Clinical Practice Guideline: Cochlear Implants
American Academy of Audiology. (2019).
Reston (VA): American Academy of Audiology, 1-113.
This guideline from the American Academy of Audiology provides recommendations on the evaluation for and management of cochlear implantation for children and adults.
American Academy of Audiology
<div>Post-cochlear implantation intervention for adults should focus on auditory training (Levels 1 and 4, Grades A-B, EF/EV). Music perception and appreciation should be targeted for individuals wishing to improve their music perception abilities (Level 1, Grade B, EF/EV).</div>
<div>When programming a cochlear implant device, audiologists should</div>
<ul>
<li>review any available imaging, operative, or intra-operative reports (Level 6, Grade D, EF/EV);</li>
<li>discuss any progress or changes noted by the CI recipient (No Rating);</li>
<li>check the skin flap (No Rating);</li>
<li>measure electrode impedances (Level 4, Grade B, EF/EV);</li>
<li>select the processing/coding strategy (No Rating);</li>
<li>establish the electrical dynamic range (EDR) on selected electrodes using both psychophysical and objective measures (Levels 1, 3-6, Grades A-D, EF);</li>
<li>optimize program with loudness balancing and pitch scaling (Levels 3, 4, and 6, Grades B-D, EF/EV);</li>
<li>go live to ensure comfort and audibility (Level 6, Grade D, EF/EV);</li>
<li>load program(s) into the sound processor (Level 6, Grade D, EV/EV); and</li>
<li>counsel the individual on topics such as device care, types of programs, importance of aural rehabilitation, and consistent device use (No Rating).</li>
</ul>
<div>For adults who receive a cochlear implant, outcomes assessment should include measures of speech perception (No Rating) and subjective input from the recipient and their communication partners (Levels 3-4, Grade B, EV). Assessment tools should be determined based on the individual’s needs (Level 3, Grade B, EF). Additional testing is required should an individual demonstrate poor performance during validation testing in the sound booth (Level 4, Grade B, EF).</div>
<div>During post-cochlear implantation (CI) follow-up appointments, audiologists should counsel and educate CI recipients and their communication partners (e.g., caregiver, spouse) on device care, use, and strategies (Levels 4 and 6, Grades B-D, EF/EV), on the importance of full-time CI use (Levels 3-4, Grade B, EF/EV), and discuss other resources or support groups available (Level 4, Grade C, EV).</div>
<div>During cochlear implantation surgery, audiologists have an active role conducting intra-operative testing of device function and of an individual’s baseline neural function (Levels 3-4, Grades B-C, EF/EV) using measures such as impedance telemetry (Levels 3-4, Grades B-C, EF/EV), electrically-evoked compound action potential (ECAP) (Levels 2-4, Grades A-C, EF/EV), or electrically-evoked stapedial reflex threshold (ESRT) (Levels 2-4, Grades B-C, EF/EV) and intra-operative testing to monitor acoustic trauma and hearing preservation using electrocochleography (eCochG) (Level 3, Grade B, EF).</div>
<div>During post-cochlear implantation (CI) follow-up appointments, audiologists should assure equipment fit and function (No Rating), measure telemetry/impedance (Levels 3-4, Grade B, EF/EV), assess electrical dynamic range (EDR) (Levels 3, 4, and 6, Grades B-D, EV), optimize programming (Levels 2-4 and 6, Grades A-D, EF/EV), measure physiological auditory system responses to electrical stimulation (Levels 3-4, Grades B-C, EF), and use validation measures of audibility and speech perception (Levels 4 and 6, Grades B and D, EF/EV). Bilateral stimulation should be considered, when not contraindicated (Levels 1, 3-4, Grades A-B, EF/EV).</div>
<div>During post-cochlear implantation (CI) follow-up appointments, audiologists should discuss and implement hearing assistive technology options (Levels 3 and 6, Grades B and D, EF/EV), especially for school-aged children (Levels 1 and 4, Grades A-B, EF). Special consideration should be made for providing supports and tools for activities of daily life and safety (e.g., telephone use, vibrotactile alarms) (Levels 3-4, Grade B, EF/EV).</div>
<div>Post-cochlear implantation intervention for children should focus on the child’s holistic developmental process (Levels 1-3, Grade A, EF), engage family and educators in therapy (Levels 3-4, Grade B, EF/EV), and support a range of communication options (e.g., auditory-verbal, American Sign Language) (No Rating).</div>
<div>For children who receive a cochlear implant, "the following follow-up schedule is recommended for the first year of device use:</div>
<ul>
<li>Initial activation: Typically occurs 1-4 weeks post-operatively, in accordance with the recommendation and approval of the surgical team; [and]</li>
<li>[additional follow-ups at] 1 week post initial activation, 2 months post initial activation, 3 months post initial activation, 6 months post initial activation, 9 months post initial activation, and 12 months post initial activation.</li>
</ul>
<div>The follow-up schedule after the first year of device use should be dependent upon the progress the child has made with the device and the caregiver’s comfort and skill in maintaining equipment" (Levels 4 and 6, Grades B and D, EF/EV; p. 66).</div>
<div>When determining candidacy for cochlear implantation (CI), estimating post-implantation outcomes, and establishing post-CI goals for individuals with hearing loss, speech and language evaluation should be conducted "by a speech-language pathologist with experience working with adults and/or children with hearing loss" (p. 31) using standardized communication assessments (No Rating).</div>
<div>For adults who receive a cochlear implant, "the following follow-up schedule is recommended for the first year of device use:</div>
<ul>
<li>Initial activation: Typically occurs 1-4 weeks post-operatively, in accordance with the recommendation and approval of the surgical team; [and]</li>
<li>[additional follow-ups at] 1 week post initial activation, 1 month post initial activation, 3 months post initial activation, 6 months post initial activation, 12 months post initial activation.</li>
</ul>
<div>The follow-up schedule after the first year of device use should be dependent upon the progress the individual has made with the device. For most adults, follow-up appointments can occur biannually (e.g., every 6 months) or annually" (Levels 4 and 6, Grades B and D, EF/EV; p. 67).</div>
<div>When determining candidacy for cochlear implantation for individuals with hearing loss, audiological evaluation should be developmentally appropriate and include</div>
<ul>
<li>case history (Levels 1, 3, and 4, Grades A-B, EV/EF);</li>
<li>unaided air conduction thresholds (Levels 1 and 4, Grades A-B, EV);</li>
<li>bone-conduction thresholds (Levels 1 and 4, Grades A-B, EV);</li>
<li>auditory speech perception (Levels 1 and 4, Grades A-B, EF/EV);</li>
<li>assessment of peripheral auditory system and lower brainstem function (e.g., otoacoustic emissions, immittance, auditory brainstem response, and/or auditory steady state response testing) (No Rating);</li>
<li>vestibular assessment (Level 1, Grade A, EV/EF); and </li>
<li>assessment of subjective ability and determination of need (e.g., quality of life assessment, needs and expectations assessment) (Levels 3-4, Grade B, EF).</li>
</ul>
<div>When fitting cochlear implants for individuals with hearing loss, signal processing parameters that should be considered include</div>
<ul>
<li>impedance (Level 4, Grade B, EV);</li>
<li>directional microphones (Level 2, Grade A, EF);</li>
<li>electric dynamic range (Levels 2-4, Grades A-D, EF);</li>
<li>input dynamic range (Levels 2-4, Grades A-D, EF);</li>
<li>sensitivity (Level 3, Grades A-B, EF/EV);</li>
<li>rate (Levels 2-4, Grades A-B, EF/EV);</li>
<li>pulse duration (Level 2, Grade A, EF/EV);</li>
<li>processing/coding strategies (Levels 2 and 6, Grades A and D, EF/EV);</li>
<li>channels/bands/frequency allocation tables (Levels 1-3, Grades A-B, EF/EV); and</li>
<li>other processing features (Levels 2-3, Grades A-B, EF).</li>
</ul>
<div>During post-cochlear implantation follow-up appointments, audiologists should refer for additional evaluations or supports (e.g., medical care, social work, early intervention, educational support) as needed (Levels 2 and 6, Grades B and D, EF/EV).</div>
<div>For children who receive a cochlear implant, outcomes assessment should include measures of speech perception (No Rating) and subjective input from the recipient and their communication partners (Level 4, Grade B, EV). Assessment tools should be determined based on the individual’s needs (Level 6, Grade D, EV). Additional testing is required should an individual demonstrate poor performance during validation testing in the sound booth (Level 2, Grade B, EF).</div>
<div>Audiologists and other related service providers should provide pre-operative counseling to individuals who are candidates for cochlear implants and their support system (e.g., caregiver, spouse) during the candidacy process (No Rating).</div>
