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Cochlear Implant Referrals: Your Important Role in Patient Success

March 2019

Regina Presley

In 2018, the World Health Organization (WHO) estimated the prevalence of disabling hearing loss to be 45 million adults and nearly 1 million children in the United States (WHO, 2018). Efficient, streamlined protocols of service are needed to ensure optimized patient care while maintaining the strong partnership with the patients whom we serve. Patients expect their trusted audiology professional to expertly guide them to optimization of their hearing performance using a full continuum of hearing health care options. With ever-changing technology, it is challenging for audiologists and medical professionals to remain current regarding cochlear implant candidacy guidelines, the cochlear implant process, technology, and the tremendous benefits provided by cochlear implantation.

Why Refer For a Cochlear Implant?

Patients commonly ask why a cochlear implant works when a hearing aid does not provide benefit. Traditional amplification provides amplified sound to the cochlea, where fewer functioning hair cells remain. This means that hearing aid technology can only be as good as the system receiving the information. As the degree of hearing loss increases, traditional amplification is unable to provide access for detection and clarity of sound in the speech frequency range, limiting patient performance. When patient report and diagnostic assessment demonstrate decline, it is an appropriate time to consider implantation. A cochlear implant bypasses the damaged cochlea and stimulates the auditory nerve, providing auditory information to the brain and thus improving access to sound, which is necessary for effective development of speech and language and for effective communication.

Early intervention is critical for pediatric and adult cochlear implant recipient success. Regardless of age, better outcomes are associated with shorter durations of the presence of severe hearing loss. Cochlear implantation is widely recommended due to evidence showing its benefits on speech and language skill development in young children (Niparko et al., 2010). Despite the compelling evidence for early cochlear implantation for optimal speech and language development, it is still estimated that only 55% of children in the United States who are candidates for cochlear implantation actually receive an implant (Valencia, Rimell, Friedman, Oblander, & Helmbrecht, 2008). A critical window for language development occurs for young children with significant hearing loss. Children who receive cochlear implants before 12 months of age display better outcomes than their peers who received implants at 12–24 months age (Dettman, Pinder, Briggs, Dowell, & Leigh, 2007). Children who receive early implantation often catch up to their hearing peers by kindergarten.

The importance of early identification of adult candidates is just as crucial to the impact of quality of life and success as it is for pediatric patients. Results of a study by Lin and colleagues (2013) suggest that older adult CI candidates who are younger at implantation and have higher preoperative speech scores display the highest outcomes regarding speech understanding scores following cochlear implantation (Lin et al., 2012). In addition, current literature identifies the strong link between fall risks, dementia, and depression with the presence of significant hearing loss (Lin et al., 2013). It is imperative that adult performance be monitored regularly for decline in hearing aid benefit and speech perception abilities to ensure a timely cochlear implant referral.  

Who Is a Candidate?

Traditional cochlear implantation guidelines exist for pediatric patients with severe-to-profound sensorineural hearing loss and for adults with moderate-to-profound bilateral sensorineural hearing loss. For adult candidates, speech perception scores should be ≤ 50% for the ear to be implanted and ≤ 60% in the opposite ear. Pediatric candidates must show limited benefit from amplification at 12–24 months and must display poor speech perception scores for age-appropriate assessment at 2–17 years of age. Speech perception test batteries include the completion of individual word recognition and sentences in quiet noise. Pediatric test materials are determined on the basis of age, current auditory and language skills, and cognitive status.

With the development of new implant designs and improved surgical techniques, preservation of residual hearing is now possible for patients with a ski-sloped hearing loss. For those patients with poor speech perception skills but better low-frequency hearing, Electric Acoustic Stimulation (EAS) technology is recommended. EAS allows the patient to optimize the use of natural acoustic hearing while benefiting from electrical hearing in the mid- to high-frequency range. Adults are considered an EAS cochlear implant candidate if they present with an aided word score between 10% and 60% and a pure-tone average (PTA) at 2k, 3k, 4k > 75 dB HL in the ear to be implanted, and a word score no better than 80% and a PTA of 2k, 3k, 4k > 60 dB.  

See sample candidacy guideline tool for application in your clinic [PDF].  

How Would a Cochlear Implant Candidate Present?

It is important that we focus on patients’/parents’ anecdotal report of the impact the hearing loss is having on lifestyle, quality of life, and daily function. This is a good precursor to identifying potential CI recipients. Your practice’s choice of patient questionnaires may assist in identifying red flags for possible referral. Below are common concerns you may hear expressed by the patient and/or their family during your case history.  

See additional candidacy consideration tools for your clinic use [PDF]. 

Cochlear Implant Candidacy for Children

  • Patient has little or no benefit with appropriately fitted hearing aids—no changes in vocalization, no demonstration of awareness to sound
  • Patient shows lack of progress in auditory skill development despite appropriate intervention
  • Patient experiences poor or declining academic performance
  • Patient experiences poor or worsening articulation
  • Patient withdraws from social situations (young adults)

 Cochlear Implant Candidacy for Adults

  • Patient reports limited benefit with appropriately fitted hearing aids
  • Patient reports difficulty on the telephone
  • Patient relies on visual cues for successful communication
  • Family and friends report that the patient experiences communication difficulties even with the use of amplification
  • Patient has family make appointments for them
  • Patient reports that noise significantly impacts speech perception

Hybrid Cochlear Implant Candidacy for Adults

  • ​​Patient reports limited benefit with appropriately fitted hearing aids
  • Patient may report similar performance with and without hearing aids use
  • Patient reports that one-on-one conversations are manageable but listening in noise is very difficult
  • Patient notices a decline in hearing aid benefit over time
  • Patient has increased difficulty with telephone use  

The CI team will complete a thorough assessment for all candidates to verify that they meet candidacy criteria, have no existing physical contraindications for placement of the implant, have appropriate medical clearance for surgery, and patient/parent expectations are realistic.  

What Is a Cochlear Implant?

A cochlear implant is a prosthetic device that requires surgical insertion. An electrode array is placed within the cochlea, and the body of the implant is placed underneath the skin behind the ear. The surgery is conducted on an outpatient basis and lasts approximately 90 minutes. The implant is commonly activated 2 weeks following surgery to allow for healing and reduction of any swelling. With consistent use and adaptation to the new electrical signal, a patient will gradually improve their auditory skills. The electrical stimulation provided by the cochlear implant provides improved clarity and speech understanding. Consistent CI use is necessary to optimize hearing performance, but additional improvements can be noted thereafter.

Patient success is impacted by the support network and commitment to follow-up. Aural rehabilitation therapy is recommended for both pediatric and adult patients. Frequency of therapy sessions will be determined by patient need and availability. A new candidate will often return for audiologic cochlear implant management 4–5 times during the first year and annually thereafter.  

What Should New Cochlear Implant Recipients Expect?

No one can guarantee the amount of benefit that a CI recipient can receive; however, several factors influence patient performance. These factors include duration of deafness, auditory memory, age at implantation, status of the inner ear, level of patient commitment, and rehabilitation. Patients can expect sound awareness at the time of activation. Patients will progress through the following hierarchy: detection, discrimination, recognition, and advanced skills (e.g., listening in noise, music, and on the telephone). The CI team will provide candidates with their clinical judgment regarding individual realistic outcomes based on clinical knowledge and patient history. 

Candidates are counseled regarding the cochlear implant technology options that are available to fit their lifestyle. Cochlear implant recipients now have access to the following options: ear-level or head-worn–style processors with t-coils, wearing options for patients who are small in stature and/or active, rechargeable and disposable batteries, waterproof systems, and wireless streaming technology for both Apple and Android products. Patients are provided with a 10-year warranty on their internal device and a 5-year warranty on their external processor. Internal devices are made backwards compatible so that patients can access advanced technology through either software or external hardware upgrades in the coming years.  

How Do We Collaborate?

When you refer a patient for a cochlear implant candidacy evaluation, you remain an active provider in your patient’s care. You are instrumental in developing a collaborative partnership with a cochlear implant center and in providing ongoing service. In addition to the technology mentioned above, cochlear implant manufacturers have recognized the importance of bimodal listening and the value of compatibility between cochlear implant processors, hearing aids, and accessories. Referring audiologists should be familiar with compatible technology and confident in fitting the appropriate device to the nonimplanted ear. Patients will be grateful to take advantage of bimodal benefits such as improved richness and quality of sound, localization, and bilateral streaming capabilities.

Are you curious to know how many patients within your practice could benefit from cochlear implant technology? An easy way to evaluate your current caseload is through the assistance of a Noah search ( Noah is a software system owned and designed by the Hearing Instrument Manufacturers’ Software Association [HIMSA]). Within Noah, enter a minimum and maximum range of air conduction thresholds according to traditional or hybrid candidacy guidelines. The system will identify patients within your practice who may possibly benefit from cochlear implant technology.

You may be surprised by the number of individuals under your care who may benefit from cochlear implant technology. The next step to providing a full continuum of care for your patients is to communicate with cochlear implant facilities in your area and develop an effective, efficient collaboration and referral process. Your patients will be forever grateful for your expertise. It is wonderful to know that when amplification is not enough, cochlear implants are a viable option for improved hearing health. With this technology, we can all be an integral part of improving the quality of life for many.  

About The Author

Regina Presley, AuD, CCC-A, FAAA, currently serves as the Senior Cochlear Implant Audiologist at the Presbyterian Board of Governors Cochlear Implant Center of Excellence at Greater Baltimore Medical Center. She has served as an audiologist within a pediatric hospital and private ENT practice prior to beginning her work in the field of cochlear implantation 19 years ago. In addition to clinical responsibilities, she is responsible for consumer and professional outreach to ensure patients and colleagues remain current on the latest cochlear implant candidacy and technology. Her research has been geared toward quality of life, effectiveness of new technology, and development of a new clinical model. In addition to national organizations, Dr. Presley is involved with The Audiology Project and Alstrom Syndrome International. She can be reached at       


Dettman, S. J., Pinder, D., Briggs, R. J., Dowell, R. C., & Leigh, J. R. (2007). Communication development in children who receive the cochlear implant younger than 12 months. Ear and Hearing, 28 (Suppl), 11S–18S. Retrieved from

Lin, F. R., Chien, W. W., Li, L., Clarrett, D. M., Niparko, J. K., & Francis, H, W. (2012). Cochlear implantation in older adults. Medicine (Baltimore), 91, 229–241. Retrieved from

Lin, F. R., Yaffe, K., Xia, J., Xue, Q., Harris, T. B., Purchase-Helzner, E., ...Simonsick, E. M. (2013). Hearing loss and cognitive decline among older adults. Journal of the American Medical Association Internal Medicine, 173, 293–299. Retrieved from

Niparko, J. K., Tobey, E. A., Thal, D. J., Eisenberg, L. S., Wang, N. Y., Quittner, A. L., & Fink, N. E. (2010). Spoken language development in children following cochlear implantation. Journal of the American Medical Association, 303, 1498–1506. Retrieved from

Valencia, D. M., Rimell, F. L., Friedman, B. J., Oblander, M. R., & Helmbrecht, J. (2008). Cochlear implantation in infants less than 12 months of age. International Journal of Pediatric Otorhinolaryngology, 72, 767–773. Retrieved from

World Health Organization. (2018). WHO global estimates on prevalence of hearing loss. Geneva, Switzerland: Author. Retrieved from [PPT].

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