Ear Symptoms and Earphone Usage: A Web-Based Survey Study
Article information
Abstract
Background and Objectives
This study aimed to investigate the potential impact of earphone use on the occurrence of otitis externa (OE) by conducting a survey.
Subjects and Methods
This study included 517 participants. The questionnaire comprised 22 items divided into three categories; general information, earphone use, and OE. The questionnaire was designed using Google Forms and distributed through a notice posted on a hospital bulletin board. This notice included a QR code that enabled any interested individual to participate, and the responses were collected automatically.
Results
The proportion of respondents who had experienced OE at least once was 21%. Among them, 33.7% experienced OE within the preceding month. For “adhering to the recommendation usage time,” individuals who responded “likely” had a 0.440 (odds ratio=0.440, 95% confidence interval=0.195-0.993) times higher likelihood; they were at lower risk of experiencing OE compared to those who responded “very unlikely.”
Conclusions
Our findings suggest that proper earphone use can reduce the risk of OE. Despite the lack of a significant relationship between earphone type, physical activity, and cleaning practices, continued adherence to these factors is recommended to prevent OE.
Introduction
Earphones are compact electronic devices that convert electrical signals into sound signals and can be comfortably worn inside or near the ears. In recent times, it has become very common to observe individuals using earphones in various settings. According to a survey conducted on a sample of 1,000 individuals between the ages of 13 and 59 who regularly use earphones, people dedicate approximately one-third of their waking hours to wearing earphones [1].
However, excessive earphone use can lead to potential health risks such as hearing loss (HL), ear infections, and other ear-related problems. One of the most significant issues related to earphone use is HL, which can occur due to prolonged exposure to high-volume levels [2]. Otitis externa (OE) is another potential health risk related to earphone use, because they can create a warm, moist environment in the ear canal that facilitates bacterial or fungal growth. Wearing earphones for extended periods can also cause ear irritation or discomfort, resulting in other ear-related problems.
Previous studies on earphone use have mainly focused on the relationship between high-volume exposure and noise-induced HL, which can damage the hair cells in the inner ear over time [2,3]. However, recent reports suggest a potential link between frequent earphone use and OE. Research on OE caused by hearing devices has primarily focused on headphones [4] or hearing aids [5-8]. Few studies have specifically evaluated the risk of OE with earphone use.
OE is a prevalent condition that is caused by factors like bacterial or fungal overgrowth, skin conditions, or trauma to the ear canal (Fig. 1). This infection is also known as swimmer’s ear, because it can occur after prolonged exposure to water [9]. The symptoms of OE include pain, itching, discharge, and inflammation.
Example of otitis externa.
As technology advances, numerous types of earphones have been released. People use earphones for media consumption and increasingly for online meetings, especially during and as a result of the COVID-19 pandemic. The purpose of this study is to explore the patterns and habits of earphone usage among individuals, and examine the current situation and prevalence of OE. Furthermore, we sought to evaluate the relationship between earphone use and OE development.
Subjects and Methods
Participants
We conducted a survey targeting men and women aged 13 years or older who have used earphones. The study participants were required to meet the following inclusion criteria: 1) to be 13 years or older; 2) to have used earphones within the past month; and 3) to use earphones for at least 30 minutes per day.
Questionnaires
The survey questionnaire aims to collect data on the patterns of earphone use among the participants and investigate the potential relationship between earphone use and OE. The questionnaire is comprised of 22 items that are divided into the following three categories: general information, earphone use, and OE. The general information category includes two items: sex and age. The earphone use category includes the following nine items: replacement frequency of earphones, earphone types, earphone tip types, duration of use of earphones, daily usage time of earphones, most frequent activity when using earphones, experience of pain when using earphones, experience of earphones falling off during use. The OE category includes the following 11 items: earphone cleaning, earphone sharing, adhering to the recommended usage time, earphone use while exercising, experiencing inflammation outside of the ears, tympanic membrane perforation or otitis media, otitis media in the preceding month, cleaning ears with a cotton swab, potential correlation between earphone use and OE. The questionnaire uses a combination of yes/no choice, multiple-choice, and open-ended questions. It was designed to be easy to understand. The survey questions are listed in Supplementary Material (in the online-only Data Supplement).
Procedure
We designed the survey questionnaire using Google Forms (Supplementary Fig. 1 in the online-only Data Supplement) and posted a notice on the hospital’s bulletin board containing a QR code for the survey, which allowed any interested individual to participate. We informed the participants that their participation was voluntary and anonymous. We kindly requested that each participant only respond to the survey once. The responses were automatically collected and stored on the Google Forms platform. The survey was conducted between April 2023 and June 2023.
Statistical analysis
For general information and descriptive analysis, means and standard deviations were calculated for continuous variables, while numbers and percentages were calculated for nominal variables. To compare the characteristics of individuals with and without OE, the independent t-test or chi-square test was used. Additionally, factors influencing OE were identified using multivariate logistic regression. Variables with p<0.15 in the independent t-test or chi-square test were included as independent variables. The logistic regression model’s goodness-of-fit was assessed using the Hosmer-Lemeshow test to evaluate its predictive accuracy for OE. All statistical analyses were conducted using SPSS Version 29.0 (IBM Corp.).
Ethics statement
This study protocol was reviewed and approved by the Institutional Review Board of Samsung Medical Center (approval No. 2023-04-052). Informed consent was submitted by all participants when they were enrolled.
Results
General information
A total of 517 people participated in the survey, including 171 men (33.1%) and 346 (66.9%) women. The average age of the participants was 30.39±9.45 years.
Earphone use
Over the preceding month, 482 of the 517 individuals (93.2%) used earphones, while 35 (6.8%) did not use earphones. Some reasons for not using earphones included not having a need for them, concerns about potential HL, and already using alternative personal listening devices such as headphones or speakers. One participant was excluded from the analysis for not completing the survey. Therefore, the analysis was conducted based on the responses of the remaining 481 participants.
In the univariate analysis, there was a significant difference in the answer to the question “Do you feel pain when you currently use earphones for a long time?” (p=0.003) between individuals with and without OE (Table 1).
Differences in variables pertaining to earphone use by group (n=481)
External ear infection
Of the 481 individuals who reported earphone use in the preceding month, 101 individuals (21%) experienced OE symptoms or were diagnosed with OE. Among those 101 individuals, 34 (33.7%) experienced symptoms of OE within the preceding month. We conducted a survey to assess the symptoms of OE using a multiple-choice format. The most common OE symptom was itching, followed by pain, discharge, and rash.
In the univariate analysis, there were significant differences in the responses to the following questions between individuals with and without OE: “Do you typically use earphones for extended periods of time (i.e., longer than 1 hour at a time)?” (p<0.001); “Have you ever had another bacterial or fungal infection (i.e., athlete’s foot, jock itch)?” (p=0.002); “Have you ever been diagnosed with otitis media or had surgery for otitis media in the past?” (p<0.001); and “Do you think the earphone use affects the occurrence of external ear infection?” (p<0.001) (Table 2).
Differences in variables pertaining to external ear infection by group (n=481)
Factors influencing external ear infection
A logistic regression analysis was performed using the variables that showed a significance level of p<0.15 in the univariate analysis as independent variables for the OE. The logistic regression model was found to be statistically significant (χ2= 14.230, p=0.076). The model’s explanatory power was approximately 24.4% (NagelKerke R2=0.244).
The significance test of the regression coefficients indicated that the following questions had a significant impact on the outcome: “Do your earphones easily fall off your ears when you wear them and move around?”; “Do you typically use earphones for extended periods of time (i.e., longer than 1 hour at a time)?”; “Have you ever had a bacterial or fungal infection (i.e., athlete’s foot, jock itch)?”; and “Have you been diagnosed with an eardrum perforation or inflammation of the middle ear within the last month?”
For the variable “Earphones fall off during use,” individuals who responded “Very often” had a 0.237 (odds ratio [OR]= 0.237, 95% confidence interval [CI]=0.058–0.973) times higher likelihood of experiencing an OE than did those who responded “Never.” For the variable “Adherence to recommended usage time,” individuals who responded “Likely” had a 0.440 (OR=0.440, 95% CI=0.195–0.993) times higher likelihood of experiencing an OE compared to those who responded “Very unlikely.” For the variable “Experiencing inflammation outside of the ears,” individuals who responded “No” had a 4.222 (OR=4.222, 95% CI=1.650–10.808) times higher likelihood of experiencing an OE compared to those who responded “Yes.” For the variable “Presence of otitis media in the past month,” individuals who responded “No” had a 3.423 (OR=3.423, 95% CI=1.822–6.431) times higher likelihood of experiencing an OE compared to those who responded “Yes” (Table 3).
The logistic regression model for external ear infection
Discussion
To the best of our knowledge, this research is the first of its kind to evaluate the correlation between earphone usage and OE. This study sought to assess the lifetime prevalence of OE, its prevalence within the past month, and to examine the potential factors that influence OE occurrence.
We found that among individuals with recent earphone usage, the lifetime prevalence of OE was 21%, while the prevalence of OE within the past month was as high as 33.7%. According to a study conducted in 2019, the lifetime prevalence of OE is approximately 10% [10]. Our research suggests that the increased prevalence of OE compared to the results from the 2019 study could be attributed to the growing population of earphone users. Notably, another group found that the incidence of OE among 136 headphone users was only 5.9% [4]. Despite potential differences in sample size and other factors, these results imply that headphones, which have less direct contact with the ear than earphones do, may not increase the risk of OE as much as earphones can.
One noteworthy finding is that individuals who adhere to the recommended usage time have a 56% lower incidence rate of OE compared to those who do not follow these recommendations. These results suggest that following the advised earphone usage time can decrease the likelihood of developing OE. Although there is no specific research investigating the relationship between recommended earphone usage time and OE, studies on association between earphone usage and ear disorders have recommended limiting usage to less than one hour per day [11]. If prolonged earphone use is necessary, it would be advisable to take breaks every hour to allow the external canal to ventilate. The unexpected result of this study was the absence of a significant difference between individuals who experience OE and those who did not in relation to variables such as the type of earphone used, earphone use while sweating, and regular earphone cleaning. This finding contradicts the claims made by several experts through news outlets, newspapers, and other sources. However, because these expert recommendations are intended to prevent OE [12], it is still advisable to adhere to them.
The study has several significant limitations. The primary limitation is the absence of a control group, which is crucial for meeting the objectives of this research. A prospective design that divides participants into two groups—one using earphones and the other not—would be necessary. Future studies should implement such a design. Additionally, the diagnosis of “OE” was made solely based on otologic symptoms self-reported in a survey, without any physical examination or history taking by a doctor. Future research must utilize objective and reliable diagnostic methods that include comprehensive evaluations by medical professionals.
Supplementary Materials
The online-only Data Supplement is available with this article at https://doi.org/10.7874/jao.2024.00192.
Supplementary Material
The survey questionnaire pertaining to the relationship between earphone use and external ear infections
Supplementary Fig. 1.
Survey created using Google Forms.
Notes
Conflicts of Interest
The authors have no financial conflicts of interest.
Author Contributions
Conceptualization: all authors. Data curation: Ga-Young Kim. Formal analysis: Ga-Young Kim. Funding acquisition: Ga-Young Kim. Investigation: Ga-Young Kim, Mini Jo. Methodology: all authors. Project administration: Ga-Young Kim, Mini Jo. Resources: Ga-Young Kim. Software: Ga-Young Kim. Supervision: Il Joon Moon. Validation: Il Joon Moon. Visualization: Ga-Young Kim. Writing—original draft: Ga-Young Kim. Writing—review & editing: Ga-Young Kim, Young Sang Cho, Il Joon Moon. Approval of final manuscript: all authors.
Funding Statement
This research was supported by Basic Science Research Program through the National Research Foundation of Korea (NRF) funded by the Ministry of Education (#2022R1A6A3A01086146).
Acknowledgments
None