Evaluation of vestibular functions and balance in Edirne Band musicians

Abstract

BACKGROUND:

It has been found that intense noise may affect the peripheral vestibular system and consequently causes problems in balance mechanisms.

OBJECTIVE:

The aim of this study was to investigate the effects of exposure to chronic noise on vestibular functions and balance in Edirne Band musicians.

METHODS:

Twenty-two individuals working in the Edirne Band for at least 5 years and a control group of 22 individuals working at Trakya University with similar sociodemographic characteristics were included. The socio-demographic questionnaire was used to inquire about the demographic characteristics of individuals, the ABC Scale to assess how they felt about the balance, and the DHI to determine the quality of life related to dizziness. A 3D ultrasonic system was used to assess the static and dynamic balance of the individuals.

RESULTS:

There was a statistically significant difference between the band and the control group in terms of longitudinal deviation and self-spin parameters of the Unterberger test, dizziness handicap inventory scores, functional balance according to activity-specific balance confidence scale (p < 0.05).

CONCLUSIONS:

As a result of our study, it has been shown that the balance, quality of life and vestibular system functions are negatively affected in the band exposed to noise for a long time.

Keywords

Noise vestibular system balance quality of life

1 Introduction

Maintaining balance is one of the most important parameters for an individual to carry out functional activities [1]. In order to maintain balance, the individual receives inputs from the visual, somatosensory and vestibular systems and effectively identifies the appropriate motor response by determining the position of each body segment [2].

The vestibular system, which perceives gravity and movements of the head, is one of the most important parts of the nervous system in controlling posture and balance [3]. The vestibular system has both sensory and motor function [4]. Sensory function and somatosensory and visual senses by acting in conjunction with the central nervous system allow the body to perceive the position and movement. With motor function, vestibular system controls the eyes, head and trunk with the inputs sent to motor pathways such as vestibulospinal path and provides coordination of postural movements [5]. Vestibular disorders due to inner ear pathology or central dysfunction causes symptoms such as dizziness and balance disorders [6].

Exposure to high-intensity sound level may cause irreversible hearing loss. The effects of exposure to high-intensity sound level on the hearing system have been supported by the results achieved in both human and animal experiments [7]. Noise-induced hearing loss can occur due to overexposure to acoustic stimuli, either acute or chronic. Environmental and occupational factors are the two most important factors that cause hearing loss due to chronic noise [8]. Noise-induced hearing loss can be studied in two categories. The first is direct mechanical trauma, and the second is the metabolic injury of the cortical organ [9]. Similar to the effects of acoustic trauma on the cochlea, some parts of the vestibular system may also be affected [10]. Many studies have shown that these patients with hearing loss experience balance problems. The reason for the low incidence of clinical symptoms is explained by central nervous system compensation [8].

The close relationship between the vestibular labyrinth and the auditory system, the great similarity between the hair cells and the presence of both balance and hearing receptors in the membranous labyrinth and the vascularization of both the cochlea and the vestibular end organ through the same artery support the association between noise-induced hearing loss and vestibular disorder [11]. Although the negative impact of high-intensity sound level on the cochlea and hearing has been well explained, there is not enough information about the effect on the vestibular system.

In this context, the aim of this study was to investigate the effects of exposure to high-intensity sound on vestibular functions and balance in the Edirne Band musicians. We believe that the results of this study will contribute to the explanation of possible effects on vestibular system in individuals working at the band and in the occupational groups exposed to chronic high-intensity sound.

2 Materials and methods

2.1 Participants

The study was approved by the Scientific Research Ethics Committee of the Faculty of Medicine of Trakya University under approval code 2017/234 and was carried out in accordance with the Declaration of Helsinki. The participants were informed about the aim of the study and the evaluations to be made and their consent was obtained.

The study group included individuals over 18 years of age, had at least 5 years of experience at the band and who had no diagnosed vestibular disease, no cervical spine problems or musculoskeletal problems during the evaluation. Of the 30 people working in the band, one person excluded because of a diagnosed vestibular problem, 3 people for less than 5 years of experience, 2 people for not willing to participate in the study and 2 people for retiring during the research phase. A total of 22 individuals were included. For the control group, 22 individuals working in the Trakya University, with similar sociodemographic characteristics were included.

2.2 Assessments

The socio-demographic questionnaire was used to obtain the demographic characteristics and alcohol-cigarette use of the individuals. The Dizziness Han-dicap Inventory (DHI) was applied to determine the quality of life related to dizziness, and the Activities-Specific Balance Confidence Scale (ABC) was used to investigate how they feel about their balance. Ind-ividuals’ balance and vestibular functions were evaluated with Romberg and Unterberger’s tests using a 3D ultrasonic motion analysis system.

Dizziness Handicap Inventory (DHI): DHI is a questionnaire that evaluates the quality of life and the disability caused by complaints related to dizziness and imbalance. DHI, developed by Jacobson and Newman, is a 25-item scale that identifies sensory and functional outcomes in patients with vestibular system problems, as well as factors affecting dizziness and balance disorder [12]. Three subscales are aimed to determine the physical, sensory and functi-onal effects of vestibular system diseases. The subscale scores which are considered as the limit for the determination of disability are 28 points for physical disability and 36 points for functional and sensory disability. Higher scores indicate that the person has more disability due to dizziness. According to the to-tal score taken from the scale, people are divided into 3 groups: 0–30 points (mild disability), 31–60 points (moderate disability), 61–100 points (severe disability) [13]. The validity and reliability study of the scale into Turkish was done by Karapolat et al. [14].

Activities-Specific Balance Confidence Scale (ABC): ABC, developed by Myers and Powel, is a questionnaire based on evaluations of how confidently they can do 16 activities within and outside the house. Each activity scored between 0 (insecure) and 100 (completely confident) [15]. The total score (0–1600) is divided into 16 and the individual’s ABC score is obtained. It has been shown to be reliable in patients with vestibular dysfunction [16]. The validity and reliability study of the scale into Turkish was done by Ayhan et al. [17].

Romberg and Unterberger tests: To evaluate the balance and vestibular functions of the participants, the Zebris CMS20P-2 device (Zebris Medical GmbH, Isny, Germany) at Trakya University Medical Faculty Anatomy Department, Motion Analysis Laboratory was used (Fig. 1). In this system, 3-dimensional ultrasonic static and dynamic balance evaluation were performed by using transmitters and measuring device fixed to the body. Romberg and Unterberger’s tests were assessed in this system. All measurements were performed in a quiet environment. For the Romberg test, the participant was asked to stand in quiet stance for 60 seconds with his eyes closed, his feet contiguous, and his shoulders at 90 degrees flexion. The sway during the test in medio-lateral direction (Lateral sway) and anterior-posterior direction (Longitudinal sway) were recorded. The distance covered by head movement (Forehead covering area) and the end position of the head in comparison to the shoulders (Torticollis angle) were also determined. For the Unterberger’s test, subjects closed their eyes and began stepping in place at their own pace for 60 seconds with shoulder at 90 degrees flexion, arms extended forward. The movement from initial position to end position in anterior-posterior direction (Longitudinal deviation) and medio-lateral direction (Lateral deviation) were recorded. The angle of rotation between the initial and end positions (Angular deviation) and angle of rotation on their own vertical axis (self spin angle) were determined. Data was evaluated with WinBalance software on a Microsoft Windows 7 installed computer (Fig. 2). After the initial calibration of the system for each measurement, postural sway distances and head movements in the Romberg test were recorded for 60 seconds. Then the system was recalibrated for the Unterberger’s test and the rotation, displacement and oscillations of the body axis through the transmitters were recorded for 60 seconds. Data were recorded in the software on the computer [18]. The normal values of the Romberg test are between 1.75 cm–10.53 cm for the longitudinal sway and between 1.74 cm to 7.06 cm for the lateral sway. In the Unterberger’s test, the normal values are between 30.03 cm and 113.35 cm for longitudinal deviation, between 5.17 cm and 16.15 cm for the lateral deviation [19]. The flow chart of the study is shown in Fig. 3.

Fig. 1

Zebris system components (WinBalance user manual, Zebris Medical GmbH) [18].

Fig. 2

Zebris system postural sway data (WinBalance user manual, Zebris Medical GmbH) [18].

Fig. 3

Study flow diagram.

2.3 Statistical analysis

Statistical analyses were performed using SPSS version 22.0 software (SPSS, Inc., Chicago, IL, USA). Descriptive statistics were given using mean and standard deviation. The suitability of the variables to normal distribution was examined by visual (histogram) and analytical methods (Kolmogorov-Smirnov and Shapiro-Wilk tests). Chi-square test was used to compare categorical variables between groups. For the numerical measurements, the Mann-Whitney U test was used for parameters which did not show normal distribution and Independent Samples T-Test for parameters showed normal distribution. The Scheirer-Ray-Hare test was used to evaluate if there is a possible effect of cigarette and alcohol consumption on the analysis of assessed parameters. The results were evaluated with a confidence interval of 95%and a significance level of p < 0.05.

3 Results

The study group consisted of 22 men working in the Edirne Band and 22 men working at Trakya University as the control group. The age of the band ranged from 25 to 50, with a mean of 37.09±6.83 years. The age of the control group ranged from 25 to 54 years, with a mean of 37.36±7.22 years. The mean BMI of the control group was 27.14±5.39 kg/m². In the band group, the mean BMI was 27.10±3.88 kg/m² (Table 1). The working time of the band group for Edirne Band ranged from 5 to 21 years, with a mean of 9.45±3.87 years. There was no statistically significant difference between the band and the control group in terms of age, height, weight and BMI values (p > 0.05) (Table 1).

Table 1
Demographic information of the study participants

Band group (n = 22) Control group (n = 22) P value¹

Mean±standard deviation Median Mean±standard deviation Median

Age (year) 37.09±6.83 39.00 37.36±7.22 35.00 p = 0.898

Height (m) 1.76±0.060 1.75 1.77±0.059 1.76 p = 0.919

Weight (kg) 84.41±12.41 82.50 83.78±14.79 80.00 p = 0.878

BMI (kg/m²) 27.10±3.88 26.17 27.14±5.39 26.11 p = 0.980

	Band group (n = 22)	Control group (n = 22)	P value¹
Age (year)	37.09±6.83	39.00	37.36±7.22	35.00	p = 0.898
Height (m)	1.76±0.060	1.75	1.77±0.059	1.76	p = 0.919
Weight (kg)	84.41±12.41	82.50	83.78±14.79	80.00	p = 0.878
BMI (kg/m²)	27.10±3.88	26.17	27.14±5.39	26.11	p = 0.980

1: Independent Samples T-Test.

Table 2 shows the mean, standard deviation and median values of the physical, functional, emotional subscales and total scores of Activity-Specific Balance Confidence Scale and the Dizziness Handicap Inventory scores of individuals. There was a statistically significant difference between two gr-oups in terms of ABC score (p = 0.003), DHI total score (p < 0.001), physical (p < 0.001), functional (p < 0.001) and emotional subscale (p = 0.020) scores (Table 2).

Table 2

Comparison of groups in terms of DHI and ABC scale scores

	Band group (n = 22)		Control group (n = 22)		P value¹
	Mean±standard deviation	Median	Mean±standard deviation	Median
ABC scale score	1472.27±20.56	1500.00	1546.81±9.63	1560.00	P = 0.003
DHI physical subcale	4.45±0.64	3.00	1.18±0.39	0.00	P < 0.001
DHI functional subcale	3.64±0.60	4.00	1.27±0.65	0.00	P < 0.001
DHI emotional subcale	1.45±0.53	0.00	0.45±0.37	0.00	P = 0.020
DHI total score	9.55±1.38	9.00	2.73±1.25	0.00	P < 0.001

1: Mann-Whitney U test.

The mean, standard deviation and median values of the Zebris 3D ultrasonic measurements of the groups are shown in Table 3. There was a statistically significant difference only in terms of torticollis angle (p = 0.011) between the two groups during the Romberg test (Table 3).

Table 3

Comparison of groups in terms of Zebris 3D ultrasonic measurement results

	Band group (n = 22)		Control group (n = 22)		P value
	Mean±standard deviation	Median	Mean±standard deviation	Median
Romberg test longitudinal sway (cm)	5.65±0.41	5.60	5.62±0.50	5.45	p = 0.733¹
Romberg test lateral sway (cm)	2.52±0.34	2.10	2.25±0.27	1.85	p = 0.347¹
Romberg test forehead covering area (cm)	18.23±4.26	12.60	16.25±3.21	13.50	p = 0.742¹
Romberg test torticollis angle (degree)	4.99±0.72	3.60	11.01±1.93	8.10	P = 0.011¹
Unterberger’s test longitudinal deviation (cm)	80.39±5.73	80.35	57.59±4.61	58.90	P = 0.004²
Unterberger’s test lateral deviation (cm)	24.95±6.69	10.20	14.05±1.35	12.90	p = 0.742¹
Unterberger’s test angular deviation (degree)	22.47±4.72	14.10	20.90±4.21	13.05	p = 0.944¹
Unterberger’s test self spin (degree)	47.99±9.36	37.70	24.70±5.41	16.10	P = 0.035¹

1: Mann-Whitney U test. 2: Independent Samples T-Test.

There was a statistically significant difference in longitudinal displacement distance (p = 0.004) and self-spin angle (p = 0.035) between the two groups during the Unterberger test, there was no significant difference between the other values (p > 0.05) (Table 3).

Smoking and alcohol consumption rates of the groups are shown in Table 4. A statistically significant difference was found between the two groups in terms of both smoking (p < 0.001) and alcohol consumption rates (p = 0.015) (Table 4).

Table 4

Smoking and alcohol consumption

	Band group (n = 22)		Control group (n = 22)		P calue¹
	Yes	No	Yes	No
Smoking	16 (%73)	6 (%27)	4 (%18)	18 (%82)	P < 0.001
Alcohol consumption	17 (%77)	5 (%23)	9 (%41)	13 (%59)	P = 0.015

1: Chi-Square tests.

In the analysis performed by the Scheirer-Ray-Hare test, it was found that smoking did not affect the relationship between results of group comparisons on ABC scores, DHI scores, Romberg and Unterberger test (p > 0.05) (Table 5). Also, it was found that alcohol consumption did not affect the relationship between the results of group comparisons on ABC scores, DHI scores, Romberg and Unterberger test (p > 0.05) (Table 6).

Table 5

Results of Scheirer-Ray-Hare test for DHI and ABC scale scores

	Df	SS	H	P value
ABC scale score
Smoking	1	457.18	2.79	p = 0.095
Alcohol consumption	1	20.21	0.12	p = 0.726
DHI physical subcale
Smoking	1	183.91	1.21	p = 0.272
Alcohol consumption	1	417.29	2.74	p = 0.098
DHI functional subcale
Smoking	1	12.41	0.09	p = 0.770
Alcohol consumption	1	182.80	1.26	p = 0.262
DHI emotional subcale
Smoking	1	59.46	0.63	p = 0.428
Alcohol consumption	1	49.75	0.52	p = 0.469
DHI total score
Smoking	1	116.80	0.74	p = 0.390
Alcohol consumption	1	430.61	2.72	p = 0.099

DF: Degrees of freedom; SS: Sum of squares; H: Scheirer-Ray-Hare non-parametric two-way analysis of variance statistic. 1: Scheirer-Ray-Hare test.

Table 6

Results of Scheirer-Ray-Hare test for Zebris 3D ultrasonic measurement results

	Df	SS	H	P value¹
Romberg test longitudinal sway
Smoking	1	15.09	0.09	p = 0.762
Alcohol consumption	1	23.12	0.14	p = 0.708
Romberg test lateral sway
Smoking	1	175.63	1.07	p = 0.301
Alcohol consumption	1	81.93	0.50	p = 0.480
Romberg test forehead covering area
Smoking	1	208.51	1.26	p = 0.261
Alcohol consumption	1	9.87	0.06	p = 0.807
Romberg test torticollis angle
Smoking	1	42.81	0.26	p = 0.610
Alcohol consumption	1	382.09	2.32	p = 0.128
Unterberger’s test longitudinal deviation
Smoking	1	6.57	0.04	p = 0.842
Alcohol consumption	1	38.57	0.23	p = 0.629
Unterberger’s test lateral deviation
Smoking	1	97.92	0.59	p = 0.441
Alcohol consumption	1	38.81	0.24	p = 0.628
Unterberger’s test angular deviation
Smoking	1	69.37	0.42	p = 0.517
Alcohol consumption	1	170.47	1.03	p = 0.309
Unterberger’s test self spin
Smoking	1	1.05	0.01	p = 0.936
Alcohol consumption	1	190.28	1.15	p = 0.283

DF: Degrees of freedom; SS: Sum of squares; H: Scheirer-Ray-Hare non-parametric two-way analysis of variance statistic. 1: Scheirer-Ray-Hare test.

4 Discussion

This study aimed to compare the band musicians exposed to loud noise for a long time in terms of balance and vestibular tests. Results of the study showed that the balance, quality of life and vestibular system function parameters of the band exposed to noise were found to be affected negatively compared to the control group. In this context, the results of this study indicate the presence of possible vestibular system dysfunction in the band group and are compatible with the literature.

In the literature, first of all, Haberman described balance disorders in repairers with professional hearing loss, in the 1890s. Later, in 1929, Tullio found vestibular reactions in response to acoustic trauma [20].

In animal experiments, the study of mice exposed to high intensity, sudden sound showed that vestibular evoked potentials of the otolithic organs were changed, while the vestibular evoked potentials of the semicircular canal remained the same [21]. In a study investigating the functional and morphological effects of hearing and vestibular system on guinea pigs exposed to 120 dB intensity for one hour, it was found that the acoustic trauma affects both cochlear and vestibular organs, although the acoustic and vestibular function loss correlates, loss of function in the auditory system is higher [22]. In the study which examined the effects of high intensity sound on the vestibular system of guinea pigs, it was stated that there was a vestibular detriment and the detriment was permanent [23]. In the study performed in mice exposed to sound at 116 dB for three hours, it was stated that loud voice caused serious damage in the peripheral vestibular system as well as hearing loss, but these damages could not be observed with a significant vestibular symptom [24].

In human experiments, the study of vestibular evoked potentials in individuals with noise induced hearing loss, it was shown that vestibular problems were associated with hearing and the possibility of developing vestibular system dysfunction increased significantly in people with chronic noise exposure. It has been suggested that metabolic damage of the sacculocolic reflex may be the cause of abnormal vestibular function values [25]. In the study, which examined neuro-otological symptoms (dizziness, imbalance, nausea) and quality of life in factory workers exposed to noise, it was stated that exposure to noise increased the incidence of neurotological symptoms and negatively affected the quality of life [26]. Raghunath et al. in their study on factory workers, found that prolonged exposure to noise could lead to vestibular symptoms without clinically detectable hearing loss. The reasons for neglecting these symptoms are connected to the absence of functional cap-acity loss [27]. However, Dalgıç et al. could not find a relationship between vestibular dysfunction and noise-induced hearing loss and stated that damage in the vestibular structures are less than damage in the cochlea [28]. In another study conducted in individuals with noise-induced hearing loss showed that the function of the cochlea, sacculus, utriculus, and semicircular canals are impaired after chronic noise exposure and this impairment is greater in the cochlea and sacculus [29]. Similar to this study, Zeigelboim et al. studies musicians working in the military band and showed that, according to the caloric test results, 37%of individuals showed vestibular problems, of which dizziness was most common [30].

In the study investigating the vestibular system and balance scales used for evaluating dizziness and balance problems, the DHI and ABC scale have been shown to be reliable in determining balance confidence, perceived disability, and fear of falls in people who experience dizziness or balance problems [31]. Whitney et al. investigated the ABC scale and DHI in patients with vestibular dysfunction and found that ABC scale and DHI has a negative correlation. They also stated that these scales are simple and effective for assessing balance in everyday activities and the quality of life [32]. These data indicate that DHI and ABC are useful tools in defining vestibular pathologies and are effective tools for evaluating the balance and quality of life of individuals. Our study indicates a possible vestibular dysfunction in the band group, which has significantly lower ABC scale score and higher score of DHI total and all its subscales.

In studies using Unterberger and Romberg tests, Serafini et al. compared the results of Unterberger test of the normal group with individuals with peripheral vestibular dysfunction and they showed that there was no difference between the groups in terms of lateral displacement distance, torticollis angle and lateral swing but the angular displacement distance and the self-spin angle were significantly higher in vestibular dysfunction group [33, 34]. Szirmai et al. used the 3D ultrasonic evaluation system similar to our study and stated that the higher displacement distance and the self-spin angle in Unterberger test performed with the 3-dimensional ultrasonic system will indicate the vestibular system pathology [35]. The Romberg test showed that the amount of longitudinal sway was significantly higher in the vestibular pathology and there was no difference between the lateral sway distances. Head covering area was significantly lower in the normal group and the torticollis angle was not significantly different between the groups but higher in the normal group. In the Unterberger test, it was found that the longitudinal deviation distance was significantly higher in the groups with pathology, whereas the lateral sway distance was higher within the normal limits in the central pathology group, but there was no significant difference between the angular deviation and self-spin degree values [35]. Finally, Juntunen et al. examined the postural sways in military personnel who had noise-induced hearing problems and reported that individuals exposed to prolonged high-intensity noise showed more sway in posturography tests than normal individuals [36]. In our study, although there was no significant difference between the groups in terms of longitudinal sway distances and forehead covering areas in the Romberg test results, these values were higher in the band group. Torticollis angle values were significantly higher in the normal group. When compared with the Unterberger test results, the longitudinal deviation distance and self-spin angle values were significantly higher in the band group. Although there was no significant difference between the groups in terms of lateral sway and angular deviation values, these values were higher in the band group. In this context, the results of our study indicate a worse postural control in the band group exposed to noise in accordance with the literature and indicates a possible vestibular dysfunction.

5 Conclusion

In this study, we aimed to investigate the effects of exposure to high-intensity sound on vestibular functions and balance in the musicians of the Edirne Band. Compared to the control group, the individuals exposed to high-intensity sound had a significantly greater range of displacement and self-spin angles in Unterberger’s test, significantly lower ABC scores, and significantly higher scores in the DHI total score and all subscale scores. When the groups were compared in terms of Romberg test results, although there was no significant difference except the torticollis angle, the anteroposterior sway and lateral sway values were higher in the band group.

As a result, the study showed that balance, quality of life and vestibular system function were affected in the experimental group who exposed to high-intensity sound for a long time and that possible vestibular system problems should be taken into consideration when examining musicians playing in a band.

The limitations of the study are the difference between the group’s alcohol and cigarette consumption rates and lack of a gold standard evaluation method for the vestibular system. We used the Sch-eirer-Ray-Hare Test to eliminate the effects of alcohol consumption and smoking on the results. Another limitation of the study is that auditory functions of participants and high sound pressure levels (as dB) were not evaluated. Studies conducted with multidisciplinary teams, using objective assessment methods in the occupational groups exposed to noise for long time will contribute to the literature.

Conflict of interest

None to report.

Footnotes

Acknowledgments

This is an original work. It has never been published nor has been under consideration for publication elsewhere. All authors have substantially contributed to the study.

References

Tramontano

, Martino Cinnera

, Manzari

, Tozzi

, Caltagirone

, Morone

, et al. Vestibular rehabilitation has positive effects on balance, fatigue and activities of daily living in highly disabled multiple sclerosis people: A preliminary randomized controlled trial. Restor Neurol Neurosci. 2018;36(6):709–18.

Takakusaki

. Functional neuroanatomy for posture and gait control. J Mov Disord. 2017;10(1):1.

Nardone

, Turcato

. An Overview of the Physiology and Pathophysiology of Postural Control. Advanced Technologies for the Rehabilitation of Gait and Balance Disorders: Springer; 2018. pp. 3–28.

Cullen

. The vestibular system: multimodal integration and encoding of self-motion for motor control. Trends in Neurosciences. 2012;35(3):185–96.

Herdman

, Clendaniel

. Vestibular rehabilitation: FA Davis; 2014.

Brandt

, Dieterich

. The dizzy patient: don’t forget disorders of the central vestibular system. Nat Rev Neurol. 2017;13(6):352.

Clark

, Bohne

. Effects of noise on hearing. Jama. 1999;281(17):1658–9.

Golz

, Westerman

, Goldenberg

, Netzer

, Wiedmyer

, et al. The effects of noise on the vestibular system. Am J Otolaryngol. 2001;22(3):190–6.

Hou

, Wang

, Zhai

, Hu

, Yang

, He

. Effects of α-tocopherol on noise-induced hearing loss in guinea pigs. Hearing Research. 2003;179(1-2):1–8.

10.

Shupak

, Bar-el

, Podoshin

, Spitzer

, Gordon

, Ben-david

. Vestibular Findings Associated with Chronic Noise Induced Hearing Impairment. Acta Oto-Laryngologica. 2009;114(6):579–85.

11.

Lonsbury-Martin

, Martin

, Telischi

. Noiseinduced hearing loss. Philadelphia, Mosby Elsevier. 2010;2140:2152.

12.

Jacobson

, Newman

. The development of the Dizziness Handicap Inventory. Arch Otolaryngol Head Neck Surg. 1990;116(4):424–7.

13.

Treleaven

. Dizziness Handicap Inventory (DHI). Australian Journal of Physiotherapy. 2006;52(1):67.

14.

Karapolat

, Eyigor

, Kirazlı

, Celebisoy

, Bilgen

, Kirazli

. Reliability, Validity and Sensitivity to Change of Turkish Dizziness Handicap Inventory (DHI) in Patients with Unilateral Peripheral Vestibular Disease. Journal of International Advanced Otology. 2009;5(2).

15.

Powell

, Myers

. The activities-specific balance confidence (ABC) scale. The Journals of Gerontology Series A: Biological Sciences and Medical Sciences. 1995;50(1):M28–M34.

16.

Legters

, Whitney

, Porter

, Buczek

. The relationship between the Activities-specific Balance Confidence Scale and the Dynamic Gait Index in peripheral vestibular dysfunction. Physiother Res Int. 2005;10(1):10–22.

17.

Ayhan

, Büyükturan

, Kirdi

, Yakut

, Güler

. The Turkish Version of the Activities Specific Balance Confidence (ABC) Scale: Its Cultural Adaptation, Validation and Reliability In Older Adults 2014;17(2):157–63.

18.

Zebris Medical GmbH. WinBalance for Windows: User Manual. Isny, Germany. 2006.

19.

Claussen

, Franz

. Contemporary & practical neurooto-logy. Solvay. Hannover, 2006—410 pp. 2006.

20.

Addams-Williams

, Wu

, Ray

. The experiments behind the Tullio phenomenon. J Laryngol Otol. 2014;128(3):223–7.

21.

Perez

, Freeman

, Cohen

, Sohmer

. Functional impairment of the vestibular end organ resulting from impulse noise exposure. Laryngoscope. 2002;112(6):1110–4.

22.

Fetoni

, Ferraresi

, Picciotti

, Gaetani

, Paludetti

, Troiani

. Noise induced hearing loss and vestibular dysfunction in the guinea pig. Int J Audiol. 2009;48(11):804–10.

23.

Akdogan

, Selcuk

, Take

, Erdogan

, Dere

. Continuous or intermittent noise exposure, does it cause vestibular damage? An experimental study. Auris Nasus Larynx. 2009;36(1):2–6.

24.

Stewart

, Yu

, Huang

, Maklad

, Tang

, Allison

, et al. Effects of high intensity noise on the vestibular system in rats. Hear Res. 2016;335, 118–27.

25.

Kumar

, Vivarthini

, Bhat

. Vestibular evoked myogenic potential in noise-induced hearing loss. Noise Health. 2010;12(48):191–4.

26.

OrHaN

, Müjdecİ

. Investigation of health-related quality of life in factory workers who work in noisy environments. 2016.

27.

Raghunath

, Suting

, Maruthy

. Vestibular symptoms in factory workers subjected to noise for a long period. Int J Occup Environ Med. 2012;3(3):136–44.

28.

Dalgic

, Yilmaz

, Hidir

, Satar

, Gerek

. Analysis of Vestibular Evoked Myogenic Potentials and Electrocochleography in Noise Induced Hearing Loss. J Int Adv Otol. 2015;11(2):127–32.

29.

Tseng

, Young

. Sequence of vestibular deficits in patients with noise-induced hearing loss. Eur Arch Otorhinolaryngol. 2013;270(7):2021–6.

30.

Zeigelboim

, Gueber

, Silva

TPd

, Liberalesso

PBN

, Gonçalves

CGdO

, Faryniuk

, et al. Vestibular findings in military band musicians. International Archives of Otorhinolaryngology. 2014;18(2):122–7.

31.

Friscia

, Morgan

, Sparto

, Furman

, Whitney

. Responsiveness of self-report measures in individuals with vertigo, dizziness, and unsteadiness. Otol Neurotol. 2014;35(5):884–8.

32.

Whitney

, Hudak

, Marchetti

. The activities-specific balance confidence scale and the dizziness handicap inventory: a comparison. J Vestib Res. 1999;9(4):253–9.

33.

Serafini

, Caovilla

, Gananca

. Computerized analysis of established craniocorpography. Int Tinnitus J. 2002;8(2):97–9.

34.

Serafini

, Caovilla

, Gananca

. Digital craniocorpography and peripheral vestibular diseases. Int Tinnitus J. 2008;14(1):34–6.

35.

Szirmai

, Maihoub

, Tamás

. Usefulness of ultrasound-computer-craniocorpography in different vestibular disorders. The International Tinnitus Journal. 2014;19(1):6–9.

36.

Juntunen

, Ylikoski

, Ojala

, Matikainen

, Ylikoski

, Vaheri

. Postural Body Sway and Exposure to High-Energy Impulse Noise. The Lancet. 1987;330(8553):261–4.