Clinical UM Guideline

This document addresses cochlear implants, auditory brainstem implants, and replacement or upgrade of speech processor and controller components. This document does not address replacement parts other than as specifically described below.

A single- or multi-channel unilateral or bilateral cochlear implant is intended to restore a level of auditory sensation to an individual with bilateral severe to profound sensorineural hearing loss by means of electrical stimulation of the auditory nerve. A unilateral hybrid cochlear implant is intended to restore a level of auditory sensation to an individual with residual low-frequency hearing sensitivity and bilateral severe to profound sensorineural hearing loss.

An auditory brainstem implant is a device designed to restore some hearing in an individual with neurofibromatosis type 2 (NF-2) who has been rendered deaf by the surgical removal of neurofibromas involving both auditory nerves.

I. Cochlear Implants

Medically Necessary:

1. Cochlear implantation is considered medically necessary when both criterion 1 and criterion 2 listed below are met:
   1. The individual meets All the following criteria (a through c):
      1. Has received limited benefit from conventional hearing aids; and
      2. Is able to participate* in a post-cochlear implant rehabilitation program; and
      3. Absence of any of the following (i through iv):
         1. Active middle ear infections; or
         2. Lesions in the auditory nerve; or
         3. Lesions in the central auditory pathway; or
         4. Auditory neuropathy spectrum disorders.
            *Note: For a young child, a parent or guardian may act as the surrogate for participation.
            and
   2. The individual has unilateral or bilateral sensorineural deafness with hearing loss in the ear(s) to be implanted greater than or equal to 70 dB.
      (Implantation may be unilateral, bilateral-simultaneous [same session] procedures, or bilateral-sequential [different session] procedures. If bilateral-sequential, hearing tests do not need to be repeated between procedures.)
2. Upgrade to or replacement of an existing external speech processor, controller or speech processor and controller (integrated system) is considered medically necessary when the following criteria (1 and 2) are met:
   1. The existing components no longer meet the individual’s needs as demonstrated by one of the following:
      1. Functional but inadequate to the point of interfering with the activities of daily living; or
      2. No longer functional;
         and
   2. The request is NOT for convenience or to upgrade to a newer technology when the current components remain functional.
3. Unilateral implantation of a hybrid cochlear implant device (for example, Nucleus^® Hybrid^™ L24 Cochlear Implant System) is considered medically necessary when all of the following criteria are met (1, 2, and 3 are required):
   1. Hearing requirements for the ear to be implanted (both a and b required):
      1. Hearing loss is 60 dB or lower at 125, 250, and 500 Hz; and
      2. Hearing loss is 75 dB or greater at 2000, 3000, and 4000 Hz; and
   2. Hearing loss in the contralateral (non-implanted) ear is 60 dB or greater at 2000, 3000, and 4000 Hz;
      and
   3. Preoperative Consonant-Nucleus-Consonant (CNC) word recognition (speech perception) scores show both of the following (both a and b required):
      1. Ear to be implanted CNC score is between 10% and 60%; and
      2. Contralateral (non-implanted) ear CNC score shows both of the following criteria (i and ii required):
         1. CNC score is 80% or lower in the best-aided condition; and
         2. CNC score is higher than the ear to be implanted.

Not Medically Necessary:

1. Upgrade to or replacement of an existing external speech processor, controller or speech processor and controller (integrated system) is considered not medically necessary when the criteria specified above are not met.
2. A cochlear implant is considered not medically necessary for all other indications when the above criteria are not met, including as a treatment of tinnitus in the absence of severe hearing loss (greater than or equal to 70 dB).

II. Auditory Brainstem Implants

Medically Necessary:

1. An auditory brainstem implant is considered medically necessary in an individual when all of the following criteria are met: 
   1. Is 12 years of age or older; and
   2. Diagnosed with neurofibromatosis type 2; and
   3. Is completely deaf as a result of bilateral neurofibromas of the auditory nerve.
2. Upgrade to or replacement of an existing external sound processor, remote assistant or both components is considered medically necessary for an individual whose response to existing components is inadequate to the point of interfering with the activities of daily living or when components are no longer functional.

Not Medically Necessary:

1. Upgrade to or replacement of an existing external sound processor, remote assistant, or both components is considered not medically necessary when the criteria specified above are not met; including as a treatment for tinnitus in the absence of severe hearing loss.
2. An auditory brainstem implant is considered not medically necessary for all other indications when the above criteria are not met.

The following codes for treatments and procedures applicable to this document are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

Cochlear Implants
When services may be Medically Necessary when criteria are met:

When services are Not Medically Necessary:
For the procedure codes listed above when criteria are not met or for all other diagnoses not listed; or when the code describes a procedure or situation designated in the Clinical Indications section as not medically necessary.

Auditory Brainstem Implants
When services may be Medically Necessary when criteria are met:

When services are Not Medically Necessary:
For the procedure codes listed above when criteria are not met or for all other diagnoses not listed; or when the code describes a procedure or situation designated in the Clinical Indications section as not medically necessary.

Background Information and Description of the Technology

A person with normal hearing can perceive sounds in the 20 to 20,000 Hz frequency range. The range between 500 and 4000 Hz is most important for understanding speech. Hearing loss is objectively assessed by pure-tone audiometry. While in a sound-proof room, the subject is presented with a series of tones at different frequencies and at increasing decibel levels. Earphones are used to test air conduction hearing. A transducer is placed over bone to test bone conduction.

A decibel (dB) reflects the logarithmic ratio of different sound pressures. An increase of 10 dB shows that the sound energy is 10 times more than the lower value. The hearing threshold is defined as the lowest decibel level at which the subject perceives half of the presented tones. An individual’s thresholds typically differ at different frequencies. The American Speech-Language-Hearing Association classifies hearing loss as follows (Clark, 1981):

In addition to pure tone testing in a quiet environment, a complete audiologic assessment will include testing perception in a noisy environment and specific testing of speech recognition. In the Hearing In Noise Test (HINT), sentences are presented from the front and then from each side, both with and without sound. The results are reported as the signal-to-noise ratio at which the tested individual correctly repeats 50% of the sentences. The Consonant-Nucleus-Consonant (CNC) test is an open set word recognition test that is administered in quiet. It uses 10 recorded lists of 50 monosyllabic words to determine speech intelligibility.

In the evaluation for potential implantation of a cochlear implant, adults typically receive pure tone and speech audiometric tests with or without an external hearing aid. Infants and young children receive other objective tests of auditory function. Visual reinforcement audiometry (VRA) is preferred for measuring hearing sensitivity in children between 6 and 24 months of age. VRA uses operant techniques to reward the child for turning their head toward a sound. Once the child is trained to turn their head, sound perception can be tested at different frequencies and intensities. This testing is not appropriate for infants who are less than 6 months old because they do not respond to sound with directed head turns (Holt and Svirsky, 2008). For very young infants, audiologists can assess the auditory system with other objective measures, including evoked otoacoustic emissions (OAE) testing, auditory brainstem response testing (ABR), and auditory steady-state response testing (ASSR).

After an initial diagnosis of hearing loss is made, a cochlear implant team will perform additional testing to determine whether the individual is suitable for cochlear implantation. This testing may include additional audiologic testing to fully characterize the type and degree of hearing loss. Psychological testing is done to assess the individual’s ability to accept a central nervous system implant and to participate in post-implant rehabilitation. A full medical history and physical examination are done to ensure that there is no active infection or other contraindication to anesthesia or the implant surgery. The process often involves advanced imaging techniques such as computerized tomography or magnetic resonance imaging to evaluate the inner ear anatomy.

Tinnitus

Single- or Multi-Channel Cochlear Implantation

A cochlear implant directly stimulates the auditory nerve, bypassing the physiologic transduction of sound into neural impulses by a poorly functioning cochlea. A cochlear implant includes both external and internal components. The external components include a microphone, headset, an external sound processor, and an external transmitter/audio input selector. Internal components include an internal receiver implanted within the temporal bone and an electrode array that extends from the receiver into the cochlea through an opening created in the round window of the middle ear. The microphone picks up sounds that are carried to the external sound processor through the skin to the implanted internal receiver. The receiver converts the incoming signals into electrical impulses that are sent through the electrode array to the auditory nerve.

Several FDA-approved cochlear implant systems are commercially available in the United States.

The first cochlear implants used in the 1960s had limited utility because they could only provide stimulation at a single frequency. Devices in use since the 1970s can stimulate different areas of the cochlea separately to enable perception of different frequencies. Compared to earlier devices, currently marketed cochlear implants have improved electrode designs and speech processing capabilities. Furthermore, smaller devices and the accumulating experience with use of cochlear implants in children allow these devices to be used by children as young as 12 months of age. Specific criteria for use are different for each device. The FDA-labeled indications for each device are available on the FDA Premarket Approval (PMA) website (FDA, 2018).

Binaural hearing assists in localizing sound and understanding speech in a noisy environment. The auditory benefits enabled by binaural hearing include addressing “head shadow,” “binaural summation,” and “binaural squelch” (Gantz, 2002). Head shadow is the barrier the head creates between sounds emitted from one direction and the contralateral ear. Head shadow dampens sound reaching the contralateral ear to create an intelligible signal-to-noise or “speech-to-noise” ratio (SNR). The “signal” is the sound being focused on while the  “noise” is the background sound. Head shadow is also critical for sound localization. Binaural squelch is a central nervous system processing function that diminishes (squelches) background sound and accentuates perception of sound from the ear with the better SNR. This is essential for focus in a noisy environment such as listening to one conversation in a room full of talking people.

Centers for Disease Control and Prevention (CDC) and Other Recommendations

Cochlear implant recipients should be up-to-date with age-appropriate pneumococcal conjugate and Hemophilus influenza type b conjugate vaccinations in accordance with current CDC and the Advisory Committee on Immunization Practices (ACIP) recommendations (CDC, 2018).

In 2010, the American Academy of Pediatrics (AAP) issued a policy statement on cochlear implants in children addressing surgical site infections and prevention and treatment of acute otitis media and meningitis. This statement was reaffirmed in 2018. The policy statement includes the following recommendations:

Children with profound deafness who are candidates for cochlear implantation should receive all age-appropriate doses of pneumococcal conjugate and Hemophilus influenzae type b conjugate immunization against influenza. In addition, starting at 24 months of age, a single dose of 23-valent pneumococcal polysaccharide vaccine should be administered. Before implant surgery, primary care providers and cochlear implant teams should ensure that immunizations are up-to-date, preferably with completion of indicated vaccines at least 2 weeks before implant surgery. Imaging of the temporal bone/inner ear should be performed before cochlear implantation in all children with congenital deafness and all patients with profound hearing impairment and a history of bacterial meningitis to identify those with inner-ear malformations/cerebrospinal fluid fistulas or ossification of the cochlea (Rubin, 2010).

Efficacy and Safety of Single or Multi-Channel Cochlear Implantation

When they were first developed, cochlear implants were typically implanted only in one ear, even for individuals with severe bilateral hearing loss. It is now common to provide implants to both ears to treat bilateral severe hearing loss. Early peer-reviewed literature included several reports on individuals with bilateral cochlear implants (Long, 2003; Muller, 2002; Schoen, 2005; Tyler, 2002; van Hoesel, 2002; van Hoesel, 2003). These early reports evaluated small numbers of individuals and provided limited outcome information. Most, but not all, individuals in these studies reported very slight to modest improvements in sound localization and speech intelligibility with bilateral cochlear implants. The benefit was more likely to be experienced in noisy backgrounds, but not necessarily in quiet environments. When reported, the combined use of binaural stimulation improved hearing by only a few decibels or percentage points. This improvement appeared marginal and was thought not to outweigh the significant risks of a second implantation. (Morera, 2005).

Subsequently, several published prospective case series have shown that bilateral cochlear implants can provide some of the benefits of binaural hearing for sound localization and speech perception in both adults (Gantz, 2002; Laszig, 2004; Litovsky, 2004; Schoen, 2005; Verschuur, 2005) and in children (Kuhn-Inacker, 2004; Litovsky, 2006a). The largest and most complete of these early case studies included a case series of 30 U.S. children with sequentially placed bilateral cochlear implants (Peters, 2007).

Lammers and colleagues (2014) summarized evidence of the effectiveness of bilateral cochlear implantation compared with unilateral implantation among children with sensorineural hearing loss. A total of 21 studies evaluated bilateral implantation in children, with no randomized controlled trials identified. The authors were unable to perform pooled statistical analysis due to a limited number of studies, heterogeneity in outcomes and comparison groups, and a high risk for bias in the studies. A “best-evidence synthesis” was performed, with results “…indicating the positive effect of the second implant for especially sound localization and possibly for preverbal communication and language development.” One study demonstrated improvements in language development, although other studies found no significant improvements. The currently available evidence consists solely of cohort studies that compare a bilaterally implanted group with a unilaterally implanted control group, with only one study providing a clear description of matching techniques to reduce bias.

Cochlear Implantation in Adults with Bilateral Severe-to-Profound Hearing Loss

Over the past several decades, many studies have investigated the use of bilateral cochlear implantation in adults with severe postlingual hearing loss (Gantz 2002, Litovsky 2004, Laszig 2004, Schoen 2005, Verschuur 2005, Litovsky 2006b). When viewed together, these small retrospective case studies show that bilateral cochlear implantation can improve sound localization in most adults and may improve speech perception in others when compared with unilateral implantation.

Kraaijenga and colleagues (2017) conducted a multicenter randomized clinical trial at five tertiary referral centers. This study evaluated objective and subjective measures of simultaneous versus sequential bilateral cochlear implantation in 40 adults with postlingual severe to profound hearing loss and a maximum duration of 10 years without hearing aid use in both ears. The simultaneous bilaterally implanted group received two cochlear implants during one surgical procedure. The sequential group received two cochlear implants with an interval of 2 years between implants. Results for the two groups were compared at 1 and 3 years after implantation. The primary outcome measure was speech intelligibility in noise from straight ahead. Secondary outcome measures included speech intelligibility in noise from spatially separated sources, speech intelligibility in silence, localization capabilities, and self-reported benefits assessed with hearing and quality of life questionnaires. Nineteen participants were randomized to receive simultaneous bilateral cochlear, and another 19 participants were randomized to undergo sequential bilateral cochlear implants. The clinical and demographic characteristics of the groups were similar. Three participants in the sequential group did not receive a second cochlear implant and were unavailable for follow-up. One year after simultaneous or sequential bilateral cochlear implants, similar outcomes were observed for speech intelligibility in noise from straight ahead (difference, 0.9 dB; 95% confidence interval [CI], -3.1 to 4.4 dB) and all secondary outcome measures except for localization with a 30° angle between loudspeakers (difference, -10%; 95% CI, -20.1% to 0.0%). In the sequential bilateral cochlear implant group, all participants performed significantly better after the bilateral cochlear implants on speech intelligibility in noise from spatially separated sources and on all localization tests. This was consistent with most of the participants' self-reported hearing capabilities. Speech intelligibility-in-noise results improved in the simultaneous bilateral cochlear implant group up to 3 years following implantation. This study shows comparable objective and subjective hearing results 1 year after receiving simultaneous bilateral cochlear implants and sequential bilateral cochlear implants with an interval of 2 years between implants. Significant additional improvement was seen after the second implant for those in the sequential bilateral cochlear implant group.

A technology assessment on the effectiveness of cochlear implants in adults completed by the Tufts Evidence-based Practice Center for the Agency for Health Care Research and Quality (AHRQ, 2011). The assessment examined 22 studies with 30 or more participants and concluded that unilateral cochlear implants are effective in adults with sensorineural hearing loss. The authors noted that while reviewed studies were rated as poor-to-fair quality. Pre- and post-cochlear implant scores on multi-syllable tests and open-set sentence tests demonstrated significant gains in speech perception regardless of whether a contralateral hearing aid was used along with the cochlear implant. Additionally, the assessment found generic and disease-specific health-related quality of life improvement with unilateral cochlear implants. The available evidence was insufficient to draw conclusions on improvements in open-set sentence test scores or on the association between pre-implantation characteristics of individuals and outcomes (for example, age, duration of hearing impairment, HINT scores, and pre- or post-linguistic deafness).

Gaylor and colleagues (2013) published an update to the 2011 AHRQ technology assessment evaluating the communication-related outcomes and health-related quality of life outcomes after unilateral or bilateral cochlear implantation in adults with sensorineural hearing loss. A total of 16 of 42 studies published through May 2012 evaluated use of unilateral cochlear implants. Most unilateral implant studies showed a statistically significant improvement in mean speech scores as measured by open-set sentence or multisyllable word tests. Meta-analysis of 4 studies revealed a significant improvement in cochlear-implant relevant quality of life after unilateral implantation (standard mean difference: 1.71; 95% CI, 1.15 to 2.27). However, these studies varied in design, and there was considerable heterogeneity observed across studies.

In summary, studies of cochlear implants in adults with severe-to-profound hearing loss who only receive limited or no benefit from amplification with conventional hearing aids show consistent clinical effectiveness in speech reception (especially in noise) and in sound localization with bilateral cochlear implants.

Cochlear Implantation in Unilateral Deafness (with or without Tinnitus)

Earlier peer-reviewed evidence did not permit conclusions concerning the effect of cochlear implantation for the treatment of unilateral hearing loss (single-sided deafness), including cochlear implants for tinnitus relief in individuals with unilateral deafness. That evidence consisted of observational studies and case series with small sample sizes and heterogeneity in evaluation protocols and outcome measurements (Arndt, 2017; Arts, 2012; Dillon, 2017a; Dillon, 2017b; Mertens, 2017; van de Heyning, 2008).

Blasco and Redleaf (2014) published a systematic review and meta-analysis of studies evaluating cochlear implantation for improvement of tinnitus and speech comprehension in unilateral sudden deafness. In a pooled analysis of nine studies with 36 participants, subjective improvement in tinnitus occurred in 96% of 27 assessed participants. Subjective improvement in speech understanding occurred in 100% of 16 assessed participants, and subjective improvement in sound localization occurred in 87% of 16 assessed participants. The meta-analyses demonstrated a high degree of inter-study heterogeneity among a small study population. The authors recommended additional study with follow-up of durations longer than 24 months to compare symptoms and performance between unilateral cochlear implantation and more traditional strategies for hearing rehabilitation.

Van Zon and colleagues (2015) published a systematic review of studies evaluating cochlear implantation for single-sided deafness or asymmetric hearing loss. Nine studies (n=112 subjects) were considered in the data review. The authors could find no high-quality studies of cochlear implantation in this population. They were unable to pool the data for meta-analysis due to high between-study heterogeneity in participants (classification of hearing loss, duration of deafness, and the indication for cochlear implantation [hearing loss vs. tinnitus]), test conditions (pre-implant vs. post-implant), follow-up duration, and outcome measurement methods. The authors concluded the “current literature suggests important benefits of cochlear implantation in this population regarding sound localization, quality of life, and tinnitus. Although results for speech perception in noise are promising as well, varying results between studies were reported for this outcome.”

Sladen and colleagues (2016) conducted a prospective repeated-measures study examining speech recognition and self-perceived health-related quality of life in a cohort of 20 adults and children who received a cochlear implant for unilateral hearing loss (> 6 months, but < 2 years). Hearing loss was attributed to idiopathic sudden sensorineural hearing loss (n=15), otosclerosis (n=2), vestibular schwannoma (n=1), cholesteatoma (n=1), and bacterial sepsis (n=1). A total of 15 (75%) participants reached the 6-month post-activation point and were included in the final data analysis. A significant improvement in speech recognition in both quiet and noise was reported at the 6-month post-activation point. Consonant-Nucleus-Consonant (CNC) scores improved from 4.8% in the preoperative period to 42.3% 6 months after activation. Limitations of this study include the small sample size, comprised of predominantly younger adults with a short duration of reported hearing loss prior to implantation, and the short follow-up period. 

Sladen and colleagues (2017) retrospectively reviewed prospectively collected data of short-term outcomes for 23 adults and children who received a cochlear implant to treat single-sided deafness due to multiple etiologies (most frequently, sudden sensorineural hearing loss [n=12] and congenital conditions [n=3]). Participants had mild to severe sensorineural hearing loss with ≤ 40% CNC word recognition on the affected side and normal hearing in the nonimplanted ear. CNC word recognition improved significantly from pre-implantation to 3 months post-activation (p=0.001), but not between the 3-month and 6-month intervals in 13 of the 20 evaluable participants. There was no significant improvement in 8 participants from pre-implantation to 6 months post-activation for AzBio sentence understanding in noise (+ 5 decibels signal-to-noise). Twelve of the 13 participants who reported tinnitus prior to surgery reported subjective improvement after implantation. Limitations of this study include its small sample size with retrospectively collected data from a variable number of participants at the 3- and 6-month intervals. Additionally, study outcomes were evaluated with different testing protocols at the two participating centers. Finally, the heterogeneous study population comprised of children and adults with various hearing loss etiologies and duration of deafness limits drawing conclusions as to the net health benefit of cochlear implantation in individuals with unilateral sensorineural hearing loss.

A systematic review and meta-analysis of evidence for cochlear implantation to treat single-sided deafness in adults was published by Oh and colleagues in 2023 (Oh, 2023). The review was conducted without commercial involvement and in full accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses). The analysts found 50 studies published between 2008 and 2020 that met their inclusion criteria. Of these, 41 (82%) were prospective cohort studies, 7 (14%) were retrospective cohort studies, and 2 (4%) were case series. The 674 participants in these studies ranged in age between 19 and 93 years and had an average duration of deafness between 0.8 and 68 years. The most recent outcomes reported in the included studies occurred less than 6 months after implant for 2 studies and 36 months post-implant for 3 studies, with most of the studies reporting at 12 months. Outcomes of the review and meta-analysis are summarized in the table below. Due to heterogeneity of methods and reporting, meta-analyses could only be conducted for a portion of the studies reporting each outcome.

Daher and colleagues also performed a systematic review and meta-analysis on this topic, with results published in 2023 (Daher, 2023). As for the work separately completed by Oh, et al., the Daher review was conducted in accordance with PRISMA and had no commercial involvement. This review found 36 studies reporting spatial hearing and/or quality of life (QoL) outcomes after cochlear implants for adults with severe-to-profound sensorineural hearing loss. All of these studies were retrospective or nonrandomized prospective cohort studies with small to medium sample sizes (10-100 participants). Speech recognition in noise was reported in 25 (69%) of the reviewed studies. Meta-analysis could be conducted with data from 19 of these studies. The aggregated results showed significant improvements in speech recognition in quiet and in noise. The greatest benefit was seen when both the signal and noise were presented from the side of the head with the implanted ear (SciNnh configuration, implant on vs implant off, mean difference [MD], −6.2 dB [95% CI, −7.7 to −4.8 dB]; p <0.00001). Sound source localization outcomes were reported in 17 (47%) of the reviewed studies. Twelve of these studies reported root-means-squared (RMS) values that could be combined in a meta-analysis. That analysis showed that cochlear implant use significantly improved the RMS error for sound localization (MD, −25.3 degrees; 95% CI, −35.9 to −14.6 degrees; p<0.001). Tinnitus severity or loudness was reported in 12 of the 36 (33%) reviewed studies. Ten of these studies supported a meta-analysis of the tinnitus handicap index (THI). Compared to preoperative THI assessments, the postoperative THI was found to have been significantly improved (MD, −29.9; 95% CI, −43.9 to −16.1; p<0.001). Tinnitus loudness was assessed on a visual analog scale (VAS) in 5 studies. Meta-analysis of these 5 studies’ results showed significant postoperative loudness improvement (MD, −5.1; 95% CI, −6.5 to −4.16; p<0.001). Meta-analysis of data for QoL outcomes reported from 9 of the 36 (25%) studies also showed significant improvement (MD, 2.3; 95% CI, 1.7–2.8; p<0.001). The authors concluded that cochlear implantation to treat single-sided deafness resulted in significant improvements in speech recognition in noise, sound localization, tinnitus, and QoL. The authors noted that the small sizes of these studies and methodologic differences made it not possible for them to control for potentially confounding factors such as duration of deafness prior to implantation, cause of deafness, or age at implantation.

Although evidence of benefit from cochlear implantation to treat single-sided deafness consists of cohort studies, 2 meta-analyses indicate that cochlear implant use is associated with improved speech perception, tinnitus, sound localization, and quality of life.

Cochlear Implantation in Children 12 Months of Age and Older

The early peer-reviewed literature concerning the use of bilateral cochlear implants in children is limited. Kuhn-Inacker and colleagues (2004) observed significant improvement in speech discrimination in noise with bilateral implants compared to unilateral implants. Litovsky and colleagues (2006a) reported that 9 of 13 (70%) children with bilateral cochlear implants discriminated source separations of ≤ 20^o and 7 of 9 children performed better when using bilateral (vs. unilateral) devices. Sharma and Dorman (2006) studied congenitally deaf children to establish the existence and time limits of a sensitive period for the development of central auditory pathways in humans. The authors reported that central auditory pathways are “maximally plastic” for a period of about 3½ years in children with cochlear implants. Stimulation delivered within this timeframe results in auditory evoked potentials that reach normal values in 3 to 6 months. However, when stimulation occurs after 7 years, changes occur within 1 month, but then have little to no subsequent change.

Peters and colleagues (2007) reported experience with 30 children between 3 and 13 years old who were bilaterally implanted with sequential surgeries at least 6 months apart. All children received their first cochlear implant prior to 5 years of age. Children acquired speech perception in the second ear within 6 months. However, children under 8 years of age acquired speech perception in the second ear more rapidly and ultimately gained a higher level of speech understanding than older children. The authors reported that sequentially implanted children in all age groups showed better mean speech perception scores in background noise with bilateral implants than with a single implant. Speech performance in quiet was improved to a lesser degree, but this difference did not meet a level of statistical significance. In younger children, speech perception scores improved for 12 months following the second implant while scores for older children plateaued at 6 months. The rate of improvement in speech perception scores in the second ear was inversely related to the child’s age at the time of the second implant.

Other studies have reported benefits for children (and adults) with a unilateral cochlear implant with hearing aid in the opposite ear. Ching and colleagues (2006) reported on 29 children (and 21 adults) with unilateral cochlear implants and a contralateral hearing aid. The authors noted that both children and adults derived binaural advantages related to sentence perception in noise and localized sound that was better with bilateral cochlear implants. In another report, Holt and colleagues (2005) concluded that children with severe hearing loss who used a unilateral cochlear implant benefited from wearing an appropriately fitted hearing aid in the nonimplanted ear to maximally benefit from bilateral stimulation.

Cochlear Implantation in Infants Younger than 12 Months of Age

On November 10, 2020 the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) revised its position statement on cochlear implants to, “Consider unilateral and bilateral cochlear implantation as appropriate treatment for adults and children over 9 months of age with moderate to profound hearing loss who have failed a trial with appropriately fit hearing aids.” In April 2020, the AAO-HNS issued a position statement on pediatric cochlear implants stating:

Cochlear implantation should occur as soon as practicable, including in infants between six and 12 months of age. The Academy states that implantation below 12 months of age is associated with better language outcome and as such, implantation should not be delayed by a hearing aid trial.

Other studies and developments in clinical practice have occurred with the advent of universal neonatal hearing screening in some countries and the availability of screening programs for at-risk infants in other countries, including earlier referral, diagnosis, and intervention for infants with hearing loss. Improvements in device technology, over 2 decades of pediatric clinical experience, and a growing recognition of the efficacy of cochlear implants have led to increasing numbers of young children receiving cochlear implants. There are multiple small retrospective studies and small and large case series which suggest improved health outcomes in several objective measures in children implanted before 12 months of age. There is some data to suggest that earlier implantation leads to improved language acquisition during this critical period of development of spoken and aural language skills; it has been shown that the age at the time of auditory stimulation is a strong predictor of auditory and language outcomes (Harrison, 2005; Miyamoto, 2005; Nicholas, 2006; Sharma, 2005; Tomblin, 2005). Cumulatively, these reports and an increase in recent evidence suggest that cochlear implantation can be performed safely and successfully without serious complications in select children younger than 12 months of age with profound bilateral sensorineural deafness (Colletti, 2005b; Colletti, 2009; Dettman, 2007; Holman, 2013; Holt and Svirsky, 2008; Loundon, 2010; Roland, 2009; Tait, 2007; Valencia, 2008; Vlastarakos, 2010b; Waltzman and Roland, 2005).

In addition to information about children with congenital deafness, there are several small prospective and retrospective case reviews and a matched-pair analysis suggesting that children with profound bilateral sensorineural deafness secondary to bacterial meningitis may benefit from early cochlear implantation (El-Kashlan, 2003; Hehar, 2002; Johnson, 1995; Young, 2000). Philippon and colleagues (2010) performed a descriptive analysis of data, including the cause of meningitis, preoperative imaging evaluation, age at implantation, time lapse between meningitis and implantation, and relevant surgical findings, in an attempt to propose guidelines for the management of profound bilateral sensorineural hearing loss after bacterial meningitis. The mean age at implantation was 3 years 8 months; the mean time delay between meningitis and surgery was 2 years 1 month for the children. A total of 18 children (67%) were implanted within a year. Labyrinthitis ossificans was evidenced at the time of surgery in 62% of the total study subjects (children and adults). Open-set speech discrimination was achieved by 37% of the children (10 of 27). The authors recommended early cochlear implantation for individuals with bilateral profound deafness secondary to bacterial meningitis as an interventionist approach to avoid complications presented by labyrinthitis ossificans and to optimize hearing outcomes.

Vlastarakos and colleagues (2010a) conducted a meta-analysis of prospective controlled studies, prospective and retrospective cohort studies, clinical guidelines, and review articles reporting the diagnostic challenges and safety considerations in cochlear implantation in 125 children younger than 12 months of age. Overall, no major anesthetic complication was reported; the rate of surgical complications was reported at 8.8% (3.2% major complications), similar to the respective complication rates in older implanted children (major complications ranging from 2.3 to 4.1%). The authors summarized that cochlear implantation can be performed in otherwise healthy infants, provided that the attending pediatric anesthesiologist is considerably experienced and appropriate facilities of pediatric perioperative care are readily available. A number of concerns, with regard to anatomic constraints, existing co-morbidities or additional disorders, tuning difficulties, and special phases of the developing child should be also taken into account. The meta-analysis did not find an increased rate of anesthetic or surgical complications in implanted infants, although it identified a lack of studies with long-term follow-up reporting improved health outcomes.

Colletti and colleagues (2011) reported on the 10-year results of 19 children who received cochlear implants between the ages of 2 to 11 months, comparing them to 21 children implanted between 12-23 months and 33 children implanted between 24-35 months. Within the first 6 months post-implantation, there was no significant difference among groups in Category of Auditory Performance testing but differences became significantly better in the infant group (early implantation) at the 12- and 36-month testing.

In summary, given the strong evidence of benefit in children with profound hearing loss when cochlear implantation is performed after the age of 12 months, the additional evidence suggesting further benefit at ages under 12 months, and the lack of evidence that performing implantation at an earlier age is harmful, it is reasonable to perform cochlear implantation in children under 12 months of age.

Cochlear Implantation in Special Populations or Clinical Conditions

Several systematic reviews have evaluated outcomes after cochlear implantation for specific causes of deafness and in subgroups of the pediatric population. Eze and colleagues (2013) published a systematic review comparing outcomes of cochlear implantation for children with developmental disability with those without developmental disability. The authors stated that while approximately 30% to 40% of children who receive cochlear implants have developmental disability, evidence about outcomes in this group is limited. A total of 13 studies met the inclusion criteria that compared receptive or expressive language outcomes in children with cochlear implants with and without developmental disability. A meta-analysis of pooled data was not performed as the studies were heterogeneous in terms of comparator groups and outcome measures. Seven of the eligible studies in the structured systematic review demonstrated a significantly poor cochlear implant outcome in children with developmental disability, while the remaining 6 studies reported no significant difference in outcomes between the groups.

Humphriss and colleagues (2013) published a systematic review evaluating outcomes after cochlear implantation in a pediatric population with auditory neuropathy spectrum disorder (ANSD), a sensorineural hearing disorder characterized by abnormal auditory brainstem response with preserved cochlear hair cell function as measured by otoacoustic emissions testing. A total of 27 observational studies were selected for review, including case studies, cohort studies, and comparison studies between children with ANSD and severe sensorineural hearing loss. Eleven of the 15 noncomparative studies did not include a measure of speech recognition before cochlear implantation. Among the comparative studies, those comparing cochlear implantation to “usual care,” typically a hearing aid, provided the most information about effectiveness of cochlear implantation among children with ANSD; a single small study that used this design found no significant differences between the groups. The quality of the available evidence was limited by methodological concerns, including risk of bias and confounding.

Fernandes and colleagues (2015) evaluated 18 published studies and 2 dissertations that reported hearing performance outcomes for children with ANSD and cochlear implants. Five studies were nonrandomized controlled trials considered high quality, 5 randomized controlled trials considered low quality, and 10 were clinical outcome studies. A total of 14 studies compared speech perception in children with ANSD and cochlear implants with speech perception in children with sensorineural hearing loss and cochlear implants. Most of the studies (n=13) concluded that children with ANSD and cochlear implants developed hearing skills similar to children with sensorineural hearing loss and cochlear implants; however, these types of studies do not allow comparisons of outcomes between children with ANSD treated with cochlear implants and those treated with usual care.

In a subsequent small retrospective case series, Kontorinis and colleagues (2014) retrospectively evaluated pre- and post-cochlear implantation hearing outcomes for 27 implanted children with ANSD. Cognitive disorders were found in 4 subjects: 3 children were diagnosed with autism and another child with dyspraxia. Another child had severe additional co-morbidities (hemiplegia). One of the autistic children became a non-user of her cochlear implant. The average age at implantation was 35.4 months (range, 19-68 months) with follow-up for an average of 63.1 months (range, 6-140 months). Nine children were implanted bilaterally and 18 unilaterally. The mean preoperative categories of auditory performance (CAP) and Manchester spoken language development scale (MSLDS) scores with hearing aids were 2.5 (range, 0-5) and 2.5 (range, 0-6), respectively. The mean post-cochlear implant CAP and MSLDS scores were 5.8 (range, 2-9) and 7.7 (range 3-10), respectively. The difference between the preoperative and post-cochlear implant scores was statistically significant for both CAP (p<0.001) and MSLDS (p<0.001). In 3 children the post-cochlear implant outcomes were fluctuating. The authors identified cognitive disorders as a significantly negative prognostic factor for cochlear implant outcome. Limitations of this study include the retrospective design and lack of information on how many children would have otherwise qualified for a cochlear implant without ANSD.

In summary, additional well-designed studies are needed to draw any conclusions around the effectiveness of cochlear implantation in improving speech recognition in children with ANSD.

Hybrid Cochlear Implantation

Background Information and Description of the Technology

On March 20, 2014, the FDA granted premarket approval (PMA) status to the Nucleus Hybrid™ L24 Cochlear Implant System (also referred to as “Hybrid L24”) (Cochlear Americas, Englewood, CO) as a unilateral cochlear implant system for individuals with residual low frequency hearing sensitivity who have obtained limited benefit from bilateral conventional hearing aids. The Hybrid L24 is an electric-acoustic stimulation (EAS) cochlear implant system that consists of both internal and external components. The Hybrid L24 is designed to allow individuals to hear in two ways: electrically (similar to approved cochlear implants) for severe to profound hearing loss at mid and high frequencies, and acoustically (similar to hearing aids) for normal to moderate hearing loss at low frequencies. The Hybrid L24 includes an implant consisting of a receiver/stimulator and an intracochlear electrode array using short implant electrodes placed in the cochlea through a small cochleostomy or round window insertion to preserve low-frequency hearing. An externally worn sound processor can be fit with an acoustic component, programming software/instruments, and various remote control options. Using a small microphone, the sound processor picks up sound from the person’s surroundings and separates it into different groups of sounds by frequency (that is, the low or high "pitch" of a sound). The higher frequency information about the sound is sent to the receiver/stimulator and electrode array of the implanted part of the device. Since the electrode array is located inside the person’s cochlea, this sound-related information is relayed to the brain, allowing the person to hear. For person’s who have enough of their own acoustic low-frequency hearing after implantation, the sound processor also provides amplified low-frequency sound to the ear through the acoustic component. After implantation, some persons do not have enough low-frequency hearing to use the acoustic component so these individuals hear only electrically using the implant for all (lower and higher) sound frequencies (FDA, 2014).

The Hybrid L24 implant is intended for use in one ear by persons aged 18 years or older who obtain limited benefit from appropriately fitted conventional hearing aids in both ears and meet the following criteria (FDA, 2014):

• Typical preoperative hearing of candidates ranges from normal to moderate hearing loss in the low frequencies, with severe to profound loss in the mid to high frequencies; and
• The CNC word recognition score will be between 10% and 60%, inclusively, in the ear to be implanted in the preoperative aided condition and in the other ear will be equal to or better than that of the ear to be implanted but not more than 80% correct; and
• Previously have undergone a suitable hearing aid trial, unless already appropriately fit with conventional hearing aids.

The Hybrid L24 should not be used for individuals who have any of the following conditions:

• Deafness due to lesions of the acoustic nerve or central auditory pathway; or
• Active middle ear disease, with or without tympanic membrane perforation; or
• Absence of cochlear development; or
• Duration of severe to profound hearing loss of 30 years or greater.

Other hybrid hearing devices have been developed but do not have FDA 510(k) clearance or premarket approval for use in the U.S., including the Synchrony Electric Acoustic Stimulation (EAS) Hearing Implant System (MED-EL, USA, Durham, NC). The hybrid implant’s manufacturer states it is designed for use in individuals with “partial deafness,” that is, mild to moderate low-frequency hearing loss combined with profound hearing loss in the higher frequencies.

Efficacy and Safety of Hybrid Cochlear Implantation

The FDA approval of the Hybrid L24 was based on a multicenter, nonrandomized, unblinded single-subject study where participants served as their own control (so that post-implant performance was compared to each participant’s baseline or pre-implant performance) (Roland, 2016). According to the FDA PMA (P130016), criteria for study inclusion required that candidates be aged 18 years and older with preoperative hearing ranges from normal to moderate hearing loss in the low frequencies (thresholds no poorer than 60 decibels HL up to and including 500 hertz), with severe to profound mid-to-high frequency hearing loss (threshold average of 2000, 3000, and 4000 hertz ≥ 75 decibels HL) in the ear to be implanted, and moderately severe-to-profound mid-to-high frequency hearing loss (threshold average of 2000, 3000, and 4000 hertz ≥ 60 decibels HL) in the contralateral ear. A CNC word recognition test score was required to be between 10% and 60%, inclusively, in the ear to be implanted in the preoperative aided condition and in the contralateral ear, equal to or better than that of the ear to be implanted, but not more than 80% correct. Individuals with severe to profound high-frequency hearing loss for > 30 year’s duration or congenital hearing loss (onset prior to 2 years of age) were excluded from participation. Prospective candidates were required to go through a suitable 2-week hearing aid trial unless already appropriately fitted with conventional hearing aids.

The study was conducted at 10 United States sites, enrolled 50 participants (age at implantation, range: 23 to 86.2 years), and involved up to 9 visits before and after implantation for approximately a 1-year period. The Hybrid L24 was implanted in one ear and activated following a healing period of 2 to 4 weeks. Postoperative measurements included verification of hearing device functioning, unaided hearing thresholds and tympanometry, aided audiometric thresholds, aided CNC test in quiet, aided AzBio sentences-in-noise test, and adverse event reporting at 3-, 6-, and 12-month intervals. Co-primary effectiveness endpoints included CNC word-recognition scores and AzBio sentence-in-noise scores compared across 2 conditions: the baseline “Acoustic Alone” condition and the 6-month “postactivation Hybrid” condition. Success was defined as statistically significant improvement in both co-primary endpoint measures. A total of 49 of the 50 enrolled participants (98%) completed all effectiveness outcome assessments at the 6-month interval, while 48 participants completed the audiometric testing for hearing sensitivity; 46 subjects were evaluable at the 12-month interval. Based on data from 50 participants (including worst-case imputed scores for data missing for 1 participant), both co-primary effectiveness endpoints were met. Statistically significant improvements in mean CNC word score (35.7%: 27.8% to 43.6%; 95% CI, p<0.0001) and mean AzBio sentence-in-noise score (32.0%: 23.6% to 40.4%; 95% CI, p<0.0001) occurred from the baseline (Acoustic alone, hearing-aided) to the 6-month interval postactivation (Hybrid condition), respectively. Secondary effectiveness endpoints compared 6-month postoperative performance in the Hybrid condition to preoperative (ipsilateral) Acoustic Alone performance. All secondary endpoints were met as more than 75% of the participants performed similar to or better on each of the 3 specified measures: CNC words (96%), CNC phonemes (96%), and AzBio sentences (88%).

The primary safety endpoint was the number and proportion of participants experiencing an adverse event, defined as any surgical and/or device events. A total of 71 adverse events were reported to have occurred during the study. Of the 50 implanted participants, 34 (68%) experienced at least 1 adverse event, with multiple (2 to 4) adverse events experienced by 20 to 50 subjects; 24 of 71 adverse events in 23 participants were unresolved during the study. The two most frequently observed adverse events that were reported as resolved included tinnitus-related issues and device-related open shorts experienced by 28% and 22% of participants, respectively. By May 31, 2013, 30 of 50 (60%) participants exhibited more than a 30 decibels loss in their residual low-frequency hearing. Unresolved adverse events observed included profound/total loss of residual low-frequency hearing occurring in 22 of 50 (44%) participants. As of February 10, 2014, 6 of 50 (12%) participants were subsequently explanted and reimplanted with a standard cochlear implant. Based on these results, the FDA stated “It is yet to be determined over the long-term how many additional subjects who experience profound loss will be explanted and re-implanted with a traditional cochlear implant array.”

Despite an improvement in speech recognition in terms of CNC words and AzBio sentences reported for the majority of the study population, the FDA concluded the potential risks of profound and possibly total loss of low-frequency hearing that occurred in 44% of the participants:

…is a known risk and renders the device usage to electrical (cochlear implant) stimulation only since the acoustic amplification is ineffective for these levels of hearing loss. For subjects who lost low-frequency residual hearing to the profound/total level(s), the device showed benefit for only about half (9 of 17) or 53% of these subjects. Furthermore, 6/50 subjects who lost residual low-frequency hearing chose to undergo explantation of the Hybrid L24 and be reimplanted with an approved standard cochlear implant.

Considering the risks and benefits of the device, the FDA approved the hybrid implant only for unilateral use after a sufficient trial of conventional hearing aids, with an expiration date at 1 year. Continued approval of the PMA is contingent upon submission of periodic reports, which include reporting of device distribution in order to determine the frequency and prevalence of adverse events.

In 2016, Roland and colleagues published the results of the multicenter clinical trial presented to the FDA (2014) as part of the Nucleus Hybrid L24 implant system PMA review process. The study inclusion criteria (discussed previously in this document), evaluated 50 individuals aged 18 years or older with low-frequency hearing and severe-to-profound high-frequency sensorineural hearing loss who were implanted with the hybrid device at 10 clinical sites in the United States. Acoustic thresholds were measured for each ear preoperatively and postoperatively, at device activation, and 3, 6, and 12 months post-activation. The outcomes reported were consistent with the clinical trial data submitted to the FDA, that is, participants experienced a significant mean improvement (p<0.001) in both co-primary endpoints with the hybrid device over a preoperative hearing aid: CNC words (35.8 ± 27.9 percentage point change; 95% CI 27.9, 43.7) and AzBio sentences in noise (32.0 ± 29.4 percentage point change; 95% CI, 23.7, 40.4); secondary endpoints were met with the hybrid implant relative to performance with a hearing aid. Of the 17 participants that did not maintain functional acoustic hearing, 5 participants chose to have the hybrid implant explanted and replaced with a standard cochlear implant. A total of 65 adverse events were reported involving 34 of 50 participants. The most frequently occurring adverse events were profound/total hearing loss (22 events [33.8%] in 22 participants [40%]), open/short-circuited electrodes (11 events [16.9%] in 11 participants [22%]), and increased tinnitus or tinnitus not present preoperatively (6 events each [9.2%] in 6 participants [12%]). A total of 50 adverse events including tinnitus, vertigo, and other symptoms, were considered to be medical or surgically associated with a mastoidectomy with the facial recess approach used in cochlear implantation. Limitations of this clinical trial include the nonrandomized design, small number of participants, and short duration of follow-up.

The results of a prospective study conducted at 16 European cochlear implant centers evaluated the performance benefits up to 1 year post-Hybrid L24 implantation in terms of speech recognition, sound quality, and quality of life (Lenarz, 2013). Postoperative performance using a Freedom Hybrid sound processor was compared with that of preoperative hearing aids in 66 individuals with bilateral severe-to-profound high-frequency hearing loss. The group median increase in air conduction thresholds in the implanted ear for test frequencies 125 to1000 hertz was < 15 decibels across the population, both immediately and 1 year postoperatively. A total of 88% of subjects used the Hybrid L24 processor at 1 year post-implantation. A total of 65% of subjects had significant gain in speech recognition in quiet, and 73% in noise (≥ 20 percentage points per 2 decibel signal-to-noise ratio). The mean Speech Spatial Qualities (SSQ) of Hearing Questionnaire subscale scores were significantly improved (+1.2, +1.3, +1.8 points, p<0.001), as was the mean health utility-13 (HUI3) score (+0.117, p<0.01). Combining residual hearing with the hybrid device implantation gave 22 to 26 percentage points mean benefit in speech recognition scores over hybrid device implantation alone (p<0.01). Partially preserved residual hearing was maintained in 89% of subjects within 1 month follow-up, however, some degradation was reported over time with 74% of subjects retaining residual hearing within 30 decibels or preoperative levels at 1 year, and approximately 50% retained hearing within 15 decibels. There were 16 subjects whose 500 hertz thresholds increased by > 30 decibels, with 4 of 16 participants obtaining a large gain in speech recognition score for the implanted ear (55 to 65 percentage points), although the remainder of subjects had limited benefit as either no change (8 of 16 participants) or a reduced score was reported. One subject withdrew from the study after 1 month follow-up due to non-device related health problems and 4 subjects withdrew after 6 months follow-up. The authors reported missing data and inconsistent data collection throughout the study, in particular, at the 1-year primary endpoint for a total of 5 subjects, so only 6-month speech recognition scores were used if available for the Hybrid L24 implanted ear and best aided pre-to postoperative comparisons. Three adverse events were reported during the study which may have been related to the device or surgery, including prickling pain below the eye/sinusitis, middle-ear infection, and dizziness. Two individuals required re-positioning of the implant device due to poor fixation, and confirmed partial extrusion of the electrode array.

Gantz and colleagues (2016) reported on the final outcomes of a multicenter, longitudinal, single-subject (three- stage) study conducted between 2002 and 2011 evaluating 87 individuals implanted with a Nucleus Hybrid S8 implant for high-frequency hearing loss. Speech perception in quiet (CNC words) and in noise (Bamford-Kowal-Bench Sentences-In-Noise [BKB-SIN]) were collected pre- and postoperatively at 3, 6, and 12 months. Subjective questionnaire data were also collected using the Abbreviated Profile for Hearing Aid Benefit (APHAB). The surgical implantation of the 10-mm electrode in the scala tympani resulted in some level of hearing preservation in 98% of participants, with 90% maintaining a functional low-frequency pure tone average (PTA) at initial activation. Two participants experienced immediate postoperative total hearing loss. An additional 6 participants lost enough hearing in the low frequencies to be considered nonfunctional. At 3 months post-activation, a total of 14 participants experienced a total loss of hearing in the implanted ear and nonfunctional hearing. An additional 2 participants experienced total hearing loss at 12 months post-activation, resulting in 16 (18%) participants with nonfunctional hearing loss at 12 months. Data was available for 75 participants at the 12-month evaluation. A significant percentage of participants demonstrated improvement in speech perception as measured by CNC words: 82.5% of participants in the hybrid ear (that is, combined acoustic and electric in the same ear) and 87.5% of participants in the hybrid and combined condition (that is, acoustic plus electric combination when listening with both ears plus the Hybrid S8 device). In addition, all participants reported positive improvements in hearing in three of the four subscales of the APHAB. A total of 14 participants requested explantation of the Hybrid S8 implant for various reasons of dissatisfaction with the device and subsequently had placement of a standard length Nucleus Freedom cochlear implant. The authors concluded that combining acoustic plus electric speech processing has significant advantages for hearing-impaired individuals with residual low-frequency hearing. Limitations of this study include a lack of data to confirm the etiology of the decline in acoustic hearing sensitivity that resulted in the 19% rate of individuals with nonfunctional hearing loss at 12 months.

Kelsall and colleagues (2017) conducted a multicenter, prospective, nonrandomized, single-arm repeated measures, single-subject study of 50 adults (mean age 64.1 years) with severe to profound sensorineural hearing loss implanted with the Cochlear Nucleus Hybrid implant system. Subjects had residual low-frequency hearing with aided word recognition scores between 10% and 60% in the ear to be implanted and ≥ 80% in the contralateral ear. Patient-reported outcomes were assessed using the SSQ of Hearing Questionnaire, a device use questionnaire (DUQ), and the University of Washington Clinical Assessment of Music (UW-CAMP) questionnaire at preoperative intervals and after 6 and 12 months (SSQ and DUQ only) of hybrid cochlear implant use. Overall, significant improvements were reported at 6 and 12 months postactivation in mean SSQ ratings (p<0.0001) and in speech hearing, spatial hearing, and sound quality when compared with the bilateral hearing aid condition preoperatively. Significant improvement was also reported in overall satisfaction on the DUQ in the following measures: 1) listening in speech in various 1:1 and group conversation and listening at a distance; 2) listening in a number of non-speech environments; 3) listening to live and recorded music with and without signing; 4) locating sounds; 5) sound quality of one’s own voice, naturalness and clarity of speech, and clarity of environmental sounds; and, 6) across specific listening situations including social engagement. UW-CAMP pitch discrimination and music perception abilities were retained postoperatively. Although some limitations of this study exist, including the non-randomized design, limited sample size, short duration of follow-up, and data collected from subjective measures, the authors stated the benefits reported by study participants were consistent with the objective benefits reported by Roland and colleagues (2016) in the Hybrid L24 clinical trial.

Summary

For individuals who have high-frequency sensorineural hearing loss with preserved low-frequency hearing who receive a hybrid cochlear implant, there are inherent risks of surgical implantation, frequency of adverse events post-implantation, and the potential for profound and possibly total loss of low-frequency hearing resulting in explantation of the device and reimplantation with a standard cochlear implant. The available evidence reporting relevant outcomes includes prospective and retrospective studies using single-arm, within-subject comparison pre- and post-intervention (Gantz, 2016; Lenarz, 2013; Roland, 2016). These trials, along with the views of relevant medical specialists practicing in otolaryngology and neurotology, suggest that for individuals with high-frequency sensorineural hearing loss with preserved low-frequency hearing, hybrid cochlear implantation is associated with improvements in hearing of speech in quiet and noise. In addition, the available evidence also suggests that a hybrid cochlear implant improves speech recognition better than a conventional hearing aid alone in select individuals. 

Auditory Brainstem Implantation

Background Information and Description of the Technology

An auditory brainstem implant (ABI) is a device designed to restore some hearing in individuals with neurofibromatosis type 2 rendered deaf by bilateral surgical removal of neurofibromas involving the auditory nerve. The device consists of an externally worn speech processor that provides auditory information to an electrical signal that is transferred to a receiver/stimulator implanted in the temporal bone. The receiver stimulator is, in turn, attached to an electrode array implanted on the surface of the cochlear nerve in the brainstem, thus bypassing the inner ear and auditory nerve. The electrode stimulates multiple sites on the cochlear nucleus, which is then processed normally by the brain. One device has received FDA approval for auditory brainstem implantation, the Nucleus^® 24 Auditory Brain Stem Implant System (Cochlear Americas, Englewood, CO). The speech processor and receiver are similar to the devices used in cochlear implants; the electrode array placed on the brainstem is the novel component of the device.

Efficacy and Safety of Auditory Brainstem Implantation

The FDA approval of the Nucleus 24 Auditory Brain Stem Implant System was based on results of a case series of 90 individuals in which 28 complications occurred in 26 individuals; 26 of these complications resolved without surgical or extensive medical intervention (Donaldson, 2001). Two individuals had infections of the postoperative flap requiring explantation of the device. Effectiveness outcomes were evaluated in 60 individuals with a minimum experience of 3 to 6 months with the device. Device benefit was defined as a significant enhancement of lip-reading or an above-chance improvement on sound-alone tests. Based on this definition, a total of 95% (57 of 60) derived benefit from the device. While the use of an ABI is associated with a modest improvement in hearing, this level of improvement is considered significant in this group of individuals with no other treatment options. Among the 90 individuals receiving the implant, 16 did not receive auditory stimulation from the device postoperatively, either due to migration of the implanted electrodes or surgical misplacement. To place the electrode array on the surface of the cochlear nucleus, the surgeon must be able to visualize specific anatomical landmarks. Because large neurofibromas compress the brainstem and distort the underlying anatomy, it may be difficult or impossible for the surgeon to correctly place the electrode array. For this reason, individuals with large, longstanding tumors may not benefit from the device.

Studies reported by Colletti (2005a, 2006, 2007) showed improvements in word and sentence recognition over a 1 year follow-up.

Merkus and colleagues (2014) reported on a systematic review of ABIs for non-NF2 indications which included 144 non-NF2 ABI cases from 31 publications. Non-NF2 indications for which ABIs were evaluated included auditory neuropathy, autoimmune inner ear disease, bilateral traumatic cochlear nerve disruption, cochlear nerve aplasia, cochlear otosclerosis, temporal bone fractures, and vestibular schwannoma (in the only hearing ear). Cochlear implants generally resulted in better hearing than ABIs when the cochlea and cochlear nerve were intact. Complete bilateral disruption of the cochlear nerve from trauma did not exist in the literature and cochlear malformation did not preclude cochlear implantation. While comparative evidence is limited, cochlear implants appeared to demonstrate greater hearing benefits than ABI in individuals with non-NF2 indications. It was suggested that ABI may only have potential for improved outcomes in bilateral complete cochlear and inner ear aplasia, when imaging and electrophysiologic testing demonstrate that the cochlear nerve is absent. At this time, however, the available evidence in the peer-reviewed published literature is limited in drawing conclusions on the benefits of ABI for these individuals.

Sennaroglu and colleagues (2016) reported on the long-term outcomes of 35 of 60 prelingually deaf children in Turkey who received one of three different ABI models implanted for severe inner ear malformations. A total of 19 children in the analysis were deaf due to cochlear hypoplasia. At regular follow-up, children were evaluated with the CAP, Speech Intelligibility Rate (SIR), Functional Auditory Performance of Cochlea Implantation (FAPCI), and Manchester scores. Approximately one-half of the children were in the CAP category 5 and could understand common phrases without lip reading. In the subgroup with better hearing thresholds (25-40 decibels), some children (17.6%) were able to understand conversation without lip reading, use the telephone with known speaker (11.8%), and follow group conversation in a noisy room (5.9%). For children with higher hearing thresholds (> 50 decibels), none exceeded CAP category 5. SIR and Manchester scores were also better with greater hearing thresholds. Auditory performance measured with the FAPCI was in the 10th percentile for all groups and was worse compared to cochlear implantation. Children with additional nonauditory disabilities (for example, intellectual challenges) had worse outcomes. The authors reported that hearing progress was faster in the initial 2 years when compared with longer use of the ABI. Limitations of this study include the small number of participants in each hearing anomaly group which resulted in lack of certain statistical comparisons of outcomes. Additionally, as most children will have device failure at least two or three times over their lifespan, complications of revision surgery may result because of fibrotic changes in the lateral recess of the ear channel.

Asymmetric hearing loss (AHL): A condition in which hearing in the better ear is not normal, but can be restored using a conventional hearing aid (pure-tone average [PTA] between 30 dB HL and 55–60 dB HL).

Auditory brainstem response (ABR): A neurologic test of auditory brainstem function in response to auditory (click) stimuli; the most common application of auditory evoked responses.

Auditory evoked potential: Evaluates the nerve pathways from the ear to the brain; consists of a very small electrical voltage originating from the brain recorded from the scalp in response to an auditory stimulus (for example, different tones, speech sounds).

Auditory neuropathy spectrum disorder (ANSD): a cause of sensorineural hearing loss in which cochlear perception is normal, but auditory nerve dysfunction produces abnormal responses in the auditory brainstem. Individuals with ANSD have normal otoacoustic emission tests. They characteristically have deficits in speech perception that do not correlate with the measured degree of hearing loss.

AzBio Sentences-in-Noise Test: A test to assess a cochlear implant recipient’s ability to understand sentences in the presence of background noise.

Binaural hearing: Hearing with both ears.

Central auditory pathway: connections within the brain through which the auditory nerve transmits sensations for perception by the cerebral cortex. These include the cochlear nucleus, superior olivary complex, lateral lemnisci, inferior colliculi, medial geniculate nuclei, and the auditory cortex.

Cochlea: Part of the inner ear that processes sound.

Conductive hearing loss (CHL): Hearing loss that occurs when sound is conducted inefficiently through the outer ear canal to the eardrum and the small bones (ossicles) of the middle ear; this disorder involves a reduction in sound level or the ability to hear faint sounds.

Consonant-Nucleus-Consonant Test (CNC): An open set word recognition test (administered in quiet) consisting of 10 recorded lists of 50 monosyllabic words used to determine speech intelligibility in listeners with hearing impairments.

Decibel (dB): A unit of measurement indicating the loudness of sound. The intensity relates to how loud or soft a sound is. Sound scales are based on either sound pressure level (dB SPL) or hearing level (dB HL).

Electrically evoked auditory brainstem response (EABR): A measurement of auditory brainstem (ABR) integrity using an electrical stimulus with the purpose of determining if the auditory nerve responds as expected to electrical stimulation. The EABR test may be used presurgically in selected individuals to determine if cochlear implantation should be attempted and postsurgically to determine if the implant is working properly.

Evoked otoacoustic emissions (OAE): Sounds measured in the external ear canal that are a reflection of the working of the cochlea. OAE is used in the screening as well as the diagnosis of hearing impairments in neonates and young children. While the test is considered part of the standard battery of tests in infants, it is considered a specialized test in children and adults.

Hearing in Noise Test (HINT): A commonly used speech recognition test consisting of 250 sentences (25 lists of 10 sentences per list) performed in the evaluation of an individual’s ability to hear speech in quiet and in noise in the context of sentences.

Hearing loss: Loss of the sense of hearing due to loss of function of any part of the auditory system, including outer, middle, or inner ear, auditory nerves, or the part of the brain responsible for processing sound. Loss may be partial or entire, as well as uni- or bilateral.

Meningitis: Inflammation of the meninges, the membranes that surround the brain and the spinal cord. This condition may result in hearing loss or deafness.

Mixed hearing loss: Hearing loss that is both conductive and sensorineural, occurring in one or both ears. This term refers to a condition where conductive hearing loss coexists with sensorineural hearing loss.

Neural plasticity: Ability of the brain, certain parts of the nervous system, or both to adapt to new conditions, such as an injury.

Neurofibromatosis Type 2 (NF-2): A group of inherited disorders in which noncancerous tumors grow on several nerves that usually include the nerve involved with hearing.

Otitis externa: Inflammation or infection of the ear canal.

Otitis media: Inflammation of the middle ear caused by infection.

Postlingual deafness: Hearing loss that occurs after acquiring language or speech.

Prelingual deafness: Hearing loss that occurs before the development of language or speech.

Promontory/round window stimulation test (PST): The application of controlled electrical current to the promontory or round window niche of the middle ear. The current is delivered via an electrode that is inserted either through the tympanic membrane by myringotomy or puncture by the otolaryngologist. The test has been used to predict the electrical response of surviving spiral ganglion nerve fibers and felt to verify a functioning cochlear nerve.

Pure-tone average (PTA): The average of hearing sensitivity (that is, the minimum volume that the person hears) calculated at multiple frequencies (perceived by pitch), typically within the range of 0.25 to 8 kHz (kilohertz).

Scala tympani: The lower tube of the cochlear canal extending from the opening in the medial wall of the middle ear leading into the cochlea.

Sensorineural hearing loss: A permanent hearing loss related to the sensory or neural structures responsible for hearing that involves a reduction in sound level or ability to hear faint sounds; this disorder affects speech understanding or the ability to hear clearly; the involved structures include, but are not limited to, the cochlea and the acoustic nerve.

Severity of hearing loss: Severity of hearing loss is defined in terms of decibels (dB); graded as Mild (21-40 dB), Moderate (41-55 dB), Moderately Severe (56-70 dB), Severe (71-90 dB), Profound (91 dB or more).

Single-sided deafness (SSD): Significant or total hearing loss in one ear; this disorder is sometimes referred to as unilateral sensorineural hearing loss. SSD is defined as a unilateral severe-to-profound deafness (PTA ≥ 70 dB HL), with a contralateral ear that has better, normal or near-normal hearing (PTA ≤ 30 dB HL). SSD may be a result of a congenital unilateral hearing loss, a sudden sensorineural hearing loss, significant head trauma affecting the ear(s), and surgery to treat acoustic neuroma or other tumors of the eighth cranial nerve.

Speech recognition test: A test frequently used to determine cochlear implant candidacy; currently used tests include the following:

• Central Institute for the Deaf (CID) Test
• City of New York (CUNY) Sentence Test
• Hearing in Noise Test (HINT)
• Lexical Neighborhood Test (LNT)
• Multi-syllabic Lexical Neighborhood Test (MLNT)
• Phonetically Balanced-Kindergarten (PBK) Test

Tinnitus: A sensation of ringing or other noises heard in one or both ears which is not caused by an external sound, and other people usually can't hear it. Tinnitus is usually caused by an underlying condition, such as age-related hearing loss, an ear injury or a problem with the circulatory system.

Unilateral hearing loss (UHL): Is generally defined as a condition in which an individual has non-functioning hearing in one ear, receives little or no clinical benefit from amplification in that ear, and has normal or near normal audiometric function in the contralateral ear. UHL includes single-sided deafness (SSD) and asymmetric hearing loss (AHL).

Peer Reviewed Publications:

1. Arndt S, Laszig R, Aschendorff A, et al. Cochlear implant treatment of patients with single-sided deafness or asymmetric hearing loss. HNO. 2017; 65(Suppl 2):98-108.
2. Arts RA, George EL, Stokroos RJ, et al. Review: cochlear implants as a treatment of tinnitus in single-sided deafness. Curr Opin Otolaryngol Head Neck Surg. 2012; 20(5):398-403.
3. Baron S, Blanchard M, Parodi M, et al. Sequential bilateral cochlear implants in children and adolescents: Outcomes and prognostic factors. Eur Ann Otorhinolaryngol Head Neck Dis. 2019; 136(2):69-73.
4. Benchetrit L, Ronner EA, Anne S, et al. Cochlear implantation in children with single-sided deafness: A systematic review and meta-analysis. JAMA Otolaryngol Head Neck Surg. 2021; 147(1): 58-69.
5. Bianchin G, Tribi L, Formigoni P, et al. Sequential pediatric bilateral cochlear implantation: The effect of time interval between implants. Int J Pediatr Otorhinolaryngol. 2017; 102:10-14.
6. Blasco MA, Redleaf MI. Cochlear implantation in unilateral sudden deafness improves tinnitus and speech comprehension: meta-analysis and systematic review. Otol Neurotol. 2014; 35(8):1426-1432.
7. Bond M, Elston J, Mealing S, et al. Effectiveness of multi-channel unilateral cochlear implants for profoundly deaf children: a systematic review. Clin Otolaryngol. 2009a; 34(3):199-211.
8. Bond M, Elston J, Mealing S, et al. Systematic reviews of the effectiveness and cost-effectiveness of multi-channel unilateral cochlear implants for adults. Clin Otolaryngol. 2010; 35(2):87-96.
9. Bruijnzeel H, Ziylan F, Stegeman I, et al. A systematic review to define the speech and language benefit of early (<12 Months) pediatric cochlear implantation. Audiol Neurootol. 2016; 21(2):113-126.
10. Buss E, Dillon MT, Rooth MA, et al. Effects of cochlear implantation on binaural hearing in adults with unilateral hearing loss. Trends Hear. 2018; 22:2331216518771173.
11. Ching TY, Incerti P, Hill M, et al. An overview of binaural advantages for children and adults who use binaural/bimodal hearing devices. Audiol Neurotol. 2006; 11(1 Suppl):6-11.
12. Cohen SM, Svirsky MA. Duration of unilateral auditory deprivation is associated with reduced speech perception after cochlear implantation: A single-sided deafness study. Cochlear Implants Int. 2019; 20(2):51-56.
13. Colletti L. Beneficial auditory and cognitive effects of auditory brainstem implantation in children. Acta Otolaryngol 2007; 127(9):943-946.
14. Colletti L. Long-term follow-up of infants (4-11 months) fitted with cochlear implants. Acta Otolaryngol. 2009; 129(4):361-366.
15. Colletti L, Mandalà M, Zoccante L et al. Infants versus older children fitted with cochlear implants: performance over 10 years. Int J Pediatr Otorhinolaryngol. 2011; 75(4):504-509.
16. Colletti L, Wilkinson EP, Colletti V. Auditory brainstem implantation after unsuccessful cochlear implantation of children with clinical diagnosis of cochlear nerve deficiency. Ann Otol Rhinol Laryngol. 2013; 122(10):605-612.
17. Colletti V. Auditory outcomes in tumor vs. non-tumor patients fitted with auditory brainstem implants. Adv Otorhinolaryngol. 2006; 64:167-185.
18. Colletti V, Carner M, Miorelli V, et al. Auditory brainstem implant (ABI): new frontiers in adults and children. Otolaryngol Head Neck Surg. 2005a; 133(1):126-138.
19. Colletti V, Carner M, Miorelli V, et al. Cochlear implantation at under 12 months: report on 10 patients. Laryngoscope. 2005b; 115(3):445-449.
20. Crathorne L, Bond M, Cooper C, et al. A systematic review of the effectiveness and cost-effectiveness of bilateral multichannel cochlear implants in adults with severe-to-profound hearing loss. Clin Otolaryngol. 2012; 37(5):342-354.
21. Daher GS, Kocharyan A, Dillon MT, Carlson ML. Cochlear implantation outcomes in adults with single-sided deafness: a systematic review and meta-analysis. Otol Neurotol. 2023; 44(4):297-309.
22. Dettman SJ, Pinder D, Briggs RJ, et al. Communication development in children who receive the cochlear implant younger than 12 months: risks versus benefits. Ear Hear. 2007; 28(2 Suppl):11S-18S.
23. Dillon MT, Buss E, Anderson ML, et al. Cochlear implantation in cases of unilateral hearing loss: initial localization abilities. Ear Hear. 2017a; 38(5):611-619.
24. Dillon MT, Buss E, Rooth MA, et al. Effect of cochlear implantation on quality of life in adults with unilateral hearing loss. Audiol Neurootol. 2017b; 22(4-5):259-271.
25. Donaldson GS, Peters MD, Ellis MR, et al. Effects of the Clarion Electrode Positioning System on auditory thresholds and comfortable loudness levels in pediatric patients with cochlear implants. Arch Otolaryngol Head Neck Surg. 2001; 127(8):956-960.
26. El-Kashlan H, Ashbaugh C, Zwolan T, Telian S. Cochlear implantation in prelingually deaf children with ossified cochleae. Otol Neurotol. 2003; 24(4):596-600.
27. Eze N, Ofo E, Jiang D, O’Connor AF. Systematic review of cochlear implantation in children with developmental disability. Otol Neurotol. 2013; 34(8):1385-1393.
28. Fernandes NF, Morettin M, Yamaguti EH, et al. Performance of hearing skills in children with auditory neuropathy spectrum disorder using cochlear implant: a systematic review. Braz J Otorhinolaryngol. 2015; 81(1):85-96.
29. Firszt JB1, Reeder RM, Holden LK. Unilateral hearing loss: understanding speech recognition and localization variability-implications for cochlear implant candidacy. Ear Hear. 2017; 38(2):159-173.
30. Forli F, Arslan E, Bellelli S, et al. Systematic review of the literature on the clinical effectiveness of the cochlear implant procedure in pediatric patients. Acta Otorhinolaryngol Ital. 2011; 31(5): 281-298.
31. Galvin JJ, Fu QJ, Wilkinson EP, et al. Benefits of cochlear implantation for single-sided deafness: Data from the House Clinic-University of Southern California-University of California, Los Angeles Clinical Trial. Ear Hear. 2019; 40(4): 766-781.
32. Gantz BJ, Dunn C, Oleson J, et al. Multicenter clinical trial of the Nucleus Hybrid S8 cochlear implant: final outcomes. Laryngoscope. 2016; 126(4):962-973.
33. Gantz BJ, Tyler RS, Rubinstein JT, et al. Biaural cochlear implants placed during the same operation. Otol Neurotol. 2002; 23(2):169-180.
34. Gaylor JM, Raman G, Chung M et al. Cochlear implantation in adults: a systematic review and meta-analysis. JAMA Otolaryngol Head Neck Surg. 2013; 139(3):265-272.
35. Harrison RV, Gordon KA, Mount RJ. Is there a critical period for cochlear implantation in congenitally deaf children? Analyses of hearing and speech perception performance after implantation. Dev Psychobiol. 2005; 46(3):252-261.
36. Hehar SS, Nikolopoulos TP, Gibbin KP, O’Donoghue GM. Surgery and functional outcomes in deaf children receiving cochlear implants before age 2 years. Arch Otolaryngol Head Neck Surg. 2002; 128(1):11-14.
37. Hoff S, Ryan M, Thomas D, et al. Safety and effectiveness of cochlear implantation of young children, including those with complicating conditions. Otol Neurotol. 2019; 40(4):454–463.
38. Holman MA, Carlson ML, Driscoll CL, et al. Cochlear implantation in children 12 months of age and younger. Otol Neurotol. 2013; 34(2):251-258.
39. Holt RF, Kirk KL, Eisenberg LS, et al. Spoken word recognition development in children with residual hearing using cochlear implants and hearing aids in opposite ears. Ear Hear. 2005; 26(4 Suppl):82S-91S.
40. Holt RF, Svirsky MA. An exploratory look at pediatric cochlear implantation: is earliest always best? Ear Hear. 2008; 29(4):492-511.
41. Humphriss R, Hall A, Maddocks J, et al. Does cochlear implantation improve speech recognition in children with auditory neuropathy spectrum disorder? A systematic review. Int J Audiol. 2013; 52(7):442-454.
42. Johnson MH, Hasenstab MS, Seicshnaydre MA, Williams GH. CT of postmeningitic deafness: observations and predictive value for cochlear implants in children. Am J Neuroradiol. 1995; 16(1):103-109.
43. Johr M, Ho A, Wagner CS, Linder T. Ear surgery in infants under one year of age: its risks and implications for cochlear implant surgery. Otol Neurotol. 2008; 29(3):310-313.
44. Kalejaiye A, Ansari G, Ortega G, et al. Low surgical complication rates in cochlear implantation for young children less than 1 year of age. Laryngoscope. 2017; 127(3):720-724.  
45. Kelsall DC, Arnold RJG, Lionnet L. Patient-reported outcomes from the United States clinical trial for a hybrid cochlear implant. Otol Neurotol. 2017; 38(9):1251-1261.
46. Kim JS1, Kim LS, Jeong SW. Functional benefits of sequential bilateral cochlear implantation in children with long inter-stage interval between two implants. Int J Pediatr Otorhinolaryngol. 2013; 77(2):162-169.
47. Kontorinis G, Lloyd SK, Henderson L, et al. Cochlear implantation in children with auditory neuropathy spectrum disorders. Cochlear Implants Int. 2014; 15(1 Suppl):S51-S54.
48. Kraaijenga VJC, Ramakers GGJ, Smulders YE, et al. Objective and subjective measures of simultaneous vs sequential bilateral cochlear implants in adults: a randomized clinical trial. JAMA Otolaryngol Head Neck Surg. 2017; 143(9):881-890.
49. Kuhn-Inacker H, Shehata-Dieler W, Muller J, Helms J. Bilateral cochlear implants: a way to optimize auditory perception abilities in deaf children? Int J Pediatr Otorhinolaryngol. 2004; 68(10):1257-1266.
50. Kuo S, Gibson W. The role of the promontory stimulation test in cochlear implantation. Cochlear Implants Int. 2002; 3(1):19-28.
51. Lammers MJ, van der Heijden GJ, Pourier VE, Grolman W. Bilateral cochlear implantation in children: a systematic review and best-evidence synthesis. Laryngoscope. 2014; 124(7):1694-1699.
52. Laszig R, Aschendorff A, Stecker M, et al. Benefits of bilateral electrical stimulation with the nucleus cochlear implant in adults: 6-month postoperative results. Otol Neurotol. 2004; 25(6):958-968.
53. Lenarz T, James C, Cuda D, et al. European multi-center study of the Nucleus Hybrid L24 cochlear implant. Int J Audiol. 2013; 52(12):838-848.
54. Litovsky RY, Johnstone, PM, Godar S, et al. Bilateral cochlear implants in children: localization acuity measured with minimum audible angle. Ear Hear. 2006a; 27(1):43-59.
55. Litovsky RY, Parkinson A, Arcaroli J, et al. Bilateral cochlear implants in adults and children. Arch Otolaryngol Head Neck Surg. 2004; 130(5):648-655.
56. Litovsky RY, Parkinson A, Arcaroli J, et al. Simultaneous bilateral cochlear implantation in adults: a multicenter clinical study. Ear Hear. 2006b; 27(6):714-731.
57. Long CJ, Eddington DK, Colburn HS, et al. Binaural sensitivity as a function of interaural electrode position with a bilateral cochlear implant user. J Acoust Soc An. 2003; 114(3):1565-1574.
58. Loundon N, Blanchard M, Roger G, et al. Medical and surgical complications in pediatric cochlear implantation. Arch Otolaryngol Head Neck Surg. 2010; 136(1):12-15.
59. Lyu J, Kong Y, Xu TQ, et al. Long-term follow-up of auditory performance and speech perception and effects of age on cochlear implantation in children with pre-lingual deafness. Chin Med J (Engl). 2019;  132(16): 1925-1934.
60. Marx M, Mosnier I, Venail F, et al. Cochlear implantation and other treatments in single-sided deafness and asymmetric hearing loss: results of a National Multicenter Study including a randomized controlled trial. Audiol Neurootol. 2021; 26(6): 414-424.
61. McRackan TR, Bauschard M, Hatch JL, et al. Meta-analysis of cochlear implantation outcomes evaluated with general health-related patient-reported outcome measures. Otol Neurotol. 2018a; 39(1):29-36.
62. McRackan TR, Bauschard M, Hatch JL, et al. Meta-analysis of quality-of-life improvement after cochlear implantation and associations with speech recognition abilities. Laryngoscope. 2018b; 128(4):982-990.
63. Merkus P, Di Lella F, Di Trapani G et al. Indications and contraindications of auditory brainstem implants: systematic review and illustrative cases. Eur Arch Otorhinolaryngol. 2014; 271(1):3-13.
64. Mertens G, De Bodt M, Van de Heyning P. Evaluation of long-term cochlear implant use in subjects with acquired unilateral profound hearing loss: focus on binaural auditory outcomes. Ear Hear. 2017; 38(1):117-125.
65. Morera C, Manrique M, Ramos A, et al. Advantages of binaural hearing provided through bimodal stimulation via a cochlear implant and a conventional hearing aid: a 6-month comparative study. Acta Otolaryngol. 2005; 125(6):596-606.
66. Muller J, Schon F, Helms J. Speech understanding in quiet and noise in bilateral users of the MED-EL COMBI 40/40+ cochlear implant system. Ear Hear. 2002; 23(3):198-206.
67. Nicholas JG, Geers A. Effects of early auditory experience on the spoken language of deaf children at 3 years of age. Ear Hear. 2006; 27(3):286-298.
68. Nikolopoulos TP, Mason SM, Gibbin KP, O'Donoghue GM. The prognostic value of promontory electric auditory brain stem response in pediatric cochlear implantation. Ear Hear. 2000; 21(3):236-241.
69. Oh SJ, Mavrommatis MA, Fan CJ, et al. Cochlear implantation in adults with single-sided deafness: a systematic review and meta-analysis. Otolaryngol Head Neck Surg. 2023; 168(2):131-142.
70. Peter N, Liyanage N, Pfiffner F, et al. TheiInfluence of cochlear implantation on tinnitus in patients with single-sided deafness: a systematic review. Otolaryngol Head Neck Surg. 2019; 161(4):576-588.
71. Peters BR, Litovsky R, Parkinson A, Lake J. Importance of age and postimplantation experience on speech perception measures in children with sequential bilateral cochlear implants. Otol Neurotol. 2007; 28(5):649-657.
72. Peters JPM, van Heteren JAA, Wendrich AW, et al. Short-term outcomes of cochlear implantation for single-sided deafness compared to bone conduction devices and contralateral routing of sound hearing aids-Results of a Randomized controlled trial (CINGLE-trial). PLoS One. 2021; 16(10): e0257447.
73. Peters BR, Wyss J, Manrique M. Worldwide trends in bilateral cochlear implantation. Laryngoscope. 2010; 120 (Suppl 2):S17-S44.
74. Philippon D, Bergeron F, Ferron P, Bussieres R. Cochlear implantation in postmeningitic deafness. Otol Neurotol. 2010; 31(1):83-87.
75. Puram SV, Barber SR, Kozin ED, et al. Outcomes following pediatric auditory brainstem implant surgery: early experiences in a North American Center. Otolaryngol Head Neck Surg. 2016; 155(1):133-138.
76. Ramsden R, Greenham P, O’Driscoll M, et al. Evaluation of bilaterally implanted adult subjects with the Nucleus 24 cochlear implant system. Otol Neurotol. 2005; 26(5):988-998.
77. Reefhuis J, Honein MA, Whitney CH, et al. Risk of bacterial meningitis in children with cochlear implants. N Engl J Med. 2003; 349(5):435-445.
78. Ricketts TA, Grantham DW, Ashmead DH, et al. Speech recognition for unilateral and bilateral cochlear implant modes in the presence of uncorrelated noise sources. Ear Hear. 2006; 27(6):763-773.
79. Roland JT Jr, Cosetti M, Wang KH, et al. Cochlear implantation in the very young child: long-term safety and efficacy. Laryngoscope. 2009; 119(11):2205-2210.
80. Roland JT Jr, Gantz BJ, Waltzman SB, Parkinson AJ; Multicenter Clinical Trial Group. United States multicenter clinical trial of the cochlear nucleus hybrid implant system. Laryngoscope. 2016; 126(1):175-181.
81. Schoen F, Mueller J, Helms J, Nopp P. Sound localization and sensitivity to interaural cues in bilateral users of the Med-El Combi 40/40+ cochlear implant system. Otol Neurotol. 2005; 26(3):429-437.
82. Sennaroglu L, Sennaroglu G, Yucel E, et al. Long-term results of ABI in children with severe inner ear malformations. Otol Neurotol. 2016; 37(7):865-872. 
83. Sharma A, Dorman MF. Central auditory development in children with cochlear implants: clinical implications. Adv Otorhinolaryngol. 2006; 64:66-88.
84. Sharma A, Dorman MF, Kral A. The influence of a sensitive period on central auditory development in children with unilateral and bilateral cochlear implants. Hear Res. 2005; 203(1-2):134-143.
85. Sladen DP, Carlson ML, Dowling BP, et al. Early outcomes after cochlear implantation for adults and children with unilateral hearing loss. Laryngoscope. 2017(a); 127(7):1683-1688.
86. Sladen DP, Frisch CD, Carlson ML, et al. Cochlear implantation for single-sided deafness: a multicenter study. Laryngoscope. 2017(b); 127(1):223-228.
87. Summerfield QA, Barton GR, Toner J, et al. Self-reported benefits from bilateral cochlear implantation in post-lingually deafened adults: Randomized controlled trial. Int J Audiol. 2006; 45:1-9.
88. Tait M, De Raeve L, Nikolopoulos TP. Deaf children with cochlear implants before the age of 1 year: comparison of preverbal communication with normally hearing children. Int J Pediatr Otorhinolaryngol. 2007; 71(10):1605-1611.
89. Tomblin JB, Barker BA, Spencer LJ, et al. The effect of age at cochlear implant initial stimulation on expressive language growth in infants and toddlers. J Speech Lang Hear Res. 2005; 48(4):853-867.
90. Tyler R, Dunn CC, Witt SA, Preece JP. Update on bilateral cochlear implantation. Curr Opin Otolaryngol Head Neck Surg. 2003; 11(5):388-393.
91. Tyler RS, Gantz BJ, Rubinstein JT, et al. Three-month results with bilateral cochlear implants. Ear Hear. 2002; 23(1 Suppl):80S-89S.
92. Valencia DM, Rimell FL, Friedman BJ, et al. Cochlear implantation in infants less than 12 months of age. Int J Pediatr Otorhinolaryngol. 2008; 72(6):767-773.
93. van de Heyning P, Vermeire K, Diebl M, et al. Incapacitating unilateral tinnitus in single-sided deafness treated by cochlear implantation. Ann Otol Rhinol Laryngol. 2008; 117(9):645-652.
94. van Hoesel RJ, Ramsden R, Odriscoll M. Sound-direction identification, interaural time delay discrimination, and speech intelligibility advantages in noise for a bilateral cochlear implant user. Ear Hear. 2002; 23(2):137-149.
95. van Hoesel RJ, Typer RS. Speech perception, localization, and lateralization with bilateral cochlear implants. J Acoust Soc Am. 2003; 113(3):1617-1630.
96. Van Schoonhoven J, Sparreboom M, van Zanten BG, et al. The effectiveness of bilateral cochlear implants for severe-to-profound deafness in adults: a systematic review. Otol Neurotol. 2013; 34(2):190-198.
97. van Zon A, Peters JP, Stegeman I, Smit AL, Grolman W. Cochlear implantation for patients with single-sided deafness or asymmetrical hearing loss: a systematic review of the evidence. Otol Neurotol. 2015; 36(2):209-219.
98. van Zon A, Smulders YE, Stegeman I, et al. Stable benefits of bilateral over unilateral cochlear implantation after two years: a randomized controlled trial. Laryngoscope. 2017; 127(5):1161-1168.
99. Verschuur CA, Lutman ME, Ramsden R, et al. Auditory localization abilities in bilateral cochlear implant recipients. Otol Neurotol. 2005; 26(5):965-971.
100. Vlastarakos PV, Candiloros D, Papacharalampous G, et al. Diagnostic challenges and safety considerations in cochlear implantation under the age of 12 months. Int J Pediatr Otorhinolaryngol. 2010a; 74(2):127-132.
101. Vlastarakos PV, Nazos K, Tavoulari EF, Nikolopoulos TP. Cochlear implantation for single-sided deafness: The outcomes. An evidence-based approach. Eur Arch Otorhinolaryngol. 2014; 271(8):2119-2126.
102. Vlastarakos PV, Proikas K, Papacharalampous G, et al. Cochlear implantation under the first year of age-the outcomes. A critical systematic review and meta-analysis. Int J Pediatr Otorhinolaryngol. 2010b; 74(2):119-126.
103. Waltzman SB, Roland JT Jr. Cochlear implantation in children younger than 12 months. Pediatrics. 2005; 116(4):e487-e493.
104. Young NM, Hughes CA, Byrd SE, Darling C. Postmeningitic ossification in pediatric cochlear implantation. Otolaryngol Head Neck Surg. 2000; 122(2):183-188.

Government Agency, Medical Society, and Other Authoritative Publications:

1. Agency for Healthcare Research and Quality (AHRQ). Effectiveness of cochlear implants in adults with sensorineural hearing loss [Internet]. Technology Assessment Report. April 11, 2011. Project ID: AUDT0501. Available at: http://www.cms.gov/Medicare/Coverage/DeterminationProcess/downloads/id80TA.pdf. Accessed on May 15, 2023.
2. American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS). Minimal test battery for cochlear implants. Reaffirmed April 21, 2021. Available at: https://www.entnet.org/resource/position-statement-minimal-test-battery-for-cochlear-implants/. Accessed on May 15, 2023.
3. American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS). Clinical practice guideline: Sudden hearing loss (update). April 19, 2021. Available at: https://www.entnet.org/quality-practice/quality-products/clinical-practice-guidelines/sudden-hearing-loss-update/. Accessed on May 15, 2023.
4. American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS). Position statement: pediatric cochlear implants candidacy. Apr 5, 2021. Available at: https://www.entnet.org/resource/position-statement-pediatric-cochlear-implantation-candidacy/. Accessed on May 15, 2023.
5. American Academy of Otolaryngology -- Head and Neck Surgery. Position Statement: Cochlear Implants. April 5, 2021. Available at: https://www.entnet.org/resource/position-statement-cochlear-implants/. Accessed on May 15, 2023.
6. Bond M, Mealing S, Anderson R, et al. The effectiveness and cost-effectiveness of cochlear implants for severe to profound deafness in children and adults: a systematic review and economic model. Health Technol Assess. 2009b; 13(44):1-330.
7. Centers for Disease Control and Prevention (CDC). Immunization Schedules. Available at: http://www.cdc.gov/vaccines/schedules/index.html. Accessed on May 15, 2023.
8. Centers for Disease Control and Prevention (CDC). Vaccines and preventable diseases: cochlear implants & meningitis vaccination. Reviewed January 27, 2022. Available at: https://www.cdc.gov/vaccines/vpd/mening/hcp/dis-cochlear-gen.html. Accessed on May 15, 2023.
9. Centers for Medicare and Medicaid Services (CMS). National Coverage Determination: Cochlear Implantation. NCD #50.3. Effective April 4, 2005. Available at: https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=245&ncdver=2&DocID=50.3&list_type=ncd&bc=gAAAABAAAAAA&. Accessed on May 15, 2023.
10. O'Connell BP, Holcomb MA, Morrison D, et al. Safety of cochlear implantation before 12 months of age: Medical University of South Carolina and Pediatric American College of Surgeons-National Surgical Quality improvement program outcomes. Laryngoscope. 2016; 126(3):707-712.   
11. Pichora-Fuller MK, Santaguida P, Hammill A, et al. Evaluation and treatment of tinnitus: Comparative effectiveness. Comparative Effectiveness Review No. 122. Prepared by the McMaster University Evidence-based Practice Center under Contract No. 290-2007-10060-I. AHRQ Publication No. 13-EHC110-EF. Rockville, MD: Agency for Healthcare Research and Quality (AHRQ); August 2013.
12. Rubin LG, Papsin B. Committee on Infectious Diseases and Section on Otolaryngology-Head and Neck Surgery. Cochlear implants in children: surgical site infections and prevention and treatment of acute otitis media and meningitis. Pediatrics. 2010; 126(2):381-391.
13. U.S. Food and Drug Administration (FDA). Summary of Safety and Effectiveness Data (SSED): Nucleus 24 Cochlear Implant System (Cochlear Americas, Centennial CO). P970051/S172. March 17, 2020. Available at: https://www.accessdata.fda.gov/cdrh_docs/pdf/P970051S172B.pdf. Accessed on May 15, 2023.
14. U.S. Food and Drug Administration (FDA). Summary of Safety and Effectiveness Data (SSED): MED-EL Cochlear Implant System (MED-EL Corp., Innsbruck, Austria). P000025/S104. July 19, 2019. Available at: https://www.accessdata.fda.gov/cdrh_docs/pdf/P000025S104B.pdf. Accessed on May 15, 2023.

1. National Institute on Deafness and other Communication Disorders (NIDCD). Hearing, ear infections, and deafness. Available at: http://www.nidcd.nih.gov/health/hearing/Pages/Default.aspx. Accessed on May 15, 2023.
   • Cochlear implants. Updated March 24, 2021.
   • Vestibular schwannoma (acoustic neuroma) and neurofibromatosis. Updated March 6, 2017.

Auditory brainstem implants
Cochlear implants
Med-El Cochlear Implant System
MED-EL COMBI 40+ Cochlear Implant System
Nucleus hybrid L24 implant system

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