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Hearing Loss Basic Course in Occupational and Environmental Medicine, Part III Orlando, Florida, October 30, 2011 Objectives Develop an understanding of Noise Induced Hearing hearing. Loss and Hearing Learn how noise causes hearing loss. Conservation Learn about how workers can be protected from hearing loss. Learn about the OSHA standard regarding hearing loss. AOCOPM Basic Course in Occupational Medicine Learn the basics of an effective AOA Annual Osteopathic Medical Conference hearing conservation program. Orlando, Florida Sunday, October 30, 2011 The Human Ear Effects of High Noise • May cause stress and anxiety • Interferes with speech and ability to communicate • May cause sleep difficulties • Temporary hearing shifts • Pain (very high levels) • Can damage hearing Types of Hearing Loss: CONDUCTIVE SENSORI-NEURAL Hearing Loss MIXED NON-ORGANIC I-1 Basic Course in Occupational and Environmental Medicine, Part III Orlando, Florida, October 30, 2011 Conductive Characteristics Occurs from a Maintain soft speaking voice dysfunction of the outer or middle Excellent speech discrimination when ear that can speech is loud enough usually be treated Typically either low frequency or flat with medicine or hearing loss (equal at all frequencies) surgery; a deficit of loudness only. Causes Causes Blocked Eustachian Outer Ear: Tube, reduced middle ◦ Occlusion/foreign body ear pressure, TM ◦ Congenital Atresia retraction and ◦ External Otitis eventual effusion Otitis Media TM Perforation Ossicular fixation o Otosclerosis Ossicular Disarticulation Cholesteatoma Photo’s courtesy of Dr. Roy F. Sullivan, Ph.D. Photo’s courtesy of Dr. Roy F. Sullivan, Ph.D. Treatment Sensori-Neural Conductive hearing losses are due to problems Dysfunction of the inner ear or auditory that occur in the outer and middle ear which nerve, usually permanent and untreatable; are usually temporary and/or treatable with results in loudness deficit and distorted antibiotics or surgery hearing. For those few people who have uncorrectable conductive hearing losses, hearing aids are of significant benefit as sound remains clear if it is made loud enough I-2 Basic Course in Occupational and Environmental Medicine, Part III Orlando, Florida, October 30, 2011 Characteristics of SNHL: Causes Genetics/Congenital Noise Exposure: Inappropriately loud voice Disease ◦ Prolonged exposure to Tinnitus ◦ Mumps, measles hazardous noise causes ◦ Meningitis, CMV hearing loss by the High frequency loss common, Ototoxic drugs physical destruction of but any configuration possible Head trauma the hair cells in the Presbycusis cochlea. Speech sounds distorted Meniere’s Disease Background noise makes Acoustic Neuroma listening more difficult Hearing aids may help The “4 P’s” Noise Induced HL Noise induced hearing loss is: Loss can be sudden, as with acoustic trauma from an explosion • Painless More often gradual onset that may go unnoticed o NIHL also known as noise-induced permanent threshold • Progressive shift (NIPTS), typically takes years of exposure, gradual erosion of hearing that eventually affects communication • Permanent Amount of loss varies from person to person • reventable! Risk of noise-induced progression stops if no longer P From Siemens Hearing Solutions noise exposed, but aging invariably worsens loss o For most, aging effects aren’t significant before age 50+ Classic Symptoms Treatment Generally affects 3000-6000 Hz range first Sensori-neural hearing loss is due to Typically bilateral and symmetrical Tinnitus common problems that occur in the inner ear and Reduced speech comprehension, particularly in background are almost always permanent and noise. Why? untreatable. o Vowels are low frequency sounds that carry 90% of speech energy. (“I can hear you talking….) Hearing aids will benefit most people with o Consonants are higher frequency sounds that carry most of sensori-neural loss, but results can vary. the meaning of speech. NIHL begins in high frequencies. (but I can’t understand what you are saying.”) I-3 Basic Course in Occupational and Environmental Medicine, Part III Orlando, Florida, October 30, 2011 Other Types Non-organic Mixed Symptoms that should alert you to malingering: ◦ Combination of Conductive and Sensori-neural Substantial, equal hearing loss at all frequencies or no response to pure tones at all in one or both ears. Central ◦ Occurring within central nervous system (cortex, Inconsistent results, or markedly different than prior results. brainstem, or ascending auditory pathways) as opposed o Unilateral “deafness” without significant medical history unlikely to peripheral organs of hearing (cochlea and middle ear). Exaggerated attention to test, may press on earphones, difficulty Non-Organic: hearing you call them back for testing or to your directions (normal ◦ No medical or physical reason for hearing loss; may be voice level is around 60 dB), but can hear you when your back is voluntary or involuntary turned or when there are no visual cues. Unconscious development of a non-organic hearing loss – a Malingering: compensatory protective device, a psychogenic problem -- the patient ◦ Consciously faking or exaggerating a hearing impairment believes the impairment is real. The Cost of Hearing Loss Over 30 million people with significant hearing loss 10 million attributed to noise Hearing Conservation 10 million people with debilitating tinnitus Program 242.2 million dollars is estimated to be paid out yearly for disability alone for NIHL How to be successful Noise induced medical problems: hypertension, anxiety, elevated cortisol levels Contributes to: sleeplessness, fatigue, poor concentration, stress, poor productivity History of Hearing Conservation Who Needs a Hearing Conservation Program? Air Force Standard 1949 Civilian Standard, Walsh-Healey Public Contracts Act of 1935 gave Labor Department authority to regulate companies having contracts 29 CFR 1910.95 with Federal Government, Noise standard not released till 1969 1969 MSHA, 1970 OSHA regulatory agencies came into existence “The employer shall administer a Regulation OSHA/ MSHA vs. Standards NIOSH/ANSI continuing, effective hearing conservation 1971 OSHA applied noise regulation to all companies in US program whenever employee noise 1972 OSHA publishes Criteria for a Recommended Standard, exposures equal or exceed an 8-hour Occupational Exposure to Noise time-weighted average sound level (TWA) 1981 OSHA Hearing Conservation Amendment of 85 decibels measured on the A scale” 1983 Revised Version 29 CFR 1910.95 is what we work under now I-4 Basic Course in Occupational and Environmental Medicine, Part III Orlando, Florida, October 30, 2011 OSHA Standard Requirements Key elements to a good Hearing Conservation Program Employee exposures at/above AL for even one workshift per year requires: Noise Monitoring o Employees to be in a Hearing Conservation Engineering Controls Program Periodic Audiometric evaluation o Have initial/annual training and audiometric tests Worker Education Exposures at/above PEL require: Selection of appropriate HPDs o Exposure Controls - engineered Administrative Controls controls/hearing protectors Note: An audiologist or physician must be responsible for the program dBA How Loud is Loud? Not all Hearing Loss is Work Related 140 Jet engine noise - pain Acute 130 High pressure air jet Injury 120 Pneumatic chipper 110 Large industrial compressors Circular Saw 100 Chronic Power Lawnmower Injury 90 OSHA 8-hr Noise Exposure Limit Concern level for hearing loss 80 Vacuum cleaner 70 Passenger car - 50 mph 60 Normal Speech - Conversation at 3’ 50 40 Quiet Room OSHA Noise Exposure Limits Permissible Exposure Limits Limits Vary with Length of Workshift OSHA PEL is 90dB over 8 hours TWA ◦ Cut time in half for every 5dB increase. Permissible Shift Exposure Action 90dB= 4 hours, 95dB= 2 hours. Duration Limit - “PEL” Level - “AL” (Hours) (dBA) (dBA) NIOSH is different 8 90 85 ◦ Cut time in half for every 3dB 10 88 83 88dB= 4 hours 12 87 82 I-5 Basic Course in Occupational and Environmental Medicine, Part III Orlando, Florida, October 30, 2011 Measuring Noise Engineering Controls • Frequency-weighted Sound Pressure Anything done by the employer to reduce is measured in units of decibels (dB) noise. • For hearing protection, we measure ◦ Maintenance the “A-weighted” frequency range ◦ Modifying equipment ◦ Substitution of equipment - Includes broad range of ◦ Isolation frequencies ◦ Acoustic material - Emphasizes the human speech frequencies - Expressed as “dBA” Audiometric Testing Program Definition of STS Positive STS: • Baseline Audiogram + 10 dB average at 2000, 3000 and 4000 Hz • Annual Audiogram or • Standard Threshold Shift (STS) + 15 dB at 1000, 2000, 3000 or 4000 Hz • Follow-up Procedures Negative STS: • Audiometric Test Requirements - 10 dB average at 2000, 3000 and 4000 Hz or • Monitor the effectiveness of the hearing - 15 dB at 1000, 2000, 3000 or 4000 Hz conservation program Audiometric Hearing Tests Degrees of Hearing Loss Normal Hearing 10 - 25 dB HL -10 0 Normal Audiogram Mild Hearing Loss 30 - 45 dB HL 20 Moderate Hearing Loss 50 - 65 dB HL 40 Severe Hearing Loss 70 - 85 dB HL 60 Typical Noise Induced 80 Hearing Loss Profound Hearing Loss > 90 dB HL Audiogram 100 250 500 1K 2K 4K 8K Frequency I-6 Basic Course in Occupational and Environmental Medicine, Part III Orlando, Florida, October 30, 2011 Audiogram Configurations: Referral Criteria Progressive noise-induced hearing loss Two sources for Referral
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