WHO Environmental Noise Guidelines for the European Region: A Systematic Review on Environmental Noise and Permanent Hearing Loss and Tinnitus

Background: Hearing loss is defined as worsening of hearing acuity and is usually expressed as an increase in the hearing threshold. Tinnitus, defined as "ringing in the ear", is a common and often disturbing accompaniment of hearing loss. Hearing loss and environmental exposures to noise are increasingly recognized health problems. Objectives: The objective was to assess whether the exposure-response relationship can be established between exposures to non-occupational noise and permanent hearing outcomes such as permanent hearing loss and tinnitus. Methods: Information sources: Computer searches of all accessible medical and other databases (PubMed, Web of Science, Scopus) were performed and complemented with manual searches. The search was not limited to a particular time span, except for the effects of personal listening devices (PLDs). The latter was limited to the years 2008-June 2015, since previous knowledge was summarized by SCENIHR descriptive systematic review published in 2008. Study eligibility criteria: The inclusion criteria were as follows: the exposure to noise was measured in sound pressure levels (SPLs) and expressed in individual equivalent decibel values (LEX,8h), the studies included both exposed and reference groups, the outcome was a permanent health effect, i.e., permanent hearing loss assessed with pure-tone audiometry and/or permanent tinnitus assessed with a questionnaire. The eligibility criteria were evaluated by two independent reviewers. Study appraisal and synthesis methods: The risk of bias was assessed for all of the papers using a template for assessment of quality and the risk of bias. The GRADE (grading of recommendations assessment, development, and evaluation) approach was used to assess the overall quality of evidence. Meta-analysis was not possible due to methodological heterogeneity of included studies and the inadequacy of data. Results: Out of 220 references identified, five studies fulfilled the inclusion criteria. All of them were related to the use of PLDs and comprised in total of 1551 teenagers and young adults. Three studies used hearing loss as the outcome and three tinnitus. There was a positive correlation between noise level and hearing loss either at standard or extended high frequencies in all three of the studies on hearing loss. In one study, there was also a positive correlation between the duration of PLD use and hearing loss. There was no association between prolonged listening to loud music through PLDs and tinnitus or the results were contradictory. All of the evidence was of low quality. Limitations: The studies are cross-sectional. No study provides odds ratios of hearing loss by the level of exposure to noise. Conclusions: While using very strict inclusion criteria, there is low quality GRADE evidence that prolonged listening to loud music through PLDs increases the risk of hearing loss and results in worsening standard frequency audiometric thresholds. However, specific threshold analyses focused on stratifying risk according to clearly defined levels of exposure are missing. Future studies are needed to provide actionable guidance for PLDs users. No studies fulfilling the inclusion criteria related to other isolated or combined exposures to environmental noise were identified. This systematic review has been funded by theWorld Health Organization Regional Office for Europe, supported by Swiss Federal Office for the Environment, and delivered as part of the evidence-base that underpins the Environmental Noise Guidelines for the European Region. All rights in the work, including ownership of the original work and copyright thereof, is vested in WHO. The authors alone are responsible for the views expressed in this publication and they do not necessarily represent the decisions or the stated policy of the World Health Organization.