郭洋 孫淵淵 王慧 馮艷梅 時(shí)海波 殷善開(kāi)

上海交通大學(xué)附屬第六人民醫(yī)院耳鼻咽喉頭頸外科（上海200233）

上海交通大學(xué)耳鼻咽喉科研究所（上海200233）

·噪聲性聾專輯·

吸煙和飲酒對(duì)職業(yè)性噪聲暴露對(duì)工人聽(tīng)力的影響

郭洋 孫淵淵 王慧 馮艷梅 時(shí)海波 殷善開(kāi)

上海交通大學(xué)附屬第六人民醫(yī)院耳鼻咽喉頭頸外科（上海200233）

上海交通大學(xué)耳鼻咽喉科研究所（上海200233）

目的探討吸煙、飲酒、職業(yè)性噪聲暴露對(duì)工人聽(tīng)力的影響。方法選取某重型裝備制造廠中噪聲暴露環(huán)境下工人作為研究對(duì)象，問(wèn)卷調(diào)查其噪聲暴露史、吸煙史、飲酒史等，并在隔音室內(nèi)進(jìn)行純音測(cè)聽(tīng)檢查，將PTA0.25-3＞25dB HL記為低頻聽(tīng)力損失，PTA4-8＞40dB HL記為高頻聽(tīng)力損失。根據(jù)吸煙史、飲酒史將受試者分為不吸煙不飲酒組（C0A0）、吸煙不飲酒組（C1A0）、飲酒不吸煙組（C0A1）、吸煙飲酒組（C1A1），以不吸煙不飲酒組（C0A0）為對(duì)照組統(tǒng)計(jì)分析各組聽(tīng)力情況的區(qū)別。并應(yīng)用Logistic回歸分析吸煙、飲酒、噪聲的不同暴露時(shí)間（0-5年、5-10年、10-15年、≥15年）對(duì)聽(tīng)力的影響。結(jié)果C1A0、C0A1、C1A1各組中聽(tīng)力損失工人的聽(tīng)力閾值及各組聽(tīng)力損失率與C0A0組的差異無(wú)統(tǒng)計(jì)學(xué)意義。Logistic回歸分析顯示相對(duì)于噪聲暴露0-5年的工人，噪聲暴露5-10年、10-15年、≥15年的工人發(fā)生低頻聽(tīng)力損失的優(yōu)勢(shì)比分別為1.736、1.954、3.975，發(fā)生高頻聽(tīng)力損失的優(yōu)勢(shì)比分別為1.517、2.257、1.627；相對(duì)于不飲酒人群，不同飲酒時(shí)間工人發(fā)生高頻聽(tīng)力損失的優(yōu)勢(shì)比為1.777、1.814、2.402、3.134。結(jié)論飲酒可能會(huì)增加噪聲暴露下工人聽(tīng)力受損的危險(xiǎn)性，應(yīng)在加強(qiáng)工人個(gè)人防護(hù)的基礎(chǔ)上勸誡工人養(yǎng)成良好的生活習(xí)慣；而吸煙可能并不是造成聽(tīng)力損失的主要危險(xiǎn)因素。

噪聲；吸煙；飲酒；聽(tīng)力損失

This work was supported by grants from the National Natural Science Foundation of China(No.81530029 and No.81300820)

Declaration of interest:The authors declare no confict of interest.

隨著社會(huì)經(jīng)濟(jì)以及工業(yè)的不斷發(fā)展，職業(yè)性噪聲暴露成為了導(dǎo)致聽(tīng)力損失的最主要噪聲來(lái)源，全世界越來(lái)越多的勞動(dòng)者的作業(yè)環(huán)境被職業(yè)性噪聲污染[1,2]。職業(yè)噪聲暴露導(dǎo)致的噪聲性聽(tīng)力損失(noise-induced hearing loss，NIHL)是我國(guó)乃至世界上最主要的職業(yè)病危害之一。本文通過(guò)回顧性隊(duì)列研究，在噪聲暴露人群中探討職業(yè)性噪聲暴露以及吸煙、飲酒與聽(tīng)力損失之間的關(guān)系。

1 對(duì)象和方法

1.1 研究對(duì)象

對(duì)上海市某重型裝備制造廠連續(xù)性噪聲環(huán)境下的作業(yè)工人1872人進(jìn)行聽(tīng)力學(xué)檢查，研究對(duì)象的納入標(biāo)準(zhǔn)為：①年齡低于40歲；②男性工人；③外耳道及鼓膜正常；④中耳鼓室圖為A型。排除標(biāo)準(zhǔn)為：①既往有耳毒性藥物應(yīng)用史；②外耳道或鼓膜異常者；③耳聾家族史者；④中耳功能異常者；⑤顱腦外傷史者。最終819人入選，平均年齡為31.77±5.07歲，平均噪聲暴露時(shí)間為8.02±3.96年，其中電焊工339人、冷作工408人、其他工種72人，8h等效噪聲聲級(jí)dB（A）分別為81.0、80.1、81.4 dB（A）。根據(jù)各位受試者吸煙（Cigarette Smoking）、飲酒（Alcohol Consumption）經(jīng)歷分為不吸煙不飲酒組（C0A0）257人、吸煙不飲酒組（C1A0）135人、飲酒不吸煙組（C0A1）166人、吸煙飲酒組（C1A1）261人。并將受試者根據(jù)各因素的暴露時(shí)間分別分為0-5年、5-10年、10-15年、≥15年四組。納入吸煙組別的標(biāo)準(zhǔn)為：平均每天抽煙≥1支；納入飲酒組別的標(biāo)準(zhǔn)為：平均每周飲酒≥1次。

1.2 方法

1.2.1 問(wèn)卷調(diào)查

問(wèn)卷調(diào)查內(nèi)容：詢問(wèn)受試者一般情況、個(gè)人史、家族史、工種、噪聲環(huán)境工作史、耳毒性藥物應(yīng)用史、吸煙史、飲酒史以及中耳炎、顱腦外傷史等。在研究人員指導(dǎo)下，工人在規(guī)定時(shí)間內(nèi)填寫(xiě)問(wèn)卷答案以減少回憶偏倚。為減少調(diào)查偏倚，參與問(wèn)卷調(diào)查的研究人員均經(jīng)過(guò)統(tǒng)一培訓(xùn)并均通過(guò)了測(cè)試評(píng)估。

1.2.2 外耳道及中耳檢查

用耳鏡檢查受試者的外耳道情況，并用中耳分析儀檢測(cè)受試者中耳功能。

1.2.3 純音聽(tīng)閾測(cè)試

在本底噪聲＜30dB(A)隔音室中，采用丹麥爾聽(tīng)美公司科麗納?Conera?純音測(cè)試儀，測(cè)試并記錄0.25、0.5、1、2、3、4、6、8kHz的純音聽(tīng)閾值。計(jì)算聽(tīng)力較好側(cè)耳0.25、0.5、1、2、3kHz的平均聽(tīng)閾為PTA0.25-3，4、6、8kHz的平均聽(tīng)閾為PTA4-8。參照Gopi?nath B等的標(biāo)準(zhǔn)，將PTA0.25-3＞25dB HL記為低頻聽(tīng)力損失（low-frequency hearing loss,LFHL），PTA4-8＞40dB HL記為高頻聽(tīng)力損失（high-frequency hearing loss,HFHL）[3]，以此計(jì)算各組的聽(tīng)力損失人數(shù)及聽(tīng)力損失率，其中聽(tīng)力損失率（%）=聽(tīng)力損失人數(shù)/此組總?cè)藬?shù)。

1.3 統(tǒng)計(jì)學(xué)方法

采用Excel軟件錄入數(shù)據(jù)建立數(shù)據(jù)庫(kù)，利用SPSS19.0軟件進(jìn)行統(tǒng)計(jì)學(xué)分析。計(jì)量資料對(duì)比采用單因素方差分析、計(jì)數(shù)資料對(duì)比采用卡方檢驗(yàn)，以P＜0.05為差異有統(tǒng)計(jì)學(xué)意義。采用Logistic回歸分析探討職業(yè)性噪聲、吸煙及飲酒的暴露時(shí)間對(duì)工人聽(tīng)力損失的影響。

2 結(jié)果

2.1 不同吸煙飲酒史組別工人的聽(tīng)力閾值及聽(tīng)力損失率

如表1所示，各組噪聲暴露時(shí)間經(jīng)ANOVA統(tǒng)計(jì)學(xué)分析表明，四組間噪聲暴露時(shí)間中C1A0組略低于C0A1、C1A1組(P＜0.05)，而其他各組之間的噪聲暴露時(shí)間差異無(wú)統(tǒng)計(jì)學(xué)意義(P＞0.05)。

表1 工人噪聲暴露時(shí)間（n=819）Table1 Occupational noise exposure time of the workers(n=819)

表2為噪聲暴露工人低頻聽(tīng)力損失（PTA0.25-3＞25dBHL）一般情況，四組PTA0.25-3差異無(wú)統(tǒng)計(jì)學(xué)意義（F=0.635,P=0.593）。C1A0組、C0A1組、C1A1組低頻聽(tīng)力損失率與C0A0組相比差異無(wú)統(tǒng)計(jì)學(xué)意義（χ2=1.747,P=0.186;χ2=0.217,P=0.642;χ2=0.407,P= 0.524）。

表2 噪聲暴露工人低頻聽(tīng)力損失（PTA0.25-3＞25dBHL）情況（n=819）Table 2 Low-frequency hearing loss(PTA0.25-3＞25dBHL)of the occupational noise exposed workers(n=819)

表3為噪聲暴露工人高頻聽(tīng)力損失（PTA4-8＞40dBHL）一般情況，四組PTA4-8差異無(wú)統(tǒng)計(jì)學(xué)意義（F=0.20,P=0.895），C1A0組、C0A1組、C1A1組高頻聽(tīng)力損失率與C0A0組相比差異無(wú)統(tǒng)計(jì)學(xué)意義（χ2= 2.675,P=0.102;χ2=2.673,P=0.102;χ2=3.422,P=0.064）。

表3 噪聲暴露工人高頻聽(tīng)力損失（PTA4-8＞40dBHL）情況（n=819）Table 3 High-frequency hearing loss(PTA4-8＞40dBHL)of the occupational noise exposed workers(n=819)

2.2 不同吸煙時(shí)間、飲酒時(shí)間、噪聲暴露時(shí)間對(duì)聽(tīng)力的影響

不同吸煙時(shí)間、飲酒時(shí)間、噪聲暴露時(shí)間對(duì)工人的低頻聽(tīng)力、高頻聽(tīng)力的影響如表4所示。經(jīng)卡方檢驗(yàn)分析表明，不同噪聲暴露時(shí)間組的低頻聽(tīng)力損失率差異有統(tǒng)計(jì)學(xué)意義（χ2=11.298,P=0.01），高頻聽(tīng)力損失率差異有統(tǒng)計(jì)學(xué)意義（χ2=10.326,P=0.016）。吸煙人群中，低頻聽(tīng)力損失率（χ2=2.079,P=0.556）與高頻聽(tīng)力損失率（χ2=5.814,P=0.121）雖然有隨吸煙時(shí)間的增加逐漸增加的趨勢(shì)，但不同吸煙年限之間聽(tīng)力損失率差異并無(wú)統(tǒng)計(jì)學(xué)意義。飲酒人群中，不同飲酒年限組別的低頻聽(tīng)力損失率差異有統(tǒng)計(jì)學(xué)意義（χ2=10.583,P=0.014）；高頻聽(tīng)力損失率隨飲酒時(shí)間的增加逐漸增加，但不同飲酒年限之間高頻聽(tīng)力損失率差異并無(wú)統(tǒng)計(jì)學(xué)意義（χ2=3.688,P=0.297）。

應(yīng)用SPSS19.0軟件，以后退法進(jìn)行作業(yè)工人接觸噪聲時(shí)間、飲酒時(shí)間、吸煙時(shí)間及其交互作用與聽(tīng)力損失的二分類反應(yīng)變量的Logistic回歸分析，統(tǒng)計(jì)結(jié)果如表5所示：低頻聽(tīng)力損失率主要受噪聲暴露時(shí)間的影響，不同噪聲暴露時(shí)間的優(yōu)勢(shì)比分別為1.736、1.954、3.975；高頻聽(tīng)力損失率主要受噪聲暴露時(shí)間以及飲酒時(shí)間的影響，不同噪聲暴露時(shí)間的優(yōu)勢(shì)比分別為1.517、2.257、1.627；不同飲酒時(shí)間的優(yōu)勢(shì)比為1.777、1.814、2.402、3.134;吸煙時(shí)間、飲酒時(shí)間的交互作用無(wú)統(tǒng)計(jì)學(xué)意義(P＞0.05)。

表4 不同噪聲暴露、吸煙、飲酒時(shí)間的作業(yè)工人聽(tīng)力情況（n=819）Table 4 Hearing loss of workers with different exposure durations of occupational noise,cigarette smoking and alcohol consumption(n=819)

3 討論

噪聲在工作環(huán)境中普遍存在，可以引起心血管系統(tǒng)、消化系統(tǒng)以及神經(jīng)系統(tǒng)疾病和其他生理疾病，而最嚴(yán)重的危害是對(duì)聽(tīng)覺(jué)系統(tǒng)的損傷[4,5]。長(zhǎng)時(shí)間穩(wěn)態(tài)噪聲暴露可導(dǎo)致噪聲性聽(tīng)力損失，由高頻逐漸向低頻逐漸發(fā)展[6,7]。

研究表明，年齡引起的老年性聽(tīng)力損失一般起始于40歲[8,9]，為排除年齡以及性別因素的影響，本研究只選取了40歲以下的男性作為研究對(duì)象。隨著噪聲暴露時(shí)間的延長(zhǎng)，低頻、高頻的聽(tīng)力損失率均增加(表4、5)，與Leensen等的研究結(jié)果一致[10]。而組間分析以及Logistic回歸分析表明，本研究中吸煙對(duì)聽(tīng)力損失的影響并無(wú)統(tǒng)計(jì)學(xué)意義，這與Karlsmose、Starck等的研究結(jié)果一致[11-13]。雖然有研究表明吸煙可以影響人體正常的抗氧化機(jī)制或?qū)е禄钚匝跛降脑龈遊14,15]，使內(nèi)耳對(duì)于噪聲的敏感性增高，加重噪聲引起的聽(tīng)力損失[16,17]，但Tao等研究表明噪聲暴露時(shí)間低于10年時(shí)，吸煙對(duì)聽(tīng)力損失并無(wú)影響；而噪聲暴露時(shí)間大于10年時(shí)，吸煙在4、6kHz的聽(tīng)閾明顯高于不吸煙者[18]；本試驗(yàn)中噪聲暴露時(shí)間低于10年的人數(shù)（491人）高于噪聲暴露時(shí)間高于10年的人數(shù)（328

對(duì)于飲酒對(duì)聽(tīng)力損失的影響，既往研究結(jié)論并不統(tǒng)一。Nakamura，Lao，Rosenhall等研究發(fā)現(xiàn)飲酒是引起聽(tīng)力損失的危險(xiǎn)因素而Curhan等研究表明飲酒與否對(duì)聽(tīng)力損失的關(guān)系并不大[22]，甚至有研究認(rèn)為飲酒對(duì)聽(tīng)力有保護(hù)作用[19]。而本文研究結(jié)果表明，單獨(dú)考慮飲酒時(shí)間對(duì)于聽(tīng)力損失的影響時(shí)，低頻、高頻聽(tīng)力損失率均隨飲酒時(shí)間的延長(zhǎng)而增加，但只有各組間低頻聽(tīng)力損失率差異具有統(tǒng)計(jì)學(xué)意義（表4），與急性飲酒主要影響1kHz聽(tīng)閾的研究結(jié)論相一致[23]；而校正了噪聲暴露時(shí)間及吸煙時(shí)間的影響后，飲酒時(shí)間的長(zhǎng)短主要影響高頻聽(tīng)力損失率（表5），與Verma，Ribeiro等的研究結(jié)果相一致[24,29]。Curhan研究表明維生素B12攝入較少的人群中，飲酒過(guò)多會(huì)增加聽(tīng)力損失的可能性[25]。由于維生素B12在細(xì)胞代謝、血管功能以及髓磷脂合成中的重要作用，維生素B12缺乏可能導(dǎo)致聽(tīng)覺(jué)系統(tǒng)病變的發(fā)生[26,27]，而飲酒過(guò)多時(shí)會(huì)損耗肝中的維生素B12[28]，從而使飲人），可能是導(dǎo)致本研究中吸煙對(duì)聽(tīng)力損失無(wú)影響的原因。另外，由于各研究中并不能對(duì)工人每天吸煙的數(shù)量具體量化以及暴露于二手煙[19]的情況不同，可能是導(dǎo)致各研究結(jié)果互相并不符合的原因，因此在以后的研究中需進(jìn)一步細(xì)化并規(guī)范這些指標(biāo)并分析其對(duì)聽(tīng)力損失的影響。酒者發(fā)生聽(tīng)力損失的可能性增加。而Ribeiro[29]研究表明飲酒主要引起高頻聽(tīng)力損失，而飲酒者TEOAE的異常表明飲酒可能主要引起外毛細(xì)胞的損害。飲酒可以降低興奮性神經(jīng)傳導(dǎo)（通過(guò)調(diào)控NMDA受體）以及增強(qiáng)抑制性神經(jīng)傳導(dǎo)（通過(guò)調(diào)控GABA受體）[30]，而耳蝸毛細(xì)胞受GABA能傳出神經(jīng)元的支配，因此飲酒可能通過(guò)這種路徑影響外毛細(xì)胞的正常功能[31,32]。Hwang等[33]應(yīng)用DPOAE研究同樣表明，飲酒在引起聽(tīng)閾改變之前就會(huì)引起高頻外毛細(xì)胞功能的損害。除了影響外周聽(tīng)覺(jué)系統(tǒng)，研究證明飲酒可以引起中樞聽(tīng)覺(jué)系統(tǒng)處理聲音信號(hào)的障礙[34]，比如會(huì)影響合并不同時(shí)域信號(hào)以及雙耳信息的能力[35]。而B(niǎo)egleiter，Smith等發(fā)現(xiàn)飲酒會(huì)引起聽(tīng)覺(jué)腦干誘發(fā)電位的改變[36,37]。

表5 作業(yè)工人噪聲暴露、飲酒、吸煙時(shí)間與聽(tīng)力損失Logistic回歸分析（n=819）Table 5 Logistic regression analysis for duration of noise exposure,cigarette smoking,alcohol consuming and hearing loss(n=819)

本研究通過(guò)分析噪聲、吸煙、飲酒的不同暴露時(shí)間對(duì)聽(tīng)力的影響，發(fā)現(xiàn)隨著噪聲暴露時(shí)間的增加，發(fā)生聽(tīng)力損失的幾率逐步增加，而飲酒會(huì)加重工人高頻聽(tīng)力損失，且與飲酒時(shí)間呈正相關(guān)。雖然關(guān)于不同吸煙劑量、飲酒劑量對(duì)于聽(tīng)力損失的影響需要更大樣本、更詳盡的研究來(lái)進(jìn)一步確認(rèn)，但對(duì)于噪聲工作崗位的工人來(lái)說(shuō)，應(yīng)注重日常個(gè)人防護(hù)并及早脫離噪聲環(huán)境，同時(shí)應(yīng)注意吸煙、飲酒可加重噪聲對(duì)聽(tīng)力的損害，盡早戒煙、戒酒并養(yǎng)成良好的生活習(xí)慣是有必要的。

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Smoking,Alcohol Consumption and Occupational Noise and Hearing Impairment

GUO Yang,SUN Yuanyuan,WANG Hui,FENG Yanmei,SHI Haibo,YIN Shankai
Department of Otolaryngology,Shanghai Jiao Tong University Affiliated Sixth People’s Hospital,Shanghai Jiao Tong University Otolaryngology Institute,Shanghai 200233,China

ObjectiveTo investigate the impact of smoking,alcohol consumption and noise exposure on hearing.MethodsNoise exposed workers in a large heavy industry factory were selected as the subjects of the study.Questionnaire survey was used to collect their history of smoking and alcohol consumption.Their pure tone threshold average in the sound-proofed environment was evaluated.Low-frequency hearing loss(LFHL)was defined as PTA＞25 dB HL at 0.25-3 kHz,and high-frequency hearing loss(HFHL)as PTA＞40 dB HL at 4-8 kHz.Using history of smoking and drinking,subjects were divided into a non-cigarette non-alcohol group(C0A0,or control),a cigarette smoking without alcohol group (C1A0),an alcohol consuming without cigarette group(C0A1),and a cigarette smoking and alcohol consuming group (C1A1).The duration of cigarette smoking,alcohol consuming and noise exposure was evaluated using a logistic regression model.ResultsDifferences in PTA between each group and the control group were not statistically significant,nor were hearing loss types.Logistic regression analysis showed adjusted odds ratios for HFHL at 1.736,1.954 and 3.975 and for LFHL at 1.517,2.257 and 1.627 for workers with noise exposure of 5-10 years,10-15 years and≥15 years,respectively.Smoking had no effect on hearing loss types,and adjusted odds ratios for HFHL were 1.777,1.814,2.402 and 3.13 for workers with alcohol consumption of 0-5 years,5-10 years,10-15 years and≥15years,respectively.ConclusionsAlcohol consumption may increase the risk of hearing impairment in workers exposed to noise.In addition to hearing protection measures,workers should be counseled on healthy living habits.Smoking,however,does not appear to be a critical factor in causing hearing impairment.

Occupational noise;Cigarette smoking;Alcohol consumption;Hearing impairment

R764.433

A

1672-2922（2016）06-729-6

2016-05-16）

10.3969/j.issn.1672-2922.2016.06.007

國(guó)家自然科學(xué)基金重點(diǎn)項(xiàng)目（81530029），國(guó)家自然科學(xué)基金青年科學(xué)基金項(xiàng)目（81300820）聯(lián)合資助

郭洋，碩士，研究方向：耳內(nèi)科；聽(tīng)力學(xué)基礎(chǔ)與臨床

馮艷梅，Email：feng.yanmei@126.com