Post-surgery update

I'm home, but still a little unsteady from the anesthesia, so this will be short. Surgery went well, though it started later than scheduled due to some delays at the hospital. Arrived home last night around 9:30 pm. Thanks to everyone for your support! More to come..

CI: 1 day out – what is it? (Part 1)

With less than twenty-four hours to go until surgery, I suppose it’s about time to get into the details of cochlear implants. It is a two step process. First, surgery to implant the internal processor and electrode array. Second, after a few weeks of recovery, the external processor is fitted and configured. I’ll cover the second part in a later post.

Just what is this new piece of shiny that will be forever embedded in my head?

Another angle with a nickel for size reference:

The function of that beautiful thing is to send electrical pulses down the electrode wire to the array. The coil receives both power to operate the implant and the digitized processed audio signal from the external processor, via an external coil. Both coils have magnets in the center to hold the external one in place.

Each of the sixteen contact points on the array are driven by a separate output circuit, which allows multiple contact points to be fired simultaneously (I will cover why that is a good thing in part 2).

How does it get implanted? First, here’s some artwork showing the placement of the implant:

Tomorrow my wife and I head to the hospital for a 7:15 am check-in. Surgery is scheduled for 10 am and usually takes from 3 to 4 hours. I’m not sure I have the exact sequence of events right, but the general flow of events is as follows. A small incision an inch or so in length is made just behind my left ear, which is then spread open. To accommodate the processor, a shallow divot is drilled into the area of my skull back from the ear a bit and about level with the top of the ear. Next some bone is removed just behind the ear allowing access to the middle ear and cochlea. This is a delicate process since a main facial nerve is located there. Electrodes attached to my face are monitored to help ensure the nerve is not affected. The processor is inserted under the scalp and muscles. A small opening is made in the cochlea and the electrode array is fed through it. Once everything is in place, several tests are run to ensure the array is stimulating my hearing nerve. My ear is put back where it’s supposed to be and the incision is closed up. Some nice goop over the incision creates a protective water-impermeable barrier and a big pressure bandage goes over that. Then it’s off to the recovery area to be monitored until I wake up. After about an hour I’ll be wheeled to a room. If I’m not suffering any nasty side-effects like bad vertigo, etc., after a couple of hours they will remove my bandage and kick me out the door at about 5 pm.

The following few days I will spend at home popping Keflex (antibiotic) and Vicodins for pain (if necessary), and following the instructions I noted in my previous post. And I will do my best to chronicle the recovery process here.

Now, it’s time to go have my last meal for the next 24 hours. They like you hungry for surgery!

CI: Pre-op complete

Just got home from my pre-op exam. My surgeon is so calm, it sort of makes me feel like a spaz when I jump in with some comment or question! But he's really good about it, answers everything and makes me feel comfortable. Calmness is definitely something I like in someone who is going to operate on me.

He covered the usual pre-surgical boilerplate (no eating, no drinking, etc.), then described the flow of events. Normally they make you take off your hearing aids before surgery, but I get to keep mine in so I can communicate in the OR. Once I'm knocked out they will remove them for me (I was glad to learn that because back when I had knee surgery, between no hearing aids and no contact lenses, it was nearly impossible to understand what they were saying to me. I think we had to use a notepad!) . He said surgery would take about 3 hours or so. The incision will only be about an inch long. No stitches. After closure it is covered with some kind of water impermeable glue. Next I go to recovery for an hour. Then they move me to another area until I'm ready to go home. They take the pressure bandage off then too. Since surgery is at 10 am, he guessed I'd be discharged around 5 pm.

After that he went into post-surgery instructions. Ice behind the ear hourly (he recommended frozen peas in a latex glove). Don't rub the implant area for 30 days to give scar tissue time to form and secure the implant in place. Okay to wash hair the next day, but don't rub the incision area either. We set an appointment for one week after surgery for post-op checkup at which time the activation date will be set -- as soon as a week later!

Lastly he gave me Vicodin and Keflex (antibiotic) prescriptions and sent me on my way.

Gotta run. Time to pick up our little man from daycare!

CI: 2 days out - How is my hearing now?

Okay. I’ve described the path to this point. So just how is my hearing now?

My left ear is worse than my right, as it has been since things started going downhill. So my left ear will get the implant.

In audiological lingo, my left ear has a hearing threshold that slightly declines across the frequency spectrum, ranging from 90 dB (Decibels SPL) in the low frequencies to 100 dB in the highs. My right ear is flatter, about 75 dB loss across the board except for a dip to 85 dB centered around 2 kHz. My hearing aids can lower that threshold by about 50 dB, but that no longer helps as much as one would think (more on that later). My speech recognition scores are 0% left, 20% right, unaided. And not a whole lot better aided.

A normal ear has a threshold in the 0 to 20 dB range. Speech sounds generally are about 20 to 50 dB. A vacuum cleaner is about 60 dB, a barking dog 70 dB, a piano 80 dB. Motorcycles and lawnmowers are 90 to 100 dB. Concerts, jet planes, jackhammers, guns can be 120 dB and higher.

This is known as sensorineural hearing loss (SNHL). Meaning that it is an inner ear problem. Nothing is wrong with the mechanical parts in the outer and middle ear. Most likely many of the little hair cells in the cochlea have died off and/or been blown away. Why that has happened is probably due to some genetic anomaly. My older brother has a similar condition, but it isn’t as bad. He still functions well with hearing aids. There is no known history of it in our family, which could mean there is a recessive gene involved.

A companion condition to SNHL is known as Recruitment, which has increased as my hearing has decreased. Recruitment causes both an increased sensitivity to loud sounds and frequency distortion.

Without my hearing aids, the world is pretty quiet. On the plus side, barking dogs and traffic noise don’t affect my sleep. The majority of sounds are below my threshold. Low frequencies tend to be more powerful so come through the easiest. If I walk through my wooden floored house I can hear the thump of my footsteps, but not the clack. If someone is talking close by I catch the mumble of vowels. Louder sounds, like clattering dishes, a loud motorcycle or concert, are painfully loud and distorted. The best way I can describe the distortion is the sound of an overdriven speaker. It smears the frequencies.

When wearing my hearing aids, I hear most sounds at a perceived loudness that isn’t much different than years ago. What seems to be disintegrating is clarity, which I assume is due to the frequency smearing “feature” of recruitment. I hear people talking just fine, but it sounds indistinct, mushy. At its worst, in a group setting, it’s very much like listening to a foreign language: the sounds don't assemble into words or meaning. At best, in a one-on-one conversation in a quiet environ, with someone who has a distinct voice, the remaining hearing in my right ear is able to just grab enough cues to perceive enough words to follow along. Most of the time I’m constantly guessing, using a combination of lip-reading and context. And of course I often use the old standbys, “Can you please repeat that?” or “what?” or “huh?” The most interesting conversations and monologues tend to be unpredictable, and as such are the hardest for me to take part in or follow. That is probably the number one thing I hate about my hearing loss.

Last and maybe least – what’s that sound in my head? Tinnitus is another lovely byproduct of SNHL. I have a quiet symphony of tones humming in both ears. If I concentrate I can perceive dozens of them in various frequencies, from low to very high. Most have the quality of tuning-fork purity. My left ear also has an array of clicks and tinks that follow bizarre random patterns. For the most part they are all subtle and not very bothersome. Rarely, I’ll get a quite loud explosion of sound followed by a roaring that subsides over the course of a few hours or days. The roar is like an intense suite of tuning-forks, a dissonant chord. In the aftermath of these events I nearly always sense another small decline in my hearing.

Well, that ends today’s lesson! I have my pre-op visit with the surgeon in a couple of hours, so need to have some lunch and then hit the road.

CI: 4 days out - Why CI?

Why am I getting a cochlear implant? My hearing has degraded to the point where I have great difficulty understanding speech, even in quiet surroundings, even with hearing aids. How it got to this point has been a long, slow slide. I’m going to take a shot at describing it. I hope it doesn’t come out too boring.

Hearing loss takes many shapes. Some are born with poor hearing. Others have a sudden loss, which can strike at any age. In my case it has been a mostly gradual loss that became noticeable in my early twenties. Probably the earliest indication that I was different was in my late teens when my ears would ring for days after going to a loud concert. One time I asked a friend a couple of days after a show if his ears were ringing and he said, “no, the ringing was gone by the next morning.” I thought nothing of it at the time.

A few years later, about age 23, after being in bands for a couple of years, I first noticed an actual loss in my left ear. I had a camera with an electronic flash attachment that emitted a tone that rose in frequency as the charge recycled. If I held it to my left ear, at a particular point I could no longer hear it, but could still hear it if I switched to my right ear. Even so, it was a mild loss and had no impact on conversing or playing music.

But the loss progressed. I had always used my left ear with the telephone. When I was 25 I noticed I was struggling to understand people on the phone, so I had to start using my right ear. About that time I had my first appointment with an audiologist. He told me I had the hearing of a sixty year old and should look into hearing aids -- not what a musician wants to hear. Soon after, I traveled to LA for a second opinion from the House Ear Clinic, a well known center for hearing research. Of course the audiogram was the same, but I got a better explanation of the problem: it wasn’t likely related to noise exposure, so no need to give up music at that time. That was a relief, and since I wasn’t really struggling with speech I felt no need to get hearing aids. That changed in a couple of years. By age 27, I was straining to understand soft-spoken individuals, and just about anybody situated on my left side. Within a year, at age 28, I was fitted with my first pair of hearing aids. For a person used to enjoying the nuances of sound it was quite awful. The hearing aids of the time (circa 1988) were linear amplifiers, meaning, whatever sound level entered the mic was boosted the same amount. They definitely helped me in quiet environs, but produced a distorted cacophony in any kind of sound-rich setting, like a busy street. So they spent quite a bit of time in my pocket instead of my ears.

Over the course of the next few years, even as my hearing worsened, I could still hold good conversations without hearing aids in noisy locations, and with hearing aids in normal to quiet situations. And music still sounded good. But certain circumstances were becoming difficult, such as hearing well in a widely spaced group either outdoors or in a noisy location indoors. In 1992, I upgraded to a new set of hearing aids that featured dynamic range compression. They were a huge improvement. I no longer needed to swap the aids in and out, and they performed better in all situations. It was like turning back the clock.

For about the next ten years, I continued to hear adequately with hearing aids. I could use the telephone and handle most conversations. However, I did give up performing music, partly because it no longer sounded “right.” I was also noticing that hearing was becoming more of a mental strain – it just took more work.

The summer of 2002 is when I had my “big drop.” I was returning from a week’s vacation in Northern California when my right ear started roaring, a loud continuous chord of tones. That tinnitus gradually dissipated, but gone with it was a chunk of hearing in my good ear. I had depended on my right ear, since my left was significantly worse. Phone calls and conversation went from a strain to a true struggle of attempting to fill-in missed words using context and guesswork.

For a couple of years I tried to squeeze as much performance as possible out of hearing aids, trying several new models and brands. But by 2006 it had become clear I had reached the limit of hearing aids. Louder wasn’t better. Speech was becoming even more indistinct. Music sounded mushy.

I had been following the progress of cochlear implants for quite some time. In my early investigations they didn’t seem like much of a solution for someone like me who could still hear, just had trouble discriminating. And I was bothered with the news that the good ear of the two was usually implanted, and by the fact that the surgery destroys any possibility of normal hearing. But looking into it again in 2006 I found out that the worse ear is implanted first, and that recipients were seeing big improvements in speech discrimination. I had hoped that some sort of magic bullet gene therapy solution would happen, but it looks like that’s not in our near future. CIs are here and now, and the improvements to them technologically in the past few years are astounding. So I began working my way through the HMO process of referrals, and after 18 months of starts and restarts, here I am – four days from surgery!

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CI: 8 days out

I just setup this blog that will be specific to my CI adventure. I had a few issues that could have derailed having surgery at this time -- insurance and a nasty little skin infection -- so I didn't feel like writing about it when it seemed like the bottom could fall out. Now, everything has fallen into place quite rapidly. My surgery is scheduled for next Thursday, November 29, 2007! No activation date is set yet. My CI center prefers to gauge the date after a few days of recovery. Hoping it will be before Christmas.

I still have a bit of usable hearing in my right ear when aided, so we're implanting the left. I presently wear hearing aids in both ears. I don't get any direct speech recognition from the left one, but I do find that it helps with spacial location and speech discrimination when combined with my right ear.

I chose the Advanced Bionics Harmony/HiRes 90K system, in metallic dark gray. I'm really happy they offer it in that color. After twenty years of wearing flesh colored hearing aids, it will be good to have a machine look like a machine! Choosing the brand was a difficult decision though. The Cochlear Freedom/N24 system has a lot to offer as well: more electrodes, possibly better reliability, more battery options, etc. I think what swayed me is the higher number of output circuits in the HiRes implant which enables the capability to use current steering to increase the number of spectral bands to 120 or more. From the description of CI users that have upgraded, it seems like it offers the best sound quality. I also like the full 10-year warranty on the implant. And it's black! Well, almost.

I'm heading out of town tomorrow morning, taking my family to be with the rest of the family for Thanksgiving. So won't likely post again here for a couple of days. But I plan to get into the details of my condition when I get back.