surgery

Inside My Head

By Bob Liff

I am certainly not the only person whose realization that I suffered from an increasingly severe hearing loss came upon me gradually. My difficulty became noticeable when I was working as a newspaper reporter in the late 1990s. I could manage okay on the phone but had trouble following conversations in person if there was any ambient noise. Crowd situations were unbearable.

I also suffered from periodic tinnitus, which of course is utterly frustrating, but still did not attach it to having a chronic hearing loss.

I withdrew from social situations. I started making jokes: My wife says it’s not that I can’t hear, but that I won’t listen. Because my hearing loss is asymmetrical—much worse in my right ear than my left—I was losing my echolocation. I could not tell where a sound was coming from, and would spin around to find the source.

Eventually, reality kicked in. I went for a hearing test about 12 years ago and was shocked at the degree of the loss in my right ear—more than 50 percent in the midrange frequencies, less so in other ranges—and a slight loss in the left. 

My ENT and audiologist suspected Ménière’s disease, but could not come to a conclusion, which illustrated for me how much research still needs to be done to fully understand hearing and balance issues. I was fitted with a hearing aid for my right ear. Because of the nature of my hearing loss, I could not use an in-ear aid and had to use one that went over my right ear with an external microphone.

Both ears continued to deteriorate, the right more than the left. I could hear sounds in my right ear, but could not make out words. As it was explained to me, my auditory nerve was working normally, but the other parts of the ear where sound travels before reaching the nerve, especially the hair cells inside the cochlea, were not.

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My audiologist finally said there was not much more he could do for my right ear and suggested a cochlear implant (CI) on that side. I met with Ana Kim, M.D., at Columbia Presbyterian in New York City where I live, who performed the surgery.

One of the absurdities of the health insurance industry became apparent to me when I chose a CI that would be paired with a hearing aid for my left ear. While the hearing aid alone was not covered by my insurance plan, the far more costly CI in combination with the hearing aid was covered because the two devices were synched. 

The surgery was more extensive than I expected. Dr. Kim opened up my skull behind my right ear and burrowed out a bed in the dura on my cranium to insert the implant, which was then wired through my cochlea. I maintained my wise-guy attitude about the situation, posting a picture of my bandaged head on Facebook, explaining they had opened up my head and found nothing.

I had to wait three weeks for the effects of the surgery to subside before my new audiologist, Megan Kuhlmey, Au.D., also at Columbia Presbyterian, hooked me up for the first time—and nothing happened.

I was not the first patient who expected instant magic. It took several months before hearing began to return to my right ear. Each hearing test showed progress, though I did not feel it. The hearing aid in my left ear allowed me to compensate for deficiencies in my right ear, but eventually I began making out words in my right ear as well.

That is when I discovered one of the ways I had previously been coping with my hearing loss. While having morning coffee with my wife, she would have me cover my left ear; I was hearing things with my right. When she casually covered her mouth, I could no longer make out what she was saying. In that instant, I realized I had been reading lips for years without even realizing it.

Two years after the surgery, the CI has not yet restored full hearing in my right ear, though it certainly has improved it, and I no longer have problems figuring out which direction a sound is coming from. With the type of implant I have, I cannot have an MRI, since the magnetic force could tilt the device inside my head, and I get conflicting advice on whether I can go through a metal detector. Since the technology is always improving, if you are a candidate for a CI, discuss with your doctor which one best suits your needs and lifestyle.

As an aging baby boomer who just turned 70, I find lots of company in the hearing loss crowd. It is hard to generalize how hearing loss affects people individually, but I am surprised that for many, vanity remains an issue. For me, the prospect of improved hearing outweighs any concern that signs of the vagaries of age are visibly hanging on my ear lobes. 

I do wish I had tackled this earlier, and had not dismissed comments by well-meaning people saying I was not hearing them properly. And since I have also had surgery in recent years on my eyes, nose, and throat, I realize I have kind of a bionic head anyway.

What is inside my head is another matter.     

Bob Liff is a public relations professional in New York City.

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Everything Sounds

By Caryl Wiebe

Sometime in grade school, my parents noticed I favored my right ear because I turned it toward people during conversations. Concerned about my hearing, they took me to an ear, nose, and throat doctor who put drops in my ears for my eustachian tubes, the passageways that connect the throat to the middle ear. This provided very little improvement, but I didn’t worry. I felt could hear the important things in my world and maintain my ability to sing a cappella with my sisters in grade school and then in choirs in high school and college.

At 18, I got married and had three children in the eight years that followed. Over time I noticed my hearing was considerably declining in my left ear, even though we were able to tour as a singing family for eight years to churches in Oklahoma and California, and even sang on the radio. I was always able to hear my family, but my husband and I noticed that it was hard for me to keep up when we were in church or in a group. 

With his support, I decided to see a well-respected ear surgeon, Gunner Proud, M.D., at the University of Kansas Medical Center. Dr. Proud determined that my stapes had a calcium overgrowth that prevented its movement (otosclerosis). He had a strong reputation as a surgeon, so I was comfortable undergoing a stapedectomy, a middle ear procedure to restore hearing with the insertion of a prosthetic device.

I was dizzy after the surgery, but within three or four days it was deemed a success and I was pleased by what I was able to hear again. “I can hear the tires,” I announced to my husband. He was amused—he didn’t know what it was like to live without life’s most ordinary sounds.

I was thrilled until my hearing began to deteriorate in my left ear again. Disappointed, I returned to the medical center. Dr. Proud explained that calcium had started to grow around the plastic prosthetic "hammer" that he had inserted into my left ear. Concerned another surgery would eventually lead to the same result, he suggested a hearing aid for my remaining good ear, my right ear. I was hesitant, but I was now 30 and eagerly wanted to hear. I purchased my first of many hearing aids.

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I'll never forget the first time I had my hearing aid on while giving my children a bath in our cramped little bathroom. I thought the loud noise from their splashing and kicking and laughing would drive me crazy with my aid in my ear. But I decided that if I removed it, I’d fall into the habit of removing my hearing aid in every noisy situation.

That bath was over 52 years ago, and to this day, I maintain the importance of keeping it on, especially when giving advice to older folks. Many complain that “everything sounds different with a hearing aid,” which is true—but at least you can hear! 

So this is my story, no cochlear implant or anything else. I get along very well with my hearing aid and at the age of 82 I don't want to try anything different.

Caryl Wiebe lives in Kansas.

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Your Concerns About Cochlear Implants, Answered

By René H. Gifford, Ph.D, CCC-A, and David S. Haynes, M.D., FACS

“If you qualify for a cochlear implant (CI) but do not have one, please indicate reasons you have not pursued.”

This question was one of three dozen on hearing conditions posed in Hearing Health Foundation’s 2017 Reader Survey, which was administered through the pages of this magazine, online, and also with Hearing Loss Association of America, through their magazine and online. More than 2,300 people responded to the survey. Those who responded to the CI question above gave the following answers, and they were able to check off as many as applied. In order of popularity, the responses were: 1) not convinced of improvement, 2) surgery complications, 3) waiting for biological cure, 4) concerns about sound quality, 5) cosmetic, and 6) fear of discomfort.

Although “other” with a fill-in option was offered, age did not appear to be a primary concern. In fact, many older adults with severe to profound hearing loss whose hearing aids are no longer are beneficial have found success with CIs, as demonstrated by Barbara Sinclair (page 20), who received an implant 17 years ago at age 72, and our cover story author Bruce Douglas (page 6), who had implantation surgery at age 91.

Part of the survey’s purpose is to better understand the needs of our community of readers and supporters, and so, as cochlear implant surgeons, we wanted to address these concerns.

Source: University of Illinois Hospital

Source: University of Illinois Hospital

Not convinced of improvement

All CI centers, including ours at Vanderbilt University Medical Center, perform extensive presurgical testing to determine if a CI is the right option for a patient, versus the continued use of hearing aids. The testing, based on data and experience, answers this question with an incredible degree of accuracy. Our goal is to reach a level of hearing that dramatically outperforms the best hearing aid outcomes for a given individual. Expectations are much higher than this, however, and it is extremely rare for a patient who is wearing their implant full-time not to experience much better preoperative hearing performance. The benefit has been so pronounced that Vanderbilt and other CI centers are working to expand implantation criteria so that this technology reaches people with milder forms of hearing loss.

Surgical complications

Cochlear implantation has one of the most favorable risk–benefit ratios of any surgical procedure in the U.S., offering significant communicative benefit while incurring little risk. Our center performs nearly 300 implants per year, and we monitor and track all procedures, outcomes, and complications. As with any operation your surgical team will provide a list of potential complications in order to be comprehensive, but the actual incidence of CI surgery complications ranges from under 1 percent to 3 percent. If any do occur, they are considered minor and temporary, such as postoperative taste disturbances and dizziness. At most CI centers, implantation is completed as an outpatient procedure and generally performed in 1 to 1.5 hours. We recently completed cochlear implantation on a 96-year-old patient who went home on the same day of surgery.

Waiting on a biological cure
The field of hearing restoration through hair cell regeneration—some of which is being conducted by HHF scientists, through the Hearing Restoration Project—is still in its earliest phases. While there have been exciting advances in gene therapy, current technology via cochlear implants can provide people with severe to profound hearing loss immediate access to sound, and all the benefits that this brings. In addition, improved success with CIs is linked to implantation that occurs closer to the onset of hearing loss, as auditory pathways in the brain need to be stimulated or they weaken. Otherwise the resulting permanent changes in the brain’s auditory centers may limit the ability of a patient to hear, even with a perfectly intact cochlea.

Concern about sound quality
Despite CIs being a mechanical device, the voice sound quality has the potential to be no less electronic sounding than that from a telephone, computer, or television. Often the abnormal sound is due to the stimulation of an ear that hasn't heard for many years (or an ear that has never heard). If this occurs, it typically dissipates with continued use of the CI and the stimulation of auditory pathways. Signal processing technology also continues to advance at a rapid rate, allowing for personalized programming for the best hearing outcomes, and—especially with any neural changes with age—programming is important to do at regular intervals.

Cosmetic
The thin internal portion of the CI is designed to sit flush with the skull and is not visible. The visible external components (the battery, sound processor, microphone, and transmitting coil) mostly fit behind the ear, not much larger than a standard behind-the-ear hearing aid. The latest sound processors are self-contained in a single unit about the size of a half dollar coin. These “off-the-ear” processors do not have an over-the-ear component, but rest directly over the magnet that is behind the ear and within the hairline. Eventually we expect that all implanted systems will be compatible with these smaller, off-the-ear processors, and nanotechnology and battery miniaturization will further reduce processor size. (And, the
boom in wearable consumer technology makes visible devices even more mainstream.)

Fear of discomfort
Implantation incisions behind the ear heal quickly, and the drilling of the bone required to place the
implant is a simple mastoidectomy. It is a component of most ear procedures and is not painful. Our center performs over 1,200 mastoidectomies per year across various different ear procedures. Postoperative discomfort is a rare complication and easily managed with over-the-counter medications such as acetaminophen (Tylenol).

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Do You Qualify?
If you have a hearing loss that prevents you from talking on the phone without visual cues (such as needing video calls or caption calling); are unable to understand television programs without closed captioning; and/or are actively avoiding large group gatherings for fear of conversational difficulty, talk to your hearing healthcare professional to see if you may be a CI candidate. CIs are the most successful sensory restoration prostheses to date and have been successfully placed in more than half a million individuals worldwide. The wonders of this technology vastly improve hearing, speech understanding, and overall quality of life.  

René H. Gifford, Ph.D, CCC-A, is a professor in the department of hearing and speech sciences with a joint appointment in the department of otolaryngology at Vanderbilt University, Tennessee. She and HHF medical director David S. Haynes, M.D., FACS, direct the Cochlear Implant Program at the Vanderbilt Bill Wilkerson Center.

This article also appeared in the Fall 2018 issue of Hearing Health. For references, see hhf.org/fall2018-references.

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