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Original Research

Hit the Right Notes with Musician Earplugs

Wilson, Martha W. AuD; Ennis, Cydney

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doi: 10.1097/01.HJ.0000484548.82925.f4
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Approximately 36 million (17%) Americans have some degree of hearing loss, with noise-induced hearing loss being the most common cause. It is estimated that 15 percent of the population—those between 20 and 69 years of age—have high-frequency hearing loss that may have been caused by exposure to loud sounds at work, at home, or during recreational activities. There is increasing evidence that exposure to loud music for extended periods of time can result in noise-induced hearing loss.


Martha W. Wilson, AuD

Student musicians, band directors, and music instructors in marching bands are at risk for hearing damage due to exposure to high levels of sound. Potential risk can vary, depending on the type of instrument, intensity level, amplified or acoustic music, placement of each instrument relative to other sections, time duration of exposure (including practice, rehearsal, and performance), room acoustics, ambient noise, and reverberation. Studies have indicated that student musicians are exposed to daily noise doses that exceed OSHA and NIOSH standards (Miller. Med Probl Perform Art 2007;22[4]:160 A recent study determined that 45 percent of student musicians aged 18-25 years exhibited noise-induced hearing loss, with 78 percent showing a “noise notch” at 6000Hz (Phillips. Int J Audiol 2010;49[4]:309-316


Cydney Ennis

Noise-induced, or music-induced, hearing loss can be prevented. Audiologists “have a responsibility to educate and motivate our patients, friends, and families about the hazards of noise and how to prevent damage due to excessive noise,” reports ( A publication by the National Association of Schools of Music (NASM) and the Performing Arts Medicine Association (PAMA) states, “musicians have basic hearing health responsibilities” and “musicians must take steps to protect their hearing,” including earplugs, earmuffs, and acoustic sound shields.

The NIOSH Health Hazard Evaluation Program annual report in 2012 recommended the use of “flat attenuation hearing protection, also known as musician ear plugs” (National Institute of Occupational Safety and Health. Health Hazard Evaluation Program Annual Report; 2012). Earplugs with uniform attenuation do not attenuate the high frequencies more than middle and low frequencies, thereby preserving the fidelity of the sound source.

Numerous studies have reported lack of widespread use of hearing protection by musicians. Complaints about use of hearing protection include autophonia, aural pressure, interference with perception of high frequencies, discomfort, the inability to communicate with others, difficulty hearing others’ instruments, and difficulty hearing one's own instrument (Santoni. Braz J Otorhinolaryngol 2010;76[4]:454-461; Jin. Am J Audiol 2013;22:26-39; Laitinen. Int J Audiol 2008;47[4]:160-168).).


To educate student musicians about the potential risk of music-induced hearing loss and to provide hearing protection, the primary investigator was awarded an internal university grant for the purchase of non-custom musician earplugs through the Etymotic Research Adopt-a-Band program for members of the university marching band. During band camps, information about hearing loss risk from excessive noise exposure, hearing loss prevention strategies, and fittings of musician earplugs were provided to each participant by an audiologist or an AuD student clinician.

To investigate the attitudes toward and use of hearing protection devices (HPDs) by student musicians in the Auburn University Marching Band and in the Department of Music, the primary investigator prepared and distributed two online surveys. The Institutional Review Board at Auburn University approved this project (Protocol #13-202 EX 1306). It complied with national and international regulations for the ethical treatment of human participants. The self-report surveys were developed using Qualtrics, a web-based survey software that is available to university faculty. There was no coercion or reward for participating in this project; likewise, there was no penalty for non-participation. Student email addresses were provided by the Department of Music.

The purpose of the surveys was to investigate possible patterns in use of hearing protection. For example, were students more likely or less likely to use HPDs if they play a particular instrument or type of instrument, or if they had been playing a musical instrument for a long time? If students have been wearing HPDs, did they use the equipment during practice (playing alone), rehearsals, and/or performances?

The first survey was distributed via student university email addresses prior to the dissemination of information about potential noise exposure, hearing loss prevention, and the fitting of the musician earplugs. The second survey was distributed approximately two months after the students had an opportunity to use the earplugs in a variety of settings. The purpose of the second survey was to determine if their attitudes and use of hearing protection changed as a result of instruction about the risk of noise-induced hearing loss and the provision of non-custom earplugs, free of charge. Ninety-seven students started the first survey and 95 students completed it (98% response rate); only 66 student musicians completed the second survey.


Figure 1
Figure 1:
Hearing protection devices (HPDs) used by some student musicians included in the study

Only 21 of 95 students indicated they had used HPDs in the last six months, prior to receiving information about risk of hearing loss and prevention. Of this group, 70 percent used non-custom musician earplugs, 15 percent used foam earplugs, and 15 percent used custom musician earplugs (Figure 1). When they used hearing protection, they were more likely to wear HPD during rehearsals and performances, but not during practice (55%, 50%, and 32%, respectively).

Fifty-seven percent of the students indicated they spent 0-5 hours per week in practice, 34 percent had spent 5-10 hours per week in rehearsals, and 73 percent had spent 0-5 hours per week in performances. When the student musicians wore hearing protection, 75 percent used HPDs zero to five hours per week, 10 percent used HPDs 5-10 hours or 10-15 hours per week, and only five percent used protection more than 15 hours per week. Musicians who played brass and wind instruments were more likely to use HPDs, compared with other instruments (percussion, string, keyboard, and voice).

Seventy four students reported they had not used hearing protection. The primary reasons for not using HPDs included the inability to adequately hear own music (36%), inability to hear music of others (18%), and inexperience with the use of HPD (19%), particularly for musicians.

Prior to receiving earplugs, 35 percent reported use of HPDs decreased their ability to play music, while 65 percent said ability to play music stayed the same.

On the follow-up survey, when students indicated they used earplugs, 32 percent used protection during rehearsals, 21 percent used HPDs during performance, and 13 percent used plugs during practice. When the students used hearing protection, 82 percent wore protection 0-5 hours per week; 10 percent wore plugs 5-10 hours; three percent wore plugs 10-15 hours per week; three percent wore them 15-20 hours per week; and three percent more than 20 hours.

Depending on the instrument, students were more or less likely to wear hearing protection during practice, rehearsals, and performances. For example, seven percent of percussionists used protection during practice and performances, 11 percent used protection during rehearsals.

The post-fitting survey showed slight improvement in their attitude, with 26 percent reporting HPD use decreased their ability to play music while 72 percent indicated no negative effect. Of this group, 82 percent reported average weekly HPD use of only zero to five hours.


A comparison of the two surveys showed a small increase in the use of hearing protection. Only students who play brass instruments indicated increased use of earplugs, while those who play wind instruments showed less use.

Although the study was unable to see a significant increase in the use of hearing protection or change in attitude about hearing health, it shows the importance of pursuing this health concern. In concurrence with Gopal et al., “it is strongly recommended that music educators increase their efforts to understand the specific sound levels generated during ensemble instruction, fully inform students of risk levels, and apply teaching strategies designed to prevent or minimize the risk of hearing loss on behalf of students” (Noise Health 2013;15[65]:246-252;year=2013;volume=15;issue=65;spage=246;epage=252;aulast=Gopal). Music-induced hearing loss can be prevented through continued education and awareness. Student musicians must be encouraged to be proactive in protecting their hearing health through education, hearing testing, and use of musician earplugs.

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