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Turning a Nightmare into a Dream: Taking Care of Musicians and Engineers

Turning a Nightmare into a Dream: Taking Care of Musicians and Engineers
Brian Fligor, ScD
September 21, 2015

Editor's note: This text course is an edited transcript of an AudiologyOnline webinar.  Download supplemental course materials. This text course contains audio files that can be played when reading the course online - however, if you print the text you will not have access to them. 

Learning Objectives

Dr. Brian Fligor:  After this course, you will be able to describe the values that musicians, music enthusiasts, and audio engineers bring to the table when they come seeking audiological care.  Those values might be different than ours as audiologists, but understanding their values can go a long way toward improving patient outcomes, as well as de-stressing our own experience working with them. 

You will understand how to address the prevention and treatment needs that are acceptable to this population. 

Finally, we are going to look at how we counsel patients who have critical listening needs and how best to utilize audiologic care.  This group is sound exposed.  Many of them have hearing loss, either from their own sound exposures or because of other physiologic factors such as otosclerosis, cholesteatomas, acoustic aromas, and Meniere’s disease.  They need care, but the level of care that they require can be drastically higher than that of the typical patient. 


Today we will define our target population and their values.  Audio engineers are the only group of people that I have known to come in and say, “If I use hearing protection, that will cause an adjustment to how I perceive loudness, and I want to make sure that when I am mixing in the studio that I am really mixing at the 80 phon level.  If I am listening at 65, then my equal loudness contours are different.”  They know and understand equal loudness contours better than most audiologists.

We are going to talk about risks and mitigations for sound-induced tinnitus and hearing loss.  I will talk about suggestions for hearing aid fittings, italicized on purpose, for music appreciation.  There are some limitations with current hearing aids for musicians, and we are going to do the best we can. 

We are going to wrap up with tinnitus treatment that is specific to musicians and audio engineers.  If you walk away with nothing more, understand that the tinnitus itself is much more salient to the challenges that this population is dealing with.  If they have tinnitus, that is the first thing that needs to be treated. 

Any one of these topics on our agenda could be an entire hour, so, by design, this is going be superficial.

Who are You?


Who is a musician?  Is a musician someone who has picked up a guitar in the past three months and figuring out how to play?  Is it someone who plays in the bars on the weekend as a hobby?  Is a musician someone who pays the bills by getting paid to perform?  Is it someone who has been educated at the college level in music?  The answer to all of these questions is yes.  Even within the group "musicians", we have to categorize exactly what people do and how they use their ears. 

In a hearing aid evaluation, we look at the patient’s lifestyle.  Do they live at home and have family and friends come to visit them?  Are they in an acute nursing facility, or do they work giving presentations on a regular basis and need to listen for questions from the audience?  There are some drastic differences in how people use their ears. 

Musicians often play multiple instruments, and they work in multiple different music genres.  There are some markedly different personality types also. 


The engineers to which I am referring today are audio engineers, sound engineers and acoustical engineers.  We could also be talking about electrical engineers.  These professionals may not be as musically oriented, but they are highly technical and understand signals unbelievably well. 

A sound engineer works with live sound.  They may do the front-of-house sound mixing.  This is the person that controls the venue loudspeakers.  The monitor engineers mix the sound for the performer who is on stage.  The listening requirements are totally different for this job.  Sound engineers are joked to be some of the grumpiest professionals.  There is something to be said for these highly technical, capable, and competitive individuals who, I would say, on occasion tend to be quite grumpy and dismissive of anyone who does not have the same knowledge about sound as they do.

An audio engineer may be the person in a recording studio who manages the recording levels and parameters.  They may do voiceover work for commercials or advertising, production work, post-production and mastering.  They may be involved in the acoustical designing of a concert venue.  Sometimes the job is difficult to classify.

An electrical acoustic engineer is someone who makes the receivers, speakers, or microphones that go into our hearing aids.  I would be slightly intimidated by an audio engineer who was part of developing the speaker in the hearing aids that I am about to fit on them. 


What do these people have in common?  These are all very talented and highly skilled people, particularly those who are doing live music.  These professionals are judged constantly.  When you listen to music, if the music mix sounds good, the engineer has done a good job.  By and large, they also know their hardware and software.  For instance, an audio engineer is not the least bit intimidated by the hearing aid programming software.  In fact, they are probably a bit on the curious side and may want you to explain things that you do not quite understand yourself.  These are people who routinely use software programs like Cool Edit, GarageBand, and Audiophile.  They may also understand the hardware components, too. 

These people tend to be very competitive because their industry is competitive.  They often are contractors, taking one job to the next, so their employment may not always be stable.  They also tend to be sound exposed, but their sound exposures are almost exclusively unregulated.  Technically, they could fall under OSHA (Occupational Safety and Health Administration) standards for workplace safety, but it is not the same as exposure in a manufacturing plant.  This happens venue to venue, and the people who are participating in the production of sound, whether that be engineer or musician, may or may not be employed by a venue; they may be a subcontractor.   

What is also common, according to Benj Kanters who is an audio engineering professor at Columbia College in Chicago, is that these music professionals need an audiologist the way everyone needs a dentist.  Here is an opportunity for us as the hearing health specialists to work with this group of people, who may be viewed as a nightmare to us because they are so demanding, so competitive, and so technically skilled.  However, they value hearing as we do.   The groups of people that we are talking about today know and understand good sound when they hear it.  Given that this is a shared value, perhaps that is a place where we can start to meet them. 

A Musical Journey Interrupted

Let me quickly share the story of a gentleman named Stu Nunnery.  Imagine if James Taylor had developed a sudden sensorineural hearing loss in both ears back in the late 1970s, and he went from the success of his first albums to having to pull all the way back.  Would we even know who he is today?  Stu Nunnery is an outrageously talented musician who released his first album in 1973 from Evolution Records.  It was in the Billboard top 100 in the United States, and it went to number one in Brazil.  In 1982, he had a vascular event that was not perfectly diagnosed due to the time period. As a result, he lost most of his hearing and had to interrupt his musical journey. 

In the past year, with improvements in hearing aid technology, as well as some changes within his own life, he launched a kickstarter campaign to reincarnate his musical career.  He has just released DejaS2, which is a re-release of his original album.  Now remastered, it is available on CD Baby for download.  He is featured on the Phonak blog.  You can check him out on Facebook. 

Stu has given me permission to share the details of his hearing loss with you.  He has no usable hearing in his left ear and a moderately-severe upsloping hearing loss in his right ear.  I believe it is correct to say he has been sponsored by Phonak and is using an Audeo V90, which is the newest generation of technology that Phonak has put out on the Venture platform. There is a lot of benefit with it, and I am tremendously impressed with this particular device.

For studio purposes, I fit him with a Sensaphonics 3D music enhancement system, which is essentially like a master hearing aid with a peak input level as high as 140 dB.  If Stu were standing next to a drum kit and the drummer struck the snare drum, high hat or crash cymbal at full force, the peak of that strike would saturate every hearing aid on the market, because no hearing aid is able to tolerate an input as high as 132 to 136 dB.  The 3D music enhancement system has a peak input level of 140 dB before it saturates.  To be clear, that sound is not going into his ears at 140 dB; the system brings the levels down markedly, but it does not introduce distortion into the signal when it is picked up by the ambient microphones.  This is just one example of some of the challenging cases we see with musicians.

Populations at Risk

Many people are sound exposed.  We have mandates on this from as early as 1981.  The Hearing Conservation Act and the Hearing Conservation Amendment says people cannot be exposed to sound levels above 90 dB or above 85 dB, depending on who you are and where you have worked.  Nine million people in the United States are exposed in standard occupations, and 40 million people are exposed worldwide.  This is where you are working in a manufacturing plant, and the sound exposures are an unwanted byproduct of the economic activity.  If you are building cars, it is really loud.  If you are stamping metal, it is really loud.  If you are sawing wood in a sawmill, it is really loud.  All of that sound is the unwanted byproduct. 

Despite these regulations and company incentives for undertaking good hearing loss prevention practices, and despite the fines that OSHA can levy against these companies, noise-induced hearing loss is still among the highest incidence of work-related injuries.  It accounted for nearly 12% of all non-fatal injuries in 2011 (Bureau of Labor Statistics, 2012).  Perhaps we are keeping it under control, but we are certainly not lessening the rate of hearing loss in occupational sectors.  Occupational sectors are not well regulated, and sometimes I would argue they should not be regulated, as we should be hitting this from the hearing health and safety perspectives targeting education, motivation, and personal accountability.   

A quick example is the Bamboozle Roadshow in June 2010 where an AuD student and I did live-sound dosimetry.  Stage levels were between 94 and 108 dBA, where the 108 dBA was in close proximity to the drum kit.  The audience levels over the four hours of the show were between 90 and 117 dBA.  The 117 dBA was the audience cheering for an encore.  The audience is the loudest part - crowd noise is definitely an issue.

The drum kit is noisy on stage.  The guitar amplifiers and the bass amplifiers are noisy on stage.  The stage itself might be a little quieter than the audience.  All of these are sound exposures can do damage, not just to the attendees who may only go once a year or once a month, but mainly to the performers and crew who have 150 to 200 shows a year.  A musician’s stage levels are 100 to 110 dB, unless they are using full, custom in-ear monitors and they are only keeping the levels moderate after they have been taught by their audiologist how to listen at moderate levels. 

The concert attendee is at risk.  Believe it or not, the concert attendee may be vastly overexposed - a 5000% noise dose.  That is 50 times the normal level exposure in a single setting.  It is possible to have an acoustic trauma resulting in a permanent injury from sound exposure after attending a single concert.  It is rare, but it does happen. 

We are not only talking about rock concerts or rock musicians, either.  The same is remarkably true for drum corps, orchestra or chamber music.  The violinists’ own instrument is a significant sound source.  I cannot say that most professional violinists have a left-sided noise notch, but I can tell you that I have seen quite a few professional violinists with a significant noise notch in their left ear, unless they have been using hearing protection. 

This specific group of people have to blend their own instrument in with the rest of the people around them.  They cannot be playing mezzo piano if the passage calls for pianissimo.  They will be standing out above the rest, and they run the risk of losing their job if the conductor calls them out.  Guess what happens if you have the wrong kind of hearing protection in your ears?  This interrupts your monitoring needs.  

What about the individual who needs to listen to their own instrument and is challenged because they have hearing loss?  How can they use hearing protection but still hear well enough to blend in with the rest of the musicians around them?  The conductor’s directions may not make sense, and they may miss important cues; this group will be listening in for where everyone else starts.  They are totally on edge because they may come in a half beat late.  They do not know where they are supposed to start, because they could not hear the conductor.  Those are severe communication needs. 

As an audiologist, I know that we can manage that, and it will not be terribly hard at all.  We can fit them with something open that we are able to make linear with flat amplification.  Then put a remote microphone on the conductor’s lapel or on his stand.  Know, however, that the moment you mention putting a remote microphone near the conductor, the violinist might shut down.  Who wants to hire a musician with hearing loss? 

Data from Kaharit et al. (2003) tells us that 74% of professional musicians had some kind of music-induced hearing disorder, such as tinnitus, hearing loss, abnormal pitch perception, sound sensitivity, or hyperacusis.  In Brazil, Santos et al. (2007) showed that of 30 DJs, 11 had a noise-induced permanent threshold shift.  Royster, Royster and Killian in 1991 showed over half of the members of the Chicago Symphony Orchestra had noise notches.  None of the musicians, in my experience, have readily advocated for their own occupational listening needs that are protected under the Americans with Disabilities Act (ADA).  Advocating for themselves can put them at a disadvantage for getting the next job.  It is quite a conundrum.  

Can’t We Just Stick a Plug in It?

There is a reason why fewer than 5% of concert attendees wear earplugs.  Figure 1 shows a Verifit curve, where the green curve is a maximum power output (MPO) 85 dB swept tone with the probe mic placed down to my eardrum.  Then, I took a foam earplug and placed it shallowly in my ear canal and ran another curve, in purple.  This is the way many people incorrectly use earplugs at concerts.  Next, I deeply fitted the earplug in my canal, which is the proper way to place an earplug, and ran another curve, in blue.  You should grab your pinna, open your ear canal up, roll up the earplug, place it, let go, and hold it in place. 

Real-ear measurements of a shallowly placed ear plug versus a deeply placed ear plug

Figure 1. Real-ear measurements (MPO) of a shallowly placed ear plug (purple) versus a deeply placed ear plug (blue).  The open MPO is shown in green.

A shallow plug gives next to no sound isolation, because there is not a tight seal in the canal.  Additionally, in both curves, the earplug is a mass in the ear canal that causes a change in the acoustics and resonant properties of my ear.  This resonance is referred to as the real ear unaided response (REUR); most audio engineers and acousticians refer to it as the transfer function of your open ear.  In the open ear, there is no resonance in the lower frequencies, but then it gives some amplification with the biggest boost right where we need to hear sound best for understanding speech.  When we stick a plug in the canal, it greatly changes how things sound, but it will not necessarily reduce the overall sound level.

Let’s listen to what that sounds like with a shallow plug.  This clip is from a concert, as if you were listening without hearing protection.  This is about 80 dB, but they played it at 104 dB at the concert.   

The next clip is what it sounds like when you have a shallow plug in your ear.

When you listen to both, the overall sound level is not vastly different, but the quality is very much muddier with the shallow plug.  You have lost so much of the high frequencies.  Now let's say that the person is using earplugs “as they are supposed to.”  

At a concert, this would be over protecting.  In fact, you are listening to it the same as if you are out in the parking lot.  People pay a lot of money to go to these concerts and see the artist, not to listen to them from the parking lot.   When you put a non-custom earplug in place, it attenuates sound differentially.  For instance, there is next to no sound isolation provided in the lower frequencies, but then there is a great deal of sound isolation particularly at the resonant frequency of your ear canal.  This is always the case.  Low frequencies are attenuated less than high frequencies for these non-custom foam earplugs.  Let's get into how that differential attenuation impacts timbre.


A piano has keys, number 1 up to number 88, with key number 1 on the left-hand side up to 88 the right-hand side.  The fundamental frequency of key 1 is 27 Hz.  The fundamental frequency of key number 88 is 4186 Hz.  That is a big range.   Key number 43, a D sharp 4 in the middle of the piano, is only about 311 Hz.  The fundamental on a frequency spectrum is 311 Hz and then the harmonics (H1, H2, H3) are integer multiples of the fundamental.  H1 is F0 times two, H2 is H1 plus F0, H3 is H2 plus F0 - basically, another 311 Hz, up, up, up, while it is still audible. 

The level of all these harmonics is relative to the fundamental; this is what, in large part, defines the timbre of sound.  It is the way we can tell if it is a piano that played this D sharp 4 or a violin.  You can immediately tell the difference in the instrument, despite the fact that it is the same pitch.  If we manipulate the level of these harmonics relative to the fundamental, then we change the timbre, and changing the timbre by definition means that the sound quality is poorer.  Keep that in mind for hearing protection and hearing aids.   

If a patient does not have access to timbre because of their hearing loss or the device in their ear, they do not have access to those harmonics, and things are not going to sound as good.  They will describe the sound as distorted.  This is part of the limitation of our ears, as well as hearing devices. 

Musicians Earplugs

In 1991, Etymotic Research released the Musicians Earplug with the idea that it would provide even, uniform attenuation from low-frequency to high-frequency.  A correctly fitted musician’s earplug is supposed to imitate the ear canal resonance perfectly, or as close as possible, with an even rate of attenuation across all frequencies.  However, if the sound channel, or the sleeve, is not in great contact with the skin of the ear canal, you are going to get some acoustic slit leaks.  This is called a vent in a custom hearing aid ear mold or in a hearing aid.  We put vents in all the time to allow for low-frequency in and out. 

With a hearing protection device, you need a tight seal.  If the sound channel itself is too small, you will change the resonant frequency of sound coming through this plug, and it will sound distorted to the musician.  The magic of that musician’s earplug is not just about the filter; it is about the combination of the filter as well as the acoustic mass inside the sound channel.  That is what defines whether you get even sound isolation versus uneven sound isolation. 

Figure 2 is an example using the Verifit with the open ear in green, and then with an ER15 earplug in place in purple.  In table view (200 Hz up to 8000 Hz), it shows that the plug nominally gave 16.4 dB attenuation on the left side, 17 dB on the right, with a standard deviation of 2.2 dB/3.6 dB across the whole range.  On the right, there was 12 to 23 dB least amount of attenuation to most, and 15 to 21 dB on the left side.  How much sound isolation are you providing when you are fitting custom hearing protection or flat frequency attenuators?  Are they flat or are they not flat?  If you do not verify, how you know?   If you do not verify, you may be interrupting the perception of those harmonics relative to the fundamental.

Verified uniform attenuators

Figure 2. Verified uniform attenuators (green = MPO; purple = MPO with ear protection).

Musicians with Hearing Loss

Figure 3 shows two audiograms from patients that I have seen.   The first is an opera singer.  She started losing her hearing in her 40s and now cannot hear the piano when she is singing using her hearing aids.  She had been fitted by another group with Phonak Naida Q90 receiver-in-the-canal (RICs) hearing aids.  It had a slim tip on it with a small vent.  I would argue that it was an appropriate fitting for communication, but music is not speech.  While she was singing, the sound level coming out of her ears and back into the microphone was saturating that mic, given the level of the set MPO.  It was saturating the system so that she was not able to hear the softer sound from the piano that was only a little distance from her.  I had recommended something as straightforward as remote mic pinned to the pianist.  She was then able to hear at least the fundamental of the piano so that she could sing along with the accompanist. 

Audiogram of opera singer with hearing loss

Figure 3. Audiogram of opera singer with hearing loss.

Figure 4 shows a musician who had a noise-induced hearing loss from playing.  He is a trial attorney in his late 50s.  He picked up the electric bass four years prior to me seeing him, plus he had also been going to live shows for a long time.  I fitted him with Starkey SoundLens2 invisible-in-the-canal (IIC) hearing aids.  It gave him wonderful benefit.  He takes them to play, and he uses the Etymotic Research Music Pro non-linear electronic earplugs.  It is a different application for different purposes, but he was able to use his Starkey hearing aids at typical levels when attending the show because he had participated in the programming of the hearing aid using some the Starkey software Sound Point, where we played music that he generally would like to listen to when he goes to a concert.  He was adjusting the level and frequency response on an iPad, or self-tuning. 

Audiogram of trial attorney who is an avid music fan and musician with hearing loss

Figure 4. Audiogram of trial attorney who is an avid music fan and musician with hearing loss.

Music is not Speech

When considering hearing aids, remember that music is not speech; it is vastly different.  The maximum input for speech is about 80 dB, and the total range is roughly 30 to 40 dB from softest to loudest.  For music, the intensity depends on the type of music, but the dynamic range could be 60 dB up to 100 dB.  The peaks in music are higher than the peaks in running speech.  The spectral structure for voice is 82 Hz for the fundamental frequency as high as 1046 Hz.  The piano is 27.5 Hz up to 4186 Hz.  Violin has a much narrower range, but a more complex structure of the harmonics.  Harmonic structure of music is often far above 10 kHz.

The time domain envelope is much more predictable in speech and not so predictable in music.  The intent of speech can be diluted down to say that it is for communicating some content.  However, we know it is not always that way.  When a parent trying to soothe their child, the sound of the voice is definitely communicating emotion, but the intent of music is so much more about the communication of emotion, whereas if you are listening to a podcast, it is about communicating the content.  Those are vastly different intents of the activity.   

Figure 5 shows two spectrograms.  The one on the right is eight seconds of a piano playing.  The left is that musician welcoming another musician who came to his house while I was there doing recordings.  Frequency is on the y-axis, and intensity is on the x-axis as a function of frequency.  The intensity is represented by how bright and warm the colors are.

   Spectrograms of a piano   Spectrograms of speech

Figure 5. Spectrograms of a piano (left) and speech (right).

Let’s listen to both of these, unfiltered, first pinao and then speech:

By comparison in the spectrograms, the one with the piano is incredibly vibrant across the spectrum.  The spectrogram of speech looks markedly different, with most of the energy down in the lower frequencies.  Let’s filter the piano clip through the original telephone, which has a bandwidth of about 300-3400 Hz, just to prove a point about bandwidth and hearing aids.

Now let’s listen to speech through the same band-limited filter.

I would argue that speech is far more robust and more capable of tolerating band limiting than music.  Music is much more fragile for the sake of its intent.  If the intent is communication of the emotion, music is very quickly and easily degraded relative to speech.  Speech does not sound as good to me, but if the purpose is just to hear what someone is saying, you can that over the 300-3400 Hz bandwidth, which again was the original bandwidth of telephones.  Consequently, that was the original bandwidth of hearing aids. 

Tinnitus Management

How do we manage a person’s tinnitus when they worked their whole life to tune into what things sound like?  Often, as part of our tinnitus management strategy, we are trying to help a person forget that their tinnitus is there.  We train them to habituate their reaction to their tinnitus.  One of the best ways to do that is to give sound enhancement, use tinnitus maskers, and engage in cognitive behavioral therapy.

What about someone who has been trained their entire life to hone in on multiple different pitches in a complex signal?  It can be very difficult to mask the tinnitus of a musician.  When we are masking tinnitus, we are, in fact, just trying to keep the brain busy.  We are not so much keeping the cochlea busy, because the tinnitus signal is originating neurally in the person’s auditory system, but we apply sound to the cochlea to try to keep those nerves busy.  If a person has been trained to be able to hear one signal amongst a complex series, they will still hear the tinnitus.  It is tough.

Oftentimes, their tinnitus is a result of their own sound exposures, perhaps from their own instrument, and they may feel a very high level of guilt that they have done this to themselves.  One the more helpful things I have been able to tell musicians is that this is not their fault.  They would not have known that what they were doing was going to cause this injury.  It is beneficial to get them to understand that this is the reaction to the tinnitus; it is not the tinnitus itself. 

One way that I have tried to approach this is to make an analogy to a guitar amp that is turned up.  At this intensity, you will hear the hum or the buzz of the amplifier; that is circuit noise.  It is just there.  It is not good; it is not bad.  This is the same as tinnitus.  It is not good; it is not bad. It is just there.  But one thing to consider when you are fitting for hearing loss prevention devices is to fit something that will ensure that their future sound exposures when wearing them are less than 100% noise dose.  I would argue that it should be closer to 50%.  If you are going to engage in this work, be very clear and understand what the individual sound exposures are. 

Tinnitus Suffering

If you are working with a musician who has tinnitus, they may have other comorbidities, also.  Connect with a team of complementary providers, like psychologists, as these musicians have a very high rate of comorbidity with anxiety and depression.  These people may have already had anxiety or depression prior to developing tinnitus.  Any amount of sound exposure that causes tinnitus, especially if it is chronic tinnitus, can trigger certain suffering that another person without that personality type might not feel. 

The suffering from tinnitus does not come from the perception of tinnitus, but the reaction to it.  The part of the brain that is responsible for expressing a fear reaction and assigning threat is our limbic system, which is comprised of the thalamus, hippocampus, and amygdala, which control attention, memory, and emotion.  Those three together define if something is good, bad, or neutral.  If it is neutral, our thalamus decides whether that input gets attention or gets ignored - this is known as "sensory gating".  Because tinnitus is a sound and our limbic system is trained to let sound come through, we tend to hear it and focus on it.   You know what else comes through?  Our sense of smell also comes through the thalamus.  Our noses offer information about how edible a food might be.  If it smells rotten, you are not going to eat it because it will make you sick.  This is an instinct that is important for our survival.

Hearing is also important for our survival.  Our thalamus lets sound through at full volume because it might be important for our survival.  Tinnitus tricks the limbic system into thinking that it is something important or a threat.  This can lock the person in a state of fight or flight, and given that the tinnitus is persistent, it leads them to have a persistent fight-or-flight reaction.  They remain hyperanxious.

Hearing Aid Considerations


What do we do?  We manage the tinnitus first.  Fitting with hearing aids very often reduces a tinnitus reaction because it is enhancing environmental sound.  All of a sudden they are hearing the microwave better.  They are hearing the refrigerator.  They are hearing their heating and air-conditioning system, where they may not have heard it before.  That is providing sound enhancement right away. Many of the newer devices automatically have sound enhancement, a sound generation algorithm built right into them. 


When we have addressed and managed the tinnitus, what are other suggestions should we heed when it comes to hearing aid fittings?  Get the widest bandwidth possible.  It is not just about the higher frequencies; it is about getting the lower frequencies so people can hear those fundamentals better, also.  That is where the warmth of sound resides. 

Until very recently, most hearing aids could not be adjusted for gain below 200 Hz.  There are many signals that exist below 200 Hz.  If a person has the least bit of hearing loss there, they were missing out.  Even with normal hearing there, there was less access to the harmonics.  But if you amplify music the way you amplify speech to improve speech intelligibility, you are over-amplifying the harmonics and you are markedly changing the timbre of sound.  It is important when you do a music program that you provide a balanced amount of amplification.  You will use more low-frequency gain than you would think normally appropriate in comparison to the high frequencies to provide that same access to the fundamental frequency relative to the harmonics. 

Digital Processing

We need to choose a hearing aid that has an analog-to-digital (A/D) converter that allows a signal to come in above 100 dB.  Historically, microphones have been limited at about 94 dB because the highest level that comes in for speech is usually around 80 dB.  It is not necessary to transduce things above 94 dB.  Music, however, has a larger dynamic range, so it is necessary to have both a microphone and A/D converter that can tolerate a signal well above 100 dB. 

Frequency Compression

When you are fitting someone with hearing aids for the sake of music listening, the frequency compression or frequency transposition algorithm that is effective for people at improving speech intelligibility tampers with the music signal.  I strongly advise you to turn that off in the music listening program. 


I recommend omnidirectional microphones instead of directional microphones.  Directional microphones are not desirable when trying to hear the room effect when playing an instrument.  Understanding of the music is partly defined by the room.  If you use directional microphones for music listening, you are going to miss out on some of the purposeful reverberation of the room.

Noise Reduction

Do disable the noise reduction.  As I said, more low-frequency gain than you think is appropriate.  I would also say consider disabling your feedback management. 

Play in Session

If you are working with musicians and fitting hearing aids, block enough time and ask them to bring their instrument to the fitting session.  You will save yourself time and effort in follow-ups by having them bring it from the start.  Make the adjustments necessary while they are playing.  If possible, have them record themselves while they are playing.  Replicate that recording on your system in your office with high-end speakers, and hand them an iPad that has some ability for them to control the programming.  I have done this with the Starkey hearing aids when they are appropriate for patients.

Various Devices

Consider that a person may need different devices for different applications.  Musicians have multiple guitars, different drum kits, different gear, and different hardware for different purposes.  If they are a performing musician and they need hearing aids for communication in everyday situations, you may have to fit them with something other than hearing aids when they are on stage or in the studio. 

Find their Favorite Sound

Ask about their favorite sound.  See it if is something that is recorded or if it is their own instrument.  See if you can get them, either with their hearing protection, their non-linear or music enhancement devices, or their hearing aids, to an acceptable place where they can listen to their favorite sound through their devices.  As that is, acknowledge that you have limitations. 

Acknowledge Limitations and Become their Student

Become their student.  They are so often willing and eager to teach.  I have found that when I ask them to teach me what they value about their listening experience, what they know, what they understand, and what has happened with their ears, they seem a lot more receptive when I make a suggestion.  In events where there is nothing we can do due to limitations in our own abilities, it is imperative that we be cognizant of the patient’s emotional reactions and counsel appropriately.  Understand that listening is something that is highly valuable to them, and they will go through the mourning process.  Help them to know that they can mourn the loss of hearing, and we are not going to judge them.


In summary, our values of hearing and sound are aligned with our patients’.  We know sound better than the vast majority of the world.  When I geek out over ears, the musician can also relate to that, and the audio engineer even more so. 

Protect their ears.  Do not let them be overexposed, particularly if they already have a pre-existing hearing loss.   Be very judicious about over-attenuating.  I can think of very few reasons to fit someone with an ER25 musician’s earplug; it is too much attenuation for the majority of performers.   Respect timbre. 

Where tinnitus is concerned, demystify it and disempower it.  Disempowering the tinnitus is about managing their reaction.  The tinnitus does not deserve the level of attention that their thalamus is giving to it.  It is just circuit noise. 

We have to acknowledge the limitations of our current hearing aid technology.  Figure out if there are alternative devices that can help in certain situations, such as remote microphones.  

Lastly, acknowledge your professional limitations. We may not be able to do for them what they absolutely need, but we will try our very hardest anyway.


Bureau of Labor Statistics. (2012). News release USDL-12-2204. Retrieved from

Kaharit K., Zachau, G., Eklof, M., Sandsjo, L., & Moller, C. (2003). Assessment of hearing and hearing disorders in rock/jazz musicians. International Journal of Audiology, 42(5), 279-288.

Royster, J. D., Royster, L. H., & Killion, M. C. (1991). Sound exposures and hearing thresholds of symphony orchestra musicians. Journal of the Acoustical Society of America, 89(6), 2793-2803.

Santos, L., Morata, T. C., Jacob, L. C., Albizu, E., Marques, J. M., & Paini, M. (2007). Music exposure and audiological findings in Brazilian disc jockeys. International Journal of Audiology, 46(5), 223-231.

Cite this Content as:

Fligor, B. (2015, September). Turning a nightmare into a dream: taking care of musicians and engineers AudiologyOnline, Article 15268. Retrieved from


Rexton Reach - April 2024

brian fligor

Brian Fligor, ScD

Brian Fligor, Sc.D., PASC, is Chief Audiology Officer at Lantos Technologies, Wakefield, MA, and president of Boston Audiology Consultants, Inc., and the Musicians’ Hearing Program, a private practice geared toward diagnosis and treatment of hearing disorders in musicians. Prior to joining Lantos, Dr. Fligor was Director of Diagnostic Audiology at Boston Children’s Hospital and Assistant Professor at Harvard Medical School. He is board certified in audiology with a specialty in pediatric audiology. Dr. Fligor is adjunct faculty at Northeastern University and Salus University, a member of the Children’s Oncology Group, and founder and past-chair of the Music-Induced Hearing Disorders Taskforce for the National Hearing Conservation Association. Dr. Fligor’s publications on hearing loss risk from music received considerable popular media attention, including being spoofed on the David Letterman Show in 2005. His publications on ototoxicity were incorporated into the JCIH Position Statement (2007) and helped shape a new unified international chemotherapy ototoxicity grading scale. He holds a B.S. in Biomedical Engineering and Sc.D. in Audiology from Boston University.

Related Courses

Managing the Musician with Hearing Loss: Treatment Considerations, presented in partnership with Salus University
Presented by Brian J. Fligor, ScD, PASC
Recorded Webinar
Course: #41298Level: Intermediate1.5 Hours
Musicians with hearing loss present with a unique set of needs and challenges. This course reviews the effective management of musicians within an audiology practice, with a focus on treatment considerations. Topics covered include prioritizing tinnitus, hyperacusis, diplacusis and hearing loss; engaging musicians in tinnitus management; and selecting and fitting hearing aids that also optimize music listening. This is part of a 2-part series presented in partnership with Salus University.

Acoustic Trauma from Recreational Noise Exposures
Presented by Brian J. Fligor, ScD, PASC
Recorded Webinar
Course: #31324Level: Advanced1 Hour
While unlikely, immediate, permanent damage to the auditory system can occur from recreational sound exposures. The most obvious recreational exposures is shooting firearms, but certain music exposures and motor sports can result in immediate noise-induced permanent threshold shift, tinnitus, or hyperacusis.

Current Topics in Noise Induced Hearing Loss: Selections from the 12th Annual AudiologyOnline Series
Presented by Brian J. Fligor, ScD, PASC, Colleen Le Prell, PhD, Heather Malyuk, AuD
Recorded Webinar
Course: #42080Level: Advanced3 Hours
This course features selected webinars from the 12th annual AudiologyOnline noise induced hearing loss (NIHL) series, organized by guest editor Brian Fligor, ScD, PASC. Highlights include the latest research on NIHL, specifically how it relates to a musician's risk, diagnosis via telehealth, and treatment of tinnitus and hearing loss.

Current Topics in Noise Induced Hearing Loss: Selections from the 11th Annual AudiologyOnline Series
Presented by M. Samantha Lewis, PhD, Gail Whitelaw, PhD, Brian J. Fligor, ScD, PASC
Recorded Webinar
Course: #31602Level: Advanced3 Hours
This course features selected webinars from the 11th annual AudiologyOnline noise induced hearing loss (NIHL) series, organized by guest editor Brian Fligor, ScD, PASC. This course highlights the latest research on NIHL, specifically NIHL and other auditory system effects of blast trauma, military service, and recreational activities. Applications for audiology practice and improved clinical outcomes are discussed.

Managing the Musician with Hearing Loss, presented in partnership with Salus University
Presented by Brian J. Fligor, ScD, PASC
Recorded Webinar
Course: #32378Level: Intermediate3 Hours
This two-part series presented in partnership with Salus University reviews the fundamentals and effective management of working with musicians within an audiology practice. Topics covered include terminology, diagnostic testing considerations, interpreting noise surveys, and hearing protection devices. In addition to prioritizing tinnitus, hyperacusis, diplacusis and hearing loss; engaging musicians in tinnitus management. Treatment considerations, selecting and fitting hearing aids that also optimize music listening will be discussed.

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