Roles and Responsibilities

Roles and Responsibilities of Audiologists

Audiologists play a primary role within a collaborative, interprofessional cochlear implant (CI) team throughout the assessment and (re)habilitation process. Professional roles and activities in audiology include clinical services (diagnosis, assessment, planning, and treatment); prevention and advocacy; and education, administration, and research. See ASHA’s Scope of Practice in Audiology (ASHA, 2018).

The following roles and responsibilities are appropriate for audiologists:

Education and Advocacy

• Maintain knowledge of the anatomy, physiology, and pathophysiology of the auditory system and the effects that cochlear and neural anomalies may have on outcomes with a CI.
• Maintain knowledge of cochlear malformations and cochlear ossification and the effect that they will have on CI programming parameters and outcomes.
• Remain current on information related to CI technology, hearing aid technology, hearing assistive technology systems (HATS), and other applicable technologies.
• Maintain knowledge of the effects of hearing loss on communication function and development.
• Remain current on research related to programming, testing, and outcomes for CI recipients.
• Remain informed of the availability of products, advances in implant technology, approval of new devices, implant reliability, and implant recalls.
• Instruct the patient and/or their caregivers/care partners about the proper care and use of the sound processor and its accessories and offer appropriate hands-on practice.
• Counsel the patient and/or their caregivers/care partners regarding communication-related issues and rights to services.
• Counsel the patient and/or their caregivers/care partners about expectations of device activation and prepare the patient for a period of acclimation to the electrical signal.
• Educate other professionals about CIs, assistive devices, CI recipients, and the role of audiologists on a CI team.
• Advocate for individuals with CIs and/or their families at the local, state, and national levels.

Screening and Assessment

• Coordinate and conduct a comprehensive assessment of hearing, auditory function, and vestibular function.
• Determine an individual’s CI candidacy in collaboration with a CI team.
• Gather formal and informal information on functional listening skills (e.g., in natural listening environments), social participation, and other individualized factors that may influence candidacy decisions with the use of tools such as questionnaires, self-assessments, observations, and/or teacher interviews.

Intervention and Support

• Serve as a member and/or coordinator of an interprofessional CI team.
• Refer to other professionals to facilitate access to comprehensive services.
• Develop a comprehensive plan of care with input from the patient, the caregivers/care partners, and related professionals.
• Consult with the surgeon regarding audiometric qualifications that may affect the choice of electrode array.
• Provide intraoperative monitoring/electrophysiological testing during cochlear implantation.
• Use contemporary behavioral and/or objective measures to set stimulation levels and device parameters.
• Coordinate with other professionals to develop an appropriate and comprehensive aural (re)habilitation plan.
• Provide direct (re)habilitation services, as appropriate to the scope of practice and in coordination with other professionals involved in the (re)habilitation process.
• Inspect the surgical site and alert the patient and/or their caregivers/care partners and the surgeon of the potential need for medical intervention.
• Monitor device use (i.e., check data logging) to support optimal outcomes.
• Inspect and troubleshoot external equipment for proper function and provide guidance when replacement is necessary.
• Validate the use of hearing technology in a variety of communicative settings through interprofessional communication.
• Consult with the device manufacturer if failure of the internal device is suspected or if standard programming results in poor outcomes.
• Assess speech recognition and auditory detection with the CI using measures appropriate for the individual patient.
• Develop and use ongoing progress data and functional outcome measures.
• Manage hearing aid(s), HATS, and other applicable technologies.

As indicated in ASHA’s Code of Ethics (ASHA, 2023), 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.

Roles and Responsibilities of Speech-Language Pathologists

Speech-language pathologists (SLPs) play a central role within a collaborative, interprofessional CI team throughout the assessment and (re)habilitation process. Professional roles and activities in speech-language pathology include clinical services (diagnosis, assessment, planning, and treatment); prevention and advocacy; and education, administration, and research. See ASHA’s Scope of Practice in Speech-Language Pathology (ASHA, 2016).

The following roles and responsibilities are appropriate for SLPs:

Education and Advocacy

• Maintain general knowledge of the anatomy, physiology, and pathophysiology of the auditory system.
• Maintain knowledge of the effects of hearing loss on communication function and development.
• Maintain general knowledge of various CI technologies across brands, including components, accessories, and HATS.
• Remain informed of research regarding cochlear implantation.
• Educate other professionals about CIs, assistive devices, CI recipients, and the role of SLPs on a CI team.
• Advocate for individuals with CIs and/or their families at the local, state, and national levels.
• Counsel the patient and/or their caregivers/care partners on modes of communication and expectations related to communication development, communication maintenance, and/or communication enhancement following cochlear implantation.

Screening and Assessment

• Coordinate and conduct a comprehensive evaluation of speech, language, listening, and communication skills.
• Establish a baseline for the patient’s speech and language skills prior to intervention or cochlear implantation.
• Gather formal and informal information on functional listening behaviors (e.g., in natural listening environments), social participation, and other individualized factors that may influence candidacy decisions with the use of tools such as questionnaires, self-assessments, observations, and/or teacher interviews.
• Participate in discussions of candidacy determination and outcome expectations for cochlear implantation as part of the CI team.
• Assess the patient’s speech, language, listening, and communication skills on an ongoing basis and in a variety of settings after cochlear implantation.

Intervention and Support

• Serve as a member of an interprofessional CI team.
• Refer to other professionals to facilitate access to comprehensive services.
• Coordinate with other professionals to develop an appropriate and comprehensive aural (re)habilitation plan.
• Provide direct (re)habilitation services, as appropriate to the scope of practice and in coordination with other professionals involved in the (re)habilitation process.
• Develop and use ongoing progress data and functional outcome measures.
• Share information with the CI team if a patient is not making progress using or adjusting to the device so potential causes may be investigated.

As indicated in ASHA’s Code of Ethics (ASHA, 2023), 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.

Assessment

A comprehensive assessment for cochlear implantation includes several components. Candidacy determination, counseling, and device selection are all part of the assessment process. The interprofessional CI team develops a coordinated assessment plan for cochlear implantation that requires input from the patient and/or their caregivers/care partners as well as from various professionals. Input from each team member and results from related assessments contribute to candidacy determination. The team provides an explanation of assessment results and individualized expectations of cochlear implantation to the patient and/or their caregivers/care partners to assist with informed decision making.

See ASHA’s resource on interprofessional education/interprofessional practice (IPE/IPP) and the ASHA Practice Portal pages on Counseling in Audiology and Speech-Language Pathology and Language and Communication of Deaf and Hard of Hearing Children for more information.

Candidacy

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 support systems and services. Patient and/or caregiver/care partner 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.

See the ASHA Practice Portal page on Cultural Responsiveness for information on including and responding to cultural variables and dimensions of diversity that a person brings to the table, including their impact on choices and preferences regarding the assessment process and treatment options. Cultural diversity can incorporate factors such as age, disability, ethnicity, gender identity, national origin, race, religion, sex, sexual orientation, and veteran status. Linguistic diversity is another factor to consider (ASHA, 2017).

Candidacy criteria for cochlear implantation have evolved over time (Warner-Czyz et al., 2022; Zeitler et al., 2024; Zombek & Wolfe, 2023; Zwolan & Basura, 2021). Early identification of hearing loss, through universal newborn hearing screening in the United States, contributes to children now being implanted as young as 9 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 receive little to no benefit from hearing aids, or children and adults who suddenly lose their hearing in one or both ears. In the United States, potential pediatric candidates receive CIs at a higher rate than potential adult candidates (Nassiri et al., 2023a, 2023b).

There are established guidelines for both adults and children that specify the materials and conditions necessary to assess eligibility for CIs (Dunn et al., 2024; Park et al., 2022; Warner-Czyz et al., 2022).

The U.S. Food and Drug Administration (FDA) approves CIs for use based on safety and effectiveness. Approvals are device specific, and devices are approved for specific ages. 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. This occurs when professional experience and increasing knowledge lead to evolving practices and expanded indications that are not reflected or included in FDA labeling. Clinical trials may also lead to expanded FDA 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 cochlear implantation is collected in a patient-centered manner and from a variety of sources and professionals.

Case History

A comprehensive case history for a cochlear implantation candidate may include the following items:

• age of patient
• onset and duration of deafness, whether prelingual or postlingual
• medical history
• prenatal and birth history
• results of any genetic testing
• current medications and medication history (including prescription, over-the-counter, alternative, and herbal)
• hearing health history (including previous amplification)
• current communication status (i.e., preferred communication mode) and specific communication needs
• current technology used (e.g., hearing aid[s], HATS)
• psychological history
• cognitive status
• family history of hearing loss
• information and results from other professionals
• radiologic results (e.g., computed tomography scanning, magnetic resonance imaging)
• current educational and/or vocational status
• current frustrations and listening difficulties in specific communication situations (e.g., in the presence of background noise, in rooms with poor acoustics, in group settings, in poorly lit settings, when watching television)
• patient and/or caregiver/care partner responses to questionnaires and/or self-assessment tools regarding quality of life and communication
• patient and/or caregiver/care partner goals and expectations for cochlear implantation
• extent of support system and services

For more information regarding gathering a case history, see the ASHA Practice Portal page on Cultural Responsiveness.

Otology

An otologist/neurotologist may provide information on

• radiologic imaging of the inner ear and related structures;
• the impact of case complexities (e.g., malformed cochlea);
• the potential for hearing preservation;
• the interpretation of neurological and vestibular screening and/or assessment;
• patient-specific factors that influence device and/or electrode array selection; and
• device and implantation recommendations (e.g., unilateral, bilateral, bimodal, combined electric and acoustic stimulation).

Medical/Primary Care

A primary care physician may provide information on

• general health status;
• vaccination status (e.g., meningitis);
• genetic or other health issues and/or conditions; and
• stability for surgery.

Audiology

The audiologic assessment may vary depending on the individual patient’s age and their language and cognitive abilities. Ideally, a comprehensive audiologic assessment is performed. Refer to the Assessment sections of the ASHA Practice Portal pages on Hearing Loss in Children and Hearing Loss in Adults for more information on comprehensive audiologic assessment.

An audiologist may provide information on the following factors:

• the candidate’s preoperative hearing and communicative status, including residual hearing and presence of tinnitus
• the precision of current hearing aid fit for the most optimal access to sound and/or recommendations for adjustments to current hearing device(s)
• results of a hearing aid trial and patient routines with hearing aid use
• patient and/or caregiver/care partner responses to scales or questionnaires regarding the patient’s auditory skill level
• patient and/or family responses to questionnaires and/or self-assessment tools regarding quality of life and communication
• skills related to speech recognition, auditory detection, and functional listening, as appropriate for the patient’s age, development, and cognitive and language skills
• results from vestibular testing or screening
• expectations related to cochlear implantation
• the impact of case complexities (e.g., tinnitus)
• unilateral, bilateral, bimodal, or combined electric and acoustic stimulation device recommendation
• various CI options according to candidacy findings (including counseling on the internal device, external processor options, and opportunities to learn more from manufacturers and/or other CI listeners)
• the timeline for surgery, programming of the processor, and aural (re)habilitation
• treatment options, including aural (re)habilitation

Speech-Language Pathology

An SLP may provide information on the following factors:

• speech, language, and communication skills
• auditory skills (e.g., detection, discrimination, identification) and functional listening skills (i.e., the ability to understand environmental sounds and speakers’ messages across settings and situations)
• literacy skills
• play skills in children
• metacognitive and executive functioning behaviors, such as planning, attention, and self-regulation
• diagnosed speech-language disorders
• preferred communication methods and strategies
• patient and/or caregiver/care partner responses to questionnaires and/or self-assessment tools regarding quality of life and communication
• educational, occupational, and/or vocational placements
• prognosis for the development or advancement of speech, language, and communication, including auditory, functional listening, and literacy skills
• treatment options and aural (re)habilitation (including information about timelines and follow-up assessments)
• availability of community resources (e.g., support groups)

Psychology

A psychologist may provide information on

• cognitive assessment;
• behavioral and emotional concerns;
• psychological history and conditions;
• family structure and support;
• patient and/or caregiver/care partner expectations; and
• other psychological or developmental factors that may impact success with cochlear implantation.

Educational Support

An educator may provide information on

• support services available pre- and post-implantation,
• educational and vocational placement and progress, and
• available resources.

Social Support

A social worker may provide information on

• behavioral and emotional concerns;
• family structure and support;
• patient and/or caregiver/care partner expectations;
• support services available pre- and post-implantation; and
• community, educational, and vocational resources.

Patient and Family

The patient and/or their family/caregivers/care partners may provide information on

• concerns about the patient’s listening, communication, and/or academic, vocational, and/or functional skills;
• the impact of the patient’s communication difficulties on frequent communication partners;
• long-term goals and desired outcomes of the patient and family/caregiver/care partner;
• motivation and commitment to follow-up and treatment;
• family structure and support;
• preferred communication mode; and
• any questions or concerns regarding recommendations.

Candidacy Determination

Comprehensive assessment results as well as patient and caregiver/care partner 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 caregivers/care partners 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.

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.

Selection

Selection of a CI involves consideration of medical and audiologic factors, center offerings, patient and/or caregiver/care partner input, and comparison of the available device components and features.

Patients and/or their caregivers/care partners can choose from different processor styles, depending on the device manufacturer. The manufacturer of the device selected will also be used for the external equipment. Device selection may include consideration of features that provide improved sound quality and hearing in noise. Examples of such features include

• directional microphones;
• advanced signal processing to reduce the effects of background noise;
• frequency modulation/digital modulation/remote microphone (FM/DM/RM) 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.

Treatment

All CI care is patient- and family-centered. The CI team works interprofessionally to determine the best treatment options for the patient. In addition, the team will educate and counsel a recipient and/or their caregivers/care partners about device options, surgical implantation procedures, postsurgical care, audiologic management of the device(s), future processor upgrade, aural (re)habilitation, outcome expectations, and caregiver/care partner involvement in the treatment process.

See ASHA’s resource on interprofessional education/interprofessional practice (IPE/IPP).

Surgery

Prior to surgery, the surgeon will discuss the procedure as well as possible risks and complications with the patient and/or their family/caregivers/care partners (e.g., the possibility of reimplantation at a future date).

The surgical procedure involves inserting an electrode array into the scala tympani (part of the cochlea) 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.

Electrophysiologic measures are used to verify whether the device is working properly. The measures determine the auditory nerve’s responsiveness to electric stimulation and may be used to assess cochlear trauma in an effort to preserve 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, with the response visible via physical observation or telemetric recording. Tests done during surgery may include, but may not be limited to, electrode impedance, electrically evoked compound action potentials (ECAPs), spread of excitation (SoE), and electrically evoked stapedial reflex thresholds (ESRTs).

• Electrode impedance measurements help determine whether electrode circuits are functioning within normal limits. Results do not determine whether the electrode array is properly placed.
• ECAP measurements determine functionality of the eighth nerve to electric stimulation. Thresholds to stimulation may be used intraoperatively and postoperatively.
• SoE measurements determine the decay of a signal between electrodes. They also establish whether the signal that stimulates one electrode predictably masks the neural response to the stimulation from a neighboring electrode. The purpose of SoE measurements is typically to look for tip fold-over in the electrode array that can occur during insertion.
• ESRT measurements are done less often during surgery and may be visualized by direct observation or via measurement of immittance. This threshold value is highly correlated with upper stimulation levels for CI recipients and can serve as a target for postsurgical programming of the device.

Universal clinical practice guidelines are not available for intraoperative monitoring. Each clinic and/or surgeon may develop their own protocol.

Unilateral Implantation, Bilateral Implantation, Bimodal Hearing, and Combined Electric and Acoustic Stimulation

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 options:

• Unilateral cochlear implantation refers to cochlear implantation in one ear.
• Bilateral cochlear implantation refers to cochlear implantation in both ears.
• Bimodal hearing refers to a combination of two different device stimuli addressing hearing loss (e.g., a CI in one ear and a traditional hearing aid in the other ear).
• Electric and acoustic stimulation is a combination of electric and acoustic stimulation in which the external CI sound processor includes an integrated hearing aid in the same ear. The surgical approach focuses on (although does not guarantee) the preservation of residual hearing at lower frequencies.

Unilateral cochlear implantation is an effective intervention for restoring or providing bilateral hearing to adults and children with unilateral hearing loss or single-sided deafness. Research with adults and children has shown improvements in sound localization, speech perception in quiet and in noise, self-reported quality of life (per questionnaire), and other measures after cochlear implantation (Benchetrit et al., 2021; Brown et al., 2022; Dillon et al., 2018; Lindquist et al., 2023; Park et al., 2023; Távora-Vieira & Wedekind, 2022).

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 an evaluation of each ear, a determination that each ear meets the criteria for implantation, and potential benefits for the patient.

The bimodal hearing option may provide advantages (as opposed to unilateral cochlear implantation only) in the perception and localization of sound as well as in the understanding of speech in quiet and noise (Berrettini et al., 2010; Ching et al., 2006; Luntz et al., 2005).

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, Teagle, et al., 2019), showing 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, possible, and preferred by the child’s family. Age at implantation and residual hearing status have been associated with the rate of spoken language development, the level of auditory skill development, and the likelihood of acquiring typical spoken language skills (Culbertson et al., 2022; Leigh et al., 2013; Moura et al., 2023; Niparko et al., 2010; Wu et al., 2023). Longer inter-implant intervals for bilateral implantation have been shown to 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).

Post Surgery

Detailed postsurgical and follow-up instructions are given to the patient and/or their caregivers/care partners, including keeping the area clean and safeguarding against infection. Postoperative audiologic evaluation and follow-up may include, but not be limited to, further counseling and education, inspecting and troubleshooting the device, and evaluating residual hearing.

Sound Processor Programming

The audiologist will schedule several individualized programming sessions with the patient and their caregivers/care partners across a time span of several months. During a CI programming session, the audiologist customizes the processor to the needs of the CI listener. The exact programming steps will vary according to the manufacturer and the abilities of the patient and may include subjective and/or objective measurements.

Generally, programming a CI may be divided into two phases: (1) initial stimulation and (2) follow-up.

1. Initial stimulation takes place shortly after the surgical wound is healed. During the initial stimulation session(s), the external sound processor is connected, and the implant is activated. The audiologist sets the initial levels of electrical stimulation to ensure the patient can detect sounds comfortably. Counseling and education are provided.
2. Comprehensive follow-up (e.g., programming and testing) with an audiologist is critical, especially during the first year after implantation, as adaptations may happen as early as three months. Following the initial stimulation, the patient returns for follow-up visits per the schedule determined by the audiologist and/or program. The audiologist may use objective measures, such as ESRTs, for programming guidance.

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, electrode impedance is used to measure the integrity of the electrodes in the device. Electrodes functioning with abnormal electrode impedance 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 correlated with loudness comfort levels obtained behaviorally (Kosaner et al., 2009; Lorens et al., 2004; Polak et al., 2006) as well as higher speech recognition scores and more favorable quality of sound (Holder et al., 2023). As in populations with typical hearing, reliable measurement of an electrically evoked stapedial reflex requires a healthy middle ear. The patient must sit still and remain silent to maintain an acoustic seal for the measurement probe and to prevent artifacts from movement and/or vocalization from obscuring the reflex response.

Audiologists monitor the function of both the internal and external devices, assess the patient’s access to sound, and program the device to optimize CI performance at subsequent visits. The audiologist may work collaboratively with the aural (re)habilitation provider during follow-up sessions to consider auditory and functional listening skills in respect to optimal programming.

CI Orientation

Education regarding long-term use, care, and maintenance of a CI includes instruction on the following activities:

• Wear the sound processor consistently and according to the recommended schedule.
• Regularly inspect the magnet site to monitor skin and hair health.
• Keep the device dry and clean.
• Store the device in a drying system or in a container with a desiccant, particularly after exposure to water or moisture.
• Use a waterproof processor case or cover, as appropriate.
• Change microphone filters as recommended by the manufacturer.
• Change and/or charge the batteries, as needed.
• Use protective headgear when engaging in sports or activities that may put the user at risk for head trauma.
• Refrain from tugging at, twisting, or throwing the external processor components.
• Regularly monitor magnet strength.
• Perform daily listening checks of the microphone(s) to ensure clear sound quality.
• Perform daily listening checks (e.g., behavioral listening check, routine listening questionnaire) with the device in place to ensure the perception of a variety of sounds in relevant environments and situations.
• Report any perceived change in hearing to an audiologist or a physician, as indicated.
• Use the device accessories and/or hearing assistive technologies as instructed.

Daily listening checks can be completed by the patient, a parent, a family member, a trained support person, an SLP, a teacher, or an audiologist. If the patient is utilizing combined electric and acoustic stimulation technology, daily listening checks with the acoustic portion of the implanted ear are advised to ensure acoustic hearing maintenance.

Aural (Re)Habilitation

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 pages on Aural Rehabilitation for Adults and Language and Communication of Deaf and Hard of Hearing Children for more information.

After cochlear implantation, the patient can begin aural (re)habilitation services with 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 for the patient based on age, developmental norms, hearing history, and specific needs and goals. For example, one 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/caregivers/care partners 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 between 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 can 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 and device use have been associated with successful outcomes (Park, Gagnon, et al., 2019; Purcell et al., 2021; Sharma & Campbell, 2011). In adult cases, duration of deafness has been associated with outcomes (Beyea et al., 2016; Blamey et al., 2012; Green et al., 2007; Holden et al., 2013; Leung et al., 2005). Other factors—such as consistency of device use, appropriate follow-up, and participation in (re)habilitation services—are also important.

The patient’s frequent communication partners can receive guidance on the use of effective communication strategies as well as expectations related to CI use. Family involvement is a critical part of the aural (re)habilitation process.

Communication Approaches

CI recipients may employ one or more of the following languages, tools, systems, technologies, or strategies, depending upon their individual goals and preferences:

• signed language: a visually based, manual sign language (e.g., American Sign Language, Mexican Sign Language)
• spoken language: a language based on listening and spoken communication (e.g., English, Spanish)
• signing systems: systems that support or represent spoken language (e.g., Manually Coded English)
• cueing systems: a visual communication system using specific hand shapes and placements simultaneously with spoken communication (i.e., Cued Speech)
• visual supports and tools: for example, gestures, facial expressions, pictures, and written words
• augmentative and alternative communication (AAC): communication devices, systems, and tools to replace or support spoken language
• combination: a blend of communication approaches used simultaneously or in conjunction with one another (e.g., total communication)

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/caregivers/care partners to determine how certain communication approaches align with those goals. See the ASHA Practice Portal page on Language and Communication of Deaf and Hard of Hearing Children for more information on this topic.

Treatment Plan Components

An individualized aural (re)habilitation plan may include, but not be limited to, the following components:

• Auditory training involves specific listening activities that are focused on the improvement of speech perception and functional listening skills.
• Language development activities are focused on receptive and expressive development across communication domains (phonology, morphology, syntax, semantics, pragmatics).
• Communication skills training is focused on the development or improvement of social interaction skills, conversational strategies, and repair strategies.
• Voice therapy is focused on resonance, loudness, intonation, and speech rhythm.
• Speech sound production training is focused on articulation and intelligibility.
• Speechreading activities are focused on the observation of the speaker’s mouth/lip movements in combination with their facial expressions and gestures.
• Literacy activities are focused on the connection between language development and reading readiness.
• Metacognitive and executive functioning goals are typically integrated into other activities that address concepts such as strategy use, emotional regulation, working memory, and attention.
• Counseling and education for the patient and/or their family/caregivers/care partners includes topics such as hearing device care and management, expectations related to CI use, community resources, listening strategies, impact of the environment on listening conditions, self-advocacy skills, and support group availability. Available websites and applications to assist with daily listening activities and exercises may also be provided. See the ASHA Practice Portal page on Counseling in Audiology and Speech-Language Pathology for more information.

Hearing Assistive Technology Systems

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 impacting communication can include the distance between the speaker and the 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 (e.g., baby monitor, clock alarm, doorbell, smoke detector). See ASHA’s resource on hearing assistive technology for more information.

Reimbursement

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 resource on billing and reimbursement as well as U.S. Food & Drug Administration: Cochlear Implants and Centers for Medicare & Medicaid Services: Cochlear Implantation.

ASHA Resources

• Audiology Patient Education Handouts
• Billing and Reimbursement
• Focusing Care on Individuals and Their Care Partners
• Health Literacy
• Hearing Assistive Technology
• Hearing-Related Topics: Terminology Guidance
• Infection Control Resources for Audiologists and Speech-Language Pathologists
• Interprofessional Education/Interprofessional Practice (IPE/IPP)

Other Resources

This list of resources is not exhaustive, and the inclusion of any specific resource does not imply endorsement from ASHA.

• Alexander Graham Bell Association for the Deaf and Hard of Hearing
• American Cochlear Implant Alliance
• American Society for Deaf Children
• Boys Town National Research Hospital: Baby Hearing
• Center for Auditory Training Resources
• Centers for Medicare & Medicaid Services: Cochlear Implantation
• Educational Audiology Association
• Hearing First
• Hearing Loss Association of America
• International Classification of Functioning, Disability and Health (ICF)
• KidsHealth: Cochlear Implants
• National Center for Hearing Assessment and Management (NCHAM)
• National Institute on Deafness and Other Communication Disorders (NIDCD)
• U.S. Food & Drug Administration: Cochlear Implants

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Acknowledgments

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.

Primary Version

• Kristina Blaiser, PhD, CCC-SLP
• Diane Brewer, MA, CCC-A
• Deborah Culbertson, PhD, CCC-A
• Camille Dunn, PhD, CCC-A
• Melissa Ferrello, AuD, CCC-A
• Rene Gifford, PhD, CCC-A
• Rachel Glade, PhD, CCC-SLP
• Mary O’Leary Kane, MA, CCC-SLP
• Kelly Kemnade, AuD, CCC-A
• Jordan King, AuD, CCC-A
• Amy McConkey Robbins, MS, CCC-SLP
• Christin Ray, PhD, CCC-SLP
• Meredith Anderson Rooth, AuD, CCC-A
• Jeffrey Simmons, AuD, CCC-A
• Douglas Sladen, PhD, CCC-A
• Holly Teagle, AuD, CCC-A
• MaryKay Therres, MS, CCC-SLP
• Julie Verhoff, PhD, CCC-A
• Teresa Zwolan, PhD, CCC-A

Secondary Versions

• Miriam Featherstone, AuD, CCC-A/SLP (2025)
• Lisa Park, AuD, CCC-A (2025)
• Sandra Velandia, AuD, CCC-A (2025)

ASHA seeks input from subject matter experts representing differing perspectives and backgrounds. At times, a subject matter expert may request to have their name removed from our acknowledgment. We continue to appreciate their work.

Citing Practice Portal Pages

The recommended citation for the Practice Portal page is:

American Speech-Language-Hearing Association. (n.d.). Cochlear implants [Practice portal]. https://www.asha.org/practice-portal/professional-issues/cochlear-implants/