Hearing loss associated with organic solvent exposure: a systematic review

Mont'Alverne, Lucienne Rezende; Corona, Ana Paula; Rêgo, Marco Antônio Vasconcelos

doi:10.1590/2317-6369000113615

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Review • Rev. bras. saúde ocup. 41 • Oct 2016 • https://doi.org/10.1590/2317-6369000113615 copy

Hearing loss associated with organic solvent exposure: a systematic review

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Introduction:

evidences indicate chemicals as potentially otoneurotoxic agents; however, there is no consensus as to the associations between exposure characteristics and the ototoxicity of different chemicals present in industrial environments.

Objective:

to review the available scientific literature in order to identify studies that point to evidence of association, or non-association, between hearing impairment and occupational exposure to organic solvents.

Method:

systematic review of the literature, through query on electronic databases, considering only original articles, published from January 1987 to February 2013.

Results:

thirty-one studies were included in the systematic review.

Discussion:

studies have confirmed exposure to certain solvents as a risk factor for occupational hearing loss, especially in the presence of noise. Various assessment and classification methods were used regarding cochlear and/or central hearing impairment, contributing to the understanding of the extent of chemical-induced hearing loss as well as to the identification of populations at risk. However, data on appropriate diagnostic procedures, safe levels of chemical exposure and dose-response effect have not yet been fully elucidated.

Keywords:
hearing loss; organic solvents; occupational exposure; systematic review

Reference	Exposure	Study place/design	Population/Selection/Activity	Characteristics of groups	Audiological procedures	Outcomes
^{Morata et al. (1993)}9. Morata TC, Dunn DE, Kretshmer LK, Lemasters GK, Keith RW. Effects of occupational exposure to organic solvents and noise on hearing. Scand J Work Environ Health. 1993;19(4):245-54.	Noise/Toluene/Solvent mixture:	Brazil/Cross-sectional	190 men/random sampling/printing and paint manufacturing	(1) 50 non-exposed	PTA (0.5-8 kHz)	HL/RR prevalence:
	- toluene (main component);			(2) 50 exp. noise	Immitanciometry:	(1) 8%
	- xylene;			(3) 50 exp. noise + toluene	Decay	(2) 26%/4.1 (95%CI 1.4-12.2)
	- MEK (methyl ethyl ketone);			(4) 39 exp. solvent mixture		(3) 53%/10.9 (95%CI 4.1-28.9)
	- methyl isobutyl ketone.					(4) 18%/5.0 (95%CI 1.5-7.5)
						HL classification I: majority (3) (p<0,001)
						HL classification I-IV - predictive probability (adjusted for length of service): (3)>(4)>(2)>(1)
						Recruiting (% bigger): (2) p<0,005
						Decay (% bigger contralateral and 2 kHz): (3) p<0.001
^{Sass-Kortsak, Corey e Robertson (1995)}41. Sass-Kortsak AM, Corey PN, Robertson JM. An investigation of the association and hearing loss between exposure to styrene and hearing loss. Ann Epidemiol. 1995;5(1):15-24.	Noise/Styrene	Canada/Cross-sectional	- 299 men (36.6 years ±10,7)/Convenience/Exposed: Fiber-reinforced plastic products plant Non-exposed: local offices.	(age: 36.6±10.7 years)	PTA (0.125-8 kHz) (beginning and end of work shift)	HL - overall
				(1) "directly"		- 10% compensation (0.5; 1; 2 and 3 kHz ≥ 25 dBNA);
				(2) "indirectly"		- 1/3 PA > 25 dBNA in 6 and 8 kHz.
				(3) "non-exposed"		Association between age and HL development (subjects < 50 years and HL<50 dBNA):
				Length 7.6±6.4 years		- Age: significant
						- InTSty: non-significant
						- Cigarette (P=0.001 p=0.01)
						- Extra-occupational noise: signif. ((P=0.01 β= - 0.02))
						- Extra-occupational: signif. em 4 kHz
						Correlation
						- Age and InNoise (r=0.55) - high
						- InTSty and InNoise (r=0.52) - high
						- Age and InTSty (r=0.16) - low
						Regression - InTSty/InNoise:
						- Significant association between noise and HL (3 and 4 kHz)
						- Age and InNoise: signif. interaction
						Regression - InTWA/InTWAN:
						- Association between noise and HL in 3 and 4 kHz stronger (4 kHZ - OE: P=0.006 β= 3.55)
^{Morata et al. (1997a)}7. Morata TC, Dunn DE, Sieber WK. Perda auditiva ocupacional a agentes ototóxicos. In: Nudelman A, Costa EA, Seligman J, Ibanez RN. Pair: perda auditiva induzida por ruído. Porto Alegre: Baggagem; 1997. p.189-201.	Noise/Solvent mixture:	Brazil/Cross-sectional	124 men/not informed/Rotogravure printing plant	Age average: 33.8 years (21-58)	PTA (0.5-8 kHz)	HL (3-6kHz) - 49% (overall total)
	- toluene			Study group (several combinations of solvents and noise )	Immitanciometry:	HL - age and biological marker (toluene):
	- ethyl alcohol (ethanol)			Average length of employment - years:	Decay	OR: 1.07/year of age (95%CI 1.03-1.11)
	- ethyl acetate			07 (1-25)		OR for 2.5 g/g of creatinine (100 ppm in the air): 4.4 (95%CI 2.50-7.45); 1.76/gram of hippuric acid (IC 95% 1.00-2.98)
						No significant interaction: between solvents, solvent mixture and noise, or individual solvent and noise.
^{Morata et al. (1997b)}10. Morata TC, Fiorini AC, Fischer FM, Colacioppo S, Wallingford KM, Krieg EF, et al. Toluene-induced hearing loss among rotogravure printing workers. Scand J Work Environ Health. 1997;23(4):289-98.	Noise/Solvent mixture:	South America/Cross-sectional	438 workers/Convenience/Oil refinary	(1) 41 non-exposed	PTA (0.5-8 kHz)	HL (3-6kHz) bigger number (p<0.005)/OR adjusted:
	- benzene;			(2) 89 (monitoring)	Acoustic reflex	(2) 49%/2.4 (95%CI 1.0-5.7)
	- toluene;			(3) 40 (dispatch)	Immitanciometry decay	(3) 42%/1.8 (95%CI 0.6-4.9)
	- xylene;			(4) 180 (maintenance)		(4) 50%/3 (95%CI 1.3-6.9)
	- ethylbenzene;			(5) 19 (sole previous exp. to aromatics)		(5) 42%
	- cyclohexane.			(6) 69 (quality control lab)		HL (3-6 kHz):
						(6) 15%
						Reflex decay: (2) (4) (p<0.005)
^{Sliwinska-Kowalska et al. (2001)}30. Sliwinska-Kowalska M, Zamyslowska-Szmytke E, Szymczak W, Kotylo P, Fiszer M, et al. Hearing loss among workers exposed to moderate concentrations of solvents. Scand J Work Environ Health. 2001;27(5):335-42.	Noise/Solvent mixture:	Poland/Cross-sectional	517 workers (311 men; 206 women)/Not informed/Paint and varnish companies	(1) 214 non-exposed (113 men, 101 women; 38.5±10.6 years)	PTA (1-8 kHz)	HL/RR incidence - HL in 2-8 kHz:
	- Mixed xylene isomers (ortho, meta and para);			(1a) 174		(1) 36%
	- Ethyl acetate;			(1b) 40		(2) 57,5%
	- White spirit (Detectable concentrations of toluene, butyl acetate and ethyl benzene).			(2) 207 exp. solvents (121 men, 86 women; 39.3±9.5 years)		(2a) 4.4 (95%CI 2.3-8.1)
				(2a) 104		(2b) 2.8 (95%CI 1.8-4.3)
				(2b) 103		(3) 61.5%/2.8 (95%CI 1.6-4.9)
				(3) 96 exposed noise + solvent (77 men, 19 women; 38.4±9.1 years)		OR: HL risk slightly higher in (3) than (2) (all freqs.)
				Length of employment		Higher hearing thresholds in 1-8 kHz: (2) (3)
				(2) 12.8±8.2 years		Higher hearing thresholds averages in 2-8 kHz: (3)
				(3) 12.2±8.5 years		Linear correlation:
						HL risk and solvent exposure index: not observed
						Isolated frequencies and solvent exposure index - observed (3, 4 and 6 kHz for toluene, and 2 and 3 kHz for xylene)
^{Morata et al. (2002)}20. Morata TC, Johnson AC, Nylen P, Svensson EB, Cheng J, et al. Audiometric findings in workers exposed to low levels of styrene and noise. J Occup Environ Med. 2002;44(9):806-14.	Noise/Styrene	Sweden/Cross-sectional	313 workers (278 men; 35 women)/Convenience/Fiberglass and metal products industry	(1)	PTA (0,1-8 kHz)	PTA
				(1a) 65 exp. to styrene (43 years (21-62))		(1) > thresholds in 2, 3, 4 and 6 kHz (p<0.05), being worse than the median in 4, 6 and 8 kHz (p<0.01).
				(1b) 89 exp. to styrene and noise (43 years (21-65))		(2) thresholds worse than the median in 6 and 8 kHz (p<0.01; p<0.05)
				(2) 78 exp. to noise (42 years (20-64))		HL
				(3) 81 non-exposed (45 years (26-62))		(1a) 47%
				Length of employment - years:		(1b) 48%
				(1)		(2) 42%
				(1a) 17 (01−39)		(3) 33% (no statistically significant difference between the groups)
				(1b) 15 (02−37)		2-6kHz thresholds:
				(2) 12 (01−35)		Worse for (1) compared to (2) and (3)
				(3) 18 (2−38)		OR (for each year of age)
						1.19 (95%CI 1.11-1.28)
						OR (for each 1 mmol of mandelic acid per gram of urinary creatinine)
						2.44 (95%CI 1.01-5.89).
						OR (for each 1dB of noise > 85 dB)
						1.18 (95%CI 1.01-1.34)
^{Sulkowski et al. (2002)}18. Sulkowski WJ, Kowalska S, Matyja W, Guzek W, Wesolowski W, et al. Effects of occupational exposure to a mixture of solvents on the inner ear: a field study. Int J Occup Med Environ Health. 2002;15(3):247-56.	Solvent mixture:	Poland/Cross-sectional	101 men/Not informed/Paint and varnish company	(1) 61 exp. solvents (39.8±11.2 years)	PTA	HL (above 1 kHz)
	- ethylbenzene;			(2) 40 non-exposed (39.2±10.5 years)	TEOAE, DPOAE	(1) 42%
	- xylene;			(1a) 20	Acoustic reflexes	(2) 5%
	- trimethylbenzene isomers;			(1b) 23	ENG	DPOAE amplitude - dBNPS
	- toluene;			(1c) 18		(1a) 1,99±6,14
	- ethyl toluene;			Length of employment		(1b) -0,31±10,90
	- styrene;			(1) 15.8±9.1 years		(1c) -2,87±9,06
	- n-propylbenzene.					(2) 7,48±4,67
^{Sliwinska-Kowalska et al. (2003)}11. Sliwinska-Kowalska M, Zamyslowska-Szmytke E, Szymczak W, Kotylo P, Fiszer M, et al. Ototoxic effects of occupational exposure to styrene and co-exposure to styrene and noise. J Occup Environ Med. 2003;45(1):15-24.	Noise/Styrene/Solvent mixture:	Poland/Cross-sectional	513 (men and women)/Not informed/	(1) 157 non-exposed	PTA (1-8 kHz)	HL (1 - 8kHz)/OR - HL:
	- styrene (main compound);		Exposed to solvents: plastic factory and yacht yard. Non-exposed:	(2) 356 exposed		(1) 93 (41.7%)
	- toluene;		- subgroup 1: blue-collar workers;	(2a) 194 exp. styrene		(2) 183 (63.1%)/3.9 (95%CI 2.4-6.2)
	- acetone;		- subgroup 2: metals.	(2b) 66 exp. noise		(2a) 56.2%/5.2 (95%CI 2.9-8.9)
	- dichloromethane.			(2c) 26 exp. styrene + toluene		(2b) 63.3%/3.4 (95%CI 1.7-6.4)
				(2d) 56 exp. styrene + noise		(2c) 76.8%/13.1 (95%CI 4.5-37.7)
				(2e) 14 exp.styrene + toluene + noise		(2d) 76.9%/10.9 (95%CI 4.9-24.2)
						(2e) 78.6%/21.5 (95%CI 5.1-90.1)
						Styrene and noise
						OR: 3
						Auditory threshold average in all frequencies:
						Exposed to solvents was significantly higher
						No dose-response relation for HL and solvent concentrations.
						Positive linear relation between lifetime exposure average (styrene) and auditory thresholds at 6 and 8kHz
						Difference between groups
						- Previous exposure to occupational noise (p< 0.001):
						(1) 6%
						(2) 28%
^{Chang et al. (2003)}28. Chang SJ, Shih TS, Chou TC, Chen CJ, Chang HY, Sung FC. Hearing loss in workers exposed to carbon disulfide and noise. Environ Health Perspect. 2003;111(13):1620-24.	Noise/Carbon dissulfide	Taiwan/Cross-sectional	346 men/Sudy group: census. Control groups: (3) random and (2) census/	(1) 131 exp. noise + carbon dissulfide	PTA (0.5-8 kHz)	HL /OR - HL
			Viscose manufacturing plant (1) (3). electronics and adhesive tape industries (2)	(48.3±8.7 years)		(1) 67.9 %/6.8 (95%CI 3.9-12.1)
				(1a) 41: <14.6 ppm + ≤85 dB(A)		(1a) 1.7 (95%CI 0.8-3.7)
				(1b) 5: <14.6 ppm + >85 dB(A)		(1b) 0.8 (95%CI 0.1-7.5)
				(1c) 24: ≥14.6 ppm + ≤85 dB(A)		(1c) 35.5 (95%CI 7.8-161.3)
				(1d) 61: ≥14.6 ppm + >85 dB(A)		(1d) 18.7 (95%CI 8.1-42.9)
				(2) 105 exp. noise		(2) 32.4%
				(42.2±5.8 years)		(3) 23.6%
				(3) 110 non-exposed		HL - 40-54 dBNA
				(42.0±6.2 years)		(1) 18% (noise≤85 dB(A))
				Length of employment:		(2) 4%
				(1) 20.8±10.5 years		HL 0.5. 1 e 2 kHz: (1)
				(2) 21±5.7 years		HL 4 kHz: (2)
				(3) 11.3±6.4 years		HL 6 kHz: (1) e (2)
^{Sliwinska-Kowalska et al. (2004)}12. Sliwinska-Kowalska M, Zamyslowska-Szmytke E, Szymczak W, Kotylo P, Fiszer M, et al. Effects of coexposure to noise and mixture of organic solvents on hearing in dockyard workers. J Occup Environ Med. 2004;46(1):30-8.	Noise/Solvent mixture:	Poland/Cross-sectional	906 (men and women)/Not informed/	Controls of the same company	PTA (1-8 kHz)	HL/OR - HL:
	- xylene isomers;		Exposed: dockyard.	(1) 517 exp. noise + solvent (37.4±9.2 years)		(1) 67.5 %/4.8 (IC 95% 3.9-7.6)
	- ethylbenzene;		Not exposed: white-collar workers.	(2) 184 exp. noise (42.2±9.3 years)		(2) 64.7 %/3.3 (IC 95% 2.0-5.4)
	- ethyl acetate;			(3) non-exposed (39.8±.3 years)		(3) 39.5 %
	- butyl acetate;					OR for each year of age: 1.12
	- n-butanol;					OR for for each dB(A) average of total exposure time to noise: 1.07
	- white spirit.					OR for each increase in lifetime exposure index to solvents: 1.00
						Lower thresholds for (1) and (2), especially at 8 kHz (worst at (1) - positive linear correlation with exposure time to solvents)

^{Kim et al. (2005)}31. Kim J, Park H, Ha E, Jung T, Paik N, Yanh S. Combined effects of noise and mixed solvents exposure on the hearing function among workers in the aviation industry. Ind Health. 2005;43(3):567-73.	Noise/Solvent mixture:	Korea/Cross-sectional	328 men/Convenience/ Aircraft industry	According to "Cumulative exposure index":	PTA (0.5 - 8 kHz)	HL/OR (adjusted) for HL:
	- toluene;			(1) 151 non-exposed (31.1±6.3 years)		(1) 6.0%
	- xylene;			(2) 146 exp. noise (31.2±6.1 years)		(2) 17.1%/4.8 (IC 95% 1.71-10.75)
	- methyl ethyl ketone			(3) 18 exp. solvent (38.6±6.0 years)		(3) 27.8%/2.57 (IC 95% 0.64-10.31)
	(all samples).			(4) 13 exp. noise + solvent (39.6±4.7 years)		(4) 54.6%/8.12 (IC 95% 2.03-32.53)
^{Kaufman et al. (2005)}32. Kaufman LR, Lemasters GK, Olsen DM, Succop P. Effects of concurrent noise and jet fuel exposure on hearing loss. J Occup Environ Med. 2005;47(3):212-18.	Noise/Solvent mixture:	USA/Cross-sectional	138 workers/Not informed/Military facility (aircraft maintenance and other workers)	(1) 90 exposed	Automatic PTA (0.5-6 kHz)	OR for HL by combined "noise and solvent" exp.:
	- benzene;			(42.8±6.0 years)		03 years - 1.70 (95%CI 1.14-2.3)
	- toluene;			(2) 48 non-exposed		12 years - 8.25 (95%CI 1.67-55.6)
	- xylene;			(40.8±9.9 years)		OR for regular intake of alcoholic beverage: 3.03 (IC95% 1.42-6.45)
	- hexane;			Years of employment:
	- heptane;			(1) 15.8±5.4
	- kerosene (aviation).			(2) 15.6±7.2
^{Seeber et al. (2005)}26. Seeber A, Demes P, Kiesswetter E, Schäper M, Van Thriel C, Zupanic M. Changes of neurobehavioral and sensory functions due to toluene exposure below 50 ppm? Environ Toxicol Pharmacol. 2005;19(3):635-43.	Toluene	Germany/ Retrospective cohort (5 years of follow-up)	216 workers (initially: 333 workers)/ Convenience/Printing plant	(1) 106 high exp.	PTA (0.125; 0.25; 0.5; 0.75; 1; 1.5; 2 - 12 kHz)	"Cases"
				(2) 86 low exp.		(1) 29
				(a) short exp.		(2) 28
				(b) long exp.		OR: 0.791 (95%CI 0.42-1.50)
				Exposure time - average:
				(a) 6 years
				(b) 21 years
^{Sliwinska-Kowalska et al. (2005)}13. Sliwinska-Kowalska M, Zamyslowska-Szmytke E, Szymczak W, Kotylo P, Fiszer M, et al. Exacerbation of noise-induced hearing loss by co-exposure to workplace chemicals. Environ Toxicol Pharmacol 2005;19(3):547-53.	Noise/Solvent mixture:	Poland/Cross-sectional	1117 workers/Not informed/	(1) 731 exp. solvent mixture (xylene)	PTA (1; 1.5-8 kHz)	HL/OR/ PTA freqs.:
	- xylene as main component;		(1) (2) (3): lacquers and paints, footwear, plastics, ship and yacht. (4a): metal factory. (4b): white-collar workers	(38.0±9.4 years)		(1) 63.1%/2.4 (p<0.001)/4; 6 e 8 kHz
	- mainly to styrene;			(2) 290 exp. styrene		(2) 63.1%/3.9 (p<0.001)/1-8 kHz
	- n-hexane and toluene.			(34.5±7.9 years)		(3) 73%/5.3 (p<0.001)/6 e 8 kHz
				(3) 96 exp. n-hexane and toluene		(4) 41.7%
				(39.0±8.7 years)		Only exp. to solvents
				(4) 223 non-exposed to solvents		OR: 4.1-5.2 times greater than controls
				(40.0±9.4 years)		Only exp. to noise
				(4a) 66 exp. noise		OR: 3.8 times greater than controls
				(4b) 157 non-exp. noise		Co-exp. to "noise e solvent"
						OR: 6.7-21.5
						Co-exp. to "noise and two solvents"
						OR: 20
^{Chang et al. (2006)}16. Chang SJ, Chen CJ, Lien CH, Sung FC. Hearing loss in workers exposed to toluene and noise. Environ Health Perspect. 2006;114(8):1283-6.	Noise/Toluen	Taiwan/Cross-sectional	174 men/Census/Adhesive material manufacturing	(1) 58 exp. toluene + noise	PTA (0.5-6 kHz)	HL - including 0.5 kHz/excluding 0.5 kHz
				(1a)		(1) 86.2%/67.2%
				(1b)		(2a) 44.8%/32.8%
				(1c)		(2b) 5.0%/8.3%
				(2) 118 reference		OR - including 0.5 kHz/excluding 0.5 kHz
				(2a) 58 exp. noise		(1) 10.9 times higher than (2a)/5.8 times higher than (2a)
				(2b) 60 management		Poor thresholds in all frequencies, markedly at 4 and 6 kHz, for (1) e (2a), with 1 kHz worse in (1).
				Average age:		Adjusted OR - including 0.5 kHz/excluding 0.5 kHz (1) 140 (95%CI 32.1-608)/29.1 (95%CI 9.3-91.4)
				(1) 40.0±9.7
				(2a) 41.5±3.1
				(2b) 40.9±3.4
				Length of employment:
				(1) 12.3±8.81
				(2a) 11.5±5.73
				(2b) 9.52±5.26
^{Johnson et al. (2006)}21. Johnson AC, Morata TC, Lindblad AC, Nylen PR, Svensson EB, Krieg E, Aksentijevic A, Prasher D. Audiological findings in workers exposed to styrene alone or in concert with noise. Noise Health. 2006;8(30):45-57.	Noise/Styrene	Sweden/Cross-sectional	313 (278 men; 35 women)/ (1) convenience; (2) equal selection to (1); (3) random/	(1)	PTA (0,1-8 kHz)	PTA
			(1) fiberglass products manufacturing; (2) metal products manufacturing; (3) mail terminal	(1a) 89 exp. to styrene (43 years (21-62))	DPOAE	(1) > thresholds at 2, 3, 4 and 6 kHz (p<0.05), being worse than median at 4. 6 and 8 kHz (p<0.01).
				(1b) 81 exp. to styrene and noise (43 years (21-65))	MTF	(2) thresholds worse than median at 6 and 8 kHz (p<0.01; p< 0.05)
				(2) 65 exp. to noise (42 years (20-64))	ACR	PTA after 03 years: 20% of individuals with worse auditory thresholds at one frequency at least
				(3) 78 non-exposed (45 years (26-62))	IS	MTF - threshold average
				Length of employment - years:	Speech in noise	Significant difference between (1b) and (3) and between (1b) and (2), with reduced peak values for (2)
				(1)		DPOAE - "input-output"
				(1a) 17 (01-39)		Interaction between exposed groups and signal level (p<0.006)
				(1b) 15 (02-37)		- signal up to 50 dB: (2) and (3) DPOAE higher than (1)
				(2) 12 (01-35)		- signal > 50 dB: (3) DPOAE level stabilized, (1) and (2) fell
				(3) 18 (2-38)		ACR
						(1) and (2) difference over latency score (p<0.05) compared to (3)
						Interrupted speech
						No difference in score average between groups
						Compared to reference values: (1) below 93% or 78% of corrects answers (p<0.05)
						Speech in noise
						Difference between groups (p<0.001)
						Compared to reference values: (1) and (2) below - 7.8 S/N (p<0.05)
^{Schäper, Seeber e Van Thriel (2008)}25. Schäper M, Seeber A, Van Thriel C. The effects of toluene plus noise on hearing thresholds: an evaluation based on repeated measurements in the German printing industry. Int J Occup Med Environ Health. 2008;21(3):191-200.	Noise/Toluene	Germany/Cohort (5 years)	Men	Follow-ups:	PTA (0.125-0.5; 0.75; 1; 1.5; 2-8; 12 kHz)	PA: 36%
			Initial total: 333 (100%)	- initial: 333 (100%)		Effect of noise intensity on threshold average was almost twice the effect of toluene intensity.
			Final total: 216 (64,9%)	- 2: 278 (83.5%)		Differences between exposure level or length in cases and noncases were not significant (p = 0.49; p = 0.51 respectively).
			(complete data for 192 participants)/Convenience/ Rotogravure printing	- 3: 241 (72.4%)		HL high frequencies (subsample with biomarkers): 36%
				- 4: 216 (64.9%)		No exposure variable found any significance in the statistical model.
				Complete data for 192 participants
				Stratification by intensity of exp. to toluene:
				(1) 106 high exp.
				(2) 86 low exp.
				Stratification by length of exp. to toluene:
				(3) long exp.
				(4) short exp.
				Stratification by intensity of exp. to noise:
				(5) high exp.
				(6) low exp.
				Exposure time to toluene and noise - years:
				(3) 21.3±6.5
				(4) 5.9±2.2
^{Rabinowitz et al. (2008)}33. Rabinowitz PM, Galusha D, Slade MD, Dixon-Ernst C, O'Neill A, Fiellin M, Cullen MR. Organic solvent exposure and hearing loss in a cohort of aluminium workers. Occup Environ Med. 2008;65(4):230-5.	Noise/Carbon Monoxide/Solvent mixture:	USA/Retrospective cohort (5 years)	1319 (men and women)/ Census/Aluminium industry	1319 subjects	PTA	OR (HL dichotomous outcome/exp.>5 years)
	- toluene;			(30.4±3.7 years): 1167 men		(1) 1.87 (95%CI 1.22-2.89; p=0.04)
	- xylene;			(1) 116 (8.8%) solv. exp.
	- methyl ethyl ketone.			(solv. exp. index >1)
				(2) 140 (10.6%) carbon monoxide exp.
				(solv. exp. index >1)
^{Triebig, Bruckner e Seeber et al. (2008)}22. Triebig G, Bruckner T, Seeber A. Occupational styrene exposure and hearing loss: a cohort study with repeated measurements. Int Arch Occup Environ Health. 2008;82(4):463-80.	Styrene	Germany/Cross-sectional - with repetition measures	155 men/Census/Boat building	- 128 more exp. styrene	PTA PTA high freqs. (9-16 kHz) TOAE	HL: 105 "cases"/132 "non-cases"
				- 127 less exp. (5-25 ppm (below 200mg/g creat.))		High exp.: 55%/45%
				According to biomarkers - all participants:		Low exp.: 41%/59%
				(1a) 99 low exp. (37.8±8.9 years)		(2a) 35%/65%
				(1b) 118 medium exp. (38.5±8.9 years)		(2b) 60%/40%
				(1c) 31 high exp. (37.9± 11years)		Auditory thresholds (dB) between 8 e 12.5 kHz slightly different between the high and low exposure groups, with no dose-response effect.
				According to exposure length - " extreme groups":		Change in chronic exposure from (2a) to (2b): OR 7.46 (IC>1) for HL
				(2a) 34 "low-short" exp. (42.6±8.4 years)		TEOAE
				(2b) 17 "high-long" exp. (43.5±11.1 years)		No direct association between the groups and S/N relation or amplitude.
				Length of employment - years:
				(1a) 6.2±4.3 (1-26)
				(1b) 5.7±3.6 (1-23)
				(1c) 6.3±4.8 (1-26)
				(2a) 6.4±3.4 (2-16)
				(2b) 14.6±6.7 (10-26)
^{Fuente et al. (2009)}34. Fuente A, Slade MD, Taylor T, Morata TC, Keith RW, Sparer J, Rabinowitz PM. Peripheral and central auditory dysfunction induced by occupational exposure to organic solvents. J Occup Environ Med. 2009;51(10):1202-11.	Solvent mixture:	New Haven - USA/ Cross-sectional	110 participants/Census/ Coating factory	(1) 20 minimum exp. (38.1±11.6 years; 12 women. 08 men)	PTA (0,5-8 kHz)	Altered PTA in 69 subjects/Altered PTA high freqs. in 22 subjects
	- toluene;			(2) 18 moderate exp. (41.0±12.4 years; 01 woman. 17 men)	PTA high freqs. (12 and 16 kHz)	(1) 25%
	- methyl ethyl ketone.			(3) 72 maximum exp. (39.5±11.4 years. 04 women . 68 men)	DD	(2) 61%/16.6%
	Less quantity:			(categorized by a hygeniest)		(3) 73.6%/26.4%
	- trichlorethylene;					(1) thresholds better than (3) (PTA p=0.004; PTA high freqs. p=0.034)
	- acetone;					DD
	- n-methyl-pyrrolidone;					(1) better responses than (2) (p=0.001) and (3) (p=0.000)
	- dimethylformamide;					Estimate for subjects with normal PTA: (2) -0.382(3) - 0.471
	-clorobenzeno;					Estimate for all subjects: (2) -0.274(3) - 0.386
	- isopropyl alcohol.
^{Zamyslowska-Szmytke et al. (2009)}23. Zamyslowska-Szmytke E, Fuente A, Niebudek-Bogusz E, Sliwinska-Kowalska M. Temporal processing disorder associated with styrene exposure. Audiol Neurootol, 2009;14(5):296-302.	Styrene	Poland/Cross-sectional	109 workers/Not informed/ Fiberglass for manufacturing	(1) 59 exp. styrene (40±09 years; 6 women, 53 men)	PTA (0.125-8 kHz)	PTA
				(2) 50 non-exposed (37±11 years; 16 women, 34 men)	GIN	(1) worse thresholds (0.25-8kHz)
					FPT	(1) 86.4%
					DPT	(2) 34%
						GIN/FPT /DPT
						(1) worse averages
						(1) 24%/59%/85%
						(2) 12%/20%/26%
						(1) Chi-square/ANCOVA adjusted for age and HL
						FPT: 11.7 (p<0.01) /6.8 (p<0.01)
						DPT: 26.4 (p<0.01) /19.3 (p<0.001)
						GIN: 1.2 (p>0.05)
^{Guest et al. (2010)}29. Guest M, Bogges M, Attia J, D'Este C, Brown A, Gibson R, et al. Hearing impairment in F-111 maintenance workers: the study of health outcomes in aircraft maintenance personnel (SHOAMP) general health and medical study. Am J Ind Med. 2010;53(11):1159-69.	Noise/Aircraft fuel (F-111)	Australia/Cross-sectional (with serial measurements)	1530 workers/(1) convenience; (2) (3) random/Royal Australian Air Force	(1) 605 exposed (98% men; 87%<55years)	PTA (0.5; 1; 1.5-8 kHz)	Overall HL: 25% of clinically significant difference (compensation).
				(2) 510 technical comparison - different base, same function (99% men; 91%<55years)		PTA
				(3) 398 no technical comparison - same base, different function (99% men; 90%<55years )		(0.5; 1; 1.5-8 kHz) worse than normalcy standard (presence of a noise notch at 6 kHz)
						OR for HL: similar among the three groups
						(2) 1.1 (CI95% 0.2-2.0)
						(3) 0.9 (CI95% 0.6-1.3)
^{Mohammadi, Labbafinejad e Attarchi et al. (2010)}40. Mohammadi S, Labbafinejad Y, Attarchi M. Combined effects of ototoxic solvents and noise on hearing in automobile plant workers in Iran. Arh Hig Rada Toksikol. 2010;61(3):267-74.	Noise/Solvent mixture:	Iran/Cross-sectional	441 men/Census/ Automobile plant	Average age: (33.07 years; 20-58 years)	PTA (0.5-8 kHz)	HL (average 3-8kHz)/adjusted OR
	- benzene;			(1) 173 exp. noise (33.36±6.95 years)		(1) 24.08±11.89/1
	- toluene;			(2) 104 exp. solvents - within limits (31.87±5.49)		(2) 25.71±7.01/1.8 (95%CI 1.08-3.03)
	- xylene;			(3) 164 exp. noise + solvents - above limits (33.53±6.22)		(3) 32.77±16.04/4.13 (95%CI 2.59-6.58)
	- tetrachlorethylene;			Length of employment:		(3) more common (p<0.001))
	- acetone.			8.06 years (0.5 a 30 years)
^{Beshir, Elserougy e Amer (2011)}35. Beshir S, Elserougy SM, Amer NM. Ototoxic and ototraumatic effects of organic solvents and occupational noise in ceramic workers. Aust J Basic Appl Sci. 2011;5(12):21-8.	Noise/Solvent mixture:	Sadat - Egypt/ Cross-sectional	204 men/(1) census; (2) (3) not informed/Ceramics plant	(1) 44 exp. solvent mixture (36±2 years)	PTA (0.25-2; 4; 8 kHz)	HL - 0.5; 1 and 4 kHz
	- acetone;			(2) 73 exp. noise (38.1±7.3 years)		(1) 72.7%; 45.5%; 45.5%
	- butanol;			(3) 87 non-exposed (37±3.5 years)		(2) 94.5%; 69.9%; 67.1%
	- ethanol;			Length of exposure:		(p<0.05)
	- ethyl acetate;			(1) 16±6		(1) more common at 8 kHz than 4 kHz
	- isopropanol;			(2) 15±9		(2) more common at 4 kHz than 8 kHz
	- toluene;					v-notched
	- xylene.					(1) 63.3%
						(2) 31.5%
						(p<0.01)
						Correlation between exp. length and freqs. of 4 and 8 kHz (adjusted)
						(1) 0.795 (p=0.000) and 0.869 (p=0.000)
^{Fuente, Mcpherson e Hickson (2011)}36. Fuente A, Mcpherson B, Hickson L. Central auditory dysfunction associated with exposure to a mixture of solvents. Int J Audiol. 2011;50(12):857-65.	Solvent mixture:	Chile/Cross-sectional	92 workers/(1) not informed; (2) convenience/ (1) paint factories; (2) University of Chile/Chilean police officers	(1) 46 exp. solvent mixture (37.3±8.2 years; 41 men and 05 women)	PTA (0.5-8 kHz)	Normal auditory thresholds (inclusion criterion), but worse for (1) at freqs. of 1, 2 and 3 kHz.
	- toluene;			(2) 46 non-exposed (36.1±6.1 years; 41 men and 5 women)	RGD	Score differences between groups (adjusted)
	- xylene;			Length of exposure:	MLD	DD (F=4.77; p=0.032)
	- methyl ethyl ketone;			(1) 02 to 30 years (13.3±8.2 years)	PPS	PPS (F=2.87; p=0.014)
	- varsol.				DD	FS (F=5.85; p<0.0001)
					FS	RGD (1; 2; 4 kHz) (F=3.22; 2.83; 4.20 p<0.02, respectively)
					HINT	HINT SRT (F= 13.3 p<0.0001)
						No statistically significant difference was observed for MLD and HINT (speech-in-noise subtests)
^{Morata et al. (2011)}24. Morata TC, Sliwinska-Kowalska M, Johnson A-C, Starck J, Pawlas K, Zamyslowska-Szmytke E, et al. A multicenter study on the audiometric findings of styrene-exposed workers. Int J Audiol. 2011;50(10):652-60.	Noise/Styrene	Finland, Sweden and Poland/Cross-sectional	Initial totall:	(1) 423 exp. solvents	PTA (0.125-8 kHz)	(1) and (2) worse thresholds than reference standard at all frequencies.
			1620 workers (1276 men; 312 women; 32 gender not informed). Final total: 1404 workers/Not informed/ Fiberglass products plants; industries: metal, wood products, yacht yard and office work.	(2) 268 exp. noise + solvents		(1) p=0.0001
				(3) 359 exp. noise		(2) p=0.0192
				(4) 354 non-exposed		OR for HL (for each year of age and each increase of 1 mg/m³ of styrene):
				Age - years: 18-63		(1) 1.0188 (95%CI 1.0140-1.0236)
						(2) 1.0055 (95%CI 1.0009-1.0102)
						(3) 1.01 (95%CI 0.99-1.03)
^{Kaewboonchoo et al. (2013)}38. Kaewboonchoo O, Srinoon S, Lormphongs S, Morioka I, Mungarndee S. Hearing loss in Thai naval officers of coastal patrol crafts. Asia Pac J Public Health. 2014;26(6):651-9.	Noise/Solvent mixture:	Thailand/Cross-sectional	149 men/Census/ Thailand Navy officers	Age: (20-56 years)	PTA (0.5;1; 2; 4; 8 kHz)	HL in 40 % of workers
	- toluene;			Exposed to solvents: 103 (69.1%)		Inclination at 4 kHz: 22.8%
	- xylene;			Length of employment: 0		High frequencies: 14.8%
	- ethyl acetate;			1 a 36 years (31.5%>08 years; 6.9±8.5 years)		Adjusted OR
	- butyl acetate;					Age: 15.83 (IC 95% 3.39-73.92)
	- cyclohexane.					Length of service: 2.19 (95%CI 1.01-4.97)
						Correlation coefficient adjusted for age
						Length of service - frequency of 4 kHz: 0.108 (p<0.05)
^{Fuente, Mcpherson e Cardemil et al.(2013)}27. Fuente A, Mcpherson B, Cardemil F. Xylene-induced auditory dysfunction in humans. Ear hear. 2013;34(5):651-60.	Misture of xylene isomers	Santiago - Chile/ Cross-sectional	60 workers/Convenience/ (1) public hospital histology lab; (2) University of Chile	(1) 30 exp. xylene (15 men. 15 women; 37.1±10.7 years)	PTA (0.25-8 kHz) BAEP DPOAE PPS ATTR DD MLD HINT	HL - 0.5 - 8 kHz
				- cumulative dose of methyl hippuric acid:		(1) thresholds worse than (2)
				(1a) 10		DPOAE adjusted for age
				(1b) 10		No statistically significant difference between (1) and (2)
				(1c) 10		(associated age p≤0.001)
				(2) 30 non-exposed (15 men. 15 women. 35.9 ±11.7 years)		BAEP adjusted for age
				- comared to study subgroups:		(1) greater latencies I, III e V) and inter-peak intervals (I-III, III-V e I-V) (p=0.001)
				(2a) 10		(age not statistically associated)
				(2b) 10		Score difference between groups (adjusted for age)
				(2c) 10		PPS (F=8.04 p<0.01)
				Length of exposure (self-reported):		DD (F=9.03 p<0.01)
				11.8±10.5 years (02-29 years)		HINT (final score) (F=13.77; p<0.0001)
						No statistically significant difference was observed for MLD, ATTR e HINT SRT (p>0.05)
						(age associated with HINT (final score) and PPS (p<0.01 and p<0.0001, respectively))
						BEI in (1)
						Moderate positive correlation between BEI (p=0.42) and binaural average of hearing levels at 2-8kHz (p=0.02). BEI concentrations predicted the binaural average of hearing levels (β=0.59. p<0.01): for each 1g/g of creatinine, increase of 0.034 dBNA.
						No correlation with the remaining procedures (p>0.05)
						Dose-response effect and PTA - average
						(1a) 8.1±6.7
						(1b) 9.0±3.9
						(1c) 20.7±9.1
						((1a) e (1b) significantly different from (1c))
						(1c) different from (2) (p<0.01)
						Dose-response effect and DPOAE - average
						(1a) 4.15±8.78
						(1c) -4.04±6.03
						((1a) e (1c) significantly different)
						(1b) -0.57±5.39
						There was no significant difference between the subgroups
						"Dose-response effect" subgroups and the remaining procedures.
^{Fuente, Mcpherson e Hickson (2013)}36. Fuente A, Mcpherson B, Hickson L. Central auditory dysfunction associated with exposure to a mixture of solvents. Int J Audiol. 2011;50(12):857-65.	Solvent mixture:	Santiago - Chile/ Cross-sectional	144 workers/convenience/ Paint factory	(1) 72 exp. solvents (66 men. 6 women; 39.9±8.5 years)	PTA (0.25-8 kHz)	PTA
	- methyl ethyl ketone;			(2) 72 non-exposed (58 men. 14 women; 37.5±7.1years)	BAEP	(1) worse thresholds (1, 2, 3 and 8 kHz) than (2) (p<0.003)
	- tolueno;			Length of employment - exp. to solvents:	TEOAE	TEOAE
	- xylene;			(1) 15.8±8.1 years	RGD	(1) worse S/R ration than (2) (p<0.01)
	- thinner (Stoddard solvent -mineral spirit);				HINT	CAP testing
	less quantity:					Worse scores (1) for RGD, HINT SRT, HINT1, HINT 2 and HINT (final score) - (p<0.05)
	- benzol;					No statistically significant difference between was observed for HINT3 (p>0.05)
	- esters;
	- alcohol.
^{Fuente, Mcpherson e Hormazabal et al. (2013)}37. Fuente A, Mcpherson B, Hormazabal X. Self-reported hearing performance in workers exposed to solvents. Rev Saúde Pública. 2013;47(1):86-93.	Solvent mixture:	Santiago - Chile/ Cross-sectional	96 workers/census/Paint factory	(1) 48 exp. solvents (38.6±7.1 years)	PTA (0.5-8 kHz) RGD AIADH	PTA - threshold average (dBNA) OD/OE
	- methyl ethyl ketone;			(2) 48 non-exposed (36.8±4.8years)		(1) 9.2±5.6/10.1±5.6 (worse thresholds at 0.5-4 kHz)
	- toluene;			Length of exp. to solvents:		(2) 7.1±4.3/8.4±4.1
	- xylene;			(1) 13.5 years		None of the subjects showed HL according to WHO
	- Stoddard solvent.					RGD
						(1) worse results
						(difference between (1) and (2) (p<0.05))
^{Hughes e Hunting (2013)}8. Hughes H, Hunting KL. Evaluation of the effects of exposure to organic solvents and hazardous noise among US Air Force Reserve personnel. Noise Health. 2013;15(67):379-87.	Noise/JP -8 (aircraft kerosene)/Solvent mixture:	USA/Retrospective cohort (3.2 years)	503 workers (94,6% male)/ Not informed/US Air Force Reserve	(1) 148 exp. noise	PTA 0.25-8 kHz shift threshold standard (STS):	Shift threshold standard (STS) - average of worse ear not informed:
	- toluene;			(2) 65 exp. solvents	≥ 10dB, in either ear, between 2 and 4 kHz, based on reference exam.	(1) 11±7.4
	- styrene;			(3) 220 exp. noise + solvents	Categories:	(2) 3±4.6
	- xylene;			(4) 70 non-exposed (94.6% men)	- STS (≥10 dB)	(3) 12±5.5
	- benzene.			Age (years) at date of first audiogram - median:	- hearing loss (>0 a <10 dB)	(4) 6±8.6
				(1) 28.5±8.5	- no hearing loss (≤0 dB)	RR for HL - worse ear:
				(2) 34.0±8.7		(1) 1.1 (CI95% 0.9-1.4)
				(3) 30.5±8.4		(2) 0.8 (CI95% 0.6-1.2)
				(4) 30.0±10.0		(3) 1.2 (CI95% 0.9-1.5)
				Length of follow-up - years:		(4) 1.1 (CI95% 0.7-1.5)
				(1) 3.5±2.4		Study follow-up length associated with increased HL chance (OR=1.23.CI95% 1.12 - 1.35) for each follow-up year.
				(2) 1.8±1.7
				(3) 3.3±2.0
				(4) 3.4±1.7

Substance	Below OEL and absence/noise <85 dB(A)	Above OEL and absence/noise <85 dB(A)	Below OEL and noise ≥85 dB(A)	Above OEL and/ noise ≥85 dB(A)	Association	Hearing impairment	References
Styrene				X	-	P	^{Sass-Kortsak, Corey and Robert- son (1995)}41. Sass-Kortsak AM, Corey PN, Robertson JM. An investigation of the association and hearing loss between exposure to styrene and hearing loss. Ann Epidemiol. 1995;5(1):15-24.
			X		+	P	^{Morata et al. (2002)}20. Morata TC, Johnson AC, Nylen P, Svensson EB, Cheng J, et al. Audiometric findings in workers exposed to low levels of styrene and noise. J Occup Environ Med. 2002;44(9):806-14.
				X	+	P	^{Sliwinska-Kowalska et al. (2003)}11. Sliwinska-Kowalska M, Zamyslowska-Szmytke E, Szymczak W, Kotylo P, Fiszer M, et al. Ototoxic effects of occupational exposure to styrene and co-exposure to styrene and noise. J Occup Environ Med. 2003;45(1):15-24.
			X		+	P	^{Johnson et al. (2006)}21. Johnson AC, Morata TC, Lindblad AC, Nylen PR, Svensson EB, Krieg E, Aksentijevic A, Prasher D. Audiological findings in workers exposed to styrene alone or in concert with noise. Noise Health. 2006;8(30):45-57.
	X				+	P	^{Triebig, Bruckner and Seeber (2008)}22. Triebig G, Bruckner T, Seeber A. Occupational styrene exposure and hearing loss: a cohort study with repeated measurements. Int Arch Occup Environ Health. 2008;82(4):463-80.
	X	X			+	P and HS	^{Zamyslowska-Szmytke et al. (2009)}23. Zamyslowska-Szmytke E, Fuente A, Niebudek-Bogusz E, Sliwinska-Kowalska M. Temporal processing disorder associated with styrene exposure. Audiol Neurootol, 2009;14(5):296-302.
					+	P	^{Morata et al. (2011)}24. Morata TC, Sliwinska-Kowalska M, Johnson A-C, Starck J, Pawlas K, Zamyslowska-Szmytke E, et al. A multicenter study on the audiometric findings of styrene-exposed workers. Int J Audiol. 2011;50(10):652-60.
Toluene				X	+	P and C	^{Morata et al. (1993)}9. Morata TC, Dunn DE, Kretshmer LK, Lemasters GK, Keith RW. Effects of occupational exposure to organic solvents and noise on hearing. Scand J Work Environ Health. 1993;19(4):245-54.
	X				-	P	^{Seeber et al. (2005)}26. Seeber A, Demes P, Kiesswetter E, Schäper M, Van Thriel C, Zupanic M. Changes of neurobehavioral and sensory functions due to toluene exposure below 50 ppm? Environ Toxicol Pharmacol. 2005;19(3):635-43.
		X			+	P	^{Chang et al. (2006)}16. Chang SJ, Chen CJ, Lien CH, Sung FC. Hearing loss in workers exposed to toluene and noise. Environ Health Perspect. 2006;114(8):1283-6.
	X	X			-	P	^{Schäper, Seeber and Van Thriel (2008)}25. Schäper M, Seeber A, Van Thriel C. The effects of toluene plus noise on hearing thresholds: an evaluation based on repeated measurements in the German printing industry. Int J Occup Med Environ Health. 2008;21(3):191-200.
Carbon dissulfide			X	X	+	P	^{Chang et al. (2003)}28. Chang SJ, Shih TS, Chou TC, Chen CJ, Chang HY, Sung FC. Hearing loss in workers exposed to carbon disulfide and noise. Environ Health Perspect. 2003;111(13):1620-24.
Xylene	X				+	P, C and HS	^{Fuente et al. (2013)}27. Fuente A, Mcpherson B, Cardemil F. Xylene-induced auditory dysfunction in humans. Ear hear. 2013;34(5):651-60.
Solvent Mixture				X	+	P	^{Morata et al. (1997a)}7. Morata TC, Dunn DE, Sieber WK. Perda auditiva ocupacional a agentes ototóxicos. In: Nudelman A, Costa EA, Seligman J, Ibanez RN. Pair: perda auditiva induzida por ruído. Porto Alegre: Baggagem; 1997. p.189-201.
	X				+	P and C	^{Morata et al. (1997b)}10. Morata TC, Fiorini AC, Fischer FM, Colacioppo S, Wallingford KM, Krieg EF, et al. Toluene-induced hearing loss among rotogravure printing workers. Scand J Work Environ Health. 1997;23(4):289-98.
	X				+	P	^{Sliwinska-Kowalska et al. (2001)}30. Sliwinska-Kowalska M, Zamyslowska-Szmytke E, Szymczak W, Kotylo P, Fiszer M, et al. Hearing loss among workers exposed to moderate concentrations of solvents. Scand J Work Environ Health. 2001;27(5):335-42.
	X	X			+	P	^{Sulkowski et al. (2002)}18. Sulkowski WJ, Kowalska S, Matyja W, Guzek W, Wesolowski W, et al. Effects of occupational exposure to a mixture of solvents on the inner ear: a field study. Int J Occup Med Environ Health. 2002;15(3):247-56.
				X	+	P	^{Sliwinska-Kowalska et al. (2004)}12. Sliwinska-Kowalska M, Zamyslowska-Szmytke E, Szymczak W, Kotylo P, Fiszer M, et al. Effects of coexposure to noise and mixture of organic solvents on hearing in dockyard workers. J Occup Environ Med. 2004;46(1):30-8.
			X		+	P	^{Kaufman et al. (2005)}32. Kaufman LR, Lemasters GK, Olsen DM, Succop P. Effects of concurrent noise and jet fuel exposure on hearing loss. J Occup Environ Med. 2005;47(3):212-18.
			X		+	P	^{Kim et al. (2005)}31. Kim J, Park H, Ha E, Jung T, Paik N, Yanh S. Combined effects of noise and mixed solvents exposure on the hearing function among workers in the aviation industry. Ind Health. 2005;43(3):567-73.
			X	X	+	P	^{Sliwinska-Kowalska et al. (2005)}13. Sliwinska-Kowalska M, Zamyslowska-Szmytke E, Szymczak W, Kotylo P, Fiszer M, et al. Exacerbation of noise-induced hearing loss by co-exposure to workplace chemicals. Environ Toxicol Pharmacol 2005;19(3):547-53.
					+	P	^{Rabinowitz et al. (2008)}33. Rabinowitz PM, Galusha D, Slade MD, Dixon-Ernst C, O'Neill A, Fiellin M, Cullen MR. Organic solvent exposure and hearing loss in a cohort of aluminium workers. Occup Environ Med. 2008;65(4):230-5.
	X				+	P and HS	^{Fuente et al. (2009)}34. Fuente A, Slade MD, Taylor T, Morata TC, Keith RW, Sparer J, Rabinowitz PM. Peripheral and central auditory dysfunction induced by occupational exposure to organic solvents. J Occup Environ Med. 2009;51(10):1202-11.
				*X	-	P	^{Guest et al. (2010)}29. Guest M, Bogges M, Attia J, D'Este C, Brown A, Gibson R, et al. Hearing impairment in F-111 maintenance workers: the study of health outcomes in aircraft maintenance personnel (SHOAMP) general health and medical study. Am J Ind Med. 2010;53(11):1159-69.
				X	+	P	^{Mohammadi, Labbafinejad and Attarchi (2010)}40. Mohammadi S, Labbafinejad Y, Attarchi M. Combined effects of ototoxic solvents and noise on hearing in automobile plant workers in Iran. Arh Hig Rada Toksikol. 2010;61(3):267-74.
	X				-	P	^{Beshir, Elserougy and Amer (2011)}35. Beshir S, Elserougy SM, Amer NM. Ototoxic and ototraumatic effects of organic solvents and occupational noise in ceramic workers. Aust J Basic Appl Sci. 2011;5(12):21-8.
	X				+	P and HS	^{Fuente et al. (2011)}36. Fuente A, Mcpherson B, Hickson L. Central auditory dysfunction associated with exposure to a mixture of solvents. Int J Audiol. 2011;50(12):857-65.
	X				+	P and HS	^{Fuente et al. (2013)}37. Fuente A, Mcpherson B, Hormazabal X. Self-reported hearing performance in workers exposed to solvents. Rev Saúde Pública. 2013;47(1):86-93.
	X				+	P and HS	^{Fuente et al. (2013)}37. Fuente A, Mcpherson B, Hormazabal X. Self-reported hearing performance in workers exposed to solvents. Rev Saúde Pública. 2013;47(1):86-93.
			X		-	P	^{Hughes and Hunting (2013)}8. Hughes H, Hunting KL. Evaluation of the effects of exposure to organic solvents and hazardous noise among US Air Force Reserve personnel. Noise Health. 2013;15(67):379-87.
	X				+	P	^{Kaewboonchoo et al. (2014)}38. Kaewboonchoo O, Srinoon S, Lormphongs S, Morioka I, Mungarndee S. Hearing loss in Thai naval officers of coastal patrol crafts. Asia Pac J Public Health. 2014;26(6):651-9.

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[1] Contato: Lucienne Rezende Mont'Alverne E-mail:montalvernelu@gmail.com