Roles and Responsibilities

Roles and Responsibilities of Audiologists

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:

• Maintaining 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.
• Maintaining knowledge of cochlear malformations, cochlear ossification, and the effect that they will have on CI programming parameters and outcomes.
• Remaining current on information related to CI technology, hearing aid technology, hearing assistive technology systems (HATS), and other applicable technologies.
• Maintaining knowledge of the effects of hearing loss on communication function and development.
• Serving as a member/coordinator of a collaborative, interprofessional CI team.
• Coordinating and conducting a comprehensive, culturally and linguistically appropriate audiologic assessment.
• Determining an individual's CI candidacy in collaboration with a CI team.
• Gathering formal and informal information on functional listening skills, social participation, and quality of life factors that may influence candidacy decisions.
• Referring to other professionals to facilitate access to comprehensive services.
• Developing a comprehensive plan of care with input from the patient, the family, and appropriate professionals.
• Consulting with the surgeon regarding audiometric qualifications that may affect the choice of electrode array.
• Providing intraoperative monitoring/electrophysiological testing during cochlear implantation.
• Using contemporary behavioral and/or objective measures to set the upper and lower stimulation levels and device parameters that will be used in the sound processor program.
• Coordinating with other professionals to develop an appropriate and comprehensive aural (re)habilitation plan.
• Providing direct (re)habilitation services, as appropriate to the scope of practice and in coordination with other professionals involved in the (re)habilitation process.
• Instructing the patient and/or their family about the proper care and use of the sound processor and its accessories as well as offering appropriate hands-on practice.
• Counseling the patient and/or their family regarding communication-related issues and rights to services.
• Inspecting the surgical site and alerting the patient and/or their family and the surgeon of the potential need for medical intervention.
• Counseling the patient and/or their family about realistic expectations after device activation, and preparing the patient for a period of acclimation to the electrical signal.
• Monitoring device use (i.e., checking data logging) to support optimal outcomes.
• Inspecting and troubleshooting external equipment for proper function and providing guidance when replacement is necessary.
• Validating hearing technology use in a variety of communicative settings through interprofessional communication.
• Consulting with the device manufacturer if failure of the internal device is suspected or if standard programming results in poor outcomes.
• Assessing speech recognition, auditory detection, and functional listening with the CI using measures appropriate for the individual patient.
• Developing and using ongoing progress data and functional outcome measures.
• Educating other professionals about CIs, assistive devices, CI recipients, and the role of audiologists on the CI team.
• Advocating for individuals with CIs and/or their families at the local, state, and national levels.
• Managing hearing aid technology, HATS, and other applicable technologies.
• Remaining informed of the availability of products, advances in implant technology, approval of new devices by the U.S. Food and Drug Administration (FDA), implant reliability, and implant recalls.

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 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, 2016).

Appropriate roles and responsibilities for SLPs include, but are not limited to, the following:

• Maintaining general knowledge of anatomy, physiology, and pathophysiology of the auditory system.
• Maintaining knowledge of the effects of hearing loss on communication function and development.
• Maintaining general knowledge of various CI technologies across brands, including the components, accessories, and hearing assistive technology systems.
• Serving as a member of a collaborative, interprofessional CI team.
• Providing a comprehensive, culturally and linguistically appropriate, evaluation of a patient's speech, language, listening, and communication skills.
• Establishing a baseline for the patient's speech and language skills prior to intervention or cochlear implantation.
• Gathering formal and informal information on functional listening behaviors, social participation, and quality of life factors that may influence candidacy decisions.
• Participating in discussions of candidacy determination and outcome expectations for cochlear implantation as part of the CI team.
• Referring to other professionals to facilitate access to comprehensive services.
• Coordinating with other professionals to develop an appropriate and comprehensive aural (re)habilitation plan.
• Providing direct (re)habilitation services, as appropriate to the scope of practice and in coordination with other professionals involved in the (re)habilitation process.
• Counseling the patient and/or their family on modes of communication and realistic expectations regarding communication development, communication maintenance, and/or communication enhancement following cochlear implantation.
• Assessing the patient's speech, language, listening, and communication skills on an ongoing basis and in a variety of settings after cochlear implantation.
• Developing and using ongoing progress data and functional outcome measures.
• Alerting members of the CI team if a patient is not making expected progress using or adjusting to the device so potential causes may be investigated.
• Educating other professionals about CIs, assistive devices, CI recipients, and the role of SLPs on the CI team.
• Advocating for individuals with CIs and/or their families at the local, state, and national levels.
• Remaining informed of research in the area of cochlear implantation.

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, 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 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 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.

Case History

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

• age of patient
• onset and duration of deafness, whether prelingual or postlingual
• medical history (including coexisting disabilities)
• 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 (preferred communication mode) and specific communication needs
• current technology used (hearing aid[s], hearing assistive technology)
• psychological history
• cognitive status
• family history of hearing loss
• information and results from other professionals
• radiologic results (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 family responses to questionnaires and/or self-assessment tools regarding quality of life and communication
• patient and/or family 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 may provide information on

• radiologic imaging to examine the size, length, and patency of the cochlea as well as the viability of the seventh and eighth nerves;
• the interpretation of neurological and vestibular screening/assessment;
• various CI devices based on patient factors and device availability; 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,
• other disabling conditions,
• vaccination status (e.g., meningitis),
• consideration for genetic or other health issues, and
• stability for surgery.

Audiology

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 Hearing Loss in Children, Hearing Loss in Adults, and Hearing Aids For Adults ASHA Practice Portal pages for more information on comprehensive audiologic assessment.

An audiologist may provide information on the following:

• Quantification of the candidate's preoperative hearing and communicative status, including residual hearing.
• Appropriateness of hearing aids and/or recommendation of more appropriate hearing aids.
• Results of a hearing aid trial and patient compliance with hearing aid use.
• Patient and/or family 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.
• Speech recognition, auditory detection, and functional listening, as appropriate for the patient's age, development, and cognitive/language skills.
• Vestibular testing.
• Realistic expectations for performance outcomes.
• Comparison of current status to expected outcomes with CI.
• Impact of case complexities, such as
  • abnormal auditory nerve;
  • asymmetric hearing loss;
  • auditory neuropathy spectrum disorder;
  • balance disorder;
  • cochlear ossification;
  • cognitive, emotional, and behavioral disorders;
  • disabilities in addition to the hearing loss;
  • family support and home environment;
  • hearing loss associated with syndromes;
  • malformed cochlea;
  • mobility/dexterity considerations;
  • unilateral hearing loss; and
  • visual impairment.
• Unilateral, bilateral, bimodal, or combined electric and acoustic stimulation device recommendation.
• Various CI devices based on patient factors and device availability.
• 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:

• pre-CI speech, language, and communication skills
• pre-CI auditory skills (e.g., detection, discrimination, identification) and functional listening skills (i.e., ability to understand environmental sounds and speakers' messages across settings and situations)
• pre-CI literacy skills
• play skills in children
• metacognitive and executive functioning behaviors, such as planning, attention, and self-regulation
• speech-language disorders in addition to the hearing loss
• current modes and strategies for communication
• current and desired communication approaches
• patient and/or family responses to questionnaires and/or self-assessment tools regarding quality of life and communication
• current educational placement
• prognosis for the development or advancement of speech, language, and communication, including auditory, functional listening, and literacy skills
• treatment options, including aural (re)habilitation

Psychology

A psychologist may provide information on

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

Educational and Social Support

An educator and/or a social worker may provide information on

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

Patient and Family

The patient and/or their family may provide information on

• current concerns about the patient's listening, communication, and/or academic/vocational/functional skills;
• the impact of the patient's communication difficulties on frequent communication partners;
• long-term patient and/or family goals and desired outcomes;
• motivation and commitment to follow-up and treatment;
• preferred communication mode; and
• compliance with recommendations.

Candidacy Determination

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

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.

Treatment

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).

Surgery

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).

• EI measurements help determine whether electrode circuits are functioning within normal limits. Test 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 foldover 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.

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.

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:

• 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 contralateral ear).
• Electric and acoustic stimulation is a hybrid approach 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 during cochlear implantation.

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).

Post Surgery

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.

Sound Processor Programming

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.

1. Preprogramming is used to prepare the patient for postoperative stimulation. The audiologist may fit the patient with hearing aids and/or an FM device. During this phase, emphasis is placed on counseling.
2. The goals and benefits of intraoperative testing are explained in the Surgery section of this page.
3. Initial stimulation takes place shortly after the surgical wound is healed. Programming sessions may take place on consecutive days and for multiple hours per day. Extensive counseling and education continue during this phase.
4. Comprehensive follow-up with an audiologist is critical, especially during the first year after implantation, as many adaptations may happen in the first 6–12 months after initial stimulation.

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.

CI Orientation

Education regarding long-term use, care, and maintenance of a CI prepares the patient and/or their family to do the following:

• Wear the device consistently and according to the recommended schedule.
• Keep the device dry and clean.
• Keep the skin under the device clean, and check for irritation and/or infection.
• Inspect the device for moisture and debris after daily use.
• 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.
• Remove the device nightly.
• Change the 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.
• Regularly inspect the area under the headset magnet to monitor for proper adhesion and to check for appropriate magnet strength.
• Refrain from tugging at, twisting, or throwing the external processor components.
• Keep the device and related components out of others' reach when not in use.
• 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.
  • 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.
• Report any perceived change in hearing to an audiologist or a physician, as indicated.
• Use the device accessories and/or hearing assistive technologies correctly.

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 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.

Communication Modes

CI recipients may employ one or more of the following communication modes, depending upon their individual goals and preferences:

• American Sign Language: a visually based, manual sign language
• Auditory–Oral: listening and spoken communication along with speech reading, natural gestures, and/or visual cues
• Auditory–Verbal (listening for spoken language): listening and spoken communication with reliance on hearing in the absence of visual cues, such as exaggerated facial expression, hand cues, or speech reading
• Cued Speech: a visual communication system using specific hand shapes and placements simultaneously with spoken communication
• Total Communication: a combination of communication modalities used simultaneously or in conjunction with one another including all means of communication as needed

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.

Treatment Plan Components

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

• Auditory training: Specific listening activities 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: Activities are focused on the development or improvement of social interaction skills, conversational strategies, and repair strategies.
• Voice therapy: Activities are focused on resonance, loudness, intonation, and speech rhythm.
• Speech sound production training: Activities are focused on articulation and intelligibility.
• Speech reading: 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 of 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: Topics include hearing device care and management, realistic expectations, community resources, listening strategies, impact of environment on listening conditions, self-advocacy skills, and support group availability (e.g., local, state, national, manufacturer-specific). See the ASHA Practice Portal page on Counseling For Professional Service Delivery 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 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.

International Classification of Functioning, Disability and Health

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.

Service Delivery

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.

Cultural Considerations

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

ASHA Resources

• Audiology Information Series: Cochlear Implants
• Billing and Reimbursement
• Cochlear Implants in Auditory Neuropathy Spectrum Disorder
• Cochlear Implants in the Classroom: The Role of the Educational Audiologist
• Contemporary Audiologic Management to Optimize Cochlear Implant Benefit
• Hearing Assistive Technology
• International Classification of Functioning, Disability, and Health (ICF)
• Interprofessional Education/Interprofessional Practice (IPE/IPP)
• The Mind Hears: Tuning In With a Cochlear Implant

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
• Baby Hearing
• BEGINNINGS for Parents of Children who are Deaf or Hard of Hearing
• Centers for Medicare & Medicaid Services: Cochlear Implantation
• 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
• Unilateral Cochlear Implants for Severe, Profound, or Moderate Sloping to Profound Bilateral Sensorineural Hearing Loss - A Systematic Review

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American Speech-Language-Hearing Association. (2018). Scope of practice in audiology [Scope of practice]. www.asha.org/policy/

American Speech-Language-Hearing Association. (2023). Code of ethics [Ethics]. www.asha.org/policy/

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Carlson, M. L., Sladen, D. P., Gurgel, R. K., Tombers, N. M., Lohse, C. M., & Driscoll, C. L. (2018). Survey of the American Neurotology Society on cochlear implantation: Part 1, candidacy assessment and expanding indications. Otology & Neurotology, 39(1), e12–e19.

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Dillon, M. T., Buss, E., Adunka, M. C., King, E. R., Pillsbury, H. C., Adunka, O. F., & Buchman, C. A. (2013). Long-term speech perception in elderly cochlear implant users. JAMA Otolaryngology—Head & Neck Surgery, 139(3), 279–283.

Gantz, B. J., Dunn, C., Oleson, J., Hansen, M., Parkinson, A., & Turner, C. (2016). Multicenter clinical trial of the Nucleus Hybrid S8 cochlear implant: Final outcomes. The Laryngoscope, 126(4), 962–973.

Geers, A. E., Strube, M. J., Tobey, E. A., Pisoni, D. B., & Moog, J. S. (2011). Epilogue: Factors contributing to long-term outcomes of cochlear implantation in early childhood. Ear and Hearing, 32(1 Suppl), 84S–92S.

Green, K. M., Bhatt, Y. M., Mawman, D. J., O'Driscoll, M. P., Saeed, S. R., Ramsden, R. T., & Green, M. W. (2007). Predictors of audiological outcome following cochlear implantation in adults. Cochlear Implants International, 8(1), 1–11.

Hilly, O., Hwang, E., Smith, L., Shipp, D., Nedzelski, J. M., Chen, J. M., & Lin, V. W. Y. (2016). Cochlear implantation in elderly patients: stability of outcome over time. The Journal of Laryngology & Otology, 130(8), 706–711.

Holden, L. K., Finley, C. C., Firszt, J. B., Holden, T. A., Brenner, C., Potts, L. G., Gotter, B. D., Vanderhoof, S. S., Mispagel, K., Heydebrand, G., & Skinner, M. W. (2013). Factors affecting open-set recognition in adults with cochlear implants. Ear and Hearing, 34(3), 342–360.

Incerti, P. V., Ching, T. Y. C., & Cowan, R. (2013). A systematic review of electric-acoustic stimulation: Device fitting ranges, outcomes, and clinical fitting practices. Trends in Amplification, 17(1), 3–26.

Knopke, S., Gräbel, S., Förster‐Ruhrmann, U., Mazurek, B., Szczepek, A. J., & Olze, H. (2016). Impact of cochlear implantation on quality of life and mental comorbidity in patients aged 80 years. The Laryngoscope, 126(12), 2811–2816.

Kosaner, J., Anderson, I., Turan, Z., & Deibl, M. (2009). The use of ESRT in fitting children with cochlear implants. Journal of International Advanced Otology, 5(1), 62–71.

Lammers, M. J. W., van der Heijden, G. J. M. G., Pourier, V. E. C., & Grolman, W. (2014). Bilateral cochlear implantation in children: A systematic review and best-evidence synthesis. The Laryngoscope, 124(7), 1694–1699.

Laske, R. D., Veraguth, D., Dillier, N., Binkert, A., Holzmann, D., & Huber, A. M. (2009). Subjective and objective results after bilateral cochlear implantation in adults. Otology & Neurotology, 30(3), 313–318.

Leung, J., Wang, N. Y., Yeagle, J. D., Chinnici, J., Bowditch, S., Francis, H. W., & Niparko, J. K. (2005). Predictive models for cochlear implantation in elderly candidates. Archives of Otolaryngology—Head & Neck Surgery, 131(12), 1049–1054.

Lin, F. R., Chien, W. W., Li, L., Niparko, J. K., & Francis, H. W. (2012). Cochlear implantation in older adults. Medicine, 91(5), 229–241.

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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.

• 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

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.  

Citing Practice Portal Pages

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/.