Inside a sound-treated booth at Chattanooga’s Speech & Hearing Center, Dr. Hailey Long can determine not only how much hearing a person has lost but also when a hearing aid is no longer enough.
The testing is more involved than a standard hearing exam. Patients listen while wearing a hearing aid or another form of amplification and are asked to identify speech under increasingly difficult conditions. In effect, Long is trying to determine how much help the hearing aid still provides.
For some people with severe to profound hearing loss, the results can mark a turning point: They might be candidates for a cochlear implant.
The Speech & Hearing Center recently began offering cochlear implant evaluations, programming and follow-up care, adding a local option for a service available at only a few other Chattanooga practices. Patients must still travel to Knoxville or Murfreesboro for surgery, but they can undergo their initial evaluation and receive much of their ongoing care in Chattanooga.
For Long, the addition means patients she’s treated as their hearing declines no longer have to leave her care when hearing aids stop providing enough benefit.
“When someone reaches the point where a cochlear implant is appropriate, I don’t want to have to send them somewhere else,” Long says. “I want to keep them as a patient and provide that continuity.”
Beyond hearing aids
A cochlear implant is not simply a more powerful hearing aid. Hearing aids amplify sound the ear can still process. A cochlear implant is surgically placed and bypasses part of that process, electrically stimulating the auditory nerve.
The technology is generally considered for people with severe to profound hearing loss who no longer receive enough benefit from conventional hearing aids. But the population eligible for cochlear implants has expanded.
Long says cochlear implants began gaining popularity in the 1990s, but eligibility standards have broadened significantly in more recent years. Once reserved for people with very profound hearing loss in both ears, cochlear implants can now be an option at lower levels of hearing loss. People with single-sided deafness might also qualify.
The changes mean more patients might reach a point at which cochlear implantation becomes an option. But Long is careful not to describe an implant as the inevitable destination for someone whose hearing reaches that point.
“It’s very much the patient’s decision,” she says. “If someone with severe to profound hearing loss decides they’d rather learn sign language, that’s great. I can connect them with resources in the community.”
For patients who choose an implant, however, the center can now accompany them through much more of the process.
That process begins in the same booth where Long conducts ordinary hearing evaluations. During a cochlear implant evaluation, she performs more extensive testing while the patient uses amplification, determining whether it still provides sufficient benefit. A patient who meets the audiological criteria is then referred to a surgeon for medical evaluation and imaging.
Long and the surgeon collaborate on the case, including which ear should receive the implant when either could be used. After surgery and a period of healing, the patient returns to Long. She connects the external processor and activates the implant for the first time.
That first experience can be startling.
Patients have described the initial sound as mechanical or robotic, Long says. Natural hearing relies on acoustic sound waves, while the implant is sending electrical stimulation to the auditory nerve. The brain must learn how to interpret that new signal.
“The more you wear the cochlear implant, the more the brain learns to interpret the sound, so it becomes more natural over time,” Long says. “It’s never going to be natural hearing, though. It will always have an electronic quality.”
A world that slowly grows quieter
The transition is especially dramatic because hearing loss itself is often anything but dramatic.
For many people, it arrives slowly enough that they accommodate it without realizing how much their world has changed. The television gets a little louder, they move closer to the person speaking, and they blame background noise when they struggle to follow conversations in restaurants.
Environmental sounds can disappear almost unnoticed – birds singing during the day or crickets chirping at night – Long says.
Family members often recognize the problem first.
Jenny Wood, deputy program officer for Signal Centers, the Chattanooga nonprofit that operates The Speech & Hearing Center, has experienced that with her sister, whose hearing changed significantly after a recent diagnosis. Her sister knew something was different but did not initially recognize what she was experiencing as hearing loss.
Wood remembers asking her sister whether they needed to bring in an awning.
“You want chicken for dinner?” her sister replied.
Wood’s instinct was the same as many people’s: Say the same thing again, only louder. Eventually, she says, the two wound up essentially yelling at each other.
Long taught her a different approach. Get the person’s attention before speaking – using their name can help – and if they don’t understand something, rephrase it rather than simply repeating the same words at higher volume.
Those small adjustments matter because untreated hearing loss can gradually change more than the volume of the television. Taylor Bostwick, chief marketing officer for Signal Centers, says research indicates people wait an average of seven years between learning they have hearing loss and treating it.
The reasons range from expense to vanity to simple adaptation. People learn to read lips or avoid situations in which hearing is difficult. Over time, Wood says, coping can become isolation.
“Eventually, the TV is at full volume and you might start isolating yourself,” she says. “You get tired of having to ask people, ‘What? Say that again.’”
Meeting patients where they are
Long’s approach is not to force a decision before someone is ready to make it.
She encourages patients who decline hearing aids to maintain a relationship with the center and return for regular hearing evaluations. Their hearing might change in the meantime, but so can their willingness to address it.
She recalls a patient who was told one year that hearing aids would help but wasn’t ready to use them. Long asked the patient to return the following year.
“When they came back, they said, ‘You know what? I’ve noticed that I’m straining to hear, and my family is getting a little exasperated with me. I think I’m ready.’
“Sometimes all they need is a bit of time.”
That philosophy reflects the unusual position The Speech & Hearing Center occupies in Chattanooga.
Founded in 1953, the center provides audiology and speech services regardless of income. Its place within the nonprofit Signal Centers helps make that model possible.
The Speech & Hearing Center accepts Medicaid and other insurance and offers a sliding-fee scale for people who qualify for financial assistance. It also serves private-pay patients who might prefer a clinical setting to the more retail-oriented experience of buying hearing aids elsewhere.
Bostwick says a patient who can afford to pay privately receives the same technology and care from a doctor of audiology while also helping sustain the center’s broader mission.
“By paying privately, you’re investing in the community,” she says. “You’re helping someone who can’t hear, or someone who needs speech therapy or has another communication disorder, cover their services.”
For Long, the distinction is less about where someone buys a device than what happens around it.
“My primary goal with hearing patients is education,” she says. “I want them to understand their hearing loss and why I’m making certain recommendations, not just what I’m recommending.”
That can mean allowing more time for appointments, bringing family members into discussions and teaching communication strategies in addition to fitting and programming hearing aids.
It also means remaining involved as hearing loss progresses.
Learning to hear differently
For someone whose hearing aids eventually cease to provide sufficient help, cochlear implantation involves a trade-off and a lengthy process. The implant replaces the remaining natural hearing in the implanted ear with an electronically generated sense of sound.
After activation, Long adjusts the processor to suit the individual, and the patient gradually learns to make sense of what they hear.
Wood compares the experience to putting on a new pair of prescription glasses and suddenly seeing the individual leaves on a tree again.
For years, she says, a person’s hearing might have been growing “a little softer around the edges.” When sound returns through an implant, the difference can initially seem enormous.
That’s part of what makes hearing loss difficult to recognize in the first place. There’s rarely a single morning when the world suddenly goes quiet. Instead, pieces of it fade. A conversation becomes harder to follow; a spouse seems to mumble; a crowded room becomes exhausting.
Somewhere along the way, the birds and crickets disappear.
Now, for patients whose hearing loss progresses beyond what hearing aids can adequately address, The Speech & Hearing Center can follow that journey farther than it could before – from the first audiogram showing what a patient might not yet recognize, through hearing aids and, when appropriate, into a different way of hearing altogether.