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July 28, 2003

Breaking the silence: Cochlear implant surgery was 'the easy part' for patient

From: Framingham Metro West Daily News, MA - Jul 28, 2003

By Jennifer Lord / News Staff Writer Monday, July 28, 2003

Second of a three-part series

WORCESTER -- Dr. Daniel Lee stood at a bank of MRI images, all displaying different angles of Bill Holt's head.

Holt lay only a few feet away in the operating room at the University of Massachusetts Memorial Medical Center, covered with a sterile blue sheet and a shower cap-like covering on his head. Monitors indicated breath and heart rates perfectly normal for someone who was unconscious and awaiting a cochlear implant.

"This tells us that the cochlea is going to be receptive to this device," Lee explained to several medical students, indicating the snail-shaped image on the lighted screen. "We know that there are no abnormalities, no infection. This ear has had surgery before, so there will be some scar tissue."

It was Friday, June 13, and for Holt, a turning point in his quest to hear again. A double ear infection six months before completely destroyed his already impaired hearing. Faced with a life without sound, the 48-year-old Framingham resident opted instead for a cochlear implant, a bionic device that converts sound and processes it into a form the brain can interpret.

A large blue X next to Holt's right ear marked the correct side, electrodes monitored muscles in his face -- a slip of the scalpel could irritate the facial nerves, just 2 1/2 millimeters from where Lee needed to be. Lee taped the hair around the ear away from the surgical site, carefully shaving away the remainder.

"The great thing about ear surgery -- it's all sit-down surgery," Lee said, settling into his chair. "It's all done through a very small incision, so we have to keep the area as clean as possible."

Holt was now a blue-covered bulk, with his ear the only exposed area. It was easy to forget, as Lee cut into the skin, that the ear was attached to an actual person. Lee pulled aside the ear and scraped against bone as he created a small pocket where the implant would sit. He paused momentarily to check the fit against a model of Holt's implant, which remained safely nestled in its box. At $25,000, it was far too valuable to waste on simple adjustments.

Satisfied with the pocket, Lee selected a small drill to start the most delicate portion of the surgery. A nurse swung down a microscope, its camera transmitting the magnified view to a nearby television.

"This mastoid is a little underdeveloped," Lee remarked of the projection of bone behind the ear. "He's had infections before. It's almost like a child's mastoid."

Drill whirring, Lee noted that Holt would likely be setting off metal detectors for the rest of his life. He will need to carry a card in his wallet stating that he has an implant in his head.

"We're sort of sculpting the mastoid here," Lee said. "The space we want to enter is called the facial get to this, we want to do this safely and efficiently. In the old days, they used to use chisels to get through bone. I imagine there were often complications -- unless you were Michelangelo."

The cutting slowed as Lee encountered scar tissue from a previous surgery. Holt lost hearing in this ear first as a child, and an attempt to restore it failed. Lee was confident that his brain would rewire itself to adjust to having hearing solely on the right side rather than the still-infected left.

"This is not a virgin ear," Lee said. "This alters the landscape a little bit. What we want to do is come through the middle ear from behind. We don't want to do it through the ear canal, because that's not a very clean place."

Cutting over, Lee calls for the box holding Holt's Nucleus cochlear implant to be opened. It's just slightly larger than a quarter, with two electrodes dangling off the end. In a month, after the incision is healed, Holt will be able to attach the rest of the device, a magnet that attaches to the implant through the skin and a processor that sits behind the ear.

The implant slips gently into the pocket created for it, the electrodes dangling down the mastoid. It's a perfect fit.

Lee asked the nurse to call down to the waiting room to assure Holt's wife, Mary Jane, the prognosis was good. Quickly, with obvious practice, he closed the incision.

"What's remarkable about this technology is, even in older patients, the patient is able to adapt to these foreign signals," Lee said. "For Mr. Holt, even though he hasn't had hearing in this ear for quite a while, this is by far the better ear -- we don't want to put an object into an ear that's been infected, for obvious reasons. He's had hearing in this side before, so it shouldn't be much of an issue."

The sheet beneath Holt's head was stained pink with blood. Gradually, the sterile sheets were lifted, revealing a man who is no longer just an ear. A large padding of gauze circles the ear -- Holt resembles a lopsided Princess Leia as he's wheeled to recovery.

"Honestly, this is the easy part," Lee said, snapping off his gloves and mask, energetic from the adrenaline of an hour and a half of surgery. "The surgery is easy. The hard part is defining the expectations after surgery. Everyone thinks it's like turning on a light switch, but it's not.

"The hard part is really just beginning."

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