Cochlear Implants: Candidacy
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Cochlear Implant Candidacy
Before a child is considered for cochlear implantation, he or she must meet the selection criteria to be implanted with the device. There are basic minimal requirements that must be met related to the child's type of hearing loss and hearing levels. There are also multiple associated issues for consideration in determining if the decision to pursue the surgical procedure and long-term commitment necessary to benefit from the device is an appropriate one.
Pediatric Implant Candidacy
As determination of implant candidacy is complex, it is recommended that the candidacy process include a team approach that includes the family and professionals from both the medical and educational settings involved with the child. Candidacy determinations should be multidimensional and look at all areas of the child's development. This will ensure that each child is an appropriate candidate for a cochlear implant, that the family has realistic expectations regarding outcomes for the implant, and that appropriate supports are in place to actualize benefit from the technology. While each hospital implant center may have unique candidacy requirements, general candidacy issues for children are as follows:
- In 2002 the FDA lowered the recommended age requirement to 12 months. While this is the FDA-recommended age, it is not legally binding and some hospital centers in clinical trials are completing the procedure earlier based on expectations of improved outcomes for early implantation. In addition, specific circumstances may allow for earlier implantation. For example, if meningitis is the cause of hearing loss, it may be important for the child to be implanted as early as possible as this condition causes ossification (bone build up) in the cochlea, making it increasingly difficult to surgically insert the electrode array as time passes. (Note: There may be difficulty obtaining insurance payment for the procedure if it is completed prior to the FDA-recommended age recommendation of 12 months.)
- For children from 12 to 24 months, the FDA recommends that a child have bilateral profound sensorineural hearing levels. For children from 25 months to 17 years 11 months, the recommendation widens to sensorineural hearing levels in the severe to profound range. Each implant manufacturer has its own label indications related to candidacy for its device. A child who is failing to progress in speech, listening, and spoken language development with traditional hearing aids based on parent report and observational questionnaires may be considered as a candidate.
- There are varied implant center requirements regarding timelines for the trial use of hearing aids prior to implantation. Some centers waive an extended hearing aid trial requirement in the interest of early implantation when it is clear that the child will perform better with a cochlear implant than with a hearing aid.
- A family's ability to commit to necessary follow-up, including mapping appointments and speech, language, and listening habilitation follow-up, may impact a child's candidacy for the procedure.
- There should be no medical contraindications to electrode insertion or receiver placement.
- The educational and home environments should be supportive of facilitating maintenance and care of the device and development and use of spoken language.
Some characteristics of a child who may not be a candidate for a cochlear implant include:
- No eighth nerve (auditory nerve) to carry sound from the cochlea to the brain as determined by a CAT scan (x-ray) and/or Magnetic Resonance Imaging (MRI) during the candidacy process
- Medical contraindications where a child may not be able to tolerate the surgery
- A unilateral hearing loss
- A conductive hearing loss
- Substantial access to sound from the technology of state-of-the-art digital hearing aids or other hearing devices (without surgical intervention, these devices may be an equally effective choice for some children)
Other Candidacy Considerations
- While increasing numbers of children with challenges in addition to being deaf are receiving cochlear implants, some hospital implant centers may not consider implanting children who have severe emotional, behavioral, or cognitive delays that may interfere or limit benefit from the device.
- There are older children and teens who have been deaf from birth and for whatever reasons have not consistently used hearing aids to stimulate the auditory pathways. Some hospital centers may not consider these individuals to be candidates related to evidence that the brain has been reorganized and may not be able to make sense of the incoming signals1.
- While cochlear implants are typically used with individuals who have sensorineural hearing loss, use of a cochlear implant is considered as a possible intervention for some children with Auditory Neuropathy Spectrum Disorder (ANSD) which has previously been referred to in the literature as Auditory Neuropathy (AN) and Auditory Dys-synchrony (AD). ANSD is a relatively complex type of hearing loss that is believed to be due to abnormalities at the synapse of the inner hair cell and auditory nerve and/or the auditory nerve itself. ANSD can cause problems on two fronts: 1) Hearing levels-it can result in a hearing loss of any degree (mild, moderate, severe, or profound), and 2) Speech discrimination-it can result in speech sounding very distorted. In some instances, a person with ANSD can have a relatively mild hearing loss demonstrated on an audiogram but speech sounds so distorted to him or her that he or she experiences severe problems when trying to understand conversation on a day-to-day basis2. As more is becoming known about ANSD electrophysiological tests, together with imaging, can possibly provide information regarding the underlying condition that is causing the ANSD which may be able to better guide if a child is a good candidate for an implant3.
- There are implant devices designed for individuals with usable acoustic hearing in the low frequencies. These devices are known as electro-acoustic (EAS) or hybrid devices. Candidacy for these devices continues to change. For more information:
For general information on CI candidacy requirements:
Boys Town National Research Hospital, Candidacy
Boys Town National Research Hospital, Cochlear Implants: Frequently Asked Questions for Primary Care Physicians (PDF)
Niparko, J., Lingua, C., & Carpenter, R. (2009). Assessment of candidacy for cochlear implantation. In J. K. Niparko (Ed.), Cochlear implants: Principles & practice (2nd edition, pp. 313-345). Baltimore: Lippincott Williams & Wilkins.
For more information about cochlear implant candidacy:
Gifford, R. (2011, June). Who is a candidate for a cochlear Implant? The Hearing Journal, 64(6), 16,18-22.
1 Sharma, A., Nash, A. A., & Dorman, M. (2009). Cortical development, plasticity and re-organization in children with cochlear implants. Journal of Communication Disorders, 42(4), 272-9.
3 Gardner-Berry, K., Gibson, W., & Sanli, H. (2005, November). Pre-operative testing of patients with neuropathy or dys-synchrony. Emerging trends in cochlear implants. The Hearing Journal, 11, 24-25, 28, 30-31.
Developed by Debra Berlin Nussbaum at the Cochlear Implant Education Center, Laurent Clerc National Deaf Education Center; last revised May 2012