Cochlear Implant Candidacy is very confusing at times. This is one time read for the solution to it.

1. Cochlea Implant Candidacy
Dr Udit Saxena
PhD - Hearing Sciences (National Centre for Audiology Canada)

2. Firsts
• Invented by Dr William House, 1964.
• Implanted in 1964 by Drs Simmons and White
at Stanford University.
• Modern multichannel implant was by Dr Clark
and was implanted on person named Mr Rod
Saunders in 1978.
• FDA approval: 1985.
• In India: An adult at AIIMS in 1997.

3. Statistics
• December 2012, 324000 implants have been
done (NIDCD, 2013).
– In US: 58000 Adults and 38000 children.
• In India:
– Mostly children
– Is it important to know?

4. Hearing aids vs cochlear implants
• Stimulation
– Acoustic in HAs
– Electric in CIs
• Course of auditory nerve stimulation
– EE, ME and cochlea (HA)
– Direct nerve (CI)
• Which stimulation is better?

5. Hearing aids makes use of what?
• HAs makes use of the remaining residual
hearing
• Acoustically stimulating residual hearing by
amplifying the incoming sounds.
Severe
Gain 50 dB
Moderate
Gain 30 dB

6. Residual hearing and hearing loss
• Moderate to moderately-severe hearing loss:
quite a bit of usable residual hearing.
• Severe and higher loss: limited residual hearing.
– Low frequency
– This is where one should consider Cochlear
Implant.

7. Is this enough?
• Can we suggest CI merely on the basis of the
degree of hearing loss?
– No
• Here come “Candidacy”

8. Candidacy of CI
• Bookish (it is important too)
• Real life

9. Candidacy of CI: Team
• Otologist trained CI surgeon
• Audiologists
• Speech language Pathologists
• Psychologists
• Counselors

10. Medical candidacy of CI
• Dr Khan
• Audiology counseling about CI should be done after
medical investigations including otoscopy, MRI, CT,
etc.
– Auditory structures
• Age
– As young as 12 months (FDA approved).
– Companies says as low as few months. Depending on
individual circumstances and local practices
– In olders: depends on the surgical contraindications

11. Audiological candidacy of CI
• FDA approved candidacy criteria
– Why FDA
• Most standard and research based
– Specific to the implant companies
• Companies proposes their product and layout candidacy
• FDA experts then evaluate the mention quantitatively and
then give approvals
– Specific to adult and children

12. Adult CI-Candidacy (Audiological)
(18 years of age or older)
Advanced Bionics
• Bilateral severe to profound cochlear hearing loss
(>70 dB HL)
• Postlingual onset
• Limited benefit from appropriately fit hearing aids
– Scoring 50% or less on a test of open-set sentence
recognition (HINT sentences)

13. Adult CI-Candidacy (Audiological)
(18 years of age or older)
Cochlear
• Bilateral moderate-to-profound hearing loss in the low
frequencies
• Bilateral profound hearing loss in the mid to high
speech frequencies.
• Limited benefit from amplification
– Scores of 50% correct or less in the ear to be implanted
(60% or less in the best-aided listening condition) on tape-
recorded tests of open-set sentence recognition

14. Adult CI-Candidacy (Audiological)
(18 years of age or older)
Medel
• Bilateral severe to profound cochlear hearing loss.
– Pure-tone average of 70 dB or greater at 500, 1,000,and
2,000 Hz.
• Limited benefit from amplification
– Scores of 40% correct or less in best-aided listening
condition on DC-recorded tests of open-set sentence
recognition (Hearing in Noise Test [HINT]sentences)

15. Children CI-Candidacy (Audiological)
(12 months to 17.11 years)
Advanced Bionics
• Bilateral severe-profound hearing loss.
• Hearing aid usage
– at least 6 months in children 2–17 years of age
– at least 3 months in children 12–23 months of age.
– The minimum duration of hearing aid use is waived
if X-rays indicate ossification of the cochlea.

16. Children CI-Candidacy (Audiological)
(12 months to 17.11 years)
Advanced Bionics (contd…)
• Little or no benefit from appropriately fit hearing aids
– In younger children (<4 years of age)
 Failure to reach developmentally appropriate auditory milestones
o Infant-Toddler Meaningful Auditory Integration Scale
o Meaningful Auditory Integration Scale
o <20% correct on a simple open-set word recognition test (Multisyllabic
Lexical Neighborhood Test [MLNT]) administered using monitored live
voice (70 dB SPL).

17. Children CI-Candidacy (Audiological)
(12 months to 17.11 years)
Advanced Bionics (contd…)
• Little or no benefit from appropriately fit hearing aids
– In older children (>4 years of age)
 <12% on a difficult open-set word recognition test (Phonetically
Balanced Kindergarten Test)
 <30% on an open-set sentence test (HINT for Children)
 70 dB SPL

18. Children CI-Candidacy (Audiological)
(12 months to 17.11 years)
Cochlear
• 12-24 months of age: Bilateral profound HL.
• > 2years of age: Bilateral severe to profound hearing
loss.
• 3-6 months hearing aid usage.
• Limited hearing aids benefits.
– In young children
 Lack of progress in the development of simple auditory skills.
 Meaningful Auditory Integration Scale or the Early Speech
Perception test

19. Children CI-Candidacy (Audiological)
(12 months to 17.11 years)
Cochlear (contd…)
• Limited hearing aids benefits.
– In older children
 ≤30% correct on the open-set MLNT or Lexical Neighborhood
Test (LNT), depending on the child’s cognitive and linguistic skills

20. Children CI-Candidacy (Audiological)
(12 months to 17.11 years)
Medel
• As young as several months
• Bilateral severe to profound hearing loss.
• Hearing aid usage: 3-6 months.
• Limited progress with hearing aids
– In younger children : Simple auditory skills not
developed.
– In older children: <20% correct on the MLNT or
LNT

21. Audiological tests to assess candidacy
• Pure-tone Audiometry
• Speech Audiometry
– SRT and SI
– SDT
• Tympanometry and Reflexometry
• OAEs
• ABR
• EABR

22. Audiological tests to assess candidacy after a
certain period of hearing aid usage
• Pure-tone Audiometry
• Speech Perception Tests

23. Audiological tests to assess candidacy after a
certain period of hearing aid usage
• Speech Perception Tests
– Adults
 Minimum Speech Test Battery (MSTB)
o Bamford-Kowal-Bamford Speech-in-Noise (BKB-SIN) test
(Etymotic Research, 2005)
o AzBio sentences (Spahr & Dorman, 2004)
o Consonant-Nucleus-Consonant (CNC) test (Peterson & Lehiste,
1962)

24. Audiological tests to assess candidacy after a
certain period of hearing aid usage
• Speech Perception Tests
– Children
– Early Speech Perception Test (ESP) (Moog and Geers,1990)
– Meaningful Auditory Integration Scale (MAIS) (Robbins et al., 1991)
– Infant-Toddler Meaningful Auditory Integration Scale (IT-MAIS)
(Zimmerman-Phillips et al., 1998)
– Word Intelligibility by Picture Identification (WIPI) Test (Ross and
Lerman, 1979)
– Northwestern University-Children’s Perception of Speech (NU-CHIPS)
Test (Elliott and Katz, 1980)
– Phonetically Balanced Kindergarten (PBK)-50 Word List (Haskins, 1949)
– Bamford-Kowal-Bench (BKB) Sentences (Bench et al., 1979)
– Glendonald Auditory Screening Procedure (GASP) (Erber, 1982)
– Lexical Neighborhood Test (LNT) (Kirk et al., 1995)
– Multisyllabic Lexical Neighborhood Test (MLNT)(Kirk et al., 1995)

25. Speech and language evaluations
• To estimate child’s speech and language
development. To set a base-line.
– Expressive and receptive language skills
– Articulation skills
– Speech intelligibility

26. Psychological evaluations
• Primarily in children
– To see factors such as cognitive, emotional, social and
adaptive abilities other than hearing impairment are
impairing auditory development.
– To rule out cognitive impairment
• Difficulty in detecting autism till 2years
• Parents should be informed that outcome will be limited in case
of cognitive disabilities
• In adults, if, concerns of cognitive status or mental
function

27. ADIP CI candidacy-Children
• <5years
• Bilateral severe to profound hearing loss
• 3 months hearing aid usage
• Limited benefit with HAs

28. Arogyasri CI candidacy-Children
• <2years
• Bilateral severe to profound hearing loss
• 3 months hearing aid usage
• Limited benefit with HAs

29. Things to see other than candidacy criteria
Adults
• Have a strong desire to be part of the hearing world
and communicate through listening, speaking, and
speech reading
• Have lost their hearing after speech and language
development

30. Things to see other than candidacy criteria
Children
• Parents motivation
• Realistic expectations
• Economic status to sustain maintenance

31. Questions for CI Audiologist
1. What are the advantages of a cochlear implant over a hearing aid?
2. Is the implant guaranteed to work?
3. Can we talk to someone who has had an implant?
4. What happens at the cochlear implant clinic?
5. How long will we have to wait to have the surgery?
6. What happens during surgery?
7. Will child be able to hear immediately after surgery?
8. Will there have a visible scar?
9. What are the risks of surgery?
10. How familiar are you with cochlear implants?
11. Which ear will be have implanted?
12. What is the latest technology?
13. What is a hybrid cochlear implant or bimodal hearing solution?
14. What adaptors or accessories can I use with a cochlear implant?
15. Will child/I be able to swim and play sports?
16. What support can we expect?

32. Limitation in CI program (India)
• Poor counseling
– Non-professionals
• Un-realistic expectations
• Maintenance of CI poorly explained