). The incidence of vertigo in noise-exposed (n = 19; 12.7%) and unex-
posed (n = 11; 7.3%) subjects showed no signi icant between-group difference (Chi square =
2.37; P = 0.124) [Table 1].

The analysis of reports obtained from the self-assessment of hearing loss, all noise unexposed

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workers reported no abnormality, while 7.3% of workers exposed to occupational noise re-
ported subjective hearing impairment (Chi square = 11.42, P = 0.001). Table 1 shows the per-
centage of workers reporting alcohol intake and smoking habit in both noise-exposed and unex-
posed groups.

Workers exposed to noise had a mean of 13.2 ± 9.2 years of exposure. A high percentage of these
workers (88.6%) regularly used some form of hearing protection, including earplugs and/or
earmuffs. Out of these workers, 35.3% simultaneously used both personal protective devices,
while 53.3% used only one of these devices. About 11% of these workers exposed to occupa-
tional noise reported that they never used any kind of hearing protection [Figure 1].

We analyzed the relationship of noise-related factors and the results of the audiometric test
(normal or pathological). We found that workers with pathological audiograms had signi icantly
longer noise-exposure duration (16.2 ± 11.4 years) relative to those with normal audiograms
(10.2 ± 7.0 years; t = 3.99, P < 0.001). The vast majority of those who never used hearing protec-
tion measures had audiometric abnormalities (94.1%), whereas in those using hearing protec-
tion there was a similar distribution of normal (46.6%) and pathological (53.4%) audiograms [
Figure 1]. The difference in pathological audiograms between these groups (never vs regular use
of protection) was statistically signi icant (Chi square = 10.26; P = 0.001). An exploratory analy-
sis within workers using hearing protection devices revealed that those using at least one of the
devices (earplugs or earmuffs) had a 67.5% of pathological audiometry, which contrasts with
those using both measures of protection simultaneously that only had a 32.1% of audiometric al-
terations (Chi square = 16.07; P < 0.001) [Figure 1].

Logistic regression analysis was performed using audiometry (normal or pathological) in occu-
pational noise-exposed group as the dependent variable. The nominal independent variables
(predictors) that were entered into the logistic regression model were gender, hearing protec-
tion use, incidence of vertigo or tinnitus, and recreational noise exposure. Continuous indepen-
dent variables were age, duration of noise exposure, number of cigarettes/day, and the daily
amount of alcoholic beverages [Table 2]. This logistic regression model was found to be signi i-
cant (Chi square = 68.79, df = 8; P < 0.001). The results of the regression analysis revealed that
signi icant predictors of occupational hearing loss in workers exposed to noise were the use of
hearing protection measures at work (OR = 12.30, CI = 4.36-13.81, P < 0.001) and the duration
of noise exposure (OR = 1.35, CI = 1.08-1.99, P = 0.040). This logistic regression model correctly
predicted 78.2% of individuals with pathological audiograms in this sample, indicating a high
level of classi ication.

Discussion

In this study, we compared workers with high occupational noise exposure and those unexposed
to identify whether symptoms commonly related to hearing disturbance (subjective sensation of
hearing loss, tinnitus, and vertigo) as well as the use of hearing protection devices are indeed
closely associated with objective hearing loss, as measured by audiometric test. We also aimed at
determining predictive factors of NIHL after controlling for confounding variables such as age,

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and tobacco or alcohol consumption. We found that, as expected, workers exposed to occupa-
tional noise exhibit a signi icant increase in pathological audiograms, compared with unexposed
individuals. Importantly, although subjective symptoms, including self-reported hearing impair-
ment, and tinnitus were particularly present in workers exposed to occupational noise, only the
lack of use of hearing protection measures and a long duration of noise exposure emerged as im-
portant predictors of NIHL.

It is well established that hearing loss is the most common problem associated with exposure to
noise.[21] The National Institute of Health, United States, reported that nearly 20 million work-
ers were regularly exposed to noise, of which 50% (10 million) suffered some hearing damage of
different severity.[22] A study conducted by Wu et al., using a system of health surveillance for
hearing loss in Taiwan, found a 58% incidence of hearing impairment among workers exposed
to noise.[6] Other studies performing pathological audiometry have found that 53-78% of work-
ers exposed to occupational noise have hearing impairment worldwide.[1,5,23,24,25] In a recent
study, Money et al. reported that up to 95% of workers exposed to noise had some sort of audio-
metric alteration.[3] In our study, we found a 73.7% of pathological audiograms in noisy work-
ing environments. This incidence is within the range of the literature.[3,20] Relly et al. suggested
that the total number of workers with hearing impairment is sometimes underestimated.[26]
However, the progressive introduction of monitoring systems increasingly identi ies jobs with
hazardous noise levels that require attention for hearing health status of their workers.

Various auditory-related tinnitus are thought to be associated with hearing impairment. In our
study, tinnitus was signi icantly more frequent in noise-exposed workers than in unexposed
workers, although its incidence was lower than expected. Other studies of workers exposed to
noise indicate that tinnitus is mainly associated with advanced hearing loss due to occupational
noise exposure, while the subjects in this study had mild-to-moderate hearing loss.[27,28]
Because the presence of self-reported tinnitus was assessed using a simple (yes/no) question,
we cannot rule out that the way this question was formulated may have in luenced the results.
Vertigo, however, was found to have no signi icant difference between groups. Our results sug-
gest that despite a relatively low frequency of these symptoms in workers exposed to occupa-
tional noise, tinnitus rather than vertigo might be related to NIHL. However, the regression
model revealed no predictive value of these symptoms for the development of NIHL.

Hearing disorders are often associated with objective manifestations, such as audiometric ab-
normalities as well as with the subjective sensation of hearing loss. However, it is not clear
whether subjective manifestations, particularly in individuals regularly exposed to noise, appear
early or not, and if they represent a good indicator of an actual hearing impairment. This would
signi icantly help in the prevention of occupational hearing loss. Although several studies on
NIHL are based on subjective symptoms of self-reported hearing loss, there is growing evidence
of the need for objective measures of hearing damage, such as audiometry, for early and reliable
detection of hearing impairment attributable to the work environment, and thus avoid severe
and irreparable damage to hearing.[29,30] Kerr et al. studied hearing as perceived by the indi-
vidual and audiometry in 147 construction workers and 150 farmers in order to promote ac-
tions that lead to a reduction of NIHL. The sensitivity of perceived hearing loss compared to au-
diometric damage ranged 0.30-0.72 suggesting that self-reported hearing loss is not consistent

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with an actual hearing loss measured by audiometry. The poor relationship between loss of per-
ceived and actual audition found suggests that best practice in assessing this dimension of hear-
ing requires the inclusion of audiometric examination as part of a prevention program hearing
loss.[23] Of note, although the percentage of pathological audiometry was 58% in our study only
7.3% of this sample reported subjective hearing loss.

It is well-known that there is a causal association between occupational exposure to noise and a
permanent hearing loss.[31] The lack of use of hearing protection devices worsens hearing ca-
pacity of individuals exposed to noise.[23]

In our study, we evaluated the appropriate use of personal protective equipment in workers ex-
posed to noise. In the noise exposed group, the majority of workers who did not use protective
measures had pathological audiograms (94%). Among those who used these measures, there
was a similar distribution of normal and pathological audiometry. When analyzing the combined
use of protective measures, it was demonstrated that it has greater ef iciency than the isolated
use of earplugs or earmuffs, as those using both devices simultaneously had only 32% of patho-
logical audiograms while those who opted for either an earplug or an earmuff had 68%.

Most studies agree that the use of hearing protection devices is a key factor for prevention of
hearing loss due to occupational noise exposure, and only these devices, and to a lesser extent
rehabilitation, can ensure good hearing health in workers exposed to this physical agent.
[32,33,34] Pavó n's study on the level of environmental noise in opencast mining in the commu-
nity of Madrid noted the existence of high noise levels in most workplaces. Nevertheless, there
were a high number of workers who were reluctant to use hearing protection.[16] To promote
safety and health at work should be emphasized in the training of workers. In this sense, Neitzel
et al. conducted a study to assess the importance of training in awareness for the use of personal
protective equipment to workers in the construction sector. Their results showed that the train-
ing of workers exposed to occupational noise is essential to achieve a good level of conservation
of hearing health.[35]

A study conducted by Salazar et al. aiming to determine the cochlear function using otoacoustic
emissions showed early and subtle damage in the hair cells of the cochlea that did not correlate
with changes in conventional audiometry. The study showed that occupational noise signi i-
cantly decreased the otoacoustic emissions in subjects exposed to noise who used hearing pro-
tectors throughout the workday.[36] Taken together, these studies and our results suggest that
hearing protection for workers in noisy environments is the best measure and probably the only
and most effective measure in preventing occupational deafness, as it has proven to be the main
factor for hearing preservation despite the existence of subtle damage to hair cells of the
cochlea.

So far, we have shown results of our study that indicate an association between various factors
and hearing loss in exposed workers compared to those not exposed to occupational noise.
However, it is not entirely clear whether the same association persists when analyzing all factors
together. This approach would help to have a better view of which factors are more determi-
nants to be independently associated with increased risk of hearing damage in individuals regu-

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larly exposed to noise at work in this sample. For this reason, we decided to carry out a logistic
regression analysis, taking as dependent variable the audiometric damage in workers exposed to
occupational noise, and evaluate the predictive power of a number of independent variables. The
logistic regression model was found to be signi icant, indicating that they could correctly predict
the dependent variable (audiometric damage) in exposed workers. The results indicated that
taking all factors into consideration, only a long duration of noise exposure and the lack of use of
hearing protection measures emerged as predictive factors of the risk to develop objective hear-
ing impairment, as indicated by the audiometric test. This means that despite the undeniable
fact that age-related factors such as presbycusis affect the quality of hearing in subjects working
in any kind of environment, sustained noise exposure plays an essential role in NIHL, in addition
to a lack of use of protective measures at work. The logistic regression model correctly predicted
about 80% of individuals with normal and pathological hearing in the sample, which shows a
high level of classi ication.

Most previous studies proposed that the duration of noise exposure and a bad use of hearing
protection devices negatively in luenced the audiometric results. Hong et al.'s study assessed the
prevalence and characteristics of hearing loss among engineers operating with heavy construc-
tion machinery using audiometric tests as part of a protection program. They found that the rate
of hearing loss was particularly higher among subjects with more years of work experience in
the construction industry. The average use of hearing protection devices was 48% of the time
that is required to be used. A signi icant inverse correlation between the highest frequency (4-6
kHz) hearing loss and use of hearing protection devices (r = –0.134, P < 0.001) was observed.[1]
In a study similar to ours, it was found that hearing thresholds among workers of a nuclear cen-
ter were much higher than those observed in the population of industrial workers with low
noise exposure. A review of noise and health indicate that prevention of the effects of occupa-
tional noise on health should focus on measures to protect workers rather than on the control of
the source of noise.[37]

The objective risk of hearing damage was signi icantly higher for construction workers com-
pared with controls (OR = 1.6, 95% CI = 1.3-2.1) and increased with the duration of time em-
ployment, although the confounding effect of other factors such as age and smoking was not
ruled out.[38] Interestingly, Rubak et al. found that workers exposed for more than 20 years at a
level of exposure above 85 dB (A) had a threefold increased risk (OR = 3.05, 95% CI = 1.33-6.99)
of developing NIHL, which is consistent with our results. Workers who started to work in a noisy
environment in the last 10-15 years or workers under 30 years of age showed no increased risk
of hearing impairment.[31]

In conclusion, our indings support and extend the following notions:

1. Workers exposed to occupational noise are particularly prone to objective audiometric

damage,
2. Auditory-related symptoms such as tinnitus are weakly associated to NIHL, and
3. Self-report hearing loss does not represent a good indicator of an early objective audiometric
damage.

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In addition, the results of logistic regression analysis indicate that the main predictors of occupa-
tional hearing loss were irst the use of hearing protection measures at work and second the du-
ration of occupational exposure to noise. Furthermore, the combined use of hearing protection
measures, in particular earplugs and earmuffs, are associated with a lower rate of audiometric
abnormalities in subjects with high occupational noise exposure. Thus, routine monitoring of
noise levels and hearing status in certain populations should be included as part of a program ef-
fective hearing conservation.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no con licts of interest.

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Figures and Tables

Table 1

Demographic and clinical data in workers exposed and unexposed to occupational noise

Variables Exposed (n = 150) unexposed (n = 150)

Age (mean ± SD) 40.9±10.3 41.2±11.4

Gender (F/M) 6/144 79/71

Abnormal audiometry [n (%)] 87 (58)* 31 (20.6)

Tinnitus [n (%)] 16 (10.7)** 4 (2.7)

Vertigo [n (%)] 19 (12.7) 11 (7.3)

Self-report hearing loss 11 (7.3) 0

Alcoholism [n (%)] 62 (41.3) 43 (28.7)

Smoking habit [n (%)] 70 (46.7) 48 (32.0)

*
P < 0.001, **P < 0.005

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Figure 1

Effects of hearing protection devices on pathological audiometry. Distribution of workers exposed to occupational noise
according to (a) The use of hearing protection devices and (b) Audiometric results. The bottom panel (table) shows the
distribution of workers using hearing protection devices (earplugs, headphones) in isolation or in combination

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Table 2

Multivariate logistic regression analysis. Predictive factors of abnormal audiometry in workers exposed to occupational
noise

Variables β SE Wald P OR 95%; CI

Age (years) −0.038 0.030 1.666 0.197 0.963 0.908 1.02

Cigarettes/day 0.021 0.021 0.975 0.324 1.021 0.98 1.065

Alcohol/day (g) 0.009 0.007 1.834 0.176 1.009 0.996 1.023

Noise exposure (years) 0.670 0.033 4.210 0.040 1.359 1.087 1.997

Gender −0.412 1.092 0.143 0.706 0.662 0.078 5.629

Protection measures 2.510 0.485 26.825 0.000 12.306 4.76 13.814

Vertigo 2.045 1.150 3.162 0.075 7.729 0.811 73.62

Recreational noise −0.186 0.636 0.086 0.770 0.830 0.239 2.888

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