22/05/2026
COCHLEAR IMPLANTATION
“Right Patient. Right Time. Best Outcome.”
> “The goal is not just to hear, but to understand, learn and live without limits.”
KEY PRINCIPLE
Bypass damaged hair cells and directly stimulate spiral ganglion cells.
1. AUDIOLOGICAL CRITERIA
Adults
-Bilateral severe-to-profound SNHL (sensorineural hearing loss)
-PTA > 70–80 dB HL
-Poor aided sentence recognition ≤ 50–60% in best-aided condition
-Minimal functional benefit from hearing aids
Children
-Bilateral severe-to-profound SNHL
-Limited auditory & speech-language development despite amplification
-Delayed speech / language milestones
-Hearing aid trial: 3–6 months (unless meningitis / cochlear ossification)
ACI Alliance 60/60 Referral Guideline
Refer for CI evaluation if:
-PTA ≥ 60 dB HL
-Word recognition ≤ 60%
2. AGE
Children
-FDA approved: > 9–12 months*
(*depends on device)
-Earlier is better!
-Best outcomes with implantation early -ideally before 12–18 months of age
Adults
-No upper age limit
-Consider medical fitness, motivation & realistic expectations
3. HEARING AID BENEFIT
-Properly fitted digital hearing aids with adequate trial
-Assess functional benefit through:
-Speech perception in quiet & noise
-Aided audiogram
-Real life performance
Children: Use
MAIS / IT-MAIS
CAP score
SIR score
Poor benefit = key criterion for CI
4. MEDICAL & RADIOLOGICAL CRITERIA
-Intact cochlear nerve
-Patent cochlea suitable for electrode insertion
-No active middle ear infection
-Fitness for surgery & general anesthesia
Imaging Workup
HRCT Temporal Bone
MRI IAC / Brain
To Assess:
Cochlear patency
Cochlear malformations
Cochlear nerve deficiency
Ossification
Mastoid anatomy
Retrocochlear pathology
5. PSYCHOLOGICAL / SOCIAL CRITERIA
Realistic expectations
Strong family / caregiver support
Motivation for rehabilitation
Commitment to long-term AVT
Ability for regular follow-up & mapping
Multidisciplinary team assessment
-ENT
-Audiology
-Speech Therapy
-Psychology
> “Good outcomes are a team effort, not just a surgical one!”
6. CONTRAINDICATIONS
Absolute
Absent cochlear nerve
Complete cochlear aplasia
Medically unfit for surgery / anesthesia
Relative
Severe cochlear ossification
Active CSOM / cholesteatoma
Severe developmental delay
Poor rehabilitation compliance
Unrealistic expectations
7. SPECIAL SITUATIONS
-Single-Sided Deafness (SSD)
-Profound unilateral SNHL with severe tinnitus or poor sound localization
-CI improves quality of life significantly
-Asymmetric Hearing Loss
-CI in poorer ear + HA in better ear (bimodal hearing)
-Better speech in noise & localization
-Auditory Neuropathy Spectrum Disorder (ANSD)
-Selected patients benefit significantly if cochlear nerve is present
-Residual Hearing / Hybrid Implants
-EAS / Hybrid implants preserve low-frequency hearing + electrical stimulation for high frequencies
8. PEDIATRIC RED FLAGS — REFER EARLY!
No startle response by 3–4 months
No babbling by 9 months
No meaningful words by 18 months
Failed newborn hearing screening
Post-meningitic deafness
Progressive / fluctuating hearing loss
> “Early referral. Early implant. Better future.”
9. ASSESSMENT TOOLS
Audiological
BERA / ABR
ASSR
OAE
PTA
Speech audiometry
Aided audiogram
Pediatric Functional Scores
MAIS / IT-MAIS
CAP Score
SIR Score
Meaningful Auditory Integration Scale
Categories of Auditory Performance
10. Recently practice
Earlier implantation in infants
Expansion to SSD, asymmetric loss & ANSD
Hearing preservation & hybrid devices
Bilateral simultaneous implantation in children
Outcome based on auditory deprivation duration
> “Early duration of auditory deprivation inversely affects CI outcomes.”
QUICK DECISION FLOW
Severe-Profound SNHL
↓
Trial with Hearing Aids
↓
Poor aided benefit
↓
Audiological + Radiological evaluation
↓
Cochlear nerve present & cochlea patent
↓
Motivated patient/family
→ CI
Gist idea
Best predictor of good pediatric CI outcome is early implantation
Presence of cochlear nerve on MRI is mandatory
CI bypasses damaged hair cells and directly stimulates spiral ganglion cells
Post-lingual adults generally perform better than pre-lingual adults
BASED ON GUIDELINES FROM
AAO-HNS Clinical Practice Guidelines
American Cochlear Implant Alliance (ACI)
FDA Device Indications
NICE (UK) Guidelines
Manufacturer Guidelines (Cochlear, MED-EL, AB)
Contemporary CI Literature & Consensus
FINAL MESSAGE
“RIGHT CANDIDATE + RIGHT TIME + RIGHT REHABILITATION = LIFE-CHANGING OUTCOMES”
