Monday, July 27, 2009

The Other Ear

A few weeks ago I was at a party. People who had not seen me since before the surgery were there. I had the best time, and everyone thought my new ear was cool. I had a blue headpiece cap on, and wore a retro hat, which covered the headpiece. I felt like an extra from the holodeck with the combination of retro stylin' and hi-tech gear. Although I could hear much better than I ever, ever could before, it was still difficult. I wondered how having a second bionic ear would have helped.

Last week, on Friday, Brian and I had a meal at a very nice, but noisy restaurant. He was sitting just to the left of me, right by my bionic ear. We had no problem conversing. I wondered what I would hear with just the hearing aid, and pulled the magnet off to find out. Instead, I found out what I could not hear. I couldn't hear myself talk in the noise. I couldn't hear Brian talk, either. Before the CI, Brian would have had to sign at a place like this. Before the CI, we probably wouldn't have gone out to eat at a place like this.

The next day, we were at the car dealer, in the finance office. Hours earlier, we had stopped in to check around, and now Brian was in the final moments of buying a new car. Poof, my CI battery died. We did not plan to be out this long, and I did not have a spare battery. The hearing aid was still chugging away, and it wasn't like the noisy restaurant, so I settled in to make do. I quickly realized that I couldn't make anything out; I couldn't make do. I announced that I was getting nothing out of this, and that since Brian would drive his new vehicle home, I would be on my way.

I had no patience for not being able to hear. How times change. How quickly I grew accustomed to my much more capable bionic ear. The dominant ear has switched sides to the bionic ear. Now it's easy to forget how bad the hearing aid alone sounds. How much better could I hear with two bionic ears? Going bilateral improves hearing in noise and locating sounds, as well as overall hearing comprehension. I've considered going bilateral since before the first implant. Now that I know how massively superior cochlear implants are to hearing aids, I am moving forward with my 2nd implant.

Monday, July 20th was the bilateral evaluation along with the third mapping appointment. The day before, because I wasn't wearing it, my hearing aid was in my short pockets. These shorts were about to be washed. *cue Jaws theme* The hearing aid eluded the pocket-emptying process before starting its sudsy bath. It was already at the final spin cycle when I realized where it must be and rescued it. Because this was the day before my bilateral evaluation, I needed to have a functioning hearing aid. Calmly, I put it on. Nothing. I changed the battery. Bingo, it was working. It was working just fine, which was impressive. Phonak did a fine job making the Naida water resistant. The aid has worked fine since then. That this happened told me something. Since I was a small child, I've been very diligent about where my hearing aids are. I've never lost my hearing aid, much less washed it. Now, not long after the new ear comes into town, the old one gets left behind, forgotten, and mistreated.

At the center, we did the mapping portion first. We went through the electrodes, and adjusted the levels. They didn't change much, showing that my levels were settling down. Then we went to the sound booth. To qualify for a bilateral implant, I needed to score less than 60% in the best aided condition. The center I go to considers the CI in the 'best aided condition.' Fortunately, I got exactly 60% correct on sentences in noise with the CI and the HA, so I should qualify.

The next part was met with elation. Using just the CI, I correctly repeated 97% of the words in a test, hearing sentences in quiet. I also tested at normal hearing levels with my CI, responding at 15-20 dB all the way across the frequencies. This is the goal range, the optimum for bionic ears. I am so grateful that I have raw hearing power as good as it gets. I still need to work on my agility and comprehension with the ear, though those abilities are coming along nicely.

Now, I wait. The insurance approval process will take a little time. It may happen this year, or maybe early next. Until then, I'll keep working on my first ear, looking forward to the day when both ears are upgraded and hearing is even better.

Monday, July 6, 2009

Progress Report: Twelve weeks

Newness is turning into familiarity and confidence in my hearing. Tentatively, I am beginning to make phone calls. Yesterday, I needed to talk to someone, and debated between walking to his desk or calling him. I decided to call. No problem. No problem at all.

Before, I couldn't listen to spoken word audio for any length of time. Now, I have finished 4 audiobooks, and countless podcasts, with an ever expanding queue of books I've always wanted to read. By now, I have logged dozens of hours listening to spoken word. Before, I avoided social situations and the inevitable frustration and boredom. Now, I can follow the conversation and have a good time. It is still challenging in noisy environments, but I persevere.

There is something called a "wow" moment, when you hear something and just go "wow" because you just can't believe you heard that. They come fast and furious at first, and then they taper off, but grow more spectacular. At first, my wow moments were like being able to crisply hear a door closing from a distance away, or the slight fluttering sound of a cat vigorously shaking its head from across the room. Now, the winning wow moment is when I was standing near a buddy in a parking lot, and someone 50 feet away was talking to him. Fifty feet away. I thought, "No way, you cannot hear that," and proceeded to listen. To my astonishment, I made out a couple of words, and confirmed them with my buddy.

I do still have difficult moments. Sometimes my mind is not able to grasp what I'm hearing, and speech comes in as nonsense. Those difficult moments remind me that I am not a hearing person. It is easy to forget, with the progress I've made. In twelve short weeks. And it will only get better.

Friday, May 22, 2009

Progress Report: The First Audiobook

I was never able to effortlessly listen to recorded speech with just any voice. When I was younger, I was able to hear some if the speech was very clear, and unobstructed by any noise.

Knowing that people with cochlear implants can have good success with speech comprehension, I looked for something free on iTunes, and found a podcast of the Wizard of Oz. Before the implant, I tried to listen to the first chapter, The Cyclone. I got an occasional sentence, but generally did not follow it much at all, getting only a vague sketch of what was happening. I got that Kansas was gray. There was a cyclone. Dorothy was in the house being carried by the cyclone. Then she landed? Fell asleep? Was she already talking to the Munchkins? What's happening? Will the wizard give me an ear?

After the implant, I tried it again. Incoherent. Forget it. I couldn't hear it. I heard maybe three of the sentences that I heard before the surgery. Still, I kept listening to it, going back and trying again and again. I was hearing more and more of it each time. It was like a puzzle, piecing together the sentences word by word, gleaned by repetition. Then one night, it started to spill through. I was hearing the majority of it, but still missing some chunks of the story here and there.

To help with filling out the missing chunks of the story, I decided to transcribe it, which also increased the rigor of this exercise. I heard the entire chapter dozens of times as I read along the transcript, trying to fill out missing sections. Finally, three days later, I had a 98% transcribed chapter. The last few stubborn words held out on me, but hopefully someday I'll get them.

"The north and south winds met where the house stood, and made it the exact center of the cyclone. In the middle of the cyclone, the air is generally still, but the great pressure of the wind on every side of the house raised it up higher and higher until it was at the very top of the cyclone, and there it remained and was carried miles and miles away, as easily as you could carry a feather."

All that work on The Cyclone chapter swirled around my auditory cortex and raised its comprehension levels higher and higher. As I started on chapter two, The Council With The Munchkins, I found I was hearing the words much faster than I could type them. I stopped typing and kept listening. There is no transcript of chapter two. I listened to it twice and got the story. Dorothy's house landed in Oz, killing an evil witch, and Dorothy met all sorts of interesting beings, then set upon her way to Oz on the road with yellow bricks to try to get back home.

The next few nights, I made it through the next few chapters on the first try. I wasn't getting 100%. I would miss an occasional word or phrase. Sometimes I'd miss a sentence or two. But I heard enough to know what was going on with no doubt. I'm now on Chapter 14, and there are 24 chapters. Soon, I will finish my first ever audiobook.

Sunday, April 19, 2009

Electroded Droid Ear

After anxiously waiting all day April 9, 2009, at 12:45PM, I was wheeled into the operating room. The anesthesiologist showed me the vials of the medication and gave me a thumbs up. I returned a thumbs up. Getting comfortable, I stared up at the ceiling. It started to dance a bit as I started to feel tingly. That is the last moment I remember. In the next hour, the surgeon created an incision behind my ear, milled out a pocket in my skull for placing the magnet, antenna, and computer chip, and threaded the electrode array delicately into my pea-sized cochlea, an inch and a half into my skull, deftly maneuvering between several critical nerves and blood vessels.

My first memory afterwards is of the nurse gently shaking me awake. My mouth felt horribly dry and she brought me a Sprite. I kept forgetting that the surgery was over in the first hazy half hour after coming to. I kept discovering Brian by my side. I greeted him several times before finally getting deja vu. I recall shared tears of joy that it was over, that my face was not paralyzed, and that I could taste the sweetness of the Sprite on both sides of my tongue just fine. The biggest aftereffect by far was the nausea and dizziness. I could not move very quickly without my head spinning in a swirl of eddies.

The nurse asked me how my ear felt. It felt fine... no real pain at all. That meant that I needed no further painkiller injections, and no further hospital care. I could go. Very slowly and carefully, I got dressed, and left the hospital via wheelchair. The two hour ride home to Tucson loomed as an impossibly long trek, but thankfully it went quickly. Residual effects of the anesthesia left me loopy enough to just ride it out with my eyes shut, nibbling on a sandwich Brian picked up at Paradise Cafe. At home, I got far too enthusiastic about moving around and promptly hurled everything I had eaten. I decided to play it safe then and reclined for the rest of the night, nibbling very slowly on dry, flavorless crackers, and sleeping with my head upright. For the next couple of days, the dizziness and nausea stayed at bay as long as I didn't move around too much. By the time Easter rolled around, 3 days after the surgery, dizziness was no longer a problem.

I woke the first morning after the surgery feeling a tender spot, high on the side of my head. Could that be where the magnet goes? It seemed really high. At the pre-op a couple of weeks prior, I brought my bike helmet to see how it would affect the magnet location. In order to completely fit within the helmet area, the doctor said the magnet placement would be a little higher on the head than usual. I wanted to minimize this effect, so I bought a new helmet with lower straps and better head coverage. The doctor said it did allow for a lower position. Feeling the tender spot, and comparing the bumps to the smoothness of the other side of my head, I guessed that was where the magnet was. It didn't seem like getting a new helmet mattered, the magnet was so high on my head. I have to be glad for the custom installation, though, because otherwise the implant would have been under a bike helmet strap and possibly had issues. As it is, it fits perfectly within the helmet, and had no issues on a test ride.

My organic ear gave its life for its bionic future. Sometimes, recipients are able to hear still after implantation, but my implanted ear lost all of its residual hearing. I noticed that the dogs barking no longer registered in the implanted ear. I tested further by banging a hammer against some wood with my ear right by it. Absolutely nothing. Soon, its bionic transformation would be complete.

Monday, April 13, 2009, I woke up excited for what lay in store. I roused Brian enthusiastically. Today's the day! Today's the day! We allowed plenty of traffic time, and had enough time to stop at a Starbucks before showing up at the Ear Center just before 8:00, with my device kit. The surgeon had given me the device kit before the surgery. We were able to look through it before the activation. I was able to stick the magnet on and confirm high placement. We just had to remember to bring it to the activation.

The expectant mood was palpable. Checking in and taking care of the co-pay, it felt so routine, but I was going through one of the biggest days of my life. After taking a seat in the waiting room for just a few moments, the audiologist, Linda, called me back. We went to a spacious office and I took a seat. A specialist from Advanced Bionics was also in the room, Lalita. Linda set up a processor and hooked it to my head. The headpiece would not stay on well, so she replaced the magnet with a stronger one. She commented that my hair was cut so short it was standing up. Longer hair works better because it can be laid flat against the skull, allowing the magnet to nestle more snugly against the receiver inside my head.

Then it was time to activate me. First, I turned off my hearing aid so I could focus on sounds coming in from the implant. Linda conditioned my electrodes, which took about 30 seconds. I tried to listen for sounds during this 'boot up' phase, but could hear none. She said my impedance values were "Beautiful." That's something to brag about. I have good impedance values.

They did a live speech activation, which means all they did was turn up the volume until I could hear it. After she turned it up a couple of times, I could hear her voice. It sounded like tinnitus in speech patterns, formless sounds that happened to coincide with her mouth moving. I could hear my own voice too. It was louder, and deeper.
"I can tell my voice is a lower pitch." I heard the ch sound. I repeated it, "Chhhhh."
"You can hear that, can't you?" Lalita asked.
I nodded. We played with some more phonemes. Lalita covered her mouth and apparently made a variety of speech sounds. I could barely hear any of them. There was a bird outside the window. No go. Couldn't hear it. A fan blowing was noisily buzzing away. I could hear that just fine. They decided to turn up the high frequencies. They loaded up the processors with different programs to experiment with. I made the next appointment, and then I was free to go.

Activation happened. Implantees are routinely advised to keep expectations low, that being able to tell the difference between loud and soft is a successful first day, and that how it sounds at first is not how it will sound a week later, and beyond. I vibrated with the anticipation fulfilled. Now I had a sense of how it sounds, and it could only get better as my brain adapted to the foreign signals.

What does it sound like? Such a simple question, so difficult to answer. Brian went into a Chipotle to grab lunch after the activation, leaving me in the car to play my first song with the implant. I chose "Holiday," an oldie, a song I know so well that I can play it back in my head without hearing it. It started in with the familiar light percussion and melody. As the song built, bringing in the bassline, the synths, and the cowbells, I started to weep. I had heard so much about how music was lost with a cochlear implant. "Music is absolutely ruined," I was told. It was my biggest fear by far, in going bionic. It was due to testimonials on just how amazing the Hi-Res Fidelity 120 program was in conveying music that I cautiously, optimistically chose Advanced Bionics over the other device makers. And here I was, hearing the cowbell, the rich bassline, the tambourine, and the synths, totally overwhelmed with the relief and joy I felt.

The lows are generally rich and full. There is an occasional electronic quality, sometimes a little buzzy. The middle to high frequencies seem flat and off, but that could be my brain. As we discovered at the activation, my brain wasn't even registering the higher pitches, sounds it didn't hear with the organic ear. I could not hear turn signals at first. In activation story after activation story, I read about how recipients heard the turn signal!!! So I therefore expected to hear the turn signal!!! But it was silent. I could see the green flashing arrow of the signal. No sound. Then later on, I did notice something, after all. An almost imperceptible, dog-whistle pitched clicking sound. Then once my brain was able to bring it into focus, it was inescapable. They are clear as day now. The process took about as long as the trip back to Tucson from the activation.

At first, when I took the headpiece off, my brain tingled, stunned, ricocheting with the electrical current. Now, just a few days later, my brain doesn't tingle. Instead it creaks with faint tinnitus, a slow, low, buzzing electrical sound, mourning to be rejoined with its electronic half. I am ravenously listening to music, and listening to audiobooks, training my fledgling bionic auditory cortex within the confines of my computer. I've had over a week to recover from the surgery. Monday, it is time to return to work as a cyborg, and see how the CI does in real life.

Wednesday, March 25, 2009


When the night has come
And the land is dark

"Stand By Me" is playing on the iPod. A high pitched bell, maybe a triangle, chimes once a measure. It has been so clear in the past. Today, it is gone. I strain to listen for it, and I don't know where it is.

Now, I am standing in the yard, listening. I can hear a dog barking and some nearby traffic. The tree is moving in a gentle breeze. Silently. I stare at it, looking to see if the leaves are actually hitting each other. It doesn't look like they are. Maybe there is no rustling after all. I get Brian. He comes out and listens. He hears the tree rustling. It's quiet, but he hears it. There's also a bird calling. We walk back to the patio. Brian asks if I can hear our dogs walking on the concrete. They're making sounds too? I can't hear anything at all. They are silent.

At just over 2 years of age, I was diagnosed with a severe-to-profound hearing loss, and promptly fitted with hearing aids. In the beginning, both ears were similar, with the left being worse in the high frequencies. The worse ear kept getting worse. It didn't take long for those high frequencies to vanish. By the time I was a teenager, all I had left were low frequencies. Thankfully, my right ear had more hearing, and was steady, with very little ongoing loss.

In 1986 or 1987, I received a new hearing aid, a Rion model. It hit the sweet spot for my right ear. A whole new world opened up to me. It crystallized the high frequency sounds. Speech became much more crisp and distinct. Trees rustling in the breeze, keys jangling, brakes squealing, doors squeaking, chalk writing on a blackboard.. New sounds became apparent in my favorite songs. High hat, bells, and tambourines punctuated the music I was so familiar with before.

Over the years, better and new hearing aids came out. Better noise suppression techniques. Dual microphones for improved directionality. Digital for better control of the input sound. On February 3, 2009, I had a routine hearing test for a new hearing aid. My good ear had its first "No Response," at 8000Hz, the highest tested frequency. I received the news with sudden, overwhelming grief. If the nerve cells no longer respond, it doesn't matter how good a hearing aid is. My CI journey started here.

Standing on the patio, listening, I hear a scrape. Turning to Brian, I ask him if there was a scraping sound. He scraped his foot in answer. Yes, I heard that. I will also soon hear the tree rustling in the breeze, the bird calling, and the dogs walking on the concrete. I will hear when the transmitter is attached, and the light on the sound processor is green. I will hear when electrodes inside my skull fire on command, illuminating my cochlea with sound.

The CT Scan was last Monday. It was a perfect appointment. I was in at 8:10 to fill out paperwork, as instructed, for an 8:40 appointment. I was in the scanner and out the door at 8:30! The result appears to be normal. I have an appointment tomorrow with the Primary Care Physician to get surgery clearance and a meningitis vaccination. The day after, I have a pre-op appointment with the surgeon. Moving along. I should have a surgery date soon.

Friday, February 27, 2009

Candidacy Determination

Yesterday, Brian and I got up at 5, and we hit the road at a little after 6. On the way up, we talked about a lot of things, and cochlear implants came up a lot. Traffic wasn't too terrible in Phoenix and we arrived at 8:30, the sun shining bright and the air thick with citrus bloom. I dropped off my paperwork at the front desk, and we waited. The office was clean and bright, with plenty of space. There were people of all ages in the waiting room.

The audiologist came out and called my name. I do not remember her name, but she was very nice. We went to the soundproof testing room and she set up the ear-buds. First, we did the standard hearing test: push the button when you hear the beep. Then the word test, where she read off a standard list of words in each ear alone, and I repeated what I heard back to her. When she did the left ear, the quality of the sound was so poor that I told her she sounded like a dog barking. I laughed at how ridiculous she sounded. I was able to make out some words, albeit very few.

Next, the aided portion. She came in and took the earbuds out, and I put my hearing aids in. Using speakers, she re-did the first part: push the button when you hear the tone. Then we did the HINT portion, Hearing In Noise Test. It was hard. Once in a while I made out a few words or the entire sentence, but I missed a lot of them. We all had a good chuckle at some of my answers. There's no way "He broke his nail" wound up on the sentences list. But that's what I heard.

Finally, we were done. She said I was audiologically qualified to be implanted. I still need to be medically evaluated with a CT scan.

Next, I met the surgeon. He started with the standard "When were you deaf? When did you start wearing hearing aids?" Looking at my audiogram, learning my history, and hearing me speak, he complimented me on my speech. I thanked him, and said it was the result of a lot of work. In addition, I said that I owed a lot of success to a good ear for hearing speech, which was now showing decline.
"Your hearing sucks," he replied.
"What?" I said.
"Your hearing is terrible. It's just getting more terrible," the doctor said. He said that I have probably been a qualified candidate for quite some time.

We talked about devices. He implants all three systems, and leaves the device selection decision completely up to me. My kind of guy. He's going to submit my name to all 3 companies for the information packet. I've already seen the packets from Cochlear and Advanced Bionics, but I'll finally get the Med-El packet. I'm pretty certain I'll do Advanced Bionics, but it's great to have the ability to choose.

We talked about which ear. I told him that my left ear used to be a bit better and faded into the corner by the time I was a teenager, so it has some auditory memory, and that I wanted to save my right ear. He agreed that the left ear would be a good choice, but we need to look at a scan first. He said that it makes a world of difference that I've continued to wear a hearing aid in that ear, keeping the auditory nerve stimulated. Serendipity from wanting my bass line.

He addressed the potential for facial paralysis and taste disturbance. The face and taste nerves are 3-4 millimeters apart, and apparently they need to drill between them. They put electrodes on the face to measure current and warn if the surgeon is getting too close. If they cannot do the operation safely between the nerves, the taste nerve is sacrificial. I'm not too thrilled with that, but I appreciate his honesty. If I do lose the taste nerve, the front 2/3 of the left side will lose taste. I'll still have the right side, and my sense of smell, and apparently I'll 'recover' and adapt.

To my surprise, he said that activation is 3-4 days after surgery. I'm not sure how they can activate so quickly yet. Hopefully we can do the surgery on a Monday, and activate on Thursday or Friday, with a weekend to adjust to it before going back to work as a newly assimilated cyborg. I'm not sure how useful it will be right off the bat, but it will be good to skip waiting a month without sound in the implanted ear.

I asked about where the implant would go, and the need to accommodate a cycling helmet. He said to bring the helmet to the surgery, and they would do what they could. It won't be the first time he has done that. He accommodated similar requests for a woman who rode horses, and a construction worker who needs to wear a safety hat.

The next step is to do the CT scan and make sure I am normal in the head. I know for a fact that I'm not normal in the head, but the bones are probably ok. Along with that, I need a meningitis vaccine. There is a heightened risk of contracting meningitis due to the type of surgery. Then the insurance packet is prepared and submitted for approval. This step is expected to be routine. I am a qualified candidate, and my insurance covers it, so it's a matter of ensuring the approval before going under the knife. I'm not sure how long it will all take, but I think it's safe to assume I'll be implanted and activated by the end of April.

Here we go!

Tuesday, February 24, 2009

Caveat Emptor

Cochlear implants apparently can do a fantastic job of restoring the world of sound. However, your mileage may vary. I've been reading testimonials, blogs, forums, and anything I can find about cochlear implants. There are some who think that it sounds natural and are able to hear again from the moment of activation. There are others who find the sound foreign, alien, and otherwordly, and struggle to interpret the signals as recognizable sounds and speech.

Most often, people find voices to be cartoonish and high pitched in tone. This is a result of the insertion depth. The hair cells at the end of the spiral of the shell-like cochlea are for the lowest frequencies, while the hair cells at the opening of the shell are for the highest frequencies. The deeper an implant is inserted, the deeper the pitch that is stimulated. Most people will experience a bias to higher pitch. Some people will experience almost normal or lower pitch, but the majority state that voices are higher and more cartoonish. Think Mickey Mouse. Alvin and the Chipmunks.

There apparently isn't much of a method to inserting an implant for accurate pitch reproduction. Every ear is different, and there's just no way for the surgeon to know how far to insert an implant. There is one implant producer, Med-El, that boasts of a longer implant than competitors have, which is intended to insert deeper and reach those lower frequencies more reliably. However, Med-El was just recently approved by the FDA for use in the US, and there is virtually no presence here yet. Also, their sound processing algorithms don't seem as advanced as AB's. Although in their favor, they have the smallest BTE (Behind The Ear) units.

People will get post-CI audiograms indicating nearly normal hearing response to frequencies from 250 Hz to 8000 Hz. The world is awash in sound, and speech can be deciphered without lip-reading in social settings and on the phone. So CIs promise to help me hear everything, but only in the pitches that the implanted device can stimulate. Hopefully I get a normal insertion, but most likely, I will get cartoon voices on activation day. I have mixed feelings about that. I'll be able to hear everything, but through a high-pitched filter.

Programming the implant is another consideration. Taking electrodes and immersing them in a salty, wet environment, one cannot expect reliable and repeatable sparks every time. The sound processor program's settings, or the map, as it is called, has to be fine-tuned to your ear and your preferences. Unfortunately, the neurological response to electrical stimulation can change over time, causing, literally, static to be heard, along with other undesired effects. That indicates that it's time for a new mapping appointment. So I'll be constantly looking for that sweet spot of optimum performance from the implant.

Also, there's the matter of the surgery. Once I go under that knife, I am committing to a life of surgery. If I have complications, I'll need surgery. If the implant fails, I'll need surgery. If I want an upgrade, I'll need surgery. If it has a limit on how long it should be in my head, I'll need surgery. Surgery has all sorts of risks, medical, financial, and otherwise. Definitely not one of the high points of going the bionic route.

But I'll be able to hear everything. Through a squawky box. Maybe.

I've always de-emphasized low frequencies in my right hearing aid, because that ear has a good level of high frequency hearing, although it is now fading. I've had good success using a strategy with crispy whispers, clinks and beeps in my right ear, and booming, rumbly bass in my left ear. I found that amplifying the lows muddied up the high frequencies, so my high-frequency ear developed a preference for quiet low frequency amplification. So when I turn off my left boomy aid, and only listen to the crispy whispers in my right ear, is that what a CI might sound like? Maybe I've already sort of trained my brain to listen to CI sound?

In other news, the old Oticon Sumo DM is back in my ear. I just don't like the Phonak. I gave it a week, almost, but found myself frustrated and hating the sound from it. Maybe modifying the Phonak's programming will help, but I have generally not had much luck with that brand. The Sumo DM seems awfully loud after wearing the Phonak, so I am wearing it low. But everything seems so much more detailed and clear with this hearing aid.