International Journal of

Environmental Research
and Public Health

Review
Hearing Loss, Tinnitus, Hyperacusis, and Diplacusis
in Professional Musicians: A Systematic Review
Arianna Di Stadio 1 , Laura Dipietro 2 , Giampietro Ricci 1 , Antonio Della Volpe 3 ,
Antonio Minni 4 , Antonio Greco 4 , Marco de Vincentiis 5 and Massimo Ralli 5,6, *
1 Otolaryngology Department, University of Perugia, 06123 Perugia, Italy;
ariannadistadio@hotmail.com (A.D.S.); giampietro.ricci@unipg.it (G.R.)
2 Highland Instruments, Cambridge, MA 02238, USA; lauradp@mit.edu
3 Santobono-Pousillipon Hospital, Cochlear Implant Center, 80129 Naples, Italy; antoniodellavolpe@yahoo.it
4 Department of Sense Organs, Sapienza University of Rome, 00185 Rome, Italy;
antonio.minni@uniroma1.it (A.M.); antonio.greco@uniroma1.it (A.G.)
5 Department of Oral and Maxillo-Facial Science, Sapienza University of Rome, 00185 Rome, Italy;
marco.devincentiis@uniroma1.it
6 Center for Hearing and Deafness, University at Buffalo, Buffalo, NY 14260, USA
* Correspondence: massimo.ralli@uniroma1.it; Tel.: +39-06-4997-6808




Received: 9 September 2018; Accepted: 24 September 2018; Published: 26 September 2018


Abstract: Professional musicians (PMs) are at high risk of developing hearing loss (HL) and other
audiological symptoms such as tinnitus, hyperacusis, and diplacusis. The aim of this systematic
review is to (A) assess the risk of developing HL and audiological symptoms in PMs and (B) evaluate
if different music genres (Pop/Rock Music—PR; Classical Music—CL) expose PMs to different levels
of risk of developing such conditions. Forty-one articles including 4618 PMs were included in the
study. HL was found in 38.6% PMs; prevalence was significantly higher among PR (63.5%) than CL
(32.8%) PMs; HL mainly affected the high frequencies in the 3000-6000 Hz range and was symmetric
in 68% PR PMs and in 44.5% CL PMs. Tinnitus was the most common audiological symptom,
followed by hyperacusis and diplacusis. Tinnitus was almost equally distributed between PR and
CL PMs; diplacusis was more common in CL than in PR PMs, while prevalence of hyperacusis was
higher among PR PMs. Our review showed that PR musicians have a higher risk of developing
HL compared to CL PMs; exposure to sounds of high frequency and intensity and absence of ear
protection may justify these results. Difference in HL symmetry could be explained by the type of
instruments used and consequent single-sided exposure.

Keywords: hearing loss; noise induced hearing loss; musicians; pop-rock; classic; tinnitus;
hyperacusis; diplacusis

1. Introduction
Hearing loss (HL) can follow exposure to loud sounds; noise-induced HL is the second
most common cause of HL, and accounts for about 16% of disabling HL in the adult population
worldwide [1,2]. Chronic exposure to noise causes a progressive destruction of inner and outer hair
cells in the cochlea following oxidative stress, metabolic exhaustion, and ischemia [3–5]. Noise-induced
HL can follow work-related and recreational noise exposure [6–10] with significant impact on quality
of life [11,12].
Tinnitus, defined as the perception of sound without an external auditory stimulus, is a condition
affecting 10–25% of the adult population, with moderate-to-severe consequences on daily activities
and quality of life [13,14]. Risk factors for tinnitus include hearing loss, exposure to loud sounds,

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Int. J. Environ. Res. Public Health 2018, 15, 2120 2 of 14

and increasing age [15,16]; tinnitus ranges from 35 to 77% in subjects with noise-induced HL [17,18].
Furthermore, subjects often report worsening of tinnitus with stress; therefore, workers subject to high
work-related stress may have an increased risk of tinnitus [19,20].
Hyperacusis is defined as a reduced tolerance to sounds of average intensity, sometimes
accompanied by painful sensitivity to ordinary environmental sounds, with perceptual, psychological,
and social dimensions [21]. Hyperacusis is often associated tinnitus [22,23].
Diplacusis is a term used to describe an anomaly whereby the same tone is perceived as having
a different pitch depending on whether it is presented in the right or in the left ear of the same
listener [24,25]; evidence suggests a higher prevalence of diplacusis in individuals with hearing loss,
especially asymmetric [24,25].
Music, at the both entertainment and professional level, can induce HL and other audiological
symptoms such as tinnitus, hyperacusis, and diplacusis [9,26]; professional musicians (PMs) are
exposed to high intensity sounds for a prolonged time during the day [27]. Many studies have focused
on the prevalence of HL among PMs and the degree of hearing loss among them [28–30]; however,
the extent to which the musical genre affects the risk of developing hearing loss in PM remains
unclear [30,31]. Different music genres such as Pop/Rock (PR) or classical (CL) music entail different
levels of noise exposure, which in turn depend on several factors including the type and number of
instruments that are played at the same time and the intensity of the sound that is generated [27–31].
The aims of this systematic review of the literature are to (A) assess the risk of developing HL and
audiological symptoms (tinnitus, hyperacusis, diplacusis) in PMs and (B) evaluate if different music
genres expose PMs to a different level of risk of developing these conditions.

2. Materials and Methods

2.1. Search Strategy

This systematic review followed the Preferred Reporting Items for Systematic Review and
Meta-Analyses (PRISMA) guidelines [32]. Two researchers independently searched PubMed, Scopus,
and Google Scholar (until 06/30/2018) using the following keywords: “hearing loss”, “tinnitus”,
“hyperacusis”, “music”, “classical music”, “rock music”, “pop music”, “musicians”, “orchestra”,
“music student”, “professional musician”, “hearing threshold”, “music exposure”, and “temporary
hearing loss”. Both researchers independently selected and reviewed the abstracts that included
a minimum of two keywords with “hearing loss” and “music” as the principal ones. The selected
articles were then thoroughly read.

2.2. Study Selection

All publication types from 1978 to April 2018, in English, French, or Italian only, were considered
for analysis, including epidemiological, case control, prospective and retrospective studies. Studies
on non-PMs were excluded; a PM was defined as a person for whom playing music was the primary
occupation. Articles from the same author were thoroughly checked to avoid duplicates.

2.3. Data Extraction

A standardised electronic data extraction form was completed with pertinent information from
each article. From the articles that were selected, the following details were extracted: study design,
number and age of subjects, type of music played, type of instrument played, rehearsal time, degree
of hearing loss, affected frequencies, hearing loss symmetry, presence of tinnitus, hyperacusis,
and diplacusis. Hearing was considered symmetrical if mean thresholds for each ear occurred within
15 dB of each other.
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2.4. Data Analysis

2.4. Data Analysis
Meta-analyses require studies of similar comparison reporting identical outcome measures.
Meta-analyses require studies of similar comparison reporting identical outcome measures. The
The studies included in the present review revealed a considerable heterogeneity in study design,
studies included in the present review revealed a considerable heterogeneity in study design, type of
type of exams performed, length of observation period, and type of outcome measures. Therefore,
exams performed, length of observation period, and type of outcome measures. Therefore, a well-
a well-defined meta-analysis was not applicable, and a systematic review of the literature was preferred.
defined meta-analysis was not applicable, and a systematic review of the literature was preferred.
All data were added to a database; data related to the PR and CL genres were compared.
All data were added to a database; data related to the PR and CL genres were compared.
Prevalence
Prevalenceof ofsymptoms
symptoms was was calculated
calculated as
as aa percentage. Nominal data
percentage. Nominal databetween
betweenPR PRandandCLCLPMs,
PMs,
namely presence or absence of hearing loss, presence or absence of tinnitus, presence
namely presence or absence of hearing loss, presence or absence of tinnitus, presence or absence ofor absence of
diplacusis were compared using chi-square (χ). Odds ratios were calculated for CL
diplacusis were compared using chi-square (χ). Odds ratios were calculated for CL and PR PMs to and PR PMs to
quantify
quantifytheir
theirrisk
riskofofdeveloping
developingHL.
HL.Statistical
Statistical significance
significance level
level was
was defined at pp << 0.05.
defined at 0.05.

3. Results
3. Results
3.1. Articles and Subjects Included in the Systematic Review
3.1. Articles and Subjects Included in the Systematic Review
A total of 57 articles matching the inclusion criteria were identified. Among these, nine
A total of 57 articles matching the inclusion criteria were identified. Among these, nine articles
articles were excluded because they addressed other topics (n = 2) or involved different populations
were excluded because they addressed other topics (n = 2) or involved different populations (non-
(non-professional musicians n = 3, singers n = 2, music technicians n = 1, general population n = 1),
professional musicians n = 3, singers n = 2, music technicians n = 1, general population n = 1), and
and seven articles were excluded because they were centered exclusively on risk assessment without
seven articles were excluded because they were centered exclusively on risk assessment without
including details on specific hearing disorders. Following this selection, 41 articles were included in
including details on specific hearing disorders. Following this selection, 41 articles were included in
the review (Figure 1).
the review (Figure 1).

Figure1.1.Preferred
Figure PreferredReporting
Reporting Items
Items for
for Systematic
Systematic Review
Review andand Meta-Analyses
Meta-Analyses (PRISMA)
(PRISMA) diagram
diagram
followedininthethe
followed present
present review.
review. TheThe
flowflow diagram
diagram depicts
depicts theofflow
the flow of information
information throughthrough the
the different
different phases of the systematic review. It maps out the number of records identified, included
phases of the systematic review. It maps out the number of records identified, included and excluded, and
excluded,
and and the
the reasons for reasons exclusions [32].
for [32].
exclusions

Detailsofofarticles
Details articlesincluded
includedin
inour
ourreview
review are
are summarized
summarized in
in Table
Table 1.
1.
Int. J. Environ. Res. Public Health 2018, 15, 2120 4 of 14

Table 1. Articles included in systematic review.

Author, Year Design Subjects (n) Age (Range) Music Genre Rehearsal Time (hs) HL (%) HL (Frequency) HL (Symmetry) Tinnitus (%) Hyperacusis (%) Diplacusis (%)
Axelsson, 1978 [33] PS 83 ns PR 1:00 30% 3000–6000 Hz Symmetric ns ns ns
Axelsson, 1981 [34] PS 38 27–33 PR 4:30 28.9% 4000–6000 Hz Symmetric ns ns ns
Axelsson, 1981 [35] PS 139 20–69 CL ns 43.2% 4000–8000 Hz Symmetric ns ns ns
Karlsson, 1983 [36] LS 392 20–69 CL ns 25% 6000–8000 Hz Asymmetric ns ns ns
Johnson, 1986 [37] CC 60 24–64 CL ns none ns ns ns ns ns
Royster, 1991 [38] PS 59 30–69 CL 2:30 52.5% 6000 Hz Asymmetric ns ns ns
Axelsson, 1995 [39] PS 83 20–46 PR 3:30 10.8% 3000–6000 Hz Symmetric 12% 9% ns
Obeling, 1999 [40] PS 57 22–65 CL ns 17.5% 4000–8000 Hz Asymmetric ns ns ns
Kahari, 2001 [41] PS 140 23–64 CL ns 52.5% 6000–8000 Hz Asymmetric ns ns ns
Kahari, 2001 [42] LS 56 30–50 CL ns 76.8% 4000–8000 Hz Symmetric ns ns ns
Eaton, 2002 [30] PS 53 25–60 CL 3:00 24.5% 3000-6000 Hz Symmetric ns ns ns
Kahari, 2003 [43] CSS 139 26–51 PR 5:00 74.1% 3000–8000 Hz Symmetric 48% 45% 2.8%
Mendes, 2007 [29] PS 34 ns PR ns 58.8% 3000–6000 Hz Symmetric 47% ns ns
Beltrao Amorim, 2008 [44] PS 30 18–40 PR and CL 3:50 16.7% 3000–6000 Hz Symmetric ns ns ns
Sayegh, 2008 [45] PS 340 18–28 CL ns 63.8% ns Asymmetric 28% ns ns
Jansen, 2009 [46] PS 241 23–64 CL ns 51.9% 6000 Hz Symmetric 17% ns 8.2%
Hasson, 2009 [47] CS 250 ns CL ns 6% ns ns 19% 14% ns
Phillis, 2010 [48] PS 329 18–25 PR and CL 2:00 45% 4000–6000 Hz Symmetric ns ns ns
Pawlaczyk, 2011 [49] PS 127 22–67 CL 4:30 26% 2000–4000 Hz Symmetric ns ns ns
Toppila, 2011 [50] PS 63 22–52 CL ns 100% 4000–6000 Hz Symmetric 9.5% 6.3% ns
Samelli, 2012 [51] CC 16 21–41 PR 3:15 100% 2000–3000 Hz Symmetric ns ns ns
Raymond III, 2012 [52] PS 32 35–64 CL ns 25% 4000–8000 Hz Symmetric ns ns ns
Patil, 2013 [53] CC 84 26–47 CL ns none ns Symmetric ns ns ns
Russo, 2013 [54] PS 44 41–57 CL 4:00 100% 4000–6000 Hz Symmetric ns ns ns
Goncalves, 2013 [55] CS 50 21–51 CL 4:00 32% 2000–16,000 Hz ns ns ns ns
Wilson, 2013 [56] PS 144 18–60 CL 3:15 22.9% 4000–8000 Hz Symmetric ns ns ns
Luders, 2014 [57] RS 42 18–58 CL ns 7.14% 250–3000 Hz Symmetric ns ns ns
O’Brien, 2014 [58] PS 367 35–51 CL ns 42.5% 2000–8000 Hz ns 34% ns ns
Schmidt, 2014 [59] CC 212 20–69 CL 4:00 60.8% 3000–6000 Hz Asymmetric ns ns ns
Halevi-Katz, 2015 [31] PS 44 20–64 PR 5:15 100% 3000–6000 Hz Symmetric 6% 2% ns
Dudarerewicz, 2015 [60] PS 18 30–58 CL 3:30 27.8% 4000 Hz ns ns ns ns
Stormer, 2015 [61] CC 111 16–52 PR 2:00 37.8% 6000 Hz Symmetric 10% ns ns
Luders, 2016 [62] PS 30 33–54 CL 3:00 43.3% 3000–6000 Hz Symmetric 53% 33% ns
Hennir, 2016 [63] PS 28 18–25 CL 2:00 25% ns Symmetric ns ns ns
Luders, 2016 [64] PS 100 28–38 PR and CL ns 32% ns ns ns ns ns
Pouryaghoub, 2017 [65] CS 125 31–38 PR and CL ns 82.4% 3000–6000 Hz Asymmetric 51.2% ns ns
Hoydal, 2017 [28] CC 111 16–52 PR ns 100% 1500–6000 Hz Asymmetric 19.8% ns ns
Pawlaczyk-Luszczynska,
CC 168 18–29 CL 4:00 13.1% 6000 Hz Symmetric 32.1% 27.4% ns
2017 [66]
Stormer, 2017 [67] CS 111 22–41 PR ns ns ns ns 19.8% ns ns
Szibor, 2018 [68] PS 22 18–62 PR ns 95.4% 6000 Hz ns 27.3% 27.3% ns
Behar, 2018 [69] LS 46 ns CL ns 100% 4000–8000 Hz ns ns ns ns
List of articles included in our systematic review. For each article, we specified: first author and year, type of study, number of subjects included, age range, type of music played by
study participants, rehearsal time, percentage of hearing loss, affected frequencies, symmetry of hearing loss, percentage of audiological symptoms (tinnitus, hyperacusis, diplacusis).
PS: prospective study; LS: longitudinal study; CS: cohort study; CC: case-control study; CSS: cross-sectional study; RS: retrospective study. PR: pop/rock; CL; classical. ns: not specified.
Int. J. Environ. Res. Public Health 2018, 15, 2120 5 of 14
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Among
Among these,
these, 25
25 (60.9%)
(60.9%) were
were prospective
prospective studies,
studies, 77 (17.1%)
(17.1%) werewere case
case studies,
studies, 44 (9.8%)
(9.8%) were
were
cohort
cohort studies, 3 (7.4%) were longitudinal studies, 1 (2.4%) was a cross-sectional study, and 11 (2.4%)
studies, 3 (7.4%) were longitudinal studies, 1 (2.4%) was a cross-sectional study, and (2.4%)
was
was aa retrospective
retrospective study.
study. Twenty-six
Twenty-six (63.5%)
(63.5%) studies
studies were
were conducted
conducted on on CL
CL PMs
PMs only,
only, 11
11 (26.8%)
(26.8%)
on
on PR PMs only, and 4 (9.7%) on PR and CL PMs. Thirty-two (78.1%) studies reported details on
PR PMs only, and 4 (9.7%) on PR and CL PMs. Thirty-two (78.1%) studies reported details on the
the
instruments
instruments played by the PM; in 9 studies (21.9%) the PMs were identified as PR or CL players but
played by the PM; in 9 studies (21.9%) the PMs were identified as PR or CL players but
details
details about
about the
the instruments
instruments werewere not
not provided.
provided.
The
The articles selected for the reviewincluded
articles selected for the review includeda total of of
a total 4648
4648PMs, 3645
PMs, CL CL
3645 PMsPMs(78.4%) and and
(78.4%) 973
PR
973 PMs
PR PMs(20.9%); 30 subjects
(20.9%); 30 subjects(0.7%) were
(0.7%) excluded
were excluded due
duetoto
lack
lackofofdetails
detailson
onthe
themusic
musicgenre
genre played
played
(Figure 2).
(Figure 2).

Figure 2. Distribution of professional musicians included in the review, divided by music genre
Figure 2. Distribution of professional musicians included in the review, divided by music genre
(Pop/Rock; Classical).
(Pop/Rock; Classical).
Age for PR and CL PMs ranged from 16 to 69 years, with no significant differences between the
Age for PR and CL PMs ranged from 16 to 69 years, with no significant differences between the
groups (p = 0.78); 2914 (63.1%) of PMs included in the review were males; 1704 (36.9%) were females.
groups (p = 0.78); 2914 (63.1%) of PMs included in the review were males; 1704 (36.9%) were females.
3.2. Hearing Loss and Audiological Symptoms
3.2. Hearing Loss and Audiological Symptoms
HL (Pure tone threshold >25 dB at any frequency in the 250–8000 Hz range) was investigated
in 41/42(Pure
HL tone
(97.6%) threshold
articles >25 dB
included in at
theany frequency
review (4507 in the and
PMs) 250–8000 Hz range)
was found wassubjects
in 1742 investigated in
(38.6%).
41/42 (97.6%) articles included in the review (4507 PMs) and was found in
PR PMs were more affected compared to CL PMs, with respectively 547/862 (63.5%) and 1195/36451742 subjects (38.6%). PR
PMs were
(32.8%) more affected
subjects; the oddscompared
ratio for to
PRCL wasPMs, with
1.3991 (CIrespectively 547/862 (63.5%)
95%: 0.4044–0.5441). and 1195/3645
The difference was
(32.8%) subjects; the odds ratio
statistically significant (χ: p < 0.0001).for PR was 1.3991 (CI 95%: 0.4044–0.5441). The difference was
statistically significant
HL affected (χ: p <the
prevalently 0.0001).
high frequencies in the range between 3000 and 6000 Hz. Among PR
PMs, HL was reported for the 2000high
HL affected prevalently the frequencies
Hz frequency in the
in 16 (2.9%)range between
subjects, 30003000
Hz inand
3526000 Hz. 4000
(64.3%), AmongHz
PR PMs, HL was reported for the 2000 Hz frequency in 16 (2.9%) subjects, 3000 Hz
in 370 (68.2%), 6000 Hz in 493 (90.1%), and 8000 Hz in 138 PMs (25.2%). In CL PMs, HL affected the 250 in 352 (64.3%),
4000 Hz in 370in(68.2%),
Hz frequency 42 (3.5%)6000 Hz in500
subjects, 493Hz (90.1%), and 8000
in 42 (3.5%), 2000Hz Hzinin138 PMs (25.2%).
74 (6.2%), 3000 HzIninCL470PMs, HL
(39.3%),
affected the 250 Hz frequency in 42 (3.5%) subjects, 500 Hz in 42 (3.5%), 2000
4000 Hz in 712 (59.6%), 6000 Hz in 964 (80.7%), and 8000 Hz in 454 PMs (38%). Interestingly, no HLHz in 74 (6.2%), 3000
Hz
wasin 470 (39.3%),
reported 4000 Hz in
for frequencies 712 (59.6%),
<2000 Hz for PR 6000
PMs.HzDetails
in 964 of (80.7%), and 8000
HL in PMs Hz in in
are shown 454 PMs 3.
Figure (38%).
Interestingly, no HL was
HL was symmetric reported for
(thresholds for each
frequencies
ear within<2000
15 dBHzoffor
eachPRother)
PMs.inDetails of and
835 PMs HL asymmetric
in PMs are
shown in Figure 3.
in 772 PMs. Characteristics on HL symmetry were not reported for 135 (7.7%) subjects (37 PR and 98
CL PMs). Symmetric HL was described in 347/510 (68%) PR PMs and in 488/1097 (44.5%) CL PMs;
asymmetric hearing loss was present in 163 (32%) PR and in 609 (55.9%) CL PMs. CL PMs showed an
odds ratio for asymmetric HL of 4.02 (CI 95%: 3.2574–4.9823). The difference between PR and CL PMs
for asymmetric hearing loss was statistically significant (χ: p < 0.0001). Figure 4 shows the percentage
of symmetric and asymmetric HL in PMs.
Int. J. Environ. Res. Public Health 2018, 15, 2120 6 of 14
Int. J. Environ. Res. Public Health 2018, 15, x FOR PEER REVIEW 7 of 15

Figure 3. Affected frequencies among Pop/Rock and Classical professional musicians (PMs) with
hearing loss included in the systematic review in the 250–8000 Hz frequency range. The most affected
frequencies in both groups were 3000, 4000, and 6000 Hz.

HL was symmetric (thresholds for each ear within 15 dB of each other) in 835 PMs and
asymmetric in 772 PMs. Characteristics on HL symmetry were not reported for 135 (7.7%) subjects
(37 PR and 98 CL PMs). Symmetric HL was described in 347/510 (68%) PR PMs and in 488/1097
(44.5%) CL PMs; asymmetric hearing loss was present in 163 (32%) PR and in 609 (55.9%) CL PMs.
CL PMs showed an odds ratio for asymmetric HL of 4.02 (CI 95%: 3.2574–4.9823). The difference
Figure 3. Affected frequencies among Pop/Rock and Classical professional musicians (PMs) with
between
FigurePR3. and CL PMs
Affected for asymmetric
frequencies hearing
among Pop/Rock andloss was statistically
Classical professional significant (χ: p with
musicians (PMs) < 0.0001).
hearing loss included in the systematic review in the 250–8000 Hz frequency range. The most affected
Figure 4 shows
hearing the percentage
loss included of symmetric
in the systematic reviewand asymmetric
in the 250–8000 HzHL in PMs.range. The most affected
frequency
frequencies in both groups were 3000, 4000, and 6000 Hz.
frequencies in both groups were 3000, 4000, and 6000 Hz.

HL was symmetric (thresholds for each ear within 15 dB of each other) in 835 PMs and
asymmetric in 772 PMs. Characteristics on HL symmetry were not reported for 135 (7.7%) subjects
(37 PR and 98 CL PMs). Symmetric HL was described in 347/510 (68%) PR PMs and in 488/1097
(44.5%) CL PMs; asymmetric hearing loss was present in 163 (32%) PR and in 609 (55.9%) CL PMs.
CL PMs showed an odds ratio for asymmetric HL of 4.02 (CI 95%: 3.2574–4.9823). The difference
between PR and CL PMs for asymmetric hearing loss was statistically significant (χ: p < 0.0001).
Figure 4 shows the percentage of symmetric and asymmetric HL in PMs.

Figure 4. Percentage of symmetric and asymmetric hearing loss found in professional musicians
Figure 4. Percentage of symmetric and asymmetric hearing loss found in professional musicians
(PMs) included in the systematic review. Symmetric HL was more common in Pop/Rock PMs,
(PMs) included in the systematic review. Symmetric HL was more common in Pop/Rock PMs, while
while asymmetric HL was more prevalent in Classical PMs. Data on symmetry were unavailable for
asymmetric HL was more prevalent in Classical PMs. Data on symmetry were unavailable for 135
135 subjects.
subjects.
The most common instruments were double bass, brass, flute, trumpet, percussion, strings, electric
The most common instruments were double bass, brass, flute, trumpet, percussion, strings,
guitar, and piano. Although some are more commonly used by PR or CL PMs, in many cases they were
electric guitar, and piano. Although some are more commonly used by PR or CL PMs, in many cases
used simultaneously in both genres. The highest extent of hearing loss was reported in PMs using
they were used simultaneously in both genres. The highest extent of hearing loss was reported in
strings (n = 1628), followed by percussion (n = 1050), brass (n = 775), double bass (n = 543), electric
PMs using strings (n = 1628), followed by percussion (n = 1050), brass (n = 775), double bass (n = 543),
guitar (n = 424), piano (n = 314), flute (n = 341), and trumpet (n = 284). Details of affected frequencies
electric guitar
Figure (n = 424),ofpiano
4. Percentage (n = 314),
symmetric flute (n = 341),
andshown
asymmetric and trumpet (n = 284). Details of affected
hearing
in PMs sorted by instrument played are in Figure 5. loss found in professional musicians
frequencies
(PMs) in PMsinsorted
included the by instrument
systematic review. played areHL
Symmetric shown
was in Figure
more 5.
common
Tinnitus was investigated in 17/41 (41.5%) studies including 2327 PMsin(760
Pop/Rock PMs,
PR, 1567 while
CL) and was
asymmetric HL was more prevalent in Classical PMs. Data on symmetry were unavailable for 135
reported in 612 subjects (26.3%). Of those, tinnitus was found in 196/760 (25.8%) PR and in 416/1567
subjects.
(26.5%) CL PMs. The odds ratio was 0.98 (CI 95%: 0.7616–1.131). No statistically significant difference
was observed for tinnitus prevalence between CL and PR PMs (χ: p = 0.45).
The most common instruments were double bass, brass, flute, trumpet, percussion, strings,
Hyperacusis was evaluated in 8/41 studies (19.5%) including 791 PMs (288 PR, 503 CL) and
electric guitar, and piano. Although some are more commonly used by PR or CL PMs, in many cases
was found in 172 musicians (21.7%). Of these, 77/288 (26.7%) were PR and 95/503 (18.9%) were CL
they were used simultaneously in both genres. The highest extent of hearing loss was reported in
PMs. The odds ratio was 1.56 (CI 95%: 1.1117–2.2095); the difference in the prevalence of hyperacusis
PMs using strings (n = 1628), followed by percussion (n = 1050), brass (n = 775), double bass (n = 543),
between CL and PR was statistically significant (χ: p= 0.01) with increased risk for PR PMs.
electric guitar (n = 424), piano (n = 314), flute (n = 341), and trumpet (n = 284). Details of affected
Diplacusis was investigated in only 2 studies (4.5%) including 380 PMs and was found in 24 of
frequencies in PMs sorted by instrument played are shown in Figure 5.
them (6.3%), specifically in 4/139 (2.9%) PR and in 19/241 (7.9%) of CL PMs.
Int. J. Environ. Res. Public Health 2018, 15, 2120 7 of 14

Tinnitus was equally prevalent in PR and CL PMs, while hyperacusis was more common in
PR PMs and diplacusis in CL PMs. Figure 6 summarizes the prevalence of hearing loss, tinnitus,
hyperacusis, and
Int. J. Environ. Res. diplacusis
Public in 15,
Health 2018, PRxand
FOR CL PMs.
PEER REVIEW 8 of 15
Figure 5. Number of professional musicians (PMs) with hearing loss in the 250–8000 Hz frequency
range sorted by instrument played.

Tinnitus was investigated in 17/41 (41.5%) studies including 2327 PMs (760 PR, 1567 CL) and
was reported in 612 subjects (26.3%). Of those, tinnitus was found in 196/760 (25.8%) PR and in
416/1567 (26.5%) CL PMs. The odds ratio was 0.98 (CI 95%: 0.7616–1.131). No statistically significant
difference was observed for tinnitus prevalence between CL and PR PMs (χ: p = 0.45).
Hyperacusis was evaluated in 8/41 studies (19.5%) including 791 PMs (288 PR, 503 CL) and was
found in 172 musicians (21.7%). Of these, 77/288 (26.7%) were PR and 95/503 (18.9%) were CL PMs.
The odds ratio was 1.56 (CI 95%: 1.1117–2.2095); the difference in the prevalence of hyperacusis
between CL and PR was statistically significant (χ: p = 0.01) with increased risk for PR PMs.
Diplacusis was investigated in only 2 studies (4.5%) including 380 PMs and was found in 24 of
them (6.3%), specifically in 4/139 (2.9%) PR and in 19/241 (7.9%) of CL PMs.
Tinnitus was equally prevalent in PR and CL PMs, while hyperacusis was more common in PR
PMs Figure
and diplacusis
5. Number in CL PMs. Figure
of professional 6 summarizes
musicians the prevalence
(PMs) with hearing of hearing
loss in the 250–8000 loss, tinnitus,
Hz frequency
Figure 5. Number of professional musicians (PMs) with hearing loss in the 250–8000 Hz frequency
hyperacusis, andby
range sorted diplacusis
instrumentinplayed.
PR and CL PMs.
range sorted by instrument played.

Tinnitus was investigated in 17/41 (41.5%) studies including 2327 PMs (760 PR, 1567 CL) and
was reported in 612 subjects (26.3%). Of those, tinnitus was found in 196/760 (25.8%) PR and in
416/1567 (26.5%) CL PMs. The odds ratio was 0.98 (CI 95%: 0.7616–1.131). No statistically significant
difference was observed for tinnitus prevalence between CL and PR PMs (χ: p = 0.45).
Hyperacusis was evaluated in 8/41 studies (19.5%) including 791 PMs (288 PR, 503 CL) and was
found in 172 musicians (21.7%). Of these, 77/288 (26.7%) were PR and 95/503 (18.9%) were CL PMs.
The odds ratio was 1.56 (CI 95%: 1.1117–2.2095); the difference in the prevalence of hyperacusis
between CL and PR was statistically significant (χ: p = 0.01) with increased risk for PR PMs.
Diplacusis was investigated in only 2 studies (4.5%) including 380 PMs and was found in 24 of
them (6.3%), specifically in 4/139 (2.9%) PR and in 19/241 (7.9%) of CL PMs.
Tinnitus was equally prevalent in PR and CL PMs, while hyperacusis was more common in PR
PMs and diplacusis in CL PMs. Figure 6 summarizes the prevalence of hearing loss, tinnitus,
hyperacusis, and diplacusis in PR and CL PMs.

Figure 6. Prevalence
Figure 6. Prevalence of
of hearing
hearing loss
loss tinnitus,
tinnitus, hyperacusis,
hyperacusis, and
and diplacusis
diplacusis in
in Classical
Classicaland
andPop/Rock
Pop/Rock
professional
professional musicians
musicians included in the
included in the meta-analysis. For each
meta-analysis. For each condition,
condition, itit has
has been
been indicated
indicated the
the
number of studies that investigated it and the total number of patients included in these studies.
number of studies that investigated it and the total number of patients included in these studies.
4. Discussion
Our systematic review of the literature showed that (A) 38.6% of PMs have some degree of HL;
(B) PR PMs are at higher risk of developing HL than CL PMs; (C) the most affected frequencies in PMs
are in the 3000–6000 Hz range; (D) CL PMs suffer from asymmetric HL significantly more than PR
PMs; and (E) tinnitus was equally prevalent in PR and CL PMs, hyperacusis was more common in PR
PMs and diplacusis in CL PMs.

Figure 6. Prevalence of hearing loss tinnitus, hyperacusis, and diplacusis in Classical and Pop/Rock
professional musicians included in the meta-analysis. For each condition, it has been indicated the
Int. J. Environ. Res. Public Health 2018, 15, 2120 8 of 14

4.1. Risk of Developing Hearing Loss Among PR and CL PMs

Our data shows that HL is common in PMs (38.6%), and PR PMs are at higher risk of developing
HL compared to CL PMs. The presence of HL in PMs is a common finding and follows prolonged
and high-intensity noise exposure, a condition that causes a progressive reactive oxygen and nitrogen
species-mediated destruction of inner and outer hair cells in the cochlea following oxidative stress,
metabolic exhaustion, and ischemia [3–5]. In the studies included in our review, HL affected mainly
frequencies in the 3000–6000 Hz range, with no significant differences between PR and CL musicians.
The higher prevalence of HL in PR compared to CL PMs can be explained by different
characteristics of the music genre, such as frequency and intensity of the instruments used, differences
in habits of PMs and in environmental acoustic settings. Instruments produce sounds that span between
different frequency ranges and emit sounds at different intensities. The frequencies generated by the
instruments played is a key factor when assessing the risk of developing HL for PMs [27]; therefore,
the musical genre may affect the characteristics of sounds PMs are exposed during practice [27].
Previous studies have shown that PR PMs are exposed to sounds of higher intensity compared to
CL PMs, both during rehearsals and live performance [31], with an average exposure of 103 dB in
PR versus 94 dB in CL PMs [27]; additionally, studies have described that PR PMs often play music
without ear protection more commonly than CL PMs [28,29].
Furthermore, the introduction of new instruments such as the violin in PR music also plays a role,
as the combination of high frequency-generating instruments and high intensity sound has been shown
to increase risk of HL [27,70].
Future research should focus on evaluating the effects of sound in the central auditory pathways.
In fact, although the role of peripheral damage in HL has been widely studied, recent research findings
support the idea that noise can induce hearing loss also by acting directly on the central auditory
pathways [71,72].

4.2. Characteristics of Hearing Loss Among PM

Our systematic review shows that CL PMs suffer from asymmetric HL significantly more than PR
PMs. This difference can be explained by the instruments played by these professionals: in a classical
music orchestra, a large portion of musicians play single-sided instruments, such as the violin (string)
or the transverse flute; with these instruments the ear that is on the ipsilateral side (commonly the
left for right handed musicians) is the most exposed to sound [65]. In PR PMs, the low incidence of
asymmetric HL could be explained by prolonged exposure to high intensity sounds, such as those
generated by electronic guitars, and the Larsen effect. Furthermore, the instruments commonly played
by PR musicians (guitar, bass, drum) are symmetric and tend to equally expose both ears to sound.

4.3. Audiological Symptoms: Tinnitus, Hyperacusis, and Diplacusis

Our review shows a prevalence of tinnitus of 26.3% in PMs in the studies that investigated the
symptom; it was almost equally distributed between CL and PR PMs. Tinnitus may follow audiological,
somatic, or psychological conditions [13,73–80]; risk factors for tinnitus include HL and increasing
age [15,16,81]. The elevate prevalence of HL found in PMs can explain the presence of tinnitus in
these patients; however, there was no higher prevalence of tinnitus among PR PMs compared to CL
PRs. This could be explained by the different number of studies that were considered to evaluate
the prevalence of HL (n = 41) and tinnitus (n = 17); unfortunately, many studies did not evaluate the
presence of tinnitus.
Hyperacusis [21] was the second most common symptom found in our review, and was more
common in PR PMs compared to CL PMs. Hyperacusis may follow functional changes within the
central nervous system and may be related to increased gain in the central auditory pathways and
increased anxiety, mood disorders, or emotional response to sound [82,83]. The higher prevalence of
hyperacusis in PR PMs could be related to changes in mood that can be elicited by the different music
Int. J. Environ. Res. Public Health 2018, 15, 2120 9 of 14

genres and the different stress levels. In fact, the volume of music can influence not only mood but
also stress level [84]. Subjects who listen to soft music commonly report an improvement in mood and
a pleasure sensation with increased levels of serotonin and decreased cortisol levels [85]; conversely,
high intensity and short sounds are associated with an increase in noradrenaline that stimulates hyper
mood activity [86].
Although rare, diplacusis was observed in both PR and CL PMs, although it was more common
among CL PMs. Diplacusis is a perceptual anomaly whereby the same sound is perceived as having
a different pitch depending on whether it is presented in the left or the right ear; this phenomenon
is common in individuals with asymmetric hearing loss [25]. The symptom can be due to a shift of
the excitation peak from a high to a more basal region of the basilar membrane following a cochlear
damage [87] which in turn causes a shift in the peak of the neural tuning curves of the auditory neurons
toward lower frequencies [88] or to the fall of a specific frequency inside a dead cochlear region that
evokes an unclear stimulus [89]. The limited number of studies that investigated this symptom
included in this review does not allow a statistical analysis and comparison to other symptoms,
but only the description of the phenomenon.

4.4. Limits of Our Study

Our study has some limits. First, the studies included in the review had a high degree of
heterogeneity, especially for methodologies, evaluation of HL prior to exposure to music and outcome
reporting. Secondly, we considered HL as any pure tone threshold higher than 25 dB; however,
definitions of HL in the included studies were not consistent. Furthermore, many studies did not
report the entity of HL; therefore, in our study we could not describe the entity of HL and could
only consider it as present/absent and symmetric/asymmetric. Associated symptoms have not been
investigated in all the studies included in the review; therefore, the prevalence of the symptom could
only be calculated for the studies that investigated it. Heterogeneity between studies also affected,
even if at a lesser extent, the definitions of tinnitus, diplacusis, and hyperacusis. Taken together, these
limits prevent the execution of a meta-analysis and should be considered when interpreting the results
and the conclusions of our review.

4.5. Future Perspectives for Early Diagnosis of Hearing Damage in Professional Musicians
The use of individual hearing protection devices and strict regulations for time and entity of
noise exposure is of paramount importance for the prevention of HL and associated symptoms in PMs.
Future perspectives in noise-induced HL risk prevention are centered on early diagnosis of hearing
impairment in predisposed individuals. On this topic, some authors recently proposed the use of
microRNAs for monitoring the hearing damage [90] because they allow to investigate the hearing
pathways from periphery (34a, 29b, 76, 96 and 431) to central auditory area (miR − 9/9 *). MicroRNA
are very sensible to the cells metabolic alterations and they are commonly used for monitoring the
progression of several disease [91,92]; furthermore, they have shown a high sensitivity in the early
identification of inner ear cellular damage [93] and could play a role in the early diagnosis of hearing
damage in individuals that are at risk of HL.

5. Conclusions
Our systematic review showed that HL is common in PMs, and PR PMs are at higher risk of
developing HL compared to CL PMs. These findings could be explained by the prolonged exposure
to high-frequency and high-intensity sounds common in PMs, that more often occurs in PR PMs.
The prevalence of asymmetric HL was significantly higher in CL PMs compared to PR PMs, probably
due to the type of instruments used. Tinnitus was equally present in PR and CL PMs; hyperacusis
was more prevalent in PR PMs and diplacusis was more common in CL PMs. The use of individual
hearing protection devices may help reduce the risk of noise-induced HL and associated symptoms in
PMs; furthermore, the monitoring of microRNAs concentration associated with traditional hearing
Int. J. Environ. Res. Public Health 2018, 15, 2120 10 of 14

tests might play a role in the early diagnosis of hearing damage in exposed individuals that are at risk
of HL.

Author Contributions: A.D.S. were the main investigators and contributed to the design and writing of the paper,
L.D. contributed to writing paper and critically reviewed the paper, M.R. contributed to the design of the paper,
A.D.V. performed the review of the literature, A.M. and A.G. supervised the work and provided experimental
insights, G.R. and M.d.V. critically reviewed the paper and contributed to its final edition.
Funding: The authors have not received financial support for this research and work.
Conflicts of Interest: The authors declare no conflict of interest.

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