The aim of this review was to summarize the studies on noise-induced hearing loss (NIHL) which were carried out in the countries of Central and Eastern Europe, South-East Europe, and former Soviet Union countries or Newly Independent States in the period from 1970 to 2012. The papers were identified by literature search of all accessible medical and other databases (Scopus, PubMed, Medline, etc.) using the terms "noise; hearing loss, NIHL" as key words and country denomination (in alphabetical order: Armenia, Azerbaijan, Belarus, Bulgaria, Bosnia and Herzegovina, Croatia, Czech Republic, Georgia, Hungary, Montenegro, Poland, Romania, Russian Federation, Serbia, Slovakia, Slovenia, former Yugoslavia, Ukraine). This review comprises both papers published in peer-reviewed international journals and articles from local sources. The main papers' topics included the assessment of the noise hazards in occupational, and very seldom in communal environment, and the prevalence of hearing impairment in employees. Simultaneously, attempts were undertaken to establish the relationship between the degree of hearing impairment and noise exposure. The effect of combined exposures to noise and vibration and/or otoxic chemicals was assessed as well. The influence of environmental, individual, and genetic risk factors on NIHL development was intensively examined. In addition, studies concerning the role of otoacoustic emissions for NIHL monitoring and clinical examinations were conducted. Some animal researches, including molecular genetics, had been also performed. The majority of papers concerned occupational exposures, whereas only a few were dedicated to community noise.
Keywords: Impulse noise, musicians, noise, noise-induced-hearing loss, organic solvents
|How to cite this article:|
Pawlaczyk-Luszczynska M, Dudarewicz A, Zaborowski K, Zamojska M, Sliwinska-Kowalska M. Noise induced hearing loss: Research in central, eastern and south-eastern Europe and newly independent states. Noise Health 2013;15:55-66
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Pawlaczyk-Luszczynska M, Dudarewicz A, Zaborowski K, Zamojska M, Sliwinska-Kowalska M. Noise induced hearing loss: Research in central, eastern and south-eastern Europe and newly independent states. Noise Health [serial online] 2013 [cited 2015 May 29];15:55-66. Available from: http://www.noiseandhealth.org/text.asp?2013/15/62/55/107157
| Introduction|| |
Hearing loss is the third most common disease in the adult population, ranked after cardiovascular diseases and hypertension. It has been estimated that worldwide, as much as 500 million individuals might be at the risk of developing noise-induced hearing loss (NIHL). 
Acoustic trauma is a sensorineural hearing loss that can appear after a single exposure to a high-level noise impulse, whereas NIHL is a sensorineural hearing impairment that develops over years of exposure to noise at moderately high levels. It is predominantly noted in the high-frequency region, with typical notch at 4-6 kHz. Individual susceptibility (or vulnerability) to noise along with the degree of hearing loss varies greatly among people.  It is believed that NIHL is a complex disease resulting from the interaction between intrinsic and environmental factors.  Besides well-known environmental factors contributing to NIHL, such as exposure to noise, some others may also play a role. They include, e.g., impulsiveness of noise (impulse noise is more harmful than steady-state noise at the same equivalent level); exposure paradigm (breaks in noise exposure allow for the recovery); co-exposures to certain chemicals (organic solvents and heavy metals), ,, co-exposure to noise and vibration;  ototoxic drugs (aminoglycosides)  and heat.  Associations have also been observed between several individual factors and NIHL, including smoking,  elevated blood pressure,  cholesterol levels, skin pigmentation, gender and age. , In contrast to environmental factors, very little is currently known about the genetic basis of NIHL. However, some recent studies suggest a possible role of potassium-recycling pathway genes and oxidative-stress genes in determining the individual susceptibility to NIHL. Other candidate genes for NIHL susceptibility are cadherine genes) responsible for the synthesis of protein components of inter-stereocilia links on cochlear hair cells. 
NIHL, a major byproduct of noisy machinery and/or technological processes in industrial settings, is considered as one of the most common occupational health hazards which carries not only an enormous cost in workers' compensation and pensions but also an even greater social cost due to loss of productivity and damage to quality of life. The prevalence of hearing loss among workers in noisy industries has been recognized since ancient times. Clinical observations of NIHL have been reported for more than a century. Beyond the workplace, the risk of hearing loss arises from some environmental exposure like hard-rock concerts, loud music listening, personal music players (PMP), shooting, military service, and fireworks. The European Union officially recognizes the importance of protecting workers from risks to health in noisy environments as specified in Directive 2003/10/EC.  Countries from South-East Europe (SEE), Central and Eastern Europe (CEE), and Newly Independent States (NIS) that are members of European Union were obliged to implement this noise directive before 15 February 2006. However, for decades, the studies on noise impact on hearing were conducted in many countries independently of this implementation process. But, due to language, financial or political barriers, the results of these investigations are not well-known.
This paper focuses on investigations concerning NIHL predominantly related to workplace, and carried out during last few decades in the countries specified above.
| Methods|| |
This review includes papers on noise impact on hearing published from 1970 till 2012. Papers were identified by literature search of all accessible medical and other databases (Scopus, PubMed, Medline, etc.) using the terms "noise, hearing loss, NIHL" as key words and country denominations such as CEE states (i.e., Poland, Hungary, former Czechoslovakia, Czech Republic, and Slovakia), and SEE states (i.e., Albania, Bulgaria, Romania, former Yugoslavia, Bosnia and Herzegovina, Croatia, Macedonia, Montenegro, Slovenia, and Serbia) and former Soviet Union (FSU) or NIS (i.e., Armenia, Azerbaijan, Belarus, Estonia, Georgia, Kazakhstan, Kyrgyzstan, Latvia, Lithuania, Moldova, Russia, Tajikistan, Turkmenistan, Ukraine, Uzbekistan).
This review includes not only papers published in peer-reviewed journals, but also articles from local sources which were published in national languages. However, due to the large number of publications, our attempt was to point out only the most important issues concerning NIHL.
| Results|| |
In general, a huge number (almost 300) of papers concerning the NIHL were collected. Most of them were from Czechoslovakia (or Czech Republic), FSU (or Russia), and Poland. The most representative publications for each country are described briefly in this study [Figure 1].
|Figure 1: Proportions of reviewed papers on noise-induced hearing loss from various countries of Central and Eastern Europe, South-East Europe and newly independent states. Data covered papers published between 1970 and 2012 included in the scopus data base|
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Central and Eastern Europe countries
In the beginning of the 70's of the 20 th century, studies carried out in Poland were mainly aimed at evaluation of exposure to noise and its effect on hearing loss in workers from various sections of industry, e.g., workers of the textile industry,  ship crews  or miners.  The influence of co-exposure to noise and hand-transmitted vibration on NIHL in workers was also analyzed.  It was proved that there was a certain interdependence between susceptibility to hand-transmitted vibration and susceptibility to acoustic trauma, and it was also concluded that the vibration disease frequently co-exists with the occupational hearing impairment.
Despite the possible risk of NIHL in workers, the risk of hearing impairment in children from mothers exposed to noise during pregnancy was also investigated.  The results suggested that working in noise at levels not exceeding 90 dB should not be harmful to the inner ear of the fetus. Since other harmful factors such as ototoxic drugs, maternal diseases, vibration, etc., together with low-level acoustic stimuli (which normally would cause no harmful effects), might produce an impairment, it was suggested that, until the above- mentioned problems have been cleared-up, it is safer to prevent pregnant women from working in noisy conditions.  Attempts were also made to evaluate the impact of excessive noise in schools, especially in school workshops, on the hearing status in the students of vocational schools and secondary schools.  Zalewski  carried out a laryngological and audiometric investigation of 1026 students of vocational schools and 208 students from secondary schools and found high frequency of hearing impairment in 36.3% of the vocational school students and 8.2% of secondary school students. Considerable hearing impairment including acoustic trauma was found in 7.3% of the vocational-school students and 2.4% from the other group. Unilateral acoustic trauma prevailed (70.6%), and hearing loss at a frequency of 6000 Hz was most frequent (48%). The prevalence of NIHL was explained as a result of exposure to excessive noise in schools, especially in school workshops. 
Simultaneously, the usefulness of various audiological tests (e.g., high-frequency pure tone audiometry [PTA], short-increment sensitivity index, Langenbeck's and Luscher-Zwislocki's, threshold tone decay, and Bekesy automatic audiometry, impedance and electrophysiologic [ERA] audiometry) in the diagnosis of hearing impairment due to noise exposure was analyzed. ,,, Later, the clinical application of otoacoustic emissions (OAEs) in the assessment of NIHL in industrial workers was intensively investigated. ,,,,,,,,
In the 90's of the 20 th century, the studies on OAE were launched by Sliwinska-Kowalska and co-workers.,,,, Extensive research was performed among the noise-exposed populations, and it has been shown that transiently evoked otoacoustic emissions (TEOAEs) and distortion-product otoacoustic emissions (DPOAEs) seem to be helpful in the differential diagnosis of occupational NIHL and allow in detecting malingering patients examined for hypoacusis. ,, Based on the longitudinal studies performed in weaving mill-workers and metal factory-workers, the same group of investigators have shown that TEOAE is a very useful tool of monitoring subtle changes in hearing caused by noise. , DPOAEs were further assessed in musicians with absolute pitch and it was shown that musical training influenced the cochlear mechanics and the greatest differences were associated with the active processes within the cochlea.  Moreover, the OAEs, particularly DPOAE contralateral suppression, was indicated as a valuable method for assessing early hearing damage caused by exposure to noise. 
The investigations aimed at the evaluation of noise exposure and the assessment of NIHL risk in various groups of workers are still conducted in Poland. For example, nowadays, Pawlaczyk-Luszczynska et al. ,, continue the studies on hearing loss in the orchestral musicians which were launched by Gryczynska and Czyzewski in 1977. They showed that professional orchestral musicians are exposed to sound at equivalent continuous A-weighted sound pressure levels of 81-90 dB, for 20-45 h per week. Exposure to such sound levels over 40 years of employment might cause hearing loss (exceeding 35 dB) of up to 26%. Playing the horn, trumpet, tuba, and percussion carries the highest risk. Moreover, high- frequency-notched audiograms typical for NIHL were found in 36% of ears of examined orchestral musicians. However, the measured hearing threshold levels (HTLs) were better than theoretical predictions according to ISO 1999:1990.  Therefore, it was concluded that music deteriorates hearing, but less than it would be from exposure to industrial noise at the same A-weighted equivalent-continuous level. ,,
The risk of NIHL in farm workers (farmers) has been investigated since 1997 by Solecki. ,,,,, His studies were aimed at the recognition and evaluation of annual exposure to noise as well as the assessment of the state of hearing among both private farmers and employees of large multiproduction farms. The studies showed that the mean annual noise- exposure level was up to 91 dB(A). The highest values of the total monthly exposure to noise usually occurred in the summer-autumn and winter seasons. During the former, the degree of noise load was directly associated with the intensity of field works and transport activities, whereas in the latter, it was associated with the frequency of using wood-cutting machines and repair activity.  The degree of hearing impairment significantly increased with age and the dose during the whole period of employment. The results allow to predict the upward tendency to hearing loss during occupational exposure of farmers to noise. 
At many workplaces, there is broadband noise dominated by frequency content of audible and low ultrasonic frequencies from 10 to 40 kHz, which is known as ultrasonic noise. This type of noise and its effects are usually given less consideration than audible noise. However, in the past, the risk of high-frequency hearing loss due to exposure to ultrasonic noise was analyzed by Grzesik and Pluta. , The authors looked at how the high-frequency hearing thresholds of 106 workers had been affected by noise from low-frequency ultrasonic technological devices such as cleaners and welders. It has been shown that noise levels greater than 80 dB in the 10, 12.5, and 16 kHz bands might cause a hearing loss in the range of 10-20 kHz. No abnormalities were found in the hearing range of 500-8000 Hz. It was concluded that the observed permanent high-frequency threshold shift depended upon the noise spectrum, daily time of exposure, and total time of job.  A follow-up paper was aimed at elucidating the dynamics of hearing loss of the ultrasonic workers after 3 consecutive years of exposure.  The observed hearing threshold shift in the range of 500 Hz-13 kHz was explained as the effect of aging, whereas in the range of 13-17 kHz (in which mean threshold elevation was found to be 2-5 dB), in addition to the hearing loss connected with aging within 3 years, the hearing loss was said to be the consequence of exposure to high-frequency noise. Later on, the possible harmful impact of ultrasonic noise on hearing was also studied by Pawlaczyk-Luszczynska et al.  The results of standard pure-tone audiometry were collected from 25 workers, mainly females, aged 23-58 years, exposed for 2-13 years to ultrasonic noise emitted by ultrasonic welders. Hearing tests were completed by evaluation of exposure to ultrasonic noise. Although the overexposure to ultrasonic noise was observed in most operators of welders, no significant progress of hearing impairment was found after exposure lasting up to 7 years.
For decades, Polish researchers have paid a special attention to impulse noise and its impact on hearing loss. ,,,,,,,, For example, Sulkowski and Lipowczan conducted noise measurements and audiometric tests in a large drop-forge factory. They analyzed the PTA results of drop-forge workers according to age, years of exposure, and in terms of percent of hearing loss, calculated according to the Fowler-Sabine formula. The observed permanent threshold shift contours were typical for NIHL. However, when audiometric HTLs were compared with the thresholds predicted according to the energy concept for steady-state noise, there was no good agreement between the actual and predicted data. The observed hearing loss was smaller than predicted at the lower audiometric frequencies, whereas at the higher audiometric frequencies, the observed hearing loss was greater than predicted. In their study of hearing loss in weavers, who were exposed to continuous noise, and drop-forge men, who were exposed to impulse noise of equivalent energy, Sulkowski et al .,  found that the hammer men had substantially worse hearing than the weavers. In the next study on impulse noise from drop-forge, besides NIHL, the prevalence of tinnitus was observed in workers, in particular in those with longer exposure duration. Moreover, it was concluded that the impulse noise-induced tinnitus might be sometimes more annoying than the hearing loss. 
The later investigations concerning the impact of impulse noise on hearing were mainly focused at impulse noise from weapons and explosions. ,,,, In particular, some of them were aimed to assess post-exposure changes in hearing measured by pure-tone audiometry and OAEs. , It has been shown that even short-term exposure to impulse noise (3-4 shoots at mean peak C-weighted sound pressure level [LC peak ] of 154 dB) from small-calibre firearms during target practice might cause temporary hearing impairment measured by TEOAE.  Similar results were noted in soldiers after shooting (15 single rounds of live ammunition at LC peak of 155-156 dB).  Moreover, when the post-exposure temporary shift of TEOAE levels was correlated with peak sound pressure and maximum sound pressure levels, a significant correlation was found for peak sound pressure and maximum sound pressure levels in 1/3-octave bands in the frequency range corresponding with the main part of the acoustic energy of impulses.  It was concluded that TEOAE was more sensitive than PTA in the assessment of temporary changes in the cochlea caused by impulse noise. In addition, the effectiveness of hearing-protection devices (HPDs) during shooting noise was confirmed by measuring both PTA and TEOAE. ,
Earlier, the effectiveness of different HPDs had been tested under laboratory conditions and in the real occupational environment by Pawlas and Grzesik.  Three methods were used, which included: (i) Physical, utilizing an artificial (dummy) head; (ii) subjective, real-ear, executed on trained human subjects; and (iii) subjective, by measuring, using PTA, of temporary threshold shift (TTS2) resulting from occupational one-workday exposure. The latter method was found to give the best data needed to define the protectors' efficiency, since this includes, simultaneously, the impact of various environmental factors, the subjective reactiveness, the nature of the professional task and the acoustical features of the protector used. Therefore, it was recommended for the estimation of the real protection offered to workers at risk of NIHL. 
At the beginning of 21 st century, Sliwinska-Kowalska,,,,, launched studies on the impact of co-exposure to noise and organic solvents on hearing loss in workers. The results of these investigations are widely available. These results provide the epidemiological evidence that exposure to organic solvents in humans is associated with an increased risk of hearing loss. The simultaneous exposure to organic solvents and noise seems to exacerbate the hearing deficit compared with isolated exposures.
Simultaneously, an optimal method of the retrospective classification of the workers into noise-susceptible and noise-resistant subjects based on the ISO 1999:1990  was developed,  which was used in the future genetic studies on NIHL-susceptibility genes. Based on the ISO 1999:1990,  a new method for the prediction of NIHL was also developed which, besides exposure to noise, takes into consideration other NIHL risk factors, such as co-exposure to organic solvents, smoking, and elevated blood pressure along with the impulsive character of noise and usage of HPDs.  For this purpose, the accessible data on exposure to noise and/or organic solvents, audiometric HTLs, as well as health status of 3741 employees of 24 factories were analyzed.
Genetic studies on NIHL constitute a relatively new approach. ,,, For example, Pawelczyk et al.,  suggested a possible role of potassium-recycling pathway genes in determining the individual susceptibility to NIHL. Another candidate gene for NIHL susceptibility is cadherin 23 (CDH23), which is a component of the inter-stereocilia links on the cochlear hair cells. 
In the Nofer Institute of Occupational Medicine, Lodz, Poland, apart of human studies, animal research had been performed in the past on guinea pig, chick, and mouse models under the leadership of Mariola Sliwinska-Kowalska. The morphological changes in the guinea pig's cochlea examined after exposures to noise using the light and electron microscopy were described. Subsequently, the morphological-structure studies were shifted to the chick's basilar papilla, which also served as an excellent model to prove hair-cell regeneration. ,, More recently, the same group used a mouse model to show the effectiveness of D-methionine in preventing hearing loss after exposure to noise. 
Czechoslovakia, the Czech Republic, and Slovakia
Similar to the other CEE countries, studies carried out in Czechoslovakia at the beginning of the 70's of the 20 th century were mainly aimed at evaluation of the exposure to noise and it's effect on hearing loss in various groups of workers, including uranium industry (mine) workers, textile (spinning mill and weaving factory) workers, as well as truck drives, forest workers, nail rifle operators, riveters, and professional and military orchestra musicians. ,,, The studies on HTLs in workers exposed to noise were continued till the end of the 20 th century.  There were also evaluations of preventive pre-employment examinations for working in noisy workplaces, e.g., the noisy sections of the uranium industry or railway. ,
Attempts were made to find out the relationship between NIHL and duration of the occupational service. , The NIHL risk assessment in some groups of workers was also evaluated. , For example, Jablonicky and Blizniak  evaluated the risk of hearing handicap in 1311 workers of the textile industry (minimum and maximum A-weighted sound pressure level of 95-90 dB and 100-105 dB, respectively and found out that it was lower than expected from ISO 1999:1975. 
The impact of non-occupational factors such as exposure to noise in the living environment on the resultant hearing loss was also analyzed.  In a group of 212 engineering plant workers exposed to excessive noise, the speed of hearing loss for the frequency 4000 Hz was found to be significantly dependent on the noisiness in the living area, i.e., in the non-occupational environment. Higher losses for the given frequency had been found in workers living in an area with daily equivalent noise level exceeding 60 dB(A), whereas for the other frequencies (500, 1000, 2000 and 6000 Hz) there were no significant differences. 
The epidemiological investigations on NIHL was a basis for developing hearing conservation programs involving in particular development and promotion of hearing tests in workers exposed to noise. ,,, The efficiency of different HPDs in various noise conditions was verified. ,
Over the last few decades, several reports on occupational diseases, in particular including NIHL, were published, ,, indicating that occupational hearing loss was one of the most frequent occupational disease in the former Czechoslovakia as well as in the Czech Republic.
The impact of noise exposure on the auditory system was extensively investigated in laboratory experiments on animal models. The main subjects of these studies were: (i) The mechanical damage and morphological changes of inner-ear structures after acoustic trauma, ,, (ii) Pathomorphological changes in the cochlear organ from excessive noise,  and (iii) Temporal changes in hearing due to noise exposure. ,, Some recent investigations were aimed at the assessment of susceptibility to noise exposure during postnatal development in rats  and the impact of noise exposure on the central auditory system and on the time-resolution ability of the auditory system (the gap detection) in rats. ,
The epidemiology of hearing loss among the employees of different branches of an industry was studied in Hungary. Kere?zti et al.  presented the epidemiological investigations regarding the prevalence of hearing loss in foundry workers. The authors examined 3000 workers to detect a hearing threshold shift of 30 dB at 4000 Hz. It was found that 54% of the subjects were affected by hearing loss.
Attempts were also made to develop a database on noise exposure in factories of different industries (20,000 noise analyses). The collecive data were expected to provide an assessment of noise situation in the whole Hungarian industry.  A more detailed research concerning particular factories were continued in the future, for e.g., in a textile factory by Kiss.  The information on occupational exposure to noise and the epidemiology of hearing loss obtained in this way helped to develop an appropriate hearing- protection system.
South-East Europe countries
In Bulgary, there were investigations recognizing the co-exposure to noise and vibration and their influence on the hearing status of employees of different industries. For example, Dipeikova and Moskov  investigated the prevalence of hearing impairment in relation to noise and years of service in the mining industry. The changes in hearing depended on occupational activity of the examined workers and duration of exposure. The authors found a large percentage of ear damage in miners operating vibrating tools and exposed to high levels of noise over long periods of time.
Kehaiov  investigated the vestibular influences on the visual and auditory function in a patient suffering from noise and vibration disease. He found an interdependence between vestibular and visual perception.
Tsvetkov and Kalburova  performed a study in a chocolate and pastry factory. The employees, mainly women, were exposed to noise and vibration. Half of the examined workplaces were found to be associated with worker exposure to excessive noise. The hearing status of the exposed workers was found to be largely impaired.
Kirkova et al.,  carried out targeted anamnesis and PTA in (200) employees, mainly females from the weaving shop (Medika Ltd.). The degree of hearing impairment related to years of work in the noisy environment was analyzed. The NHIL was noted in 60% of the workers. It was found that there was a sharp increase in hearing loss after 5 years of employment.
Gidikova et al.,  performed PTA screening tests (both air and bone conductance) in 138 employees exposed to intermittent noise at levels of 85-105 dB. In addition, 85% of the subjects were examined using DPOAE. It was found that the prevalence of hearing impairment correlated with the duration of noise exposure and age. In conclusion, the authors suggested some preventive measures to protect the hearing of a person occupationally exposed to noise.
A new area of interest is connected with the development and implementation of the hearing in noise test (HINT) for assessment of hearing impairment opened up a new area of hearing loss studies.  A modified radar plot to present HINT data was proposed.
By the end of the 20 th century, the NIHL studies focused on the relation between noise exposure and its influence on hearing status during occupational activity. One of the practical aims of these studies was to develop hearing-prevention measures for noise- exposed workers.
For example, Mihail et al.,  studied the development of hearing loss and its links with auditory fatigue due the occupational exposure to industrial noise exceeding 95 dB. In particular, the authors analyzed the relation between temporary and PTSs. They concluded that during short durations of the noise exposure (up to 5 years), auditory sensitivity can be recovered owing to adaptative phenomena, whereas in case of noise exposures extended to 10-15 years, permanent thresholds were dominant.
Obreja et al.,  investigated the hearing status and working conditions in a group of telephone operators and proposed some solutions for improving the hearing protection program in this particular group of employees.
Meer and Sirban  performed an epidemiological study in the Oradea town concerning the hearing status of workers exposed to excessive noise. They discussed the hearing loss related to the noise levels. On the other hand, Szanto and Ionescu,  in their epidemiological investigation, analyzed the influence of age and gender on HTLs in a population of Romanian workers exposed to noise at different sound pressure levels in the occupational settings and compared their results with those from foreign investigations.
The impact of long term co-exposure to noise and vibration on hearing was studied by Szanto and Ionescu.  They carried out PTA, after a 6 year-interval in the same testing conditions in a group of 132 workers (miners and miner apprentices). To evaluate the possible impact of exposure to vibration on the HTL, the results registered in a group of workers exposed solely to noise (n0 = 33) − identical continuous equivalent level/week − were compared to those found in miners. Subsequently, Szanto and Ligia  analyzed the difference in hearing loss between miners with vibration-induced white finger (VWF) and those without VWF.
Other research areas were concerned with the hearing status of women and children living in a town polluted with lead. The results revealed a lowering of the hearing threshold among the investigated groups.  Similar results were noted in a recent environmental study in a population exposed to noise and polluted with lead. 
Former Yugoslavia and new states
The investigation performed in the former Yugoslavia during 1970-1990 focused on the evaluation of noise exposure and prevalence of NIHL in the employees of various sectors of industry, including workers from metal plants, textile industry, operators of construction machinery, wood cutters, and power-saw operators. ,,,
Besides noise, other NIHL risk factors were also analyzed. For example, Milkovic-Kraus  analyzed the hearing status and blood pressure in workers with long-term exposure to noise at levels exceeding 85 dB(A). All of them had hearing loss as well as elevated systolic and diastolic blood pressure.
Bosnia and Herzegovina
Studies reported by Bosnian researches focused on PTA and the recognition of the post-acoustic trauma hearing loss. Spremo and Stupar  analyzed the correlation between the degree of sensorineural hearing loss and the type of audiogram registered in patients after acoustic trauma. There was a difference in the audiograms of patients with and without acoustic trauma. Thus, the cochlear damage contamination to acoustic trauma could be assessed from the audiogram configuration. Recently, Brigic et al.  conducted investigations in the employees of open-pit mines. Their main aim was to determine the hazardous noise level, i.e., the level that may cause hearing impairment of the employees in the surface-mine. The authors assessed the noise levels and compared them with hearing levels of exposed miners. In conclusion, the noise-exposure level of 83 dB was proposed as hazardous.
Some of the recent Croatian studies, similar to earlier investigations were aimed at the evaluation of noise exposure and hearing status in chosen groups of workers. For example, Kontosic and Vukelic  investigated the prevalence of NIHL among the sea-men in relation to age and noise exposure. Gomzi  analyzed the incidence of hearing impairment in sawmill workers. He performed very detailed noise measurements and tried to determine if the different types of working tasks affected the workers' hearing loss and injury frequency. It was found that sawmill workers were exposed to very high noise levels (up to 103 dB(A)), they did not use HPDs sufficiently, and suffered from significant NIHL, which partly caused elevated injury frequency rates.
Hursidic-Radulovic  analyzed the progress of hearing impairment in young plumbers. Lalic et al.,  investigated the risk of hearing loss in professional firefighters due to occupational exposure to noise. They concluded that to preserve good hearing in both young and experienced firefighters, a more effective hearing-conservation program should be implemented.
Besides the studies on noise exposure in the occupational settings and its impact on workers' hearing, there were investigations concerning the medical treatment of acoustic trauma. For example, Šprem et al.,  studied the role of vasodilators and vitamins in the therapy of sensorineural hearing loss following war-related blast injury.
Recently, a pilot study concerning the evaluation of the impact of loud music-listening via PMP on hearing among school students was carried in Slovenia.  The results indicated that around 18% of those engaged in excessive listening to loud music had a higher risk of acquiring permanent hearing damage in a few years with the same behavior pattern.
On the hand, previous Slovenian studies were focused on the evaluation of impulse noise from firecrackers. , The aforesaid investigations dealt with some noise aspects resulting from firecracker explosions, which were measured during New Year's Eve. Apart from the principal factors influencing the acoustic power of such an explosion, some new statistical aspects are described. A special emphasis is given to the probability distribution function of peak sound pressure levels, originating from a great number of firecracker explosions. In general, the probability distribution closely follows the Rayleigh distribution, but when the number of explosions in unit time is high enough, it tends to a Gaussian distribution.
Similar to Slovenia, there were only a few studies concerning noise effects in Serbia. Budimcic et al.,  analyzed the hearing problem in school children and its links to leisure time exposure to loud sounds.
Živic et al.,  performed comparative analysis of various tests, in particular audiometric and impedancemetric tests, in the industrial workshop workers. They found that the sense of hearing is affected not only by threshold of hearing in terms of audiometric curve at various frequencies, but also by the threshold of unpleasantness (annoyance) and pain at high intensities, manifested by the stapedial reflex.
Very recently, Dragutinovic et al.,  examined 50 workers exposed to industrial noise in order to evaluate the usefulness of supraliminal tests (Tone Decay Test, Reflex Decay Test) for the identification of subjects susceptible to NIHL. In conclusion, they suggested the necessity of modification of periodic examination of noise-exposed workers, and that tone decay and reflex decay tests be introduced into the standard procedure.
Former soviet union and newly independent states
Results of some early investigations on noise effects in the FSU were described in the monographs by Andreyeva-Galanina et al.  The complex of symptoms developed under the influence of exposure to noise was defined as "a noise syndrome" experienced first by the central nervous system and then by the auditory analyzer.
It is worth noting that studies aimed at the assessment of noise impact on hearing which were initiated in the Soviet Union were later continued mainly by Russian researches.
The first investigations concerning noise effects were mainly based on an animal model and were aimed at the evaluation of ultrastructure of the spiral organ of the cochlea under normal conditions and following an experimental acoustic trauma. , Simultaneously, laboratory investigations concerning co-exposure to noise and vibration on animals (rats or guinea pigs) were carried out. , In the human hearing, deterioration due to co-exposure to noise and hand-transmitted or whole-body vibration was analyzed based on hearing tests (e.g., conversational and whispered speech, tuning forks, pure tone, and speech audiometry). ,,,
Studies were also conducted on the hearing function in various groups of workers, e.g., railway locomotive drivers,  railwaymen engaged in making trains,  fisherman and sailors,  workers of a sheet-rolling mill,  and civil flight personnel. , Simultaneously, the attempts were undertaken to improve the diagnosis of occupational hearing impairment. 
A special attention was paid to the influence of impulsive noise on the hearing organ. , Suvorov et al.,  examined 323 blacksmiths and analyzed the physical parameters of noise exposure for its hygienic evaluation and setting of standards. The comparison of the measured and ISO 1999:1990-predicted hearing losses revealed a hyperagressiveness of impulsive noise in close connection with both noise level and years of service. Impulsive noise was recommended to be evaluated according to the peak level and number (quantity) of impulses.  In a further investigation, a continuation of the study quoted above, the aforesaid researchers revealed a reliable correlation between a peak linear (unweighted) sound pressure level (Lp ) and number of impulses (N) and the hearing loss in blacksmiths. Moreover, they concluded that the simultaneous consideration of Lp and N was preferable according to the "equal energy rule".  It is worthwhile to underline that the aforesaid studies on impulsive noise were later continued in collaboration with the Finnish researchers.  The comparisons between the measured and predicted (according to ISO 1999:1990) HTLs in workers exposed to impulse noise at SPL of 104-106 dB revealed that the hearing loss in the workers subjected to less impulsive noise were readily forecasted by the ISO standard 1999:1990.  However, hearing loss in the workers subjected to more impulsive noise was in reliable correlation with a combination of peak level and impulses number. 
Recently, the structure of occupational diseases, especially the prevalence of NIHL in various types of industry and/or different regions of Russia, was intensively investigated. ,, Attempts were made to determine the relationship between the incidence of hearing loss and concomitant pathologies in the civil flight personnel. 
During last two decades, only a few studies concerning noise and/or hearing loss were published in the former republics of the Soviet Union other than Russia. For example, Mukhin et al.,  analyzed the combined occupational diseases in coal miners from Donetsk region in Ukraine and found out that the combination of dust-induced lung disease with vibrational disease or vibrational disease and NIHL were the most frequent combination of diseases during the last 20 years. On the other hand, Reinhold and Tint  from Estonia, carried out a study focused on occupational hazards (including noise, indoor climate, and dust) and the determination of the resultant risk levels. In conclusion, they offered a flexible risk assessment method suitable for various occupational hazards. In the case of noise exposure this method leads to results which are in good conformity with the risk calculations according to ISO 1999:1990.
A comparative analysis of acoustic evoked potential and high-frequency audiometry indices in patients with early sensorineural hearing loss of radiation, noise, and vascular origin was performed by Kozak et al., from Ukraine. , The application of TEOAEs for the objective assessment of hearing function and monitoring of the influence of noise exposure and ototoxic drugs was analyzed by Janusauskas et al.,  from Lithuania. Earlier, the same team worked on processing and analyzing of TEOAE. , In particular, they used the Hilbert-Huang transform, a powerful tool for non-linear analysis of non-stationary signals, for analyzing TEOAEs. 
| Conclusions|| |
This paper reviews the main researches on NIHL conducted in the CEE, SEE, as well as FSU during the last 40 years. The range of topic was very comprehensive, and included both studies in humans and animals. The majority of papers concerned occupational settings, whereas only a few were dedicated to environmental exposures to noise.
A large number of papers were concerned with the assessment of the noise levels at the workplace, and very seldom in a communal environment, and the prevalence of hearing impairment in employees. Simultaneously, attempts were undertaken to search the relationship between degree of hearing impairment and noise exposure, including combined exposure to vibration and/or ototoxic chemicals. The impact of environmental, individual, and genetic risk factors on NIHL development were also analyzed. Many studies were concerned with development of the audiological tests for NIHL assessment, and OAEs in particular. Animal researches, including molecular genetics, had been also performed.
Although the authors of the earliest works used less-advanced research tools, papers published during the recent decades represent a good scientific level, and some of the reported research works have been performed as a part of large-scale international European scientific research projects.
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Department of Physical Hazards, Nofer Institute of Occupational Medicine, 8 Sw. Teresy Str., 91-348, Lodz
Source of Support: This study was Supported by the Ministry of Science and Higher Education of Poland (grants: IMP 18.2/2012-2013 and IMP 18.7/2011-2012),, Conflict of Interest: None