Otology & Neurotology
39:693–699 ß 2018, Otology & Neurotology, Inc.
Occupational Noise Exposure and Risk for Noise-Induced Hearing
Loss Due to Temporal Bone Drilling
Yona Vaisbuch, Jennifer C. Alyono, Cherian Kandathil, yStanley H. Wu,
Matthew B. Fitzgerald, and Robert K. Jackler
Department of Otolaryngology—Head and Neck Surgery, Stanford School of Medicine; and yDepartment of Environmental
Health and Safety, Stanford University, Stanford, California
Background: Noise-induced hearing loss is one of the most
common occupational hazards in the United States. Several
studies have described noise-induced hearing loss in patients
following mastoidectomy. Although otolaryngologists care
for patients with noise-induced hearing loss, few studies in
the English literature have examined surgeons’ occupational
risk.
Methods: Noise dosimeters and sound level meters with
octave band analyzers were used to assess noise exposure
during drilling of temporal bones intraoperatively and in a
lab setting. Frequency specific sound intensities were
recorded. Sound produced using burrs of varying size and
type were compared. Differences while drilling varying
anatomic structures were assessed using drills from two
manufacturers. Pure tone audiometry was performed on 7 to
10 otolaryngology residents before and after a temporal bone
practicum to assess for threshold shifts.
Results: Noise exposure during otologic drilling can exceed
over 100 dB for short periods of time, and is especially loud
using large diameter burrs > 4 mm, with cutting as compared
with diamond burrs, and while drilling denser bone such as
the cortex. Intensity peaks were found at 2.5, 5, and 6.3 kHz.
Drilling on the tegmen and sigmoid sinus revealed peaks at
Noise-induced hearing loss (NIHL) is a gradually
progressive, sensorineural hearing deficit, typically
occurring at higher frequencies (3–6 kHz) due to chronic
exposure to excessive sound (1). NIHL is one of the most
common forms of hearing loss in the United States,
present in nearly one in four adults (2).
Recognizing the potential for excessive noise exposure
in the workplace, the Occupational Health and Safety
Administration (OSHA) regulates both maximum sound
levels and allowable time-weighted average (TWA)
exposures (3). Current guidelines mandate that employ-
ers offer a hearing conservation program to employees
Address correspondence and reprint requests to Yona Vaisbuch,
M.D., Stanford University, 450 Serra Mall, Stanford, CA 94305;
E-mail: yona@stanford.edu
The authors disclose no conflicts of interest.
DOI: 10.1097/MAO.0000000000001851
693
Copyright © 2018 Otology & Neurotology, Inc. Unauthorized reproduction of this article is prohibited.
10 and 12.5 kHz. No temporary threshold shifts were found
at 3 to 6 kHz, but were found at 8 to 16 kHz, though this did
not reach statistical significance.
Conclusion: This article examines noise exposure and
threshold shifts during temporal bone drilling. We were
unable to find previous descriptions in the literature of
measurements done while multiple people drilling simulta-
neously, during tranlabyrinthine surgery and a specific
frequency characterization of the change in peach that
appears while drilling on the tegmen. Hearing protection
should be considered, which would still allow the surgeon
to appreciate pitch changes associated with drilling on
sensitive structures and communication with surgical team
members. As professionals who specialize in promoting the
restoration and preservation of hearing for others, otologic
surgeons should not neglect hearing protection for them-
selves. Key Words: Burr—Drill—ENT—Neurotologist—
Noise-induced hearing loss—Occupational noise exposure—
Otologist—Surgeons—Temporal bone lab—Threshold
shifts—Tinnitus.
Otol Neurotol 39:693–699, 2018.
should they be exposed to sound levels greater than 85
dBA, which is known as the ‘‘action level.’’ Ninety dBA
averaged over an 8-hour period is the maximum ‘‘per-
missible exposure limit.’’ Furthermore, for each addi-
tional increase in 5 dBA of TWA noise exposure,
employees must halve their exposure time. The National
Institute for Occupational Safety and Health is the
research body that makes recommendations to OSHA
(4). Their recommended exposure limit is stricter, at 85
dBA averaged over an 8-hour period. They also recom-
mended halving exposure time for each additional
increase in 3 dBA of TWA noise exposure (see Table 1).
While the role of noise exposure in the workplace has
been extensively studied for many professions, relatively
little is known about the potential for noise exposure in
surgical professions. Shapiro and Berland in 1972
reported one of the first studies of occupational noise
exposure in the operating room (5). Measuring sound
694 Y. VAISBUCH ET AL.
TABLE 1. Comparison of occupational exposure guidelines by regulatory/advisory agency
Cal/OSHAa Federal OSHAb EU Directivesc ACGIHd NIOSHe

Limit for requiring hearing protection (dBA) 85 85 85 85 85

Limit for enrolling in HCPf (dBA) 85 85 85 85 85
Exposure limit (dBA) 90 90 87 85 85
Exchange rate (dBA) 5 5 3 3 3
a
California Occupational Safety and Health Administration (Regulatory).
b
Federal Occupational Safety and Health Administration (Regulatory).
c
European Agency for Safety and Health at Work (Regulatory).
d
American Conference of Governmental Industrial Hygienists (Advisory).
e
National Institute for Occupational Safety and Health (Advisory).
f
Hearing Conservation Program.
OSHA indicates Occupational Health and Safety Administration; NIOSH, National Institute for Occupational Safety and Health.

levels generated during a combination cholecystectomy
and tubal ligation case, they found that the loudest noise
exposure was 86 dBA. Later studies, which included the
use of motorized equipment from other subspecialties
such as orthopedics (6–8), dentistry (9–11), and urology
(12,13), have consistently reported higher noise levels,
with maximum levels reaching 110 dBA (14–18).
With regard to otolaryngology, most studies have
focused on noise exposure to patients undergoing sur-
gery. Early studies on human cadavers showed that the
ipsilateral cochlea is exposed to noise levels of 100 dB
and the contralateral cochlea to noise level of 90 to
100 dB during mastoid drilling (19–21). These levels
of noise suggest that patients may be at risk for NIHL
when undergoing mastoidecomy. Consistent with this
view, several studies showed that patients had temporary
threshold shifts (TTSs) ranging between 5 and 40 dB at 4
and 8 kHz, when comparing pre- and postexposure elec-
trocochleograms. Moreover, the magnitude of TTS was
correlated with the duration of noise exposure, suggest-
ing the possibility of drill-induced postoperative senso-
rineural hearing loss (22–25).
In these ear-related surgeries, the risk of NIHL for
patients may be heightened by the proximity of the drill
burr to the organs for hearing which has been well
described, (22–34), Less clear, however, are the levels
of noise to which surgeons are exposed to during the
surgical procedure itself. While a few studies have
attempted to quantify this risk in the operating room
(35,36), in the English-language literature, we have not
found any addressing noise in temporal bone labs where
multiple participants (7–10) are drilling in a small, con-
fined space at the same time. Similarly, we could find no
articles specifically addressing noise exposure during
translabyrinthine surgery—only middle ear or mastoid
cases were described. As translabyrinthine surgery requires
much more bone removal than typical mastoid cases, we
thought it was important to quantify the noise exposure.
In this study, we addressed this question by performing
personal noise dosimetry, conducting room sound level
surveys in intraoperative and temporal bone lab settings
and by searching for evidence of threshold shifts after
completing the lab. While the main focus of this article
was occupational noise exposure among otologists, we
thought it was also important to include other operating
room staff, such as surgical scrub technicians, as they too
are exposed to the noise of drilling. Similarly, in the
temporal bone lab, although the main focus was noise
exposure among participants actively drilling, exposure
to teaching staff and to those who might be in adjoining
rooms was also studied.
METHODS
Setting, Subjects, and Equipment
This study was carried out at the temporal bone laboratory in
the Department of Otolaryngology—Head and Neck Surgery,
Stanford University. Participants included otolaryngology res-
idents, clinical instructors, and attending. The Stanford Univer-
sity Environmental Health & Safety and the Stanford Health
Care Environmental Health & Safety departments were
involved in conducting the noise surveys, in accordance with
the State of California, Department of Industrial Relations,
Division of Occupational Safety and Health (Cal/OSHA) Hear-
ing Conservative Standard (Title 8, Section 5097). Noise was
measured using 3 M Edge EG-5 Series (Maplewood, MN) and
3 M (Formerly Quest) NoisePro DLX (Maplewood, MN) per-
sonal noise dosimeters set to the ‘‘A’’ weighting scale with slow
response as required by Cal/OSHA. Measurements were made
intraoperatively and in two different lab settings in which
participants drilled on the temporal bone. In all sessions,
dosimeters were affixed to participants with the microphone
at ear level. 3 M SoundPro (Maplewood, MN) sound level
meters with octave band analyzers set to the ‘‘A’’ weighting
scale with slow response were used in the sound pressure level
(SPL) mode to collect general noise levels in the room. Both the
personal dosimeters and the sound level meters were field-
calibrated before and after the survey using a 3 M QC-10 Sound
Calibrator 114dB- 1000HZ sound calibrator (Maplewood,
MN). The detected noise was analyzed by 3 M Detection
Management Software in both surveys (Maplewood, MN).
The results from the personal dosimeters were used to deter-
mine the TWA noise level over an 8-hour work-shift.
Specific Outcome Measures
Room Noise Level
The general noise level in the temporal bone lab was
measured during a practicum with eight otolaryngology resi-
dents performing temporal bone dissections using Anspach
eMax 2 Plus drills (New Brunswick, NJ). A sound level meter
in the SPL mode was used to collect measurements near each
workstation approximately 2 feet from active drills. SPLs were
also measured in an office adjacent to the temporal bone lab.

Otology & Neurotology, Vol. 39, No. 6, 2018

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 OTOLOGY OCCUPATIONAL NOISE EXPOSURE
Instructor Noise Exposure
Noise exposure to two instructors was measured. Personal
noise dosimeters were affixed with microphones at the level of
the instructors’ ears. Measurements were taken as they walked
around the room between the drilling stations advising resi-
dents. Maximum noise levels were noted, and TWAs were
calculated.
Temporal Bone Lab Participant Noise Exposure
Personal noise dosimeters were affixed to two residents.
Microphones were placed at the level of the ear. To standardize
across participants who are both left and right handed, measure-
ments were taken from the shoulder ipsilateral to their drilling
hand. Noise levels were measured during drilling on preserved
temporal bones using Anspach eMax 2 Plus drills (New Bruns-
wick, NJ). Maximum noise levels were noted, and TWAs
were calculated.
Intraoperative Surgical Team Noise Exposure
A personal noise dosimeter was affixed to surgeons as they
operated during a single translabyrinthine resection of a ves-
tibular schwannoma. A dosimeter was similarly placed on the
shoulder of a scrub technician throughout the case. Maximum
noise levels were recorded, and TWAs were calculated.
Although the noise contribution from the suction was not
measured in isolation, noise measurements taken in the tempo-
ral bone lab and during translabyrinthine surgery included the
concurrent use of the drill and suction-irrigator.
Noise Frequency Spectra, Burr Effects
To assess the spectrum of sound frequencies generated, a
sound level meter with octave band analyzer was placed 40 cm
away from an instructor drilling on a fresh frozen temporal
bone. A personal noise dosimeter was also concurrently used.
Frequency spectra were recorded while drilling on different
anatomical regions (cortical bone, tegmen, and sigmoid sinus).
Overall noise levels and spectra were also recorded while using
different types of burrs (diamond versus cutting), and while
using different burr sizes for each type (2, 3, 4, 6, 7, 8, 9 mm)
and drills from two manufacturers (Anspach eMax 2 Plus (New
Brunswick, NJ) and Medtronic Visao High-Speed Otologic
Drill (Dublin, Ireland)). Maximum noise levels were recorded,
as well as averages over 5 minutes while varying the pressure
applied with the drill.
Pure-Tone Thresholds
To determine whether any threshold shifts were present after
the drilling practicum, we obtained pure-tone audiometric
thresholds both before and after each training session. In both
sessions, traditional measures for obtaining audiometric
TABLE 2. Noise level measurements during temporal bone
drilling (anspach onlya)
Drill Bit Type Size 5 Min Leqb Lmaxc
Cutting Small (4 mm) 82.6 92.3
Large (8 mm) 93.3 103.7
Diamond Small (3 mm) 83.3 95.5
Large (7 mm) 84.4 98.0
a ence on noise levels, as levels measured with the Ans-
3M (FormerlyQuest Technologies) sound level meter (Serial
#KOB020014) was pre- and postcaliibrated with QC-10 calibrator.
b
Equivalent continuous sound pressure level (over 5 min).
c
Maximum sound pressure level.
Copyright © 2018 Otology & Neurotology, Inc. Unauthorized reproduction of this article is prohibited.
695
TABLE 3. Frequency peaks according to location
Site Frequency kHz
Air 1.25
Cortex 2.5, 5, 6.3
Tegmen 10, 12.5
thresholds used the Hughson-Westlake procedure in a sound-
proofed audiometric booth by a trained technician (37). How-
ever, the frequencies that were assessed differed between the 1st
and 2nd practicum. During the 1st practicum, we measured
thresholds for 10 participants at 3, 4, and 6 kHz in each ear. In
the 2nd practicum, we measured thresholds for 7 participants at
8, 10, 12.5, and 16 kHz. Hand-dominance and any subjective
tinnitus percepts were also recorded. Postdrilling thresholds
were measured within 5 minutes of drilling cessation. Subjects
were also surveyed whether or not tinnitus was present before
and after drilling on a subjective scale of absent (), mild (þ),
moderate (þþ), or severe (þþþ).
RESULTS
Taken together, the overall noise levels during the
temporal bone lab practicum did not exceed OSHA
recommendations. During the practicum itself, the over-
all room noise level reached a maximum 79.1 dBA. The
noise level in an office adjacent to the temporal bone lab
with doors open reached a maximum of 65.0 dBA.
Personal noise dosimeters worn by two instructors
revealed TWAs of 69.1 and 77.1 dBA over a 3-hour
drilling session. Similar, but slightly lower levels were
observed on dosimeters worn by two residents (TWAs
of 59.7 and 68.0 dBA), well below OSHA regulated
thresholds.
In contrast to the overall noise levels, however, noise
levels that were significantly higher were observed for
shorter periods of time when drilling with larger burrs.
For example, burrs larger than 4 mm in diameter consis-
tently elicited noise peaks of at least 85 dBA, with a peak
of 103.7 dB SPL observed for an 8 mm cutting burr. On
the whole, cutting burrs generated higher SPL values (see
Table 2), than did diamond burrs (max level of 98 dB SPL
for an 8 mm diameter). The noise levels also seemed to
vary depending on the region of bone being drilled. The
highest SPL values were observed while drilling on the
cortex (max 103.7 dB SPL), as compared with tegmen
(max 84.4 dB SPL) or sigmoid sinus (max 86.3 dB SPL).
A spectral analysis indicated a frequency peak at
1.25 kHz when running the drill in the air. Drilling on
the cortex with either cutting or diamond burrs generated
additional frequency peaks at 2.5, 5, and 6.3 kHz regard-
less of burr size (see Table 3, and Fig. 1), while drilling on
the tegmen with either cutting or diamond burrs gener-
ated frequency peaks at 10 and 12.5 kHz (see Table 3).
Finally, the type of drill used had only a minimal influ-
pach eMax 2 Plus (New Brunswick, NJ) and Medtronic
Visao High-Speed Otologic Drill (Dublin, Ireland) were
always within 5 dBA of one other.
Otology & Neurotology, Vol. 39, No. 6, 2018
696 Y. VAISBUCH ET AL.

Max Sound Level Measured per Frequency Max Sound Level Measured (Anspach + 4mm Cutter)
(Anspach + 4mm Cuer) 100
90
100
80

Sound Level (dBA)

90
80 70
Sound Level (dBA)

70 60
60 50
50 40
40
30
30
20
20
10
10
0 0

13
25
37
49
61
73
85
97
1

109
121
133
145
157
169
181
193
205
217
229
241
253
265
277
289
301
313
325
1.00 kHz
1.25 kHz
1.60 kHz
2.00 kHz
2.50 kHz
3.15 kHz
4.00 kHz
5.00 kHz
6.30 kHz
8.00 kHz
10.00 kHz
12.50 kHz
16.00 kHz
20.00 kHz
16 Hz
20 Hz
25 Hz
31.5 Hz
40 Hz
50 Hz
63 Hz
80 Hz
100 Hz
125 Hz
160 Hz
200 Hz
250 Hz
315 Hz
400 Hz
500 Hz
630 Hz
800 Hz

Overall
Sample Time (seconds)

Max Sound Level Measured per Frequency Max Sound Level Measured (Anspach + 8mm Cutter)
(Anspach + 8mm Cutter)
100
100 90
90 80

Sound Level (dBA)

80
Sound Level (dBA)

70
70
60
60
50 50
40 40
30 30
20 20
10 10
0 0
16 Hz
20 Hz
25 Hz
31.5 Hz
40 Hz
50 Hz
63 Hz
80 Hz
100 Hz
125 Hz
160 Hz
200 Hz
250 Hz
315 Hz
400 Hz
500 Hz
630 Hz
800 Hz
1.00 kHz
1.25 kHz
1.60 kHz
2.00 kHz
2.50 kHz
3.15 kHz
4.00 kHz
5.00 kHz
6.30 kHz
8.00 kHz

Overall
10.00 kHz
12.50 kHz
16.00 kHz
20.00 kHz

1
5
9
13
17
21
25
29
33
37
41
45
49
53
57
61
65
69
73
77
81
85
89
93
97
Sample Time (seconds)

FIG. 1. Maximum sound levels generated by a 4 mm cutting burr. A, By frequency. B, Over time.

Behavioral results demonstrated a trend toward TTS
and increased subjective tinnitus percepts after completing
the practicum, but the effect was relatively small. No
audiometric threshold shifts were observed between 3
and 6 kHz. Some individuals revealed threshold shifts
between 8 and 16 kHz with 4 of 7 individuals demonstrat-
ing an increase of at least 5 dB at 8 kHz (see Table 4).
However, these results should be treated with caution as
many of the observed shifts fall within test–retest reliabil-
ity for audiometric threshold measurements. Finally, there
was an increase in the incidence of subjective tinnitus.
Before drilling, one of seven participants who have mod-
erate sensory neural hearing loss, reported subjective
tinnitus while sitting in a sound proof audiometry booth.
Following temporal bone drilling, in the same booth, five
of seven participants reported either new onset tinnitus, or
an increase in their baseline tinnitus (see Table 4).
During translabyrinthine surgery, the TWA was 61.6
dBA for the surgeon, with a maximum noise level of
106.6 dBA. For the scrub technician, the TWA was 27
dBA, with a maximum noise level of 85.4 dBA. While
not drilling, the maximum noise level remained below
80 dBA.
DISCUSSION
Although several governmental and independent agen-
cies in the United States have established NIHL preven-
tion guidelines, a lack of consensus remains surrounding
these recommendations. A TWA of 8-hour duration
forms the basis of all advocated occupational noise
exposure limits; however, there are variations in the final
exposure limit. Reflecting the somewhat arbitrary nature
of mandated limits, there is variability in standards laid
down by international agencies (see Table 1).
In otolaryngology, studies have consistently found
noise exposure to be under official OSHA limits. Prasad
and Reddy found that the noise generated while drilling

TABLE 4. PTA threshold shifts after temporal bone practicum

Frequency kHz
AD AS
Residents 8 10 12.5 16 8 10 12.5 16 Tinnitus

1 5 0 0 20 0 0 5 5 (þþ)
2 5 5 5 10 5 10 0 15 (þþ)
3 5 0 5 5 5 5 5 5 (þþ)
4 5 0 0 0 5 0 0 5 (þþþ)
5 0 5 5 0 5 5 0 10 (þþ)
6 5 0 5 0 0 10 0 5 (þþ)
7 0 0 0 15 0 0 0 10 ()

AD indicates right; AS, left; PTA, pure tone average.

Otology & Neurotology, Vol. 39, No. 6, 2018

Copyright © 2018 Otology & Neurotology, Inc. Unauthorized reproduction of this article is prohibited.
 OTOLOGY OCCUPATIONAL NOISE EXPOSURE
reached up to 72.4 dBA, and thus concluded that power
instruments used in ‘‘ENT surgery are safe and pose no
occupational hazard’’ (38). Other studies have found
exposure levels ranging from 68.5 to 83 dBA (36,39).
In this study, overall room noise levels during temporal
bone practicums did not exceed OSHA noise exposure
limits. This held true even while eight residents were
drilling on eight temporal bones at the same time. One
caveat, however, is that our temporal bone lab has an
acoustically absorbing ceiling while many operating
rooms have hard ceilings. Working in a small operating
room with acoustically reflective walls and ceilings may
concentrate sound due to resonance.
Sound measured on personal noise dosimeters also did
not reveal levels exceeding OSHA limits for either the
residents actively drilling, or instructors walking between
drilling stations. These results are in concordance with
those found by Verhaert et al. (39), who also found that
surgeons are exposed to the loudest sound during oper-
ations, as compared with nursing and anesthesiology
staff. However, the intensities generated may nonetheless
be loud enough to cause temporary, and potentially long-
term, damage to surgeons’ hearing. Although hair cell
damage is the most commonly observed change follow-
ing NIHL, cochlear neurons have also been shown to be
vulnerable to noise exposure (40–47). After temporary
threshold shifts, even with no loss of hair cells, there can
be a rapid and irreversible loss of synaptic connections
between hair cells and cochlear neurons, and a slow
degeneration of nerve cell bodies and axons (45–47).
This phenomenon could possibly contribute to ‘‘hidden’’
hearing loss sometimes attributed to cochlear synaptop-
athy (45,48–51). Thus, although our noise exposure
survey results did not exceed OSHA limits, the cumula-
tive effects of noise generated while drilling may still
increase surgeons’ risk of hearing loss over their life-
times. Accordingly, studies of dentists have found an
increased rate of sensorineural hearing loss as compared
with age-sex matched controls (52) and compared with
other academic professionals as controls (53). A study of
11 orthopedic surgeons also found patterns of noise-
induced hearing loss (54).
Another consideration is the effect that noisy
environments have on concentration. In 2007, the
Netherlands Standardization Institute released guide-
lines regarding workplace noise. While they proposed
that noise above 80 dBA is potentially dangerous, noise
between 35 and 80 dBA can disturb communication and
concentration (55).
Certain drilling conditions may pose particular risk to
hearing. Specifically, drilling on cortical bone with cut-
ting burrs larger than 5 mm in diameter consistently
produced noise greater than 85 dBA. Other studies are
in agreement these results, with variable noise levels
generated based on burr size and anatomical structure
(i.e., cortical bone vs. mastoid cavity) (20,56). In this
study we examined electric drills from two manufac-
turers, with peak sound pressure levels reaching 103.7 dB
SPL. Air drills, which were more commonly used in the
Copyright © 2018 Otology & Neurotology, Inc. Unauthorized reproduction of this article is prohibited.
697
past, have been shown to be significantly louder in
multiple studies, with peaks reaching 118 dBA
(28,57). Piezeoelectric drills, based on ultrasonic frag-
mentation of bone, may represent an area for future
research. Studies examining their impact on patients’
hearing have shown conflicting results, with some
authors finding no inner ear damage (58–61) and others
finding high-frequency hearing loss (62,63). In a review
of the English literature, we were unable to find studies
comparing them to electric or air drills in terms of noise
exposure to surgeons.
We also found that drilling produced noise peaks at
2.5, 5, and 6.3 kHz, except when drilling on the tegmen,
when additional peaks were generated at 10 and
12.5 kHz (see Table 4). This provides an opportunity
to dampen potentially harmful noise peaks at lower
frequencies, while still allowing the surgeon to perceive
a change in pitch when a critical structure such as the
tegmen is drilled upon. Another option, which is com-
mercially available, would be to use high fidelity ear
filters, also known as musicians ear plugs. Available at
several noise reduction levels, these reduce sound evenly
across the frequency spectrum so that speech remains
clear and natural, and not muffled as with traditional
ear plugs.
Noise exposure was measured during a translabyrin-
thine surgery, one of the surgeries in the field of otology/
neurotology that requires the most drilling. Our intraop-
erative noise measurements were considerably lower
than those measured in the temporal bone lab. This
may be attributed to the increased working distance in
neurotologic as compared with otologic surgery. Another
factor may be the larger, bulkier microscope used in the
operating room reflecting or absorbing more sound, as
compared with the lighter, thinner microscopes used in
the temporal bone lab. The scrub technician’s noise
exposure was much lower than that of the surgeon, as
they are positioned further from the drill. The techni-
cian’s noise exposure during drilling was no higher than
the ambient noise in the room.
We did not measure noise produced by the suction in
isolation, though suction a known contributor to high
noise levels in the operating room (28). Instead, noise
measurements were taken in the temporal bone lab and
during translabyrinthine surgery during the concurrent
use of the drill and suction-irrigator, as this is standard
practice in patient care.
Despite personal noise exposures remaining below
OSHA limits, several residents reported subjective tinni-
tus after drilling, which was noticed especially after
entering a sound proof audiometry booth. Although
our observed threshold shifts did not reach statistical
significance, the presence of tinnitus suggests some level
of auditory damage. It is also possible that this study was
simply underpowered to detect threshold shifts, and that
in future studies with a larger number of participants, a
shift may become significant. Tinnitus may indicate a
central auditory system homeostatic response as a result
of a temporary insult to the cochlear neurons (50). It may
Otology & Neurotology, Vol. 39, No. 6, 2018
698 Y. VAISBUCH ET AL.
be that our study is under-powered to detect subtle
threshold shifts. Auditory brainstem responses might
be queried in future studies for changes in wave I
amplitude or latency.
Another limitation of this study is that 8-hour TWAs
were extrapolated from 3-hour drilling sessions. In the
future, assessment of sound exposure could be conducted
during a surgeon’s full day in the operating room.
Our results emphasize the importance of hearing pro-
tection for surgeons using powered instruments. In par-
ticular, there are potential detrimental cumulative effects
from repeated exposures over the course of a surgeon’s
career. Based on our findings, we advocate for the use of
hearing protection. Considering the importance of com-
munication within a surgical environment, may hinder
adoption of ear protection by some surgeons. One way
this can be achieved is through gradual implementation
that starts during temporal bone practicums with the use
of specialized musician’s ear plugs that can afford sub-
stantial noise protection to higher sound intensities while
still allowing the surgeon to appreciate pitch changes
while drilling on different structures, and to communi-
cate efficiently with the surgical team. As professionals
who specialize in promoting the restoration and preser-
vation of hearing for others, otologic surgeons should not
neglect hearing protection for themselves.
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