There are only a few studies that have directly examined whether and how noise exposure affects the progression of hearing loss in humans after the exposure has ceased. These studies are summarised in
Table 1. Of these studies, four [
24,
25,
26,
27] were based on samples of the general population and presumably included only a small proportion of former military personnel. The other three [
5,
28,
29] were based on former military personnel, mostly army personnel (with non-exposed comparison groups).
3.5. The Study of Macrae (1971)
Macrae [
5] compared the HTLs of military veterans obtained close to the end of military service and after an interval of several years. To the author’s knowledge, this is the only longitudinal study that has focused on the effects of noise exposure during military service on the subsequent progression of hearing loss. Macrae [
5] compared the rates of change of HTL at 1 and 4 kHz with increasing age with those expected for a non-exposed population, based on the data of Spoor [
32]. Twenty years later [
6] he compared the rates of change of HTL with those expected from the ISO standard that was current at the time [
33]. Here, the rates of change of HTL are compared with those expected from ISO 7029 [
4], which is a current standard based on a large population who were carefully screened to exclude noise-exposed individuals. The section headed “Scope” in [
4] includes the statement: “The data are applicable for estimating the amount of hearing loss caused by a specific agent in a population. Such a comparison is valid if the population under study consists of persons who are otologically normal except for the effect of the specific agent. Noise exposure is an example of a specific agent”.
Macrae analysed the audiograms of 240 individuals who had hearing loss at 4 kHz at the end of military service. Selection criteria were: (1) no conductive component to the hearing loss; (2) at the end of military service, an HTL at 4 kHz 20 dB or more greater than predicted for their age, based on the data of Glorig and Nixon [
34]; (3) as far as possible, an HTL at 1 kHz not more than 10 dB greater than predicted for their age, based on the data of Glorig and Nixon [
34] (this restriction was relaxed for some of the older individuals, because very few aged over 65 years met the criterion); (4) No evidence of a hereditary or non-organic component of the hearing loss. In what follows, the HTLs measured at the end of military service are denoted initial measurements.
Macrae divided the individuals into age groups and tabulated the changes in HTL at 1 and 4 kHz from the initial measurement to the time of the second measurement for each group. The relevant time interval varied across groups and the groups themselves varied somewhat depending on the frequency of interest and age. To make it easier to compare across groups, the changes in HTL tabulated by Macrae have been converted to rates of change of HTL in dB/year. The results for the left ear at 1 kHz are shown in
Table 2. The first three columns show, for each group, the mean age, the mean initial HTL, and the observed rate of change of HTL. The rate of change of HTL tended to increase with increasing age (and increasing hearing loss), but the progression was somewhat irregular. To smooth the data, a linear regression line was fitted to the rate of change as a function of age, and the fitted line was used to predict the rate of change for each group. The results are shown in column 4 of
Table 2. Column 5 shows the rates of change expected for non-noise exposed males of the same mean age based on ISO 7029 [
4]. It is clear that the fitted observed rate of change exceeds the rate expected from ISO 7029 [
4] for every age group. In other words, the progression of hearing loss with increasing age was greater for the noise-exposed group than expected for a non-noise exposed population.
Table 3 shows the results of a similar analysis for the right ear at 1 kHz. The pattern of the results is similar to that for the left ear. For every age group, the fitted observed rate of change of HTL exceeds the rate expected from ISO 7029 [
4].
Table 4 shows the results of a similar analysis for the left ear at 4 kHz. Note that the HTLs at the end of military service were much higher than the HTLs at 1 kHz, which partly reflects the selection criteria. Even the youngest age group had a mean HTL of 52 dB HL. The pattern of the results differs from that for 1 kHz. For the groups with a mean age below 60 years, and a mean initial HTL below 60 dB HL, the fitted observed rate of change exceeds that expected from ISO 7029 [
4]. For the groups with a mean age above 60 years, and a mean initial HTL above 60 dB HL, the fitted observed rate of change is below that expected from ISO 7029 [
4].
Table 5 shows the results of a similar analysis for the right ear at 4 kHz. The results are similar to those in
Table 3, except that for the groups over 60 years of age, with initial HTLs above 60 dB HL, the observed rates of change based on the linear fit are similar to the rates of change predicted from ISO 7029 [
4].
The results in
Table 2,
Table 3,
Table 4 and
Table 5 are summarised in
Figure 2. The fitted regression lines (thick grey lines for the observed rate of change and thin black lines for the rate predicted from ISO7029) give a clear visual impression of the differences between the observed and expected rates.
Macrae [
5] also grouped individuals by the initial HTL at 4 kHz (which ranged from 40 to 80 dB HL). A similar analysis to that presented above showed that, for both ears, the line fitted to the observed rate of change of HTL had a slope close to but slightly below 1, i.e., the rate of change of HTL decreased slightly with increasing HTL at the end of military service. In contrast, based on the age range of each HTL group, the rate of change predicted from ISO 7029 increased with increasing HTL at the end of military service. For initial HTLs of 50 dB or less, the (fitted) observed rate of change was greater than predicted from ISO 7029, while for initial HTLs of 55 dB or more the (fitted) observed rate of change was similar to or less than predicted from ISO 7029.
Overall, the results of Macrae are consistent with the idea that for frequencies for which the hearing loss at the end of noise exposure is up to 50 dB, the progression of hearing loss following the end of the exposure is greater than would be expected from age alone. However, for frequencies for which the hearing loss at the end of noise exposure is 55 dB or more, the progression is similar to or less than expected from age alone. The accelerated progression produced by noise exposure, when it occurs, appears to be related more to the HTL at the end of the noise exposure than to age. This conclusion is supported by the observation that at 1 kHz acceleration occurred over the whole age range studied. It is noteworthy that acceleration occurred at 1 kHz, since it is often assumed that noise exposure has little effect at this frequency [
30,
35]. However, other more recent data support the idea that noise exposure during military service can have effects over a wide frequency range, including 1 and 8 kHz [
36,
37,
38].
3.6. The Study of Xiong et al. (2014)
Xiong, Yang, Lai and Wang [
28] performed a cross-sectional study using two groups, each containing 109 men. The two groups were matched in age, with a mean age of approximately 57 years (age range 55 to 60 years). Group I comprised military veterans who had all been exposed to the sound of shooting from rifles without hearing protection during a war. At the time of discharge, they were aged 23–25 years. All had normal hearing (HTLs ≤ 20 dB HL at all audiometric frequencies) at the end of military service. Group II comprised men with no military experience randomly chosen from a health examination center. Group II had no history of exposure to high-level sounds. Inclusion criteria for both groups were: (1) no history of ear disease; (2) no history of ototoxic drugs; (3) no familial history of ear diseases; (4) no diabetes, hyperlipidemia, cerebrovascular disease or other systemic disease. In addition, Group I met the following criteria: (1) no hearing loss, no tinnitus and other inner ear-related symptoms at the end of military service; (2) no occupational or non-occupational noise exposure after the end of military service.
Mean HTLs for the two groups, and differences across groups, are shown in
Table 6. For frequencies up to 2 kHz, the noise-exposed group actually had slightly better HTLs than the non-exposed group, but the differences were not statistically significant. The small differences might indicate that the groups were not well matched in terms of factors other than age, such as general cardio-vascular fitness or history of smoking or alcohol consumption [
39]. Alternatively, or in addition, the military veterans probably had their audiograms assessed regularly during military service, so they may have been more practiced at detecting soft sounds, leading to better HTLs. In any case, the noise-exposed group had clearly and significantly (
p < 0.01) higher HTLs at 4, 6, and 8 kHz than the non-exposed group, consistent with the idea that the noise exposure during military service accelerated the subsequent progression of hearing loss.
Some limitations of this study should be noted. Firstly, the authors did not present the audiograms obtained for Group I at the end of military service, and the audiograms for Group II were not measured when they were 23–25 years old, so it is not clear how well the two groups were matched in HTL at 4, 6, and 8 kHz at the time when Group I were discharged from military service. Secondly, because Group I were selected to have HTLs within the “normal” range at the end of military service, while many of the military personnel who fought in the same war had hearing loss at the end of military service [
28], Group I may represent those with “tough” ears, that are more resistant than average to the effects of noise, or may represent those who had lower than average noise exposure during military service.