A cochlear implant (CI) is a surgically implanted, electronic prosthetic device that provides electric stimulation directly to auditory nerve fibers in the cochlea. It effectively bypasses damaged inner ear hair cells to deliver a signal to the brain, which is then interpreted as sound. A CI consists of two components: an internal (implanted) device and an external sound processor. The sound processor (external) receives sound from a microphone, processes the digital sound signal, and transmits it to the CI (internal) electrodes in the cochlea. The signal is then received by the auditory nerve and transmitted to the brain as an electrical signal. As of December 2012, it was estimated that, in the United States, approximately 38,000 devices have been implanted in children and 58,000 devices have been implanted in adults, with an estimated 324,200 devices implanted worldwide (National Institute on Deafness and Other Communication Disorders, 2016).
In addition to the patient and the patient's family, an interprofessional CI team may include an audiologist, an otolaryngologist/otologist (implant surgeon), a speech-language pathologist (SLP), a pediatrician/primary care physician, a mental health professional, a developmental specialist, an occupational therapist, an educator, a vocational counselor, a social worker, a geneticist, and/or a neurologist. Interprofessional teams integrate different professional perspectives and backgrounds to provide high-quality comprehensive care. Depending on the specific situation, a patient may see a combination of service providers, both internal and external to a CI center. For example, a patient may see one audiologist/SLP at the CI center and another audiologist/SLP at school or one audiologist for hearing aid care and a different audiologist for CI care. Collaborative, interprofessional teams work together on a continuous basis and engage in group decision making regarding assessment, treatment, progress monitoring, and treatment outcomes. The team agrees on a follow-up plan, which includes ongoing communication and information sharing. See the American Speech-Language-Hearing Association (ASHA) resource on interprofessional education/interprofessional practice (IPE/IPP) for more information on team collaboration.
Audiologists play a primary role in a collaborative, interprofessional team in the assessment and (re)habilitation of persons with cochlear implants (CIs). Professional roles and activities in audiology include clinical and educational services (diagnosis, assessment, planning, and treatment), prevention and advocacy, administration, and research. See the American Speech-Language-Hearing Association's (ASHA) Scope of Practice in Audiology (ASHA, 2018).
Appropriate roles and responsibilities for audiologists include, but are not limited to, the following:
As indicated in ASHA's Code of Ethics (ASHA, 2016a), audiologists who serve this population should be specifically educated and appropriately trained to do so. Roles may vary depending on patient factors and specifics of the CI team.
Speech-language pathologists (SLPs) play a central role in a collaborative, interprofessional team in the assessment and (re)habilitation of persons with CIs. Professional roles and activities in speech-language pathology include clinical and educational services (diagnosis, assessment, planning, and treatment), prevention and advocacy, administration, and research. See ASHA's Scope of Practice in Speech-Language Pathology (ASHA, 2016b).
Appropriate roles and responsibilities for SLPs include, but are not limited to, the following:
As indicated in ASHA's Code of Ethics (ASHA, 2016a), SLPs who serve this population should be specifically educated and appropriately trained to do so. Roles may vary depending on patient factors and specifics of the CI team.
A comprehensive assessment for cochlear implantation includes several components. Candidacy determination, description of outcome expectations, device selection, ongoing counseling, and consideration of insurance coverage or other funding sources are all part of the assessment process. The collaborative CI team develops a coordinated assessment plan for cochlear implantation that requires input from the patient and/or their family as well as from several professionals. Input from each team member and results from various assessments contribute to candidacy determination and outcome expectations. The team will provide an explanation of assessment results and realistic expectations to the patient and/or their family to assist in informed decision making regarding cochlear implantation.
See ASHA's resource on interprofessional education/interprofessional practice (IPE/IPP) and the ASHA Practice Portal page on Counseling For Professional Service Delivery.
Determining CI candidacy is a complex and variable process. Beyond the assessment of auditory function, consideration is given to medical status, potential communication benefit, and the presence of support systems and services. Patient and/or family expectations for cochlear implantation are discussed, and counseling is provided based upon these expectations. The result of this process is the determination of an individual's candidacy for cochlear implantation.
Candidacy criteria for cochlear implantation have evolved over time. Early identification of hearing loss, through universal newborn hearing screening in the United States, is a factor contributing to children now being implanted by 12 months of age (see the ASHA Practice Portal page on Newborn Hearing Screening). In adults, age is not a contraindication, and cochlear implantation in older adults has been shown to have positive outcomes (Carlson et al., 2010; Dillon et al., 2013; Hilly et al., 2016; Knopke et al., 2016; Lin et al., 2012; Mosnier et al., 2015; Noble et al., 2009; Olze et al., 2012, 2016; Zwolan et al., 2014). CI candidates may include children and adults with prelingual deafness, children and adults who are no longer benefitting from hearing aids, or children and adults who suddenly lose their hearing in one or both ears. Worldwide, potential pediatric candidates receive CIs at a higher rate as compared to potential adult candidates (Sorkin, 2013; Sorkin & Buchman, 2015).
The FDA approves CIs for use and makes recommendations regarding age and degree of hearing loss. It is not uncommon for patients to undergo “off-label” CI surgery (Carlson et al., 2018), which refers to the use of CIs for indications outside of the current FDA-approved candidacy criteria. “Off-label” CI surgery occurs when professional experience and increasing knowledge lead to evolving common practices and expanded indications that are not reflected or included in FDA labeling. Clinical trials may also lead to expanded indications.
See U.S. Food & Drug Administration: Cochlear Implants and Centers for Medicare & Medicaid Services: Cochlear Implantation for additional information.
Information contributing to candidacy determination for a CI is collected in a patient-centered manner and from a variety of sources and professionals.
A comprehensive case history for a cochlear implantation candidate may include the following:
For more information regarding gathering a case history, see the ASHA Practice Portal page on Cultural Competence.
An otologist may provide information on
A primary care physician may provide information on
The audiologic assessment may vary depending on the individual patient's age and language/cognitive abilities. Ideally, a comprehensive audiologic assessment is performed. Refer to the Assessment sections of the Permanent Childhood Hearing Loss, Hearing Loss - Beyond Early Childhood, and Hearing Aids For Adults ASHA Practice Portal pages for more information on comprehensive audiologic assessment.
An audiologist may provide information on the following:
An SLP may provide information on the following:
A psychologist may provide information on
An educator and/or a social worker may provide information on
The patient and/or their family may provide information on
Comprehensive assessment results as well as patient and/or family input are compiled and considered by the CI team when determining whether a patient is a candidate for cochlear implantation. If a joint decision is made to proceed with cochlear implantation, then the CI team will initiate discussions with the patient and/or their family related to CI selection, surgery, follow-up, programming, and (re)habilitation. If, for any reason, the decision is to not proceed with cochlear implantation, then discussions will occur as to other aural (re)habilitation options that can be explored to optimize patient communication and participation.
Selection of a CI involves consideration of medical and audiologic factors, center offerings, patient and/or family input, and comparison of the available device components and features.
Patients and/or their families can choose from different processor styles, depending on the particular device manufacturer. Whichever CI manufacturer's device is selected, the implant recipient will be able to use only that manufacturer's external equipment. Advancement in CI technology has resulted in signal processing that adapts to various listening environments and accessories that provide improved sound quality and hearing in noise. Examples include directional microphones, advanced signal processing to reduce the effects of background noise, frequency modulation/digital modulation (FM/DM) system compatibility, telecoils that may enable clearer telephone communication and connectivity to loop systems in public venues, connectivity to Bluetooth and streaming devices, enhanced music quality, and water-resistant components that allow for processor use in water environments with a protective cover.
The CI team considers each individual's specific needs, and all CI care is patient- and family-centered. It is crucial that the CI team work interprofessionally to determine the best treatment options for the individual. In addition, the team will educate and counsel a recipient and/or their family about device options, surgical implantation procedures, postsurgical care, audiologic management of the device(s), future processor upgrade, aural (re)habilitation, outcome expectations, and family involvement in the treatment process.
See ASHA's resource on interprofessional education/interprofessional practice (IPE/IPP).
Prior to surgery, the surgeon will discuss the procedure as well as possible risks and complications with the patient and/or their family (e.g., the possibility of reimplantation at a future date). The surgical procedure involves securely inserting an electrode array into the scala tympani while attempting to avoid trauma to the inner ear anatomy and damage to the device. During the surgery, a radiologist may perform intraoperative radiographic imaging, and an audiologist may conduct electrophysiologic testing.
Intraoperative radiographic imaging is considered the gold standard for monitoring correct electrode placement during CI surgery. It may include plain film X-ray, three-dimensional rotational tomography X-ray, computed tomography scanning, and/or fluoroscopy. Intraoperative fluoroscopy may be used when implanting an abnormally shaped cochlea to confirm proper electrode placement.
The purpose of electrophysiologic measures is to verify whether the device is working properly and whether electrodes are placed properly. The measures also determine the ear's responsiveness to electric stimulation and may assess cochlear trauma and residual hearing during electrode insertion. During such testing, the seventh nerve, the eighth nerve, and/or the stapedial reflex may be activated electrically through the implanted electrodes, and the response is seen via physical or telemetric observation. Tests done during surgery may include, but may not be limited to, electrode impedance (EI), evoked compound action potential (ECAP), spread of excitation (SoE), and electrically evoked stapedial reflex thresholds (ESRTs).
As surgical techniques improve, intraoperative monitoring will likely be more useful in minimizing cochlear trauma and preserving residual hearing. Universal clinical practice guidelines are not available for intraoperative monitoring. A protocol may be established by each clinic/surgeon.
There are various approaches to cochlear implantation treatment. CIs can be used alone or in combination with other devices. Individualized treatment requires consideration of possible benefits and drawbacks of each approach based on the specifics of each patient.
Variations of cochlear implantation and implant use include the following:
Bilateral cochlear implantation may result in better sound localization, enhanced understanding of speech in quiet and noisy environments, more natural sounding speech, more patient-perceived functional benefit and satisfaction, and improved language development (Brown & Balkany, 2007; Buss et al., 2008; Lammers et al., 2014; Laske et al., 2009; Litovsky et al., 2006; Sammeth et al., 2011). The decisions regarding bilateral implantation are based on (a) evaluation of each ear separately as well as simultaneously, (b) determination that each ear meets criteria for implantation, (c) potential benefits, and (d) insurance coverage for a second implant.
The bimodal hearing option may provide advantages (as opposed to unilateral CI only) in the perception and localization of sound as well as in speech understanding in quiet and noise (Berrettini et al., 2010; Ching et al., 2006; Luntz et al., 2005).
A systematic review of research on electric and acoustic stimulation demonstrated consistently higher speech perception scores as compared with electric stimulation alone (Dillon et al., 2015; Gantz et al., 2016; Incerti et al., 2013; Park et al., 2019), demonstrating the potential significance of preserving and using low frequency hearing in the implanted ear when appropriate.
Because the first several years of life are a critical period for speech and language development, cochlear implantation is recommended at an early age, if applicable and possible. Age at implantation along with residual hearing status have been shown to be associated with the speed of spoken language skill development in children (Niparko et al., 2010). Studies have shown that longer inter-implant intervals for bilateral implantation result in discrepancy in central processing and, subsequently, have negative effects on receptive and expressive language development (López-Torrijo et al., 2015). Due to the neuroplasticity and the critical periods of auditory, speech, and language development in young children, it may be more beneficial to perform simultaneous or short-interval sequential implantation in this population (López-Torrijo et al., 2015).
Detailed postsurgical and follow-up instructions are given to the patient and/or their family, including keeping the area clean and safeguarding against infection. Postoperative audiologic evaluation and follow-up may include, but not be limited to, further patient and/or family counseling and education, inspecting and troubleshooting the device, and evaluating residual hearing.
The audiologist will schedule several individualized programming sessions with the patient and their family across a time span of several months. The sound processor will be placed and activated. During the programming, the audiologist will determine thresholds (depending on the device) and upper comfort levels on the electrodes. Sound coding strategy and parameters such as optimal electrode selection and grounding, rate of stimulation, and pre- and post-sound processing features are considered.
Generally, programming a CI may be divided into four phases: (1) preprogramming, (2) intraoperative testing, (3) initial stimulation, and (4) follow-up.
When behavioral feedback is limited, the audiologist may use objective measures as programming guidance. The most common objective measures are similar to those obtained during surgery—EI, ECAP, and ESRT (detailed in the Surgery section).
During the initial programming session, the audiologist is looking to confirm that the CI is working properly and to validate surgical procedure results. As in surgery, EI is used to measure the integrity of the electrodes in the device. Electrodes functioning with abnormal EI may result in poor sound quality, pitch confusion, and overall reduced performance of the CI. ECAP responses determine the collective response of the auditory nerve to device stimulation. ESRT values are often correlated with loudness comfort levels obtained behaviorally (Kosaner et al., 2009; Lorens et al., 2004; Polak et al., 2006). ESRTs are more challenging to obtain than ECAPs. As in populations with normal hearing, reliable measurement of an electrically evoked stapedial reflex requires a healthy middle ear. The patient must sit still and silent to maintain an acoustic seal for the measurement probe and to prevent artifacts from movement and/or vocalization from obscuring the reflex response.
The audiologist may work collaboratively with the professional providing aural (re)habilitation during follow-up sessions to consider auditory and functional listening skills when determining optimal programming.
Education regarding long-term use, care, and maintenance of a CI prepares the patient and/or their family to do the following:
The process of aural habilitation is designed to help a person with hearing loss attain listening and communication skills that they have yet to acquire (i.e., in the case of prelingual hearing loss). The goal of aural rehabilitation is to help a person with hearing loss maintain, reestablish, or improve listening skills and communication function while preventing or minimizing limitations on a person's well-being and communication due to auditory dysfunction (i.e., in the case of postlingual hearing loss). Both aural habilitation and aural rehabilitation are interactive processes, which are individualized as well as patient- and family-centered. Interpersonal, psychosocial, educational, and vocational functioning may be considered. See the ASHA Practice Portal page on Aural Rehabilitation for Adults for more information.
After cochlear implantation, the patient will receive aural (re)habilitation services by an audiologist and/or an SLP to build auditory skills to learn how to listen to, discriminate between, and understand the range of sounds (e.g., environmental sounds, spoken language, music) conveyed via the device. The treatment plan is individualized to each patient based on age, developmental norms, hearing history, and specific needs. For example, a focus of treatment for very young children is the development of overall speech, language, listening, and communication skills. In contrast, the treatment plan for school-age children may address functional listening skills, academics, independence, and self-advocacy. A treatment plan for adults may take into consideration functional listening skills and communication strategies in social and work situations as well as individual lifestyle needs. The communication mode(s) preferred by the patient and/or their family will influence the specific goals and activities in the aural (re)habilitation plan of care.
It is often difficult to predict a patient's level of success after cochlear implantation. Significant differences may exist across CI recipients in the rate of progress and in ultimate outcomes. Even in instances of successful surgery and properly functioning device(s), limited outcomes may still occur. Several factors may impact the user's benefit from the implant and the user's development of listening and spoken language skills (Cosetti & Waltzman, 2012; Geers et al., 2011; Moberly et al., 2016). In pediatric cases, early implantation is one factor that has been associated with successful outcomes (Sharma & Campbell, 2011). School placement decisions may significantly impact outcomes due to the number of hours per school day that a child spends focused on a given modality. In adult cases, duration of deafness has been associated with predicting outcomes (Beyea et al., 2016; Blamey et al., 2013; Green et al., 2007; Holden et al., 2013; Leung et al., 2005). Compliance factors—such as consistency of device use, appropriate follow-up, and (re)habilitation services—are also important and can be addressed with appropriate counseling.
The patient's family receives guidance on the use of effective communication strategies, realistic expectations, and outcome considerations. Successful and continuous family involvement is a critical part of the aural (re)habilitation process.
CI recipients may employ one or more of the following communication modes, depending upon their individual goals and preferences:
The selection of a communication approach is not a one-time decision but, rather, a dynamic process that allows for changes over time. The CI team will review the long-term goals of the patient and/or their family to determine how certain communication modes align with those goals.
An individualized aural (re)habilitation plan may include, but not be limited to, the following components:
Hearing assistive technology systems (HATS) improve speech understanding in difficult listening situations by increasing the signal-to-noise ratio. HATS may be used in conjunction with a CI. Adverse conditions affecting communication may include distance between speaker and listener, competing noise, room acoustics, and room lighting. Several types of HATS may be used with CIs to improve listening experiences and outcomes. Devices may include FM or DM systems, wireless accessories, infrared systems, Bluetooth adaptors, amplified and captioned telephones, audio loops, and amplified and/or visual alarms (baby monitor, clock alarm, doorbell, smoke detector). See ASHA's resource on hearing assistive technology for more information.
The World Health Organization (2001) published the International Classification of Functioning, Disability and Health as a classification of health and disability based upon functional status. This classification system can be used to assist clinicians in patient care management, both in establishing goals and in determining specific outcomes that can be measured through patient report. See the ASHA resource on International Classification of Functioning, Disability, and Health (ICF) for more information.
In addition to determining the optimal treatment options for each individual receiving a CI, the audiologist, the SLP, and other team members also consider service delivery variables. Examples of variables that may affect treatment outcomes include format, provider, dosage, timing of implantation, and setting.
The population of individuals with CIs reflects a wide array of differences and similarities across cultural variables. “Culture and cultural diversity can incorporate a variety of factors, including but not limited to age, disability, ethnicity, gender identity (encompasses gender expression), national origin (encompasses related aspects e.g., ancestry, culture, language, dialect, citizenship, and immigration status), race, religion, sex, sexual orientation, and veteran status. Linguistic diversity can accompany cultural diversity” (ASHA, 2017).
Alignment with one's culture(s) and the level of acculturation into other cultures may significantly influence acceptance, compliance, and decision making regarding treatment. See the ASHA Practice Portal page on Cultural Competence for more information.
Health insurance coverage for CI services has expanded in recent years. Many state Medicaid programs offer some coverage, and supplemental funds may be available through combined federal/state programs. Due to the acceptance of CIs as a standard of care, Medicare, the Veterans Health Administration, and many private insurance payers cover all or part of the CI surgery and postsurgical services. Insurance coverage can vary in regard to factors such as bilateral versus unilateral cochlear implantation, simultaneous or sequential bilateral implant surgeries, and clinical investigations approved by private payers.
For more information regarding CI coverage, visit ASHA's billing and reimbursement resource, U.S. Food & Drug Administration: Cochlear Implants, and Centers for Medicare & Medicaid Services: Cochlear Implantation.
This list of resources is not exhaustive, and the inclusion of any specific resource does not imply endorsement from ASHA.
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World Health Organization. (2001). International Classification of Functioning, Disability and Health.
Zwolan, T. A., Henion, K., Segel, P., & Runge, C. (2014). The role of age on cochlear implant performance, use, and health utility: A multicenter clinical trial. Otology & Neurotology, 35(9), 1560–1568.
Content for ASHA's Practice Portal is developed through a comprehensive process that includes multiple rounds of subject matter expert input and review. ASHA extends its gratitude to the following subject matter experts who were involved in the development of the Cochlear Implants page.
In addition, ASHA thanks the members of the Working Group on Cochlear Implants whose work on the Technical Report was foundational to the development of this content. Members of the Working Group were Carolyn J. Brown (co-chair), Ann Geers, Barbara Herrmann, Karen Iler Kirk (co-chair), and J. Bruce Tomblin. Susan Waltzman, Renee Levinson, and Gail Linn served as the National Office liaisons and members of the group. Susan Brannen, ASHA vice president for professional practices in audiology (2001-2003), provided guidance and support.
The recommended citation for the Practice Portal page is:
American Speech-Language-Hearing Association (n.d.). Cochlear Implants (Practice Portal). Retrieved month, day, year, from www.asha.org/Practice-Portal/Professional-Issues/Cochlear-Implants/.