Dr. Ross on Hearing Loss
Reflections on My Cochlear Implant: Part 2
by Mark Ross, Ph.D.
In my last article on cochlear implants, I reviewed the sequence of events that led to my decision to acquire one. I pointed out that my personal account leading to the decision was not unique. Every implant recipient has a similar tale to tell; all of us have experienced life with a severe or profound hearing loss. But, still, because we are all unique individuals, the impact of the hearing loss is, in some respects, different for each of us. For me, because I have been an audiologist for many years, my experiences and observations prior to my getting the implant could not help but be colored by my personal and professional backgrounds. I’ll be calling on the same combination of personal and professional experiences as I write these words, just about three months since the activation date.
The activation itself took place one month after the surgery to insert the internal portion of the implant. For me, this period was undoubtedly the most difficult time I experienced. While the surgery itself went well, for one month I wasn’t sure if I had made the right decision or not. After all, I had still been getting some benefit from the hearing aid in the now-implanted ear. I had known that I would be giving this up, but I didn’t know, and couldn’t know, whether the benefits I hoped to receive would produce the net hearing benefits I was hoping for.
Finally, after a very long month, the activation date arrived. This was the crucial test. How I did then had to be at least generally predictive of my ultimate performance. The audiologist hooked me up and then measured my auditory thresholds and comfort levels. I could hear these tonal sounds easily, so that in itself was a relief. Then came the time to listen to the audiologist speak to me. Judging from the reports of those who preceded me, I was fully prepared to hear a discordant cacophony that would bear little or no relationship to intelligible speech. I expected that my first challenge would be to begin the process of decoding these strange sounds and organizing them into intelligible speech. This did not occur with me. Almost from the very beginning, I could begin to understand what the audiologist was saying. Far from perfectly, of course, but then it’s been many years since I heard most any speech signal really clearly.
So it seems that I had passed the crucial initial test. After listening to the audiologist through the implant alone, I knew that my bet had paid off: that the net gain was going to more than compensate for my giving up hearing aid use in that ear. As far as I was (and am) concerned, any further improvement in hearing skills would be pure gravy. That evening I was able to listen to my wife and daughter through the implant; it was not easy, but comprehension was possible. The next day, after having these listening experiences with the implant, I returned to the Center for another mapping (programming) session. At its completion, I was then scheduled for two more follow-up sessions in subsequent weeks (a practice that I would highly recommend for hearing aid users as well!).
On my way to the bus terminal from the implant center, I found myself listening to all the sounds of New York City, many of which I could not yet identify. I could actually understand what the cab driver was saying and respond to his comments (though I was still not confident enough to initiate the conversation and continue it). Previously, when a cab driver would try to talk to me, I would politely cut it short by saying I had a hearing loss. At the bus terminal, while waiting in line, I talked to the young man standing next to me, just to get additional experience listening (as it happens, he had just returned from Iraq and had lots to say). At the terminal, I did find the background noises very disturbing even though conversation was still possible.
The first week or so was a bit overwhelming. I had to familiarize myself with the operation of the implant. I read the patient manual from cover to cover several times and practiced physically manipulating the various controls, as suggested. At the same time I was also trying to make sense of all the new sounds that I was now hearing. In this latter effort, I needed my wife’s ears to help instruct me. As others have reported, new implantees are often bombarded with environmental sounds that they have never heard or have not experienced for many years. During this period, I would often stop whatever I or we were doing to ask, “What’s that sound?” The world seemed to be full of strange noises, many of which - to be honest - were not exactly pleasant. High frequency sounds seemed the most compelling, sometimes to the point of being annoying. We do indeed live in a noisy world! However, once the source of the sound was identified, I could begin the process of relegating the auditory experiences to the background, as sounds that could be ignored or attended to only when necessary. Ironically, one of the challenges facing a new implantee is not only learning how to hear again, but also learning how to ignore irrelevant sounds. This is something that people with normal hearing take for granted and don’t bother to think about. For the newly implanted person, however, where all new sounds demand our attention, it is not easy learning to differentiate between sounds that can revert to an unconscious background and those which must be attended to.
My very first evening home with the implant, while I was reading in the living room (the instructional manual, what else?), I heard a strange high frequency scratching sound coming from somewhere. I asked my wife, who was in the kitchen at the time, about it. At first she didn’t know what I was referring to. After a moment, however, she realized that it was the sound of her sweeping the floor! I also found that my house produces a lot of noises, none of which I had been aware of previously. For example, the sounds of the heating system and the water pump are almost always audible, as I now realize. My wife was hardly aware of them until the first time I asked, “What’s that noise?” (A question that still reoccurs, though less frequently now than previously.) One time, while I was scratching my head I asked my wife the same question and she responded, “It’s you scratching your head!” Now this may appear strange, but I hadn’t connected the two events until she pointed it out to me. (Ditto with my stomach rumbling, an occasional experience that I thought was very private but evidently could be heard across the room.) I’m still not very relaxed when she’s not home and unidentified sounds occur; could they be portending a problem of some sort? But this concern is easing as I add more “unknown” sounds to my new auditory dictionary.
The fact that I cannot localize the source of a sound complicates the identification process. When I hear a new sound, it could be coming from anywhere. I have to go through a trial and error process trying to figure out what caused it. Often, I simply have to let it go and hope for the best. But once I do recognize a sound, like my wife sweeping the kitchen floor (I do dishes, not floors!), I can relax and enjoy the sound experience. When I wore a hearing aid in each ear my localization ability was a bit better, still far from normal but at least I could tell the general direction of a sound. So far, with the implant, my localization ability is very poor. Hopefully, this will improve somewhat with time.
It is also difficult for me to determine my distance from a sound source (not the same auditory skill as localization). A sound could be emanating from the next room or it might be down the road; it’s hard for me to tell the difference with the implant. Because the loudness/distance experiences with the implant are so new, I have not yet worked out the relationship between them (which I could with my hearing aids). This is not something we do consciously. The other day, when I was home alone, I could have sworn someone or something was tracking through my house; it was only when I walked around that I realized that what I heard was a dog barking down the road (very loudly). In other words, sounds being produced outside of the house may appear to be inside and vice versa. Once the nature of the sound is identified, then it can easy be assigned to its probable location.
As it happens, one type of environmental sound that I particularly love is the sounds of the birds around my house. Actually, my difficulty in hearing birdsongs was the final straw that convinced me to get an implant. Coming home for a visit one day, my daughter commented on how wonderful the birds sounded. What birds? I didn’t hear any. Now each morning when I walk to the mail box, or when I walk out on our deck, I can hear their musical performance and I love it. One local implant user, upon hearing of this reaction of mine, commented (in jest I’m sure) that pretty soon I’d wish they would shut up, they’re making that much noise! But I don’t think that will happen with me; right now, I often stand in the driveway just listening to them.
My increased awareness of environmental sounds is a wonderful boon. Still, the major reason I obtained a cochlear implant was to increase my ability to engage in verbal communication. And this, I knew, took training and patience. So I started giving myself auditory training from the first day I got home. One of the key axioms in auditory training is to begin at the right level, not too easy or too difficult. I started at a level that I thought appropriate for me, one that I could modify if it proved necessary. Since I had already shown an ability to understand some conversational speech, I began my personal training at that level by listening to children’s fairy tales, ones that I read to my own children many years ago. I found what looked like adult versions on the Internet (cihear.com) as the portal for auditory training material. (The site also contains much additional information that could be helpful to people considering implants and to those who already have them.) At first I read and listened to the stories simultaneously. Pretty soon I didn’t have to read the text at all, but could just listen to such tales as foolish Jack climbing the beanstalk. But Jack, Little Red Riding Hood, and Goldilocks and the Three Bears could only take me so far.
So then I borrowed several books on CD from the library, ones that followed the script word-for-word and were not simply abridgements of the full text. I picked two books, one with a male and one with a female narrator. Using an accessory cable, I plugged the CD right into the implant and began listening to the book while I followed the words on the page. To my surprise and pleasure, I was soon able to follow the story without continually looking at the page. When I lost my place, I could find it again by listening to the narrator. Of course, these people were excellent speakers who, while being properly dramatic, spoke clearly and at a good rate (for me). There was also no noise in the signal. However, as anybody with a hearing loss will testify, these conditions do not often occur in real life. In real life, noise is a ubiquitous presence, with people articulating poorly while speaking too fast. In this type of situation, I found that I still needed to watch people’s faces (and lips) when they talked, just as I did before I received the implant.
I was fortunate in being able to self-start my personal auditory training program at the conversational level. In my opinion, some sort of auditory training program, beginning at an appropriate level for the individual, should be a routine component of the post-implant experience. I would advise any adult who receives an implant to ask the implant audiologist about the availability of such a program. We accept the need to provide therapy for implanted children, but adults also need to learn how to “hear again.” Some auditory training programs can be self-administered at home, under the general guidance of an audiologist. One consumer guide I’m familiar with is “Better Communication and Cochlear Implant: A User’s Guide” (hearagainpublishing.com). It contains graduated training exercises and various other tips for better communication.
As I consider the listening experiences I’ve had in the past three months, it seems that I have lots of questions for which I have no explanations. Judging from what I hear, there appears to be a unique interaction between the acoustic characteristics of a specific speaker’s voice and the way it is processed through the implant. Some people come through just fine, with the quality of their voices remaining as I remember it. Their pitch seems appropriate for their gender and age. But many other people sound extremely bass, to the point where speech intelligibility is affected. This also seems to happen when I listen to my own voice (without the hearing aid in my left ear) and often when I’m listening to another person on the telephone I have commented on this several times during mapping sessions, and changes have been made, but the problem remains. Additionally, there are some voices that sound very metallic, and some people sound as if they are talking while gargling.
The variability in quality between different speakers is very apparent when I listen to a TV talk show. On many such shows five or six speakers may be participating, both women and men. Some come through just fine and I can understand them without speechreading or looking at the captions. Others, particularly women, but not all women, sound tinny or warbly. Again, I think it must relate to the acoustic characteristics of a speaker’s voice, but right now I don’t know exactly what elements specifically triggers the variant speech quality that I receive. If everybody sounded this way, I could accept that this is the new standard of “normal voice” for me. But the great variability- the fact that some people sound the way they did before I got the implant and others not - indicates that there is something about the acoustic interaction that could be identified and then, perhaps, rectified. I’m still hopeful that additional mapping - and experience - will ease this problem somewhat.
Another thing I’m trying to figure out is my performance on the telephone. The fact that I can, under optimal conditions, understand face-to-face speech quite well with the implant would suggest that I should be able to understand speech through the phone as well. And, in some conversations, I do. Mostly, however, the speech I listen to through a telephone sounds very bass, and this is true whether or not I use the telephone coil in the implant, and whether the speaker is a male or female. It was suggested to me that perhaps the natural voice of these people is very bass and that I hadn’t been picking this up earlier, when I listened to them through my hearing aids. This is not very convincing, not when my wife sounds like a deep baritone on the phone! What I’ve been doing, to be sure that I can communicate effectively is use both ears by plugging a neckloop into the phone. This works quite well, better than it did before I got the implant. But it still doesn’t solve my quandary regarding just what is happening.
From an audiological perspective, this is strange because I routinely use the telecoil as an assistive learning device when listening to the TV (via a floor loop) and the bass voice experience rarely occurs. As a personal experiment, I compared the way I understood the TV through the loudspeaker and via the floor loop. It was no contest! My comprehension was immediately and substantially better with the telecoil (and would be expected using any sort of assistive listening device). The same logic that dictated the use of assistive listening devices when I wore a hearing aid still applies; I’m still hard of hearing and I still require the extra auditory help that an assistive listening device can provide. In addition to a TV loop, I use a personal FM system with the implant, which is another way for me to improve my comprehension of speech under unfavorable acoustic circumstances. I haven’t seen many adults with cochlear implants use a personal FM system, but I would strongly advise that they consider using one. Noise and distance will likely affect their comprehension of speech, no matter how well they do with the implant in a quiet location.
Music appreciation is still something I'm working on. Although I knew, before I went into this, that full music appreciation rarely occurs for someone wearing an implant, I still had my hopes. While I can recognize melodies, particularly when a vocalist sings one of my old favorites, much of what I hear is flat and not in tune with my auditory memory. At this point, instrumental music of all kind seems to be mostly noise, with an occasional fragment of beautiful music. However, I still give myself time to listen to music every day for about fifteen to thirty minutes. As my training material, I use the songs and vocalists of many years ago; there is merit, I believe, in starting with familiar material. I plug the CD player right into the implant and listen. The other day, I began using a neckloop from the CD player and listening through the telephone coil of both the implant and the hearing aid simultaneously. This is much better. I'm beginning to enjoy music again; a big bonus for me is that it seems I can understand more of the lyrics than I could before I got the implant.
Unlike the situation years ago, more people are now considered implant candidates even though they may have functional hearing in one or both ears. The general consensus now is to recommend that implantees continue to use a hearing aid in the unimplanted ear if they did so in the past. There does not, however, seem to be a consensus on exactly how they should do this. Some audiologists recommend that the new implantee use only the implant during the initial adjustment period, however long this takes, forgoing the hearing aid. Others suggest a shorter period of exclusive listening with the implant. Still others suggest that both the hearing aid and the implant be used together from the very beginning. Nobody really knows; there is no objective evidence favoring any practice, just different theoretical rationales. Basically, people should do what they feel comfortable doing, with the ultimate goal being to integrate the signals arriving from the two ears into a unified whole.
I use a hearing aid in my left ear and I wouldn’t be without it. While I can understand speech with the implant alone, and I do often do just that while listening to the TV (via the room loop), the quality is much better when I simultaneously use the hearing aid. And not only the quality, but the ease and confidence with which I understand speech. Every once in a while, to satisfy myself that I’m doing the right thing, I will listen to the TV with first one ear, then the other, and then both. The improvement wrought when I use the two together is immediate and apparent. But we’re all different; for some people, a hearing aid in the contralateral ear may interfere with overall perception. Other people may notice little or no difference. In other words, I believe that every effort should be made to determine if the residual hearing in the unimplanted ear can be successfully utilized. I hate to see hearing wasted.
In summary: I’m doing quite well. I’m delighted that I made the decision to acquire the implant and I would do it again in a minute. I hear so much better, so much more, and so much more easily, than I did with my hearing aids alone. The day before these words are being written, I received my three month’s evaluation from the NYU Cochlear Implant Center. The results were excellent; I am particularly pleased with my performance on the monosyllabic word test, which increased substantially (from 18% to over 90%). So, clearly, I’m hearing much more. But, it is important to keep in mind that these results do not, and I want to emphasize do not, suggest that auditorally I’m functioning normally. I’m not. What it does indicate is that these speech tests may no longer be appropriate for the current generation of implant users, people like me who started out with a significant amount of usable residual hearing. I would estimate that, hearing-wise, I’m functioning somewhere around fifty to sixty percent of normal.
Rationally, I understand that the results I’ve achieved so far are excellent. But, as I noted in Part I of this article, unrealistic hopes cannot easily be quelled. So while my rationale expectations have been more than fulfilled, I can’t deny a tinge of disappointment that I’m not doing even better. But it’s been only three months and I still have lots of learning to do with the implant. While I fully expect and hope (realistically, this time) to do better three or six months from now, I’m sure that I’ll never realize, as I wrote in Part I, the ability to “function fairly normally in challenging group conversational situations” (although a personal FM system will help). Because I started out with functional hearing, I would rate the improvement in speech comprehension that I have realized to be marvelous. For someone who begins the process with little or no usable hearing, however, this much progress can seem almost miraculous. So, it depends on where we’re at when the process beings. But not everybody will be as fortunate as I was. As I think about what I have been able to achieve with the implant, my heart goes out to those proportionately few people who have received little or no benefit. They should know, however, that they made a noble effort, one that was well worth trying. Nobody fully understands why the implant fails to help in some cases, but they should know, and we should all acknowledge, that it was for no fault of their own. And it should not serve to discourage others from being implanted, if they are deemed suitable candidates.