Year One

Well. I've survived my first year with the CI. I can't quite believe it. When I went in for my one-year follow-up appointments yesterday, my surgeon walked into the room and marveled, looking at my chart, that time had passed so quickly. Sitting in that chair where I had sat, both when anxiously considering getting a CI and when anxiously wondering what would happen when it came on, I had to agree wholeheartedly.

So, one-year remapping with my audiologist: check. Speech recognition had improved since last time, and I felt more confidence in what I was hearing. Progress. At this point, the goal isn't necessarily giving me more volume - I've stabilized at roughly the point I was at six months ago - but optimizing the balance and input of the BTE to the electrode array. We stayed with similar settings to those I already had (same IDR and similar levels of stimulation), but already the changes have left me startled by the sound quality in my environment. Sounds that I'd thought were familiar (myself typing, myself swallowing, chairs scraping across the floor) seem to have shifted. They're different, more prominent, more raw. They feel new all over again. I'm wondering if this process is one that will never end - shaking things up, then stabilizing, then shaking them up again.

Perhaps so, because the learning curve continues. It might not rub my nerves as raw as it did last summer, but neuroplasticity doesn't come without breaking old ways and old molds over and over. If anything, that's what the last year has taught me, irrespective of hearing. I've experienced the world in new and astonishing ways, ways that had previously lay outside my realm of imagination, and I've discovered a flexibility and a strength and a curiosity that I didn't know I had. It's been quite a ride from that first day one year ago, that seemed so chaotic and that I remember so clearly. I'd like to reflect on it more fully at some point. But for now - a thumbs-up for hearing!

Righty Tighty, Lefty Loosie?

Getting a CI is rather like checking items off a shopping list.

1. Do I even want a CI? check.
2. Am I a good candidate? check. (more about this later)
3. Which type of device should I get? check.
4. Which ear do I implant? ummm...

The last question was the most ambiguous to answer. Most CI recipients are implanted in one ear at a time - and, out of those people, only a few go bilateral. The reasons for this are varied, but mostly because research has shown that the second implant usually provides only a marginal benefit compared with the first. Indeed, I have a few friends and relatives who are deaf in one ear but have normal hearing in the other - and they function like regular hearing people for virtually all purposes. The only major benefit of having two ears, rather than one, is better three-dimensional localization of sound. (Biology nerd moment: the brain compares the sound input - loudness, temporal sequence in reception of sound waves - from each ear, then integrates them into a mental "mapping" of where the sound is coming from. We don't even notice this intricate process - it seems to come to us automatically, as we turn to look at an unexpected noise. But, without the input of two ears to compare, it's much harder to perform such calculations.)

I never seriously considered going bilateral from the beginning, to be honest. First of all, there's the impracticality of bilateral CIs for surgery and recovery. When I talked with a friend (who had recently been implanted) about the idea of bilateral implantations, he explained that surgeons are averse to it. They're reluctant to operate on one side of a patient's head, then flip that patient over on the surgical table, on top of a fresh wound, in order to operate on the other side. Just thinking about that made me shudder and agree wholeheartedly. I'm already going to face difficulties with sleeping immediately post-surgery, when I can only lie down on one side - imagine if I couldn't put pressure on either side of my head!

My second reason for not going bilateral has to do with my lingering reservations about the CI. As ridiculous as this might sound at this point, I view my upcoming CI as an experiment. If I do not like it, if it does not work out the way I hope it will, at least by going unilateral I'll still have one ear left. Seeing that my major objection to CIs has always been that I do not want to destroy my cochlea, why would I destroy both of them at the same time? Then, in the case of catastrophe, I would truly be stuck in a world of silence. If I do like the one CI that I get, I can always get another later.

Okay, I did not want to go bilateral: check. Now the decision came down to a game of eenie-meanie-miney-moe. Which ear to implant? Which one would allow me to hear the most?

At first, I honestly considered flipping a coin. Both ears are so bad that did it really matter which one I implanted? Look:

This is an audiogram that I got a few years ago. The thick line near the top, at 20 dB, is considered "normal" hearing. My threshold is far, far below that - 90 dB at the most, and that only for lower frequencies. Once you go along the chart to higher frequencies, I almost do not hear at all. (Just for comparision, the threshold of pain for hearing people - the point at which sound becomes unbearable and causes permanent damage to the auditory nerve - is 115 to 120 dB. At this point, without hearing aids, I am only just starting to hear. Another fact: decibels are logarithmic units, so what I hear is thousands of times below what hearing people hear.)

This absymal performance is, in the end, what prompted the doctors, audiologists, and other CI evaluation specialists to unanimously agree that I'm an excellent candidate for an implant. Of course, I'd be a better candidate if I were younger, but that's neither here nor there. Their decision did not come as a surprise - after all, was there ever any doubt in my, or anyone else's mind, that I really am deaf? Ha.

Again, with this audiogram in mind, does it matter which ear I implant? In the end, probably not really. It is true that my right ear has always been slightly better than my left (though you can't see much difference on the above graph). In listening and auditory training exercises, this is always the ear I prefer to listen with, and during audiograms it is the ear that always makes me most confident that I am actually hearing tones and sounds - rather than imagining them. In a random sentence comprehension task for my pre-CI evaluation, I scored 15% out of the right ear (most of that by guessing). My score for my left ear was only 7%.

Which is the better strategy, implanting the better or the worse ear? Several people gave me different advice. Some said to implant the worse ear - that way my margin of improvement will be greater. Others said to implant the better ear, because that's the ear I feel most comfortable with anyway. Still others had more unexpected opinions. Among them was implanting the right ear because it's on the side that passengers will be talking into while I'm driving a car. A valid point, and one I would not have thought of otherwise. (But what if I move to the UK?)

In the end, my decision was more or less a crapshoot. I decided to go with the left ear, in hopes of bringing that ear up to par. The right side can always join the party later down the road, if I so choose.

A last word: this will probably sound maudlin, but I'm sad to leave my right ear behind. I'm right-handed, right-eyed, right-legged (at least from skipping around the yard) - why not right-eared? In truth, this will be the first time that I have any dominant faculty on the left side of my body. I find that weird.

Advanced Bionics

The decision to get a CI is only the beginning. I stumbled into the whole process only vaguely aware of the choices that would be involved, the decisions and commitments I would have to make along the way. My first obstacle, once I had been evaluated and deemed a good candidate, was to decide what kind of CI to get.

There are three companies that manufacture CI devices - Advanced Bionics, Med-El, and Cochlear - and all three have their subtle differences. When I first went through the choices with my audiologist, she told me that all three devices had similar performance results, so there was really no going wrong. Essentially, she was telling me, in the long run it didn't matter.

This insight was echoed by the other professionals I talked to. My future surgeon told me that, when he and his other implant specialist friends convene for lunch, they debate about which device each of them prefers. There is almost never a consensus. "Each doctor has his own preference," he told me. "It's like talking about cars. Some people love their Ford, while others would prefer to drive a BMW or a Lexus." Again, he was saying, it didn't matter. I wanted to throw up my hands - I might as well pluck a name out of a hat.

Wait a minute, though. This is a huge decision that will affect the rest of my life, the way I hear - and I'm going to take it so lightly? Even the car analogy, upon closer scrutiny, breaks down. While some people are die-hard Ford supporters, I think it's true that a Lexus is a higher-quality car. Sure, all these car models have four wheels, an engine, and will get you where you want to go, but that does not mean they are the same. Preference and subjectivity may be part of the decision to get a CI, but I did not believe that all the CI devices were inherently created equal. My parents didn't, either. Which one provided the best technological platform, the best features, the best innovative potential? We set aside the noncommittal advice of the doctors and set out to do our own research.

Quickly, we found that it was almost no use to research directly from the companies themselves. All are subject to marketing techniques, and all have detailed statistics showing why their device's performance is better than the other two. In addition, talking to company reps was inherently biased. We began to search for more fundamental comparisions between the three.

Here is a general recap:

Cochlear. By far the "name brand" on the market. Has been around the longest, since the 1980s when the cochlear implant first came into prominence. Because of this, has by far the best publicity, the best advertising (involving beaming little kids running around with their parents looking on proudly), and the most users. The friends I have who do wear CIs all have Cochlear. The inner implant has a removable magnet, in case there's ever an emergency requiring removal for a MRI (scary possibility, but necessary to consider). However, the technology of the internal processor is lagging behind the other two companies. Cochlear has just come out with a new Nucleus 5 device, but this appears to "max out" the potential of the implant for any future upgrades. Admittedly, I found this device the most attractive. The new Nucleus 5 device has gorgeous aesthetics, compared with the other two - a sleek, slim external processor looking something like a cross between a Bluetooth device and some hip new Apple technology. The hand-held remote that controls its programs looks a lot like an iPod. Sexy!

Med-El. The second most used brand after Cochlear, and it has more removable/rechargeable battery options. The external processor was much less attractive, though - blocky and unwieldy, and looked as if it were made of a cheaper-quality plastic. Better performance electronically, perhaps, but the magnet on the inner implant is not removable. We didn't pay much attention to this one, to be honest.

Advanced Bionics. The largest (and, ahem, ugliest) processor of all, I must say. The first time I saw the external BTE, I thought, "Ugh, it looks just like a brick." But AB is a newer company, and has a more forward-thinking technological platform. The inner magnet, like Cochlear, is removable. The inner array has the best electronics, and the BTE has a patented T-mic microphone that gathers sound from the ear canal itself (where the pinna of the ear naturally collects sound waves), rather than elsewhere. The processor also has a set of new programs targeted toward making it easier to hear in noise and to appreciate music. Plus the company, from talking to reps, seems to have the most vision for future innovation.

In describing the three different brands, I think I have made it generally clear why I settled on AB for my cochlear implant. I will not explain all of the pros and cons of the different companies here; there are plenty of better-versed people and websites out there for that, and my overall impressions are enough. I am especially indebted to Tina's intensive research on the different CI brands at http://funnyoldlife.wordpress.com/cochlear-implants/choosing-a-brand.

I feel confident that I have settled on the best implant for me, and hopefully AB's future technological improvements will make the device more attractive to wear. To close, here is a more detailed picture I found of what the implant will look like, inside and outside:

Above is the internal processor (and its comparative size), below is the external BTE and magnet. Kind of scary, huh? You can see why the first CI researchers gathered criticism for "unethical" experimentation with humans...

But yet - it's amazing to look at and to ponder. The marvels of science.