Photo by Doug Koontz Denise Portis has a cochlear implant, which attaches to the scalp behind the ear. The implant allows her to hear again.

Walking through a toy store around Christmas, she heard a laugh. It was a sound she recognized from childhood, and it was a sound she heard and recognized without any help. It was the Sesame Street character Elmo!

That's a moment Ms. Portis will not forget.

Nor will she forget the first time she heard the mature voices of her teenage son and daughter -- no longer the high-pitched toddler voices of her memory. The sounds of a duck quacking, the coffeemaker percolating in the kitchen and the toilet flushing were new and fascinating. It had been so many years since Ms. Portis had heard these sounds of daily life that they were all but gone from her memory.

About 18 months ago, Ms. Portis, 40, received a cochlear implant. Since then, she's gone from a world of silence and isolation to speaking nationally about hearing loss. Ms. Portis is co-founder of the local chapter of the Hearing Loss Association of America (HLAA) support group. Her husband, Terry Portis, is a psychologist and executive director of the national organization, which educates, supports and advocates for people with hearing loss.

Some types of hearing loss can be age related or genetic. Ms. Portis's hearing loss is sensorineural, or nerve-related. Though the exact cause of her hearing loss is not known, nerve-related deafness can be caused by aging, pre-natal and birth-related problems, viral and bacterial infections, heredity, trauma, exposure to loud noises, fluid backup or a benign tumor in the inner ear. Conductive hearing loss, in which the path of sound through the middle ear is interrupted by the presence of fluid, a perforation in the eardrum or an abnormality of the ossicles, can be treated medically or with hearing aids. But, according to the HLAA, cochlear implants are not an option for conductive hearing loss.

Sounds of silence and isolation

"It happened slowly, but I knew it was happening," Ms. Portis said of her adult-onset hearing loss. She was 25 at the time and a stay-at-home mom with two small children.

A car accident when she was 6 years old left her with major hearing loss in her left ear, but hearing in her right ear was perfect. Now, talking on the telephone was becoming difficult. She blamed her hearing problems on other people mumbling and a "cheap" phone.

"One of the most frustrating things was not knowing what to do," said Mr. Portis, who, at the time was with the nonprofit Brain Injury Association in North Carolina, where the family lived.

"(Hearing loss) is almost like going through the stages of grief," explained Ms. Portis. "There's denial, anger, bargaining, depression and you reach, finally, the acceptance of this loss."

She became bulimic and struggled with that, too, for a few years. She later realized the bulimia was a coping mechanism for her and that she was "trying to control something in a negative way," said Ms. Portis.

Over the next couple of years, her hearing decreased dramatically. She couldn't hear her children's high-pitched voices, but she could still hear her husband's deep voice. Talking on the phone or with friends were things she avoided. She stopped participating in church, community and school activities, and tried to keep her hearing loss secret. The concentration needed to communicate was fatiguing, which complicated communication further.

"Terry couldn't figure out why I didn't want to go on a 'date' with him," said Ms. Portis. "It was because in a restaurant, I couldn't hear him."

Communication became difficult and she had to depend on her husband to do things for her. "I needed to depend on him for things mothers have to do. He would have to make appointments, then call back, because I missed half of what the doctor said," said Ms. Portis. "I was angry because I couldn't do what mothers do."

She joined the North Carolina chapter of the HLAA (then called Self-Help for Hard of Hearing People) and learned coping skills, such as lip reading and repeating back to people what she heard them say. "You read body language and facial expressions. Sometimes I was right; sometimes I was wrong. Harsh consonants I could hear. I could hear 'Denise' but not 'mom,'" she said.

Reluctantly, she finally agreed to wearing hearing aids -- ones that could be hidden by her hair -- but even then her hearing loss was in the moderate to severe range and she still missed much in conversations.

The joy of noise

In 2002, Mr. Portis was hired by the HLAA and the family moved to Frederick . Ms. Portis's hearing loss continued to worsen and the family talked about adapting to her going deaf. Her children had grown up with her hearing loss and had learned to tap her on the shoulder and look at her before speaking, and they had learned to communicate for her.

In his position with HLAA, Mr. Portis regularly met people with cochlear implants and suggested his wife be evaluated for an implant. At first, she was resistant, but after meeting a few people with implants she made an evaluation appointment and qualified.

The procedure took place in the spring of 2005 and was successful. "At first there were so many noises," said Ms. Portis. "I was like a little kid. The first month was so hard. Everything sounded electronic," she said. But with time, "it smooths out." Ms. Portis had profound hearing loss for four years. For someone who has experienced hearing loss for a longer time, the process can be more difficult, she explained.

"I'm having to learn to ignore sounds that others ignore," like the refrigerator running. And she carries a clipboard adapted with a small directional microphone to help isolate conversations.

With a cochlear implant, sounds are picked up by a microphone and transmitted to a speech processor, which digitizes the sound into coded signals. The signals are transmitted to a receptor, implanted under the skin above the ear, then to an electrode array inserted in the cochlea. The electrodes stimulate remaining nerve fibers, then send the sound information to the brain for interpretation.

Now, Ms. Portis eagerly talks about her hearing loss and implant. "I've had young women come up to me with tears in their eyes," said Ms. Portis. "Young women react differently than young men (with hearing loss). They have a harder time adjusting. They need support, but to men, a support group is a sign of weakness."

"It's probably more of an anger reaction. Men have an easier time dealing with isolation than women do," said Mr. Portis.

Revealing her "secret," by pulling her hair back so her hearing aids could be seen, gave Ms. Portis new confidence to talk about her hearing loss and brought new encouragement from friends she had isolated herself from.

"Now I'm so public I talk nationally," said Ms. Portis. "But I meet so many people who still aren't there."

She is in training and is waiting to receive a hearing assistance dog from Fidos for Freedom in Laurel. "I want to try to keep my independence at night. When I take everything off, I'm deaf.

"I hear, but I'll never have hearing again," she said. "I long to keep that independence I've earned."

Ms. Portis still wears a hearing aid in her right ear to keep the hearing nerves stimulated "in order for some day" when technology may be available to enable her to having hearing restored to it.

"I wear bling on my implant," she said, pointing to the gem stones on her CI transmitting coil in her hair. They're red -- like Elmo.