title: Soft tissue conduction as a possible contributor to the limited attenuation provided by hearing protection devices.
abstract: BACKGROUND
  Damage to the auditory system by loud sounds can be avoided by hearing protection devices (HPDs) such as earmuffs, earplugs, or both for maximum attenuation. However, the attenuation can be limited by air conduction (AC) leakage around the earplugs and earmuffs by the occlusion effect (OE) and by skull vibrations initiating bone conduction (BC).
  
  
  OBJECTIVE
  To assess maximum attenuation by HPDs and possible flanking pathways to the inner ear.
  
  
  METHODS
  AC attenuation and resulting thresholds were assessed using the real ear attenuation at threshold (REAT) procedure on 15 normal-hearing participants in four free-field conditions: (a) unprotected ears, (b) ears covered with earmuffs, (c) ears blocked with deeply inserted customized earplugs, and (d) ears blocked with both earplugs and earmuffs. BC thresholds were assessed with and without earplugs to assess the OE.
  
  
  RESULTS
  Addition of earmuffs to earplugs did not cause significantly greater attenuation than earplugs alone, confirming minimal AC leakage through the external meatus and the absence of the OE. Maximum REATs ranged between 40 and 46 dB, leading to thresholds of 46-54 dB HL. Furthermore, calculation of the acoustic impedance mismatch between air and bone predicted at least 60 dB attenuation of BC.
  
  
  CONCLUSIONS
  Results do not support the notion that skull vibrations (BC) contributed to the limited attenuation provided by traditional HPDs. An alternative explanation, supported by experimental evidence, suggests transmission of sound to inner ear via non-osseous pathways such as skin, soft tissues, and fluid. Because the acoustic impedance mismatch between air and soft tissues is smaller than that between air and bone, air-borne sounds would be transmitted to soft tissues more effectively than to bone, and therefore less attenuation is expected through soft tissue sound conduction. This can contribute to the limited attenuation provided by traditional HPDs. The present study has practical implications for hearing conservation protocols.
authors.affiliation: Department of Communication Disorders, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
authors.forename: Shai
authors.initials: S
authors.lastname: Chordekar
authors.affiliation: Speech & Hearing Center, Hebrew University School of Medicine - Hadassah Medical Center, Jerusalem; Department of Communication Disorders, Hadassah Academic College, Jerusalem, Israel.
authors.forename: Cahtia
authors.initials: C
authors.lastname: Adelman
authors.affiliation: Department of Medical Neurobiology (Physiology), Institute for Medical Research - Israel-Canada, Hebrew University-Hadassah Medical School, Jerusalem, Israel.
authors.forename: Haim
authors.initials: H
authors.lastname: Sohmer
authors.affiliation: Department of Communication Disorders, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
authors.forename: Liat
authors.initials: L
authors.lastname: Kishon-Rabin
mesh_terms: D000328:Adult; D001309:Auditory Threshold / Q000502:physiology; D001844:Bone Conduction / Q000502:physiology*; D004430:Ear Protective Devices; D005260:Female; D006317:Hearing Loss, Noise-Induced / Q000517:prevention & control; D006801:Humans; D008297:Male; D013016:Sound; D014732:Vibration; D055815:Young Adult