By Craig A. Kasper, AuD, FAAA

After decades of following the "louder is better" mantra, many musicians, sound engineers and record label employees are now taking steps to ensure auditory longevity. The music community seems to be warming up to the idea of preventive hearing health, and this diverse patient population demands the services of knowledgeable professionals.

As a result, increasing numbers of audiologists are becoming intrigued by the concept of providing hearing preservation services to those exposed to potentially damaging levels of music. Being the audiologist of choice for this niche patient population may provide numerous benefits ranging from the tangible "coolness factor" to a means of adding a component of practice that will help further define a clinician's brand. But before announcing to the world your new specialty, a number of prerequisites do exist.

Music industry patients often present with a unique set of needs and complaints including tinnitus, loudness sensitivity issues and abnormal pitch perception. Therefore a solid knowledge base and practical experience are of primary importance. It might be necessary for the clinician to update or fine-tune their current clinical regimen. Additionally, it is the responsibility of the clinician to address myths and years of misinformation that this patient population carries into the office and provide patient/situation-specific counseling.

Background Can Help

Through my conversations over the past decade, I have found that many of the audiologists involved in caring for musicians are, in fact, very musical themselves. From a personal perspective, I spent my teenage years carelessly pounding out absurd levels of sound through my Peavey amplifier as a bass player in a NYC-style hardcore band. My music career did not go much beyond those early years, but my experiences with rehearsing, performing and recording did provide me with a set of "rules" no classroom lecture could teach me. I found that having a history of playing music and being around live sound truly makes a difference when working with musicians. Practical experiences allow the clinician to interact with the patient on a higher level and better understand their needs.

Use CE to Fill Gaps

According to Michael Santucci, MS, audiologist and founder of Sensaphonics Hearing Conservation, "Continuing education is the first step for any clinician interested in caring for the professional ear." Most practicing audiologists have been exposed to the topic of industrial hearing conservation at some point in their academic careers. Our graduate and post-graduate coursework would have undoubtedly provided the primary layers of knowledge. Topics such as sound measurement, effects of sound on the auditory system, standards and protective devices have applicability (but not always direct applicability) to the music industry.

It is this lack of direct applicability that warrants continued education through formal studies and real world experience. Santucci points to numerous seminars in the area of hearing conservation offered by the National Hearing Conservation Association (NHCA) and at the annual conventions of the American Academy of Audiology (AAA) and the American Speech-Language-Hearing Association (ASHA). Clinicians should also seek guidance from the audiologists who are considered leaders in this specialty area. By reaching out and contacting colleagues who are known for their work with musicians, it is possible to gain valuable insights from varied clinical perspectives.

Speaking to musicians, performers, sound engineers and anyone in the industry who will share their views can help the interested audiologist gain an understanding from yet another angle. Reading industry magazines and Web sites sheds light on set-ups and sound systems for live performances as well as the equipment used on stage and in rehearsals. This also allows the clinician to understand industry consensus on specific products, of which there are many to consider.

More Than Earplugs

Clinicians should be comfortable with products including, but not limited to: non-custom and custom musician's hearing protection; the various in-ear monitoring products available; bass shakers and hard-wired/wireless monitoring systems. There are numerous resources available, including manufacturer white papers, which provide information on each. Ultimately, the responsibility falls on the clinician to work in a consultative manner with the patient to determine what product(s) might best suit each situation. This is accomplished while being mindful of what is necessary to help protect the patient's hearing.

Santucci says that an understanding of all the intricacies of working with musician patients "takes time to develop and there is no substitute for experience." Getting down in the trenches allows the professional to understand all the issues confronting this unique patient population. This understanding, combined with the expertise of hearing-related issues, makes the audiologist a powerful partner in the care of any musician's hearing.

Equipment Needs

Almost any clinical practice site will have the necessary equipment to begin working with musicians and industry patients. Basic equipment needs include: a sound treated environment, an audiometer (high frequency capabilities are a plus), immittance equipment, otoacoustic emissions and standard impression taking materials. In addition, a probe microphone measurement system is becoming increasingly more useful when fitting custom in-ear devices.

Is High-Frequency Audiometry Really Necessary? When evaluating musicians, the notion of a classic "noise-induced notch" centered around 3-6 kHz is still of concern. Therefore, standard audiometric testing would reveal if significant damage has occurred to those regions. The reality is that many musicians and sound engineers ask the question, "Why do you only test to 8 kHz?"

A great deal of sound that music industry professionals depend on falls within the upper regions. As a result, many patients are concerned with high-frequency sensitivity. Although there is some question regarding normative data for high-frequency testing, some experts still suggest obtaining thresholds as it will provide a more comprehensive picture and might answer questions raised by the patient.

The Story That DPOAEs Can Tell Otoacoustic emissions have significantly added to the process of auditory differential diagnosis. With respect to musicians and industry patients, the reason to include DPOAEs in a battery of tests is quite simple. The ability to unveil evidence of cochlear damage prior to threshold shifts on the audiogram allows the clinician and patient to be more proactive in the preservation of hearing. DPOAEs might also prove valuable when investigating "qualitative" sound issues described by patients.

The Growing Value of Probe Microphone Measures For many years, probe microphone measures have provided clinicians with valuable, objective information regarding output characteristics of the hearing instruments they fit. As audiologists apply similar measures to the evaluation of custom in-ear devices they recommend to musicians, the same value is steadily being realized.

Marshall Chasin, AuD, from the Musicians' Clinics of Canada, has utilized probe mic measures in his practice to "demonstrate the spectral output of instruments" and to "determine the attenuation characteristics of hearing protection on patients' ears." He completes these measures while his patients play their instruments at various levels with and without in-ear products in place. Dr. Chasin is also able to "demonstrate spectral levels of in-ear monitors in the canal" through probe microphone testing.

Brian Fligor, ScD, from Children's Hospital in Boston and chair of the NHCA's Task Force for the Audio Engineering Society, is also starting to experiment using probe microphone measures to prescriptively fit musician hearing protection. His method is based on the patient's "average time of exposure and the spectral/decibel output of each musician's own instrument." He recognizes this might be somewhat challenging due to the fact that musicians might not always play solo and the potential for exposures from other sources is high. In addition, the environment musicians find themselves in might vary significantly. Regardless, this is a step toward truly providing accurate protection without overprotection.

Foundation of Care

Musicians and industry professionals usually walk into an audiologist's office with a stockpile of information and misinformation. I've encountered comments such as: "If it sounds good, it won't harm me;" "I get used to the levels as the show progresses;" "I don't play that loud;" or my personal favorite, "I take special supplements my drummer recommended, so I'm protected. Right?" This is where experience, knowledge of strategies and familiarity with available products combine to provide the caliber of services these patients require. After all, it is the clinician's expertise that is of most value, and the ability to translate that knowledge into accessible take-home information is priceless.

Clinicians should strive to educate, but not lecture. Most musicians already know they're at risk and are simply looking for non-intrusive solutions. In general, musicians possess a solid understanding of many of the terms common to audiology such as decibel, frequency and attenuation. Despite this fact, all counseling topics should be framed in a manner that is easily understood by the patient. It is important for the clinician to be well prepared with a quick discussion covering the auditory system, what can go wrong with it and how to protect it.

Presenting industrial standards, such as the NIOSH time/intensity exchange chart, can be useful to help patients begin to recognize the intensity + duration = auditory damage equation. In my practice I've also utilized pictures of normal versus a noise-damaged cochlea as a concluding piece of information. Patients have commented that the dramatic nature of the picture impacted them long after our appointment.

Make an Impact

When it comes to healthy hearing and custom in-ear products, audiologists are the professionals of choice for musicians and professionals in the music industry. For me it has been, and continues to be, a wonderful way to give back in some small way to all those gifted people who create the soundtrack to my life. As a profession, we are at the early stages of making an impact on this patient population. Through the work of talented clinicians and researchers, new assessment techniques and devices are surfacing that will allow the audiology community to better preserve the hearing of the music industry patients we encounter. For those interested in pursuing work in this specialty area, here are some points to consider:

1) Avoid the "I just need impressions" scenario. Audiologists are professionals who have more to offer than simply making molds of ears. Counsel those who seek out your services regarding the benefits of a baseline and annual evaluation. A baseline audiogram is also important from a medical-legal standpoint to document any pre-existing hearing loss the patient might present with.

2) Over-protection can be just as damaging as under-protection. Too much attenuation might lead to associated disorders such as vocal strain or hand, wrist and arm injuries.

3) Promote the idea of mindfulness to your patients. If they are more aware of their hearing, and take stock of it regularly, they will be more inclined to recognize potentially harmful situations. In addition, if patients notice changes in their hearing status, they might seek out services to assess and treat instead of "waiting to see if [they] get better."

4) Apply these techniques and technologies to the consumer market (mp3 users and concert goers) The same steps are useful: Educate, evaluate, provide appropriate protection/devices and re-evaluate annually.

Craig A. Kasper, AuD, FAAA, is the director of audiology for the New York Otolaryngology Group and co-director of the New York Tinnitus Center in New York City. Portions of this article have been adapted from his consumer-focused book, "The Simple Guide To Optimum Hearing Health For The mp3 Generation." Information about the book can be found on his Web site, www.DrCraigKasper.com. He can be contacted at craig.kasper@nyogmd.com.

More Info

Hearing Education & Awareness for Rockers www.hearnet.com

Musicians Clinics of Canada www.musiciansclinics.com

National Hearing Conservation Association www.hearingconservation.org

National Institute for Occupational Safety & Health

www.cdc.gov/niosh

Occupational Safety & Health Administration

www.osha.gov