golf bad for earing

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1 Department of Anesthesia andCritical Care, MassachusettsGeneral Hospital, Boston, MA02114, USA2 Biostatistics Center,Massachusetts General Hospital,Boston3 Heart Hospital, London4

Nuffield Department of Surgery,John Radcliffe Hospital, Oxford5 Department of Surgery, UniversityHospital, Coventry6 Department of Physics, Universityof Toronto, Canada7 Department of Surgery, Universityof Toronto8 University of Colorado DenverHealth Sciences Center, Aurora,Colorado, USA9 Ann Arbor, Michigan, USA

cspnn t:

P Fith [email protected]

Mtaity n Mnt evst, 19212006: siptiv styPaul G Firth,1 Hui Zheng,2 Jeremy S Windsor,3 Andrew I Sutherland,4 Christopher H Imray,5 G W K Moore,6

John L Semple,7 Robert C Roach,8 Richard A Salisbury9

Abac

Objective To examine patterns o mortality among climbers

on Mount Everest over an 86 year period.

Design Descriptive study.

Setting Climbing expeditions to Mount Everest, 1921-

2006.

Participants 14 138 mountaineers; 8030 climbers and

6108 sherpas.

Main outcome measure Circumstances o deaths.

Results The mortality rate among mountaineers above

base camp was 1.3%. Deaths could be classifed as

involving trauma (objective hazards or alls, n=113), as

non-traumatic (high altitude illness, hypothermia, or

sudden death, n=52), or as a disappearance (body never

ound, n=27). During the spring climbing seasons rom

1982 to 2006, 82.3% o deaths in climbers occurred

during an attempt at reaching the summit. The death

rate during all descents via standard routes was higher

or climbers than or sherpas (2.7% (43/1585) v0.4%

(5/1231), P


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The table outlines the characteristics o the study popu-lation. Overall, 341 accounts were analysed, including136 notes rom the Himalayan Database, 106 journalreports, 31 books, 32 direct accounts by 22 climbers,14 web based accounts, and 7 miscellaneous sources.

In total, 154 atal incidents resulting in 212 deaths wereidentied. For the classication o all 212 deaths, therewas unanimous independent agreement or 165 (78%).The Fleiss value or inter-rater agreement was 0.63,P


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atigue, late summit times, and the tendency to allbehind companions were common early eatures onon-survivors.

Strength an limitations

The strength o this study lies in the records kept over

our decades on the Himalayan Database.1

An assess-ment o deaths was, however, limited by the variabilityo circumstances. While there was substantial agree-ment between the reviewers on classication o thedeaths,4 categorisation relied on a descriptive system.This may underestimate underlying problems, suchas neurological dysunction leading to alls, disappear-ances, or vulnerability to hypothermia at extreme alti-tude. Although a retrospective study can only show anassociation and not prove causality, this simple descrip-tive technique allows broad patterns o mortality tobe detected.

distribution of eaths

The largest class o deaths involved objective haz-ards such as avalanches or alling ice. Sherpas werekilled at a greater rate per incident than climbers (1.18v 0.54, P=0.02). These incidents typically occurredon the lower sections o routes, passing below slopesprone to avalanches. The higher death rate per inci-dent among sherpas can largely be explained by moretime spent transporting equipment in these areas. Dur-ing the spring climbing seasons o the last 25 years othe study period, deaths rom objective hazards wererare. By contrast, 85.4% o deaths on the north routeand 43.9% o deaths on the south route occurred above8000 m (gure). While a typical expedition to Ever-

est now lasts about 60 days, 82.3% o deaths amongclimbers occurred during or ater the day o a summitattempt.

deaths above 8000 m

Climbers died during descent at a greater rate thansherpas (2.5% v 0.2%, P


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the interaction and relative importance o the dier-ences between populations and acclimatisation pro-les requires urther study.cmpting intst: RAS has a financial interest in the Himalayan database.

ethia appva: This study was approved by the institutional review boardof Massachusetts General Hospital.

Pvnan an p viw: Not commissioned; externally peer reviewed.

We thank Gary Landeck and Mike Weichert (American Alpine Club Library,

USA) and Yvonne Sibbald (Alpine Club Library, UK) for their help in locating

articles; the many Everest mountaineers from around the world who patiently

provided details of deaths; Charlie Cote and Scott Tolle (Massachusetts General

Hospital) for assistance in the preparation of the manuscript; and Armin Gruen

and Martin Sauerbier ( Institute of Geodesy and Photogrammetry, Switzerland)

for data and assistance in constructing the route profile.

cntibts: See bmj.com.

Hawley E, Salisbury R.1 The Himalayan database: the expeditionarchives of Elizabeth Hawley. Golden, CO: American Alpine Club,2004-7.Hackett PH, Roach RC. High-altitude illness.2 N Engl J Med2001;345:107-14.Roach RC, Bartsch P, Hackett PH, Oelz O, Lake Louise AMS Scoring3Consensus Committee. The Lake Louise acute mountain sicknessscoring system. In: Sutton JR, Houston CS, Coates G, eds. Hypoxia andmolecular medicine. Burlington, VT: Charles S Houston, 1993:272-4.Fleiss JL. Measuring nominal scale agreement amongst many raters.4Psychol Bull 1971;76:378-82.West JB. Prediction o barometric pressures at high altitude with the use5o model atmospheres.J Appl Physiol 1996;81(4):1850-4.

Huey RB, Eguskitza X. Limits to human perormance: elevated risks6on high mountains.J Exp Biol 2001;204(Pt 18):3115-9.West JB, Schoene RB, Milledge JS.7 High altitude medicine andphysiology. 4th ed. London: Hodder Arnold, 2007.Hackett PH, Yarnell PR, Hill R, Reynard K, Heit J, McCormick J.8High-altitude cerebral edema evaluated with magnetic resonanceimaging: clinical correlation and pathophysiology.JAMA1998;280:1920-5.Wu T, Ding S, Liu J, Jia J, Dai R, Liang B, et al. Ataxia: an early indicator9

in high altitude cerebral edema. High Alt Med Biol 2006;7:275-80.Boukreev A. The oxygen illusion: perspectives on the business o10high-altitude climbing.Am Alpine J 1997:37-43.Sutton JR, Reeves JT, Groves BM, Wagner PD, Alexander JK, Hultgren11HN, et al. Oxygen transport and cardiovascular unction at extremealtitude: lessons rom Operation Everest II. Int J Sports Med1992;13(suppl 1):S13-8.Imray CH, Myers SD, Pattinson KT, Bradwell AR, Chan CW, Harris12S, et al. Eect o exercise on cerebral perusion in humans at highaltitude.J Appl Physiol 2005;99:699-706.Sutherland AI, Morris DS, Owen CG, Bron AJ, Roach RC. Optic nerve13sheath diameter, intracranial pressure and acute mountain sicknesson Mount Everest: a longitudinal cohort study. Br J Sports Med2008;42:183-8.Pugh LG. Blood volume and haemoglobin concentration at altitudes14above 18,000 Ft (5500 M).J Physiol 1964;170:344-54.Niermeyer S, Yang P, Shanmina, Drolkar, Zhuang J, Moore LG. Arterial15oxygen saturation in Tibetan and Han inants born in Lhasa, Tibet. NEngl J Med 1995;333:1248-52.

Erzurum SC, Ghosh S, Janocha AJ, Xu W, Bauer S, Bryan NS, et al.16 Higher blood low and circulating NO products oset high-altitudehypoxia among Tibetans. Proc Natl Acad Sci USA 2007;104:17593-8.

Apt: 9 November 2008

Voices in the air

Jm s Wi wonders how to explain the benign presence he met on Mount Everest

Ater leaving Eric a strange eeling possessed me thatI was accompanied by another The presence

was strong and riendly. In its company I could noteel lonely, neither could I come to any harm, it wasalways there to sustain me on my solitary climb upthe snow covered slabs. Now as I halted and extractedsome mint cake rom my pocket, it was so near andso strong that instinctively I divided the mint into twohalves and turned round with one hal in my hand tooer it to my companion.1

I rst met Jimmy on the Balcony, a cold windsweptsnow shel high up on the southeast ridge o MountEverest. At an altitude o more than 8200 metres ourintroduction had been brie, with little more than a mu-

fed hello and a ew words o encouragement passingbetween us. Over my right shoulder, obscured by thebulky oxygen mask and the rim o down that smoth-ered my ace, I was sure I could see Jimmy movinglightly in the darkness. But despite him remaining closeby me or the rest o the day, I didnt see him again. Atthe time, it hadnt worried me; instead I was warmedby the thought o human company and too breathlessto question what seemed so real. I the truth be told,my thoughts were really nothing more than brie fick-ers o images or sounds that vanished with the onseto each new breath. Not only was I stupid rom lacko oxygen, as one Mount Everest mountaineer once

so memorably put it, but I was exhausted. Ater nearlythree months on Everest I had lost almost a th o my

Institute of Human Health andPerformance, University College

London, London N19 [email protected]

Cite this as:BMJ2008;337:a2667

DUNCANSMITH


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body weight, owing in large part tobouts o altitude sickness and my ussyvegetarian diet. Higher on the moun-tain, the weight loss had made mat-ters worse. Without a decent amounto at to insulate me, it had become

dicult to sleep at night and I woulddoze through the day ignoring theneed to drink and consume preciouscalories.

The climb to the Balcony had beenachieved on little more than will-power, and standing beside my new

companion I soon realised that even this energy hadbegun to ade. Jimmy seemed to have ared much better.His ew words had been measured and calm, lled witha condence that I badly lacked: Come on, changeyour cylinder and get moving. Jimmys voice was rmand commanding, stirring me into activity. Here mymemory alters. I dont recall changing the cylinder oreven the decision to carry on along the xed ropes, butI do remember Jimmy. Sometimes as I inched my wayalong I would hear the rhythmic scratches o his cram-pons on the icy path and even eel the smooth tugs o hisascender on the rope that we shared. As we rested, mynew climbing partner would stand so close that Id beable to hear the sot whisper o oxygen entering his ace-mask and the rattle o breath as he exhaled. Through-out the hours we spent together Jimmy would otenspeak, answering my questions and oering a mixtureo rm commands and gentle words o encouragementto drive me on. As we climbed higher we even indulgedin making plans or what wed do on the summit and

how wed celebrate when we returned to Kathmandu.Finally, ater almost 10 hours o climbing we emergedon the South Summit, the sun beginning to stir out tothe east, emphasising the curvature o the earth visiblear on the horizon. Like a ootball match commentatordescribing Wembley stadium on Cup Final day, Jimmypointed out the route ahead, the amous Hillary Step,and the location o the xed ropes that skirted along theicy cornice and nished on the summit. I knew at thatpoint that Id make it, and so did Jimmy. Ater a ewmore encouraging words he whispered a nal cheerioand was gone.

I hadnt been the rst to encounter someone like

Jimmy on Everest. Over the course o almost a centuryo climbs on the mountain, many similar experienceshave been recounted. For some mountaineers, thesecompanions have had a clear visual orm, such asthat described by Nick Estcourt during a climb to Camp5 on the rst successul ascent o the southwest ace in1975: I turned round and saw this gure behind me.He looked like an ordinary climber, ar enough behind,so that I could not eel him moving up the xed rope,but not all that ar below. I could see his arms and legsand assumed that it was someone trying to catch meup.2

For others, such hallucinations have tended to be

almost invisible, ranging rom aint noises or voices inthe air to amiliar characters capable o holding lengthy

conversations. During a night spent in a snow holeclose to the summit, Dougal Haston later recalled: Iwas locked in suering silence except or the occasionalquiet conversation with Dave Clarke. Hallucination ordream? It seemed comorting and occasionally directedmy mind away rom the cold.2

For many o us, companions like Jimmy have tendedto be a source o comort, providing not only a sense ocompanionship but sometimes practical help as well.In 1988 Stephen Venables completed an extraordinaryascent o the Kangshung Face without supplementaloxygen and was orced to sit out the night on a smallledge just below the summit. At times, Venables realisedthat a crowd had ormed around him: Sometimes theyoered to look ater parts o my body Perhaps itwas then that Eric Shipton, the distinguished explorerso closely involved with the history o the mountain,took over warming my hands. At the end o the ledgemy eet kept nearly alling o where I had ailed to diga thorough hollow in the snow. I was aware o severalpeople crowding out the eet, but also trying to lookater them.3

What is to be made o these benign gures? As adoctor I want to believe that Jimmys appearance waslinked to the physical and psychological stresses thatI elt that day. Herbert Tichy, the rst to climb ChoOyu (8201 metres) in 1954, summed it up well whenhe wrote: Things like this arise because the spirit hassomehow broken ree rom the anchorage which holdsit ast ar down in the valley, and strays right up to thevery rontiers o insanity.4

But as a superstitious mountaineer Im swayed by analternative explanation. Peter Habeler, who with Rein-

hold Messner in 1978 became the rst to climb Everestwithout supplemental oxygen, draws a dierent conclu-sion and links those climbing the mountain to previousgenerations: There is a saying that whoever is killed upon the mountain wanders orever ater his death, andguides the living mountaineers during their last metresto the summit.4

Today, my memories o Jimmy are so clear and vividthat it sometimes makes it impossible to embrace the sci-entic explanations that I should wholeheartedly accept.But whatever the explanation or Jimmys appearance,I know now that I wouldnt have reached the summitwithout him.

cmpting intsts: None declared.Pvnan an p viw: Not commissioned; not externally peer reviewed.

JSW was a member of Caudwell Xtreme Everest, a research project coordinated

by the UCL Centre for Altitude, Space and Extreme Environment Medicine,

University College London. The aim of the project was to conduct research into

hypoxia and human performance at high altitude to improve understanding

of hypoxia in critical illness. JSW reached the summit of Mount Everest on 24

May 2007 accompanied by Ang Kaji Sherpa, Dawa Tenji Sherpa, Lila Chhombe

Basnet, Michael Brown, Pemba Gyalzen Sherpa, Pemba Nuru Sherpa, Michael

ODwyer, and Roger McMorrow.

Smythe FS. Camp 6. In: Potterield P, ed.1 The mountaineersanthology series. IV Everest. Seattle: Mountaineers Books,2004:52.Bonington C.2 Everestthe hard way. London: Hodder and Stoughton,1997:186-92.Venables S.3 Everestalone at the summit. New York: Thunders MouthPress, 2000:184.Habeler P.4 Everestimpossible victory. London: Arlington Books,1979:167-9.

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Abac

Objective To explore the perceived wisdom that papal

mortality is related to the success o the Welsh rugby union

team.

Design Retrospective observational study o historical

Vatican and sporting data.

Main outcome measure Papal deaths between 1883 and

the present day.

Results There is no evidence o a link between papal

deaths and any home nation grand slams (when one nation

succeeds in beating all other competing teams in every

match). There was, however, weak statistical evidence to

support an association between Welsh perormance and

the number o papal deaths.

Conclusion Given the dominant Welsh perormances o

2008, the Vatican medical team should take special care o

the ponti this Christmas.

Iuci

In recent times, an intriguing urban legend has arisenin Wales: every time Wales win the rugby grandslam, a Pope dies, except or 1978 when Wales werereally good, and two Popes died (http://news.bbc.co.uk/sport1/hi/unny_old_game/4449773.stm). Weused historical data to examine whether the Vaticanmedical team caring or Pope Benedict XVI shouldbe especially vigilant in this, a year in which Waleswon the grand slam (http://en.wikipedia.org/wiki/Grand_Slam_(Rugby_Union) and http://en.wikipedia.org/wiki/Grand_Slam_(Rugby_Union)).

Meh

We investigate both parts o this claim, and reerrespectively to them as the special and general theo-ries o papal rugby. The special theory indicates the

1 Department of ClinicalNeurophysiology, UniversityHospital Wales, Heath Park, CardiffCF14 4XW2 Cardiff3 Department of Primary Care andPublic Health, School of Medicine,Cardiff University, Cardiff CF14 4YS

cspnn t: G c [email protected]

Cite this as:BMJ2008;337:a2768

rgby (th igin f Was) an its infn n thcathi hh: sh Pp Bnit XVI b wi?

Gareth C Payne,1 Rebecca E Payne,2 Daniel M Farewell3

Fig 1 | The winners of the rugby tournament with the years of grand slams and papal deaths marked

England win

Wales win

Scotland win

Ireland win

France win

0 1 2 3 4 5 6 7 8 9

1880s

1890s

1900s

1910s

1920s

1930s

1940s

1950s

1960s

1970s

1980s

1990s

2000s

No tournament contested

Grand Slam achieved

Papal death

Tournament not completed

?



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direction o the eect: when Wales win a grand slam,the chance o a papal death in that year increases. Thegeneral theory suggests a dose-response relation: whenWales perorm particularly well, the expected numbero papal deaths increases.

A grand slam is achieved when, in a given season,one nation succeeds in beating all other competing

teams in every match. We discard results rom the sixyears in which not all scheduled matches were played(1885, 1888-9, 1897-8, 1972).

To our knowledge, every pope rom St Peter to PiusIX (who was pope rom 1846 to 1878) died withouta rugby union grand slam being contested or won.Although rugby union was invented in 1823, the year1883 oered the rst opportunity or a rugby grandslam, when England, Ireland, Scotland, and Wales

completed their rst annual international rugby uniontournament. France entered the competition in 1910(though did not compete during the years 1932-9). In2000, Italy began to compete in the event, which is nowknown as the Six Nations Championship. Under ourworking denition, 53 grand slams have been achievedto date.

Since 1883, eight pontis have died, ve o whom didso in grand slam years: Leo XIII (1903) when Scotlandwon, Pius X (1914) when England won, and Paul VI(1978), John Paul I (1978), and John Paul II (2005) whenWales won. The deaths o Pius IX (1922) and BenedictXV (1939) coincided with Wales winning the tourna-ment, though without achieving the grand slam. Eachpapal death in this period coincided with victory or apredominantly Protestant nation (England, Scotland, orWales) rather than a predominantly Roman Catholicnation (France, Ireland, or Italy).

In all our investigations, we used the calendar yearo completion o the northern hemisphere rugby union

championship as our unit o analysis. Our samplesizethat is, the number o completed competitionsrom 1883 to 2007was thereore 107. Figure 1shows the winning teams or each o these years, andindicates grand slams, papal deaths, and incompletechampionships.

reul

To investigate the special theory o papal rugby, weused logistic regression to relate the years in whichpopes have died (since 1883) to home nation (England,Ireland, Scotland, and Wales) grand slams. The binaryoutcome o interest was whether at least one pope died

in that year. There was, however, no evidence o asignicant association between any individual home

Fig 2 | Performance of the rugby nations, measured by average points difference per game, showing the years of papal deaths.Dashed lines represent years when the tournament was not completed

1880

1885

1890

1895

1900

1905

1910

1915

1920

1925

1930

1935

1940

1945

1950

1955

1960

1965

1970

1975

1980

1985

1990

1995

2000

2005

2010

10

0

10

20

30

20

Year

Performance

Italy

Scotland

Wales

England

France

Ireland

Leo

XIII

PiusX

PiusXI

PiusXII

John

XXIII

PaulVI

John

PaulI

John

PaulII

BenedictXV

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nation grand slam victories and the years o papaldeaths (P>0.1).

To investigate the general theory o papal rugby, weconstructed a measure o a nations rugby perormance:the ratio o points dierence (points against subtractedrom points or) to the number o games played. Inother words, we used the average (signed) dierencein score per game as an indication o how well a teamplayed in that year. Note that we did not adjust orchanges to rugby scoring laws, nor or the beginning othe proessional era in 1995. Figure 2 plots our measureo perormance or all six nations against the year o com-petition and also indicates the years o papal death.

We then used Poisson regression to relate the numbero popes dying in a given year (with possible values0, 1, 2, ...) to all our home nations levels o perorm-ance (simultaneously). We ound a borderline signi-cant (P=0.047) association between Welsh perormanceand the number o papal deaths but no signicant

associations between papal mortality and perormanceo any other home nation.

dicui

The special theory o papal rugby is nothing more thanan urban myth, based largely on two Welsh grand slam

wins in recent memory. This comes as something o arelie, as we are at a loss to see how the events could belinked, especially given the continuing rapprochementbetween Catholic and Protestant churches.

Nevertheless, using the Six Nations data rom 2008,our model or the general theory o papal rugby predictsthat 0.62 (about 3/5) o a pope will die this year. It couldbe argued that Wales strong win over Italy articiallyinfates their measure o perormance; however, basedon the historical evidence, we do not believe the Vaticanmedical sta can ully relax until the new year arrives.This project was based on a suggestion by Geraint Fuller. We are grateful to

Christine Connolly of Six Nations Rugby Ltd for providing us with the historical

data used in our analyses.

cntibts:GP and RPP cowrote the paper and collected the historical data.DF cowrote the paper and performed the statistical analysis. GP is guarantor.

Fning:This research received no specific grant from any funding agency in thepublic, commercial, or not-for-profit sectors.

cmpting intsts: None declared.

ethia appva: Not required.

Pvnan an p viw: Not commissioned; externally peer reviewedApt: 23 November 2008


Is golf bad for your hearing?

M A Baa a ag investigate the possible hazards of modern drivers

A 55 year old right handed man presented to the ear,nose, and throat outpatient clinic with tinnitus andreduced hearing in his right ear. Clinical examinationwas unremarkable. His pure tone audiogram showedan asymmetrical sensorineural hearing loss, worse onthe right, with a decrease on that side at 4-6 kHz (g 1)typical o a noise induced hearing loss.1 He had beenplaying gol with a King Cobra LD titanium club threetimes a week or 18 months and commented that thenoise o the club hitting the ball was like a gun goingo. It had become so unpleasant that he had been

orced to discard the club.Magnetic resonance imaging o his internal acoustic

meati showed no abnormality, and we deduced that hisasymmetrical sensorineural hearing loss was attribut-able to the noise o the gol club. Other than regulargol, he had no history o prolonged occupational orrecreational exposure to loud noises (such as shooting)or exposure to ototoxic substances to account or thisnoise induced loss.

Our internet search o reviews or the King CobraLD club ound some interesting comments:

Drives my mates crazy with that distinctive loudBANG sound. Have never heard another club that

makes so distinctive a sound. It can be heard all overthe course, it is mad!!

A very orgiving club . . . albeit the unusual clank-ing sound.

I dont mind the loud BANG as it sounds like the

ball goes a really long way. It sounds like an aluminiumbaseball bat, so some may not like it.

Frequency (kHz)

Hearing

level(dB)

90

70

60

30

20

10

0

50

40

80

0.125 0.25 0.5 1 2 4 8

Left ear

Right ear

Fig 1 | Pure tone audiogram showing sensorineural hearingloss on the right, with a noise induced drop at 4-6 kHz

WhAt Is AlreAdy knoWn on thIs topIc

Rugby is ollowed religiously in Wales

Wales is a long way rom Rome

WhAt thIs study Adds

Welsh grand slams coincide coincidentally with Papal deaths


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This is not so much a ting but a sonic boom whichresonates across the course!

diagi f ie amage

Guidelines exist to help diagnose noise induced hearingloss, setting out three requirements and our modiyingactors that must be considered to ormulate a rm diag-nosis.1 Our patients audiogram met the requirementsor a high requency hearing impairment. His hearingwas at least 10 dB worse at 4-6 kHz than at 1-2 kHz,and there was a downward notch o at least 20 dB inthe 3-6 kHz range (g 1). The remaining requirement

continuous noise exposure o 100 dB (or 90 dB orsusceptible individuals)does not apply in this case aswe are dealing with impact (50 s) noise. The modi-ying actors were also consistent with noise inducedimpairment.

He had no previous history o noise exposure, andthe tinnitus described was a characteristic o noise expo-sure. In addition, calculation o Robinson-Suttons equa-tions2 conrmed that in a man o 55 years, age inducedhearing loss (presbyacusis) could not account or theloss at 4-6 kHz in his right ear, and that it must havebeen due to noise exposure.

niy clubThe coecient o restitution (COR) o a gol club is ameasure o the elasticity or eciency o energy trans-er between a gol ball and club head. The UnitedStates Gol Association, in conjunction with the Royaland Ancient, St Andrews, Scotland, stipulates that theupper limit o COR or a gol club in competition useis 0.83.3 This means that a club head striking a ball at100 miles per hour (mph) will cause the ball to travelat 83 mph. Thinner aced titanium clubs, such as theKing Cobra LD, have a greater COR and deorm onimpact more easily, the so called trampoline eect,not only propelling the ball urther, but resulting in a

louder noise. The King Cobra LD and Nike SQ bothhave CORs above 0.83, making them non-conorming

or competitions.3

The experience o our patient prompted us to studythe sound levels produced by dierent gol drivers. Aproessional goler hit three two-piece gol balls with sixthin aced titanium gol drivers and six standard thickeraced stainless steel gol drivers. We used a modularprecision sound level meter (Brel and Kjr) to recordthe levels o sound impulse (dB). The distance rom theright ear o the goler to the point o impact between thegol club and ball was 1.7 m. We thereore positionedthe sound meter 1.7 m rom the point o impact.

The thin aced titanium clubs all produced greater

sound levels than the stainless steel clubs (g 2).Interestingly, the club used by our patient (KingCobra LD) was not the loudest. Our results showthat thin aced titanium drivers may produce su-cient sound to induce temporary, or even perma-nent, cochlear damage, in susceptible individuals.The study presents anecdotal evidence that cautionshould be exercised by golers who play regularlywith thin aced titanium drivers to avoid damage totheir hearing.M A Buchanan ear, nose, and throat specialist registrar

P R Prinsley ear, nose, and throat consultant

Department of Otorhinolaryngology, Norfolk and Norwich University

Hospital, Norwich NR4 7UYJ M Wilkinson audiological scientist

J E Fitzgerald chief audiological scientist

Department of Audiology, Norfolk and Norwich University Hospitalcspnn t : M A Buchanan [email protected]

cntibts: MAB initiated the study, took sound level measurements, andswung a few golf clubs, JMW and JEF took sound level measurements, andPRP provided clinical care to the patient. MAB is the guarantor.

cmpting intsts: None declared.

Patint nsnt: Obtained.

Pvnan an p viw: Not commissioned; externally peer reviewed.

Coles RRA, Lutman ME, Buin JT. Guidelines on the diagnosis o noise-1induced hearing loss or medicolegal purposes.Clin Otolaryngol2000;25:264-73.USA Health Watch.2 Hearing impairment projection calculator.www.occupationalhearingloss.com/master_calculator.htmUnited States Gol Association.3 Rules of golf2008.

www.usga.org/playing/rules/rules.html.cite this as: BMJ2008;337:a2835

0

100

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130

PGAMidsize

JohnLetters

SwingMaster

Texacana

Stainless

Steel

RyderTPV1

00

SRIXON

MacGregorTourney

KingCobraSpeedLD

CallawayFTS

NikeSQ

MizunoMX-560

PingG10

MastersMC-Z910

Noise

(d

B)

Thicker faced stainless steel golf drivers Thin faced titanium golf drivers

Fig 2 | Comparison of peak emitted sound levels (dB) between thicker faced stainless steel (yellow) and thin faced titanium (red)golf drivers when hit three times by a professional golfer

golf bad for earing

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