American Cochlear Implant Alliance Task Force: Recommendations for Determining Cochlear Implant Candidacy in Adults
Laryngoscope
Zeitler, D. M., Prentiss, S. M., et al. (2024).
Laryngoscope, 134(S3), S1-S14.
This clinical practice guideline provides recommendations for evaluating the candidacy of cochlear implant (CI) use in adults to ensure appropriate referral of qualified candidates.
American Cochlear Implant Alliance
American Academy of Audiology
"Any patient with hearing loss who gains limited benefit from their current HAs [hearing aids] and desires improvement in hearing should be referred for a CI evaluation. Referrals for borderline candidates, even if the candidate does not quality, provides an opportunity for counseling and documents a baseline to monitor for future hearing loss progression." p. S11
Cochlear implantation "is currently the most effective option for the management of sensorineural hearing loss not optimally managed by HAs," and therefore should not be seen as a "last resort" or postponed in wait for "something better" (p. S11).
Specific recommendations for consideration regarding CI candidacy were as follows:<br />
<ul>
<li>Residual hearing is not a contraindication for CI surgery and should not be used as a reason to prevent CI use. </li>
<li>Ear-specific CI candidacy must be considered.</li>
<li>A revised 60/60 rule (i.e., referall for CI if pure tone average [PTA] is greater than or equal to 60dB HL and an unaided monosyllabic word recognition score is 60% or less) in which each ear is considered individually can be used as a clinical benchmark for referral. </li>
<li>Patient-specific factors (i.e., demographics, etiology and duration of hearing loss, HA history, and support system) must be considered to identify appropriate CI candidates and perform appropraite counseling. </li>
<li>"Patients not meeting current FDA [Food and Drug Administration] labeling and CMS [Center for Medicaid and Medicare Services] requirements should still be considered for a CI" (p. S11).</li>
<li>Cinical decision making regarding CI candicated should be guided by evidence-based medicine performed by the multidisciplinary CI team.</li>
<li>Considerations regarding insurance coverage of CI services should be included during counseling, however, these considerations should not be used as deterrent for referral for a CI evaluation.</li>
<li>"There is no 'bad' CI referral. Even if a patient does not initially qualify, the evaluation process can be educational for the patient, can provide a baseline for comparison in the future, and may result in optimization of HA technology and/or the provision of assistive listening devices" (p. 12). </li>
</ul>
If residual hearing is maintained following CI, it can lead to better outcomes (i.e., speech understanding in noise, appreciation of music, and improved sound quality) and improve outcomes of electric and acoustic stimulation (EAS) listening strategies post-operatively.
CI candidacy evaluation begins with consonant nucleus consonant (CNC) monosyllabic word testing in each ear using optimized hearing aids, with candidacy corresponding to a score of ≤50% the ear-to-be implanted, regardless of performance in the contralateral ear. To determine insurance coverage, the evaluation should then include best aided connected speech testing in the ear to be implanted using AzBio sentence recognition played with a 10-talker babble in +10 dB signal to noise ratio (SNR). "To further evaluate hearing status and qualification of insurer’s requirements, the clinician should consider decreasing the adversity (sentences obtained in quiet at 60 dB A) or increasing the adversity (AzBio in +5 dB SNR with sentences presented at 65 dB A and noise presented at 60 dB A) of the listening condition as appropriate" (p. S11).
Providers should discuss appropriate recommendations for fitting a hearing aid or other hearing technology in the contralateral, non-implanted ear to allow for optimization of binaural hearing and the use of compatible accessories.
Measuring subjective benefit via any variety of hearing-related quality of life measures can guide counseling, aural rehabilitation, and CI programming. The Cochlear Implant Quality of Life Profile-35 (CIQOL-35) "is a validated questionnaire specific to CI patients, and administration is suggested pre-implantation and at 3-months and 12-months post-CI. The CIQOL-35 can be administrated annually thereafter where appropriate to ensure the patient is progressing and meeting stated goals" (p. S11).
An aural rehabilitation program should be encouraged for CI users, as "it is essential to maximize outcomes following CI" (p. S12).
