20Q: Cochlear Implant Update

From the Desk of Gus Mueller

The world of cochlear implants always is advancing—each year this treatment option is being considered for more and more patients. Data from 2022 estimated that in the U.S., ~118,000 devices have been implanted in adults, and 65,000 in children. It’s not surprising, therefore, that many audiologists have devoted their careers to working with cochlear implant patients, and others spend several days each week with this hard-of-hearing population.

However, there remains a large group of clinical audiologists who don’t work directly with these patients, but still need to know about all the latest technology, test procedures and current thinking for counseling and referral purposes. Common questions often concern CI candidacy, FDA criteria, associated audiologic testing, hybrid/EAS advancements, single-sided hearing loss, bilateral fittings, bimodal fittings, and the list goes on.

You can see where we’re going here. Wouldn’t it be nice to have an up-to-date, easy-to-read summary paper that answered all or most of these questions? You’re welcome!

This month’s guest author is Meredith Holcomb, AuD, Associate Professor and the Director of the Hearing Implant Program at the University of Miami. She has worked with both adult and pediatric cochlear implant patients for over 20 years; you probably know her for her many book chapters, journal publications and invited presentations at national and international conferences.

Dr. Holcomb serves on the Joint Committee for Infant Hearing, the Board of Directors for the Politzer Society, the faculty of the Institute for Cochlear Implant Training, and the Audiology Advisory Board for Advanced Bionics, Med El, Hemideina, and Akouos. She is a past Chair of the American Cochlear Implant Alliance and a consultant for Cochlear.

As you can see from Meredith’s credentials, we certainly picked the right person to answer all your cochlear implant questions—and of course, she does that superbly.

Gus Mueller, PhD
Contributing Editor

Browse the complete collection of 20Q with Gus Mueller CEU articles at www.audiologyonline.com/20Q

20Q: Cochlear Implant Update

Learning Outcomes 

After reading this article, professionals will be able to:

• Apply best practices for referring patients for a cochlear implant evaluation.
• Analyze factors influencing speech perception outcomes in cochlear implant users.
• Summarize recent advancements in cochlear implant technology and their clinical implications.

Meredith Holcomb, AuD

1. I haven’t thought too much about cochlear implants in recent years, but what I remember from years back is that they were mainly for people with profound bilateral hearing loss and very poor speech understanding. My colleagues tell me this has changed considerably?

Most certainly! Cochlear implants (CIs) have been around since the 1980s and yes, in the early days, they were primarily for adults with profound bilateral SNHL and poor speech understanding. Over the course of the last few decades, CI candidacy has evolved to include adults and children with many different hearing configurations like single-sided deafness, normal low frequency hearing, and asymmetrical hearing loss.

2. Who is a good adult candidate for a CI in 2025?

Any patient who struggles with communication in their daily life when wearing appropriately fit traditional hearing aid amplification is a good candidate for a CI evaluation. For adults we have the “60/60 referral” rule (Zwolan et al 2020) which states patients with a 60dB HL or worse pure tone average (500, 1000, 2000 Hz) in the better ear and 60% or worse unaided word recognition score should be referred for a CI evaluation. As CI candidacy becomes less restrictive, we may want to think about referring patients whose worse ear meets the 60/60 and not worry as much about the better ear status. This is especially true in the single sided deafness population where the good ear often has normal hearing.

3. Is the pure-tone audiogram still the primary tool used to determine who would be a good CI candidate?

Actually, no! In fact, relying on the audiogram alone can limit referral rates and delay a patient’s access to CI technology. Unaided audiograms really have no predictive value for how a patient performs with a hearing aid, how much they can understand in a complex noise condition, or how well they will perform with a CI (Walden & Walden 2004; McRackan et al, 2018a). When determining CI candidacy, a patient-centered holistic approach, including hearing and medical history, functional performance, patient reported outcome measures, and lifestyle needs are all taken into consideration (Zeitler et al, 2024; Warner-Czyz et al, 2022). Most audiologists who manage patients recently fitted with hearing aids do not routinely perform aided testing in the sound booth and instead rely on patient report for the measure of hearing aid success. Without more formalized assessments of hearing aid performance, potential CI candidates will be missed.

4. Are there specific FDA CI criteria regarding candidacy?

Honestly, there are too many different CI criteria: FDA criteria, CI company labeling criteria, and insurance specific criteria. Each can vary by age and hearing loss configuration. It’s a lot to remember! Getting bogged down with numbers is not what we need to be doing as a community, especially for referring audiologists. Instead, we should try to identify patients in our practice who are struggling to effectively communicate in their daily lives, at their work, and in school and refer them to a CI center for a comprehensive evaluation as early as possible.

5. If my patient doesn’t meet FDA criteria for CI, but is having considerable difficulty, should I still refer to a CI center?

This is a question I see often in the social media groups and the answer is, YES! FDA criteria is a guideline, not a hard and fast rule, and if followed strictly can limit timely access to better hearing and communication (Park et al, 2021). After a formal CI evaluation, if a patient does not meet the FDA criteria but is an appropriate CI candidate, we simply justify the medical necessity of the CI in the letter to the insurance company. If approved the CI team will complete the case as an “off-label” CI surgery. The term off-label simply means that the patient has better hearing and/or speech understanding than the restrictive FDA crtieria. Off-label CI is more common now with 78% of CI surgeons reporting they perform off-label CI for varying degrees and configurations of hearing loss (Carlson et al, 2018). Implanting patients sooner, and before they meet FDA criteria, can result in improved speech and language outcomes and enhancements in quality of life (Varadarajan et al, 2020; Carlson et al, 2018; Park et al, 2025; Teagle et al, 2019, Brown & Gifford, 2021).

6. I have patients who may be interested in a CI, but they have really good low frequency hearing. Still candidates?

As I mentioned earlier, there have been several CI developments in recent years. One of these is what is termed hybrid or electric acoustic stimulation (EAS)—your patient might be a candidate for this. This type of CI device, which has a HA receiver attached to the CI processor, is best suited for patients with normal to moderate low frequency hearing. Hybrid/EAS is great for patients with intact low frequency hearing after CI surgery because it uses a CI processor to provide access to mid and high frequencies while allowing the patient to hear acoustically in the low frequencies through the HA receiver. EAS has wonderful benefits like improved sound quality, speech perception in noise (Gantz & Turner, 2004; Gantz et al, 2005; Tuner et al, 2008; Gantz et al, 2009) sound localization (Dunn et al, 2010; Gifford et al, 2014) music appreciation (Gantz & Turner, 2004; Gantz et al 2005; Kong et al, 2005; Gfeller et al, 2006; El Fata et al, 2009; Tyler et al, 2002; Kiefer et al, 1998). Similar results are also found in the pediatric population (Park et al, 2025; Wolfe et al, 2017).

So really, if you think the person is a reasonable candidate, you just need to refer them to a CI center for a formal CI evaluation. The CI team will then perform the appropriate testing to determine candidacy and will decide which CI electrode to use. Referring audiologists are simply sending their patients for more specialized testing, they are not referring for a specific electrode or indication.

7. What if my patient loses their residual hearing during the surgery, will they be upset with me for sending them for the CI evaluation?

This is a great question! I’ve been in the CI field for almost 20 years and even if a recipient loses residual hearing in the CI surgery, they still can benefit significantly from the CI in terms of communication and quality of life outcomes. Remember, the CI surgery is elective meaning the patient is electing to move forward with CI treatment. The best we can do as a CI community is to properly educate them on all risks and benefits prior to surgery. And the good news is, hearing preservation is a common outcome for CI surgery now with longer length electrodes and in both pediatric and adult populations (Van de Heyning et al, 2022)!

8. This is great information! Do any of your patients use a hearing aid on one ear and the CI on the other?

Yes, this is commonly referred to as “bimodal,” and I manage MANY patients who fall into this category, both adults and children. For adults, roughly 85% of CI candidates have a bimodal hearing profile (Holder et al, 2018). The cool thing is all three CI manufacturers have HA devices compatible with a CI, and patients love the bimodal streaming feature for phone calls. A few years back, a group of us put together some guidelines specifically to assist with management of these bimodal patients—I think you’ll find them helpful (Holder et al, 2022). I always tell my patients, we have two ears for a reason and we should take advantage of bilateral hearing if possible, whether that is with two CIs or a HA and a CI.

9. Speaking of two CIs, what is the current status on bilateral CI?

Bilateral CI is more common in children than adults with only about 20% of adults electing to get two CIs. In my experience adults are more reluctant to initially agree to a CI surgery in both ears at once (simultaneous) and then later are hesitant to do a second (sequential) surgery because they are already benefitting from the first CI. More often, adults remain in bimodal technology. For children, simultaneous CI surgery is better for development of bilateral auditory pathways (Peters et al, 2010) and is now the gold standard treatment for bilateral severe to profound hearing loss. Anytime a patient is a CI candidate in both ears, we counsel them and the family about the benefits of two CIs which include improved speech recognition in quiet and background noise, enhanced sound localization, reduced listening fatigue, enriched quality of life, and improved language development (Almeida et al, 2019; Eskridge et al, 2021; Grieco-Calub et al, 2010; Harkonen et al, 2015; Lovett et al, 2010; Reeder et al, 2014; Sivonen et al, 2021).

10. This makes me feel better about referring patients for a CI evaluation earlier. So, what is the process of a CI eval, how is the patient tested?

In addition to the routine diagnostic evaluation, for adults, we utilize the Minimum Speech Test Battery (Dunn et al, 2024) which includes presentation of recorded single words and sentences in quiet and in noise to determine how well a patient can understand speech with appropriately fitted hearing aids. We assess each ear individually to determine the ear to be implanted. We also include questionnaires like the SSQ-12 and the CIQOL-35 to better understand the impact of the patient’s hearing loss on their daily life. For children, we utilize a similar process with the Pediatric Minimum Speech Test Battery (Uhler et al, 2017) and developmentally appropriate questionnaires. All patients also undergo a medical evaluation with the CI surgeon, imaging (CT or MRI) to assess the inner ear anatomy, and other appointments as needed (speech, psychology, genetics, etc). 

11. What about children who do not have or use spoken language? How do you decide who is a CI candidate for this population?

Great question! It is often more difficult and more time consuming to obtain ear specific behavioral unaided hearing results in infants and children. For this population, anyone with an aided speech intelligibility index (SII) of 0.65 or worse at normal conversational speech level, regardless of pure tone thresholds, is an excellent candidate for a CI eval (Wiseman et al, 2023; Stiles et al, 2012). We also rely heavily on parent report and questionnaire data to help us make an early decision for CI surgery. A recent study reported children with a PTA of 65 dB HL or worse have a 75% chance of performing better with a CI than with hearing aids (Leigh et al, 2016). Ultimately, early identification and treatment of pediatric CI candidates is highly important for best outcomes including literacy and pragmatic skills, spoken language development, academic success, and quality of life (JCIH 2019; Johnson & Wiley, 2019; Birman et al, 2012; Cejas et al, 2015; Meinzen-Derr at al, 2022; Yoshinaga et al, 2020; Dettman et al, 2016; Naik et al, 2021; Fernandes et al, 2015; Oghalai et al, 2012; Wiley et al, 2005; Berrettini et al, 2008; Zaidman-Zait et al, 2015). Delaying CI access can result in poorer outcomes than if the child was referred and implanted at a younger age (Park et al, 2021).

12. Is there a lower age limit for a CI?

Technically, the FDA specifies 9 months as the lower age limit for cochlear implantation (US FDA, 2020). But I’d like to see that number decrease to perhaps 6 months in the future. CI in the very young is not only safe and effective (Miyamoto et al, 2018; Purcell et al, 2021; O’Connell et al, 2016; Cotrell et al, 2024; Hoff et al, 2019), but it is linked to numerous spoken language, academic, and quality of life benefits as we just discussed. If we can get babies appropriate access to sound at an early age, they have a better chance of performing similar to their normal hearing peers (Dettman et al, 2016).

13. For the older folks, I assume that they eligible for a CI too?

Yes, there is no upper age limit for CI! This is great news as disabling hearing loss is more prevalent in the later decades of life (WHO, 2021; Goman & Lin, 2016) Older adults and the elderly demonstrate similar post-CI speech outcomes and quality of life improvements as younger CI recipients (Carlson et al, 2010; Eshraghi et al, 2009; Zwolan et al, 2020b; Rohloff et al, 2017; Issing et al, 2020). I’d like to point out, that we as audiologists should not rule out CI as a medical treatment option simply due to older age. It is up the surgical team to determine if a patient is healthy enough to undergo surgery and a patient’s medical history should not limit their access to the CI evaluation referral.

14. Is it necessary for adults and children to wear the CI all the time for best outcomes?

Absolutely! Device use is one factor that is modifiable by the adult recipient themselves and does positively impact speech recognition (Linquist et al, 2023a; Linquist et al, 2023b; Holder et al, 2020; Schvartz-Leyzac et al, 2019). A recent study suggested a datalogging of a minimum of 12 hours per day is necessary for adults to reach their benchmark word and sentence scores faster (Linquist et al, 2023a).

For pediatrics, we recommend a minimum of 80% of Hearing Hour Percentage, or 80% of the time the child is awake. This total number of hours of device use will increase as the child ages as children sleep more as babies. Ultimately, we educate parents with the mantra of “eyes open, ears on” since increased CI wear time is strongly correlated with improved outcomes (Gagnon et al, 2020; Gagnon et al, 2021; Wiseman et al, 2021).

15. Okay, so CI device use is absolutely important for success. Will adults also need to complete auditory rehabilitative exercises?

Yes, I recommend daily listening practice and auditory rehab (AR) for all patients. Children are typically enrolled in speech therapy and parents are encouraged to continue those therapy techniques in the home. Adults should participate in a self-directed computer-based AR program using CI company apps, podcasts, or audio books as this has been shown to significantly improve speech recognition and quality of life CI outcomes after 3 months of consistent AR (Dornhoffer et al, 2022).

16. Why do you keep commenting on speech recognition outcomes AND quality of life? Aren’t they related?

Yes and no. Typically adult CI recipients see about 30% of improvement in their speech recognition scores by 3-6 months post-op (Ma et al, 2023), and children often perform 90% or better on speech tests when implanted early (Spitzer et al, 2024). However, there is some variability in speech outcomes for both populations. Regardless of the post-CI speech score, quality of life improvements are notable for most CI recipients (McRackan et al, 2018b; Cejas et al, 2024; Byckova et al, 2018). 

17. All that you’ve told me suggests that these devices are quite helpful, but isn’t CI utilization fairly low?

Unfortunately, about 90% of the people who need a CI do not have one. Two of the primary reasons for low CI utilization are lack of knowledge of CI candidacy criteria amongst healthcare providers and low referral rates for a CI evaluation (Marinelli et al, 2022; Sorkin 2013; Nassiri et al, 2021; Sorkin & Buchman, 2016). Education platforms like our conversation here, are key to getting better information out there about the significant benefits of cochlear implantation.

18. As you know, I do not work with CI patients very often, so can you give me some tips on how to counsel my patient on the technology?

Sure thing! I can even give you a great resource on how to best counsel on CI - https://adulthearing.com/wp-content/uploads/2020/08/How-to-Counsel-Hearing-Aid-Users-About-Their-Prospective-Candidacy-for-a-Cochlear-Implant.pdf. Basically, let them know there is a surgical option to help them hear and communicate better. Tell them you are going to make a referral to a CI center so they can undergo a special assessment and in-depth counseling to help them make an informed decision about their hearing healthcare. I think most patients appreciate the referral and your willingness as their audiology provider to steer them in a direction for improved hearing.

19. And are there any good resources I can provide my patients to get more information about CI?

Yes, there are lots of great resources out there to help educate our colleagues and our patients about CI. I co-authored an article a few years ago about debunking myths around cochlear implantation which is short and easy to read (Zeitler & Holcomb, 2021). Patients can find lots of good information and videos on the American Cochlear Implant Alliance website (www.acialliance.org). I also typically recommend the Facebook group: Cochlear Implant Experiences, since it has over almost 50,000 members who can help support potential candidates through the CI journey. Lastly, the CI companies have awesome consumer support resources and peer-support systems.

20. To wrap things up, if you lost your hearing tomorrow would you get a CI yourself or would you wait for future developments like gene therapy or hair cell regeneration?

Absolutely, I would choose a CI NOW! In my opinion, CI technology is one of the best inventions of my lifetime. While other therapies are in trial phases now, I do not advise patients. Given what we’ve already discussed today, accessing better hearing now is critical for children and adults to optimize their communication and quality of life.

References

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