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Borderline Cochlear Implant Candidates

October 25th, 2013 by | Tags: , , | 7 Comments »

For many who receive a CI, the choice is clear-cut: hearing aids simply do not provide sufficient benefit for language and listening to people with profound hearing loss when compared to the performance of a cochlear implant.  But what about hearing aid users who are doing “well enough” with their current technology, but are on the fence about whether or not a cochlear implant is the right option for them?  This can be a very tricky decision, because there’s no going back.  Even though today’s cochlear implantation techniques have improved and it is often possible to preserve residual hearing, going back to a hearing aid after receiving a cochlear implant is not as simple as trying on a new pair of glasses.  That said, we are seeing some really superior results in patients who initially would never have been considered as CI candidates, but, once they received their cochlear implants, are showing remarkable improvements (see links at the end of this article)1,2.


HOW do you know when it might be time to make the leap to a cochlear implant (or two) for yourself or your child1?

  • Aided thresholds are not at the TOP of the “speech banana.”  Only hearing “somewhere” inside the speech banana is not enough.  If your thresholds make a line through the middle of that region, you’re still missing a significant amount of speech sound information — and that’s at conversational levels!  Imagine what you/your child are missing in soft speech.
  • Aided speech perception scores for soft speech (30 dB SPL) and conversational speech (50dB SPL) in quiet and in noise are not in the excellent range (90% +).  Jane Madell is famous for saying of speech perception score, “If it wouldn’t be good on a math test, it’s not good on a speech perception test.”  Scores of 50, 60, 70% etc. mean that your child, in sound booth-quality conditions, with no other distractions, is still having to guess nearly half the time.  That’s no way to go through life — it’s tough, it’s exhausting, and, for developing language learners, it’s going to lead to a real uphill battle toward language competence.
  • Insufficient progress even with appropriate auditory-based therapy.  If a hearing aid user is enrolled in listening and spoken language therapy with an experienced professional, devices are worn all waking hours, and the family is committed to home carry-over but is still not progressing at the expected rate, it may be time to consider a change in technology.
  • Lack of access to all speech sounds.  If your/your child’s hearing aids are doing “pretty well” in general, but you still cannot hear soft, high-frequency speech sounds like f, sh, th, it may be time to switch.  This is especially true and VERY crucial for young children who are just developing speech.  If they can’t hear it to imitate it, they’re going to have to learn to speak by seeing — a very ineffective method that can lead to unnatural production and poorer voice quality (remember, we only SPEAK as well as we HEAR).
  • It’s important to remember that FDA guidelines are just that: guidelines.  They are not laws and surgeons have leeway to use their professional judgment to provide cochlear implants “off label” to patients who they feel would benefit (just as physicians can prescribe medicines “off label” to benefit patients for reasons other than their intended use).  Remember also that the FDA criteria for CIs are years old at the point, while cochlear implant technology is progressing every day.  The FDA guidelines have not kept up with our improvements in CI technology and rehabilitation.


WHEN is the right time to make the switch?  My bias is: the sooner the better!  Once an appropriate battery of auditory and speech-language tests have been done to establish that YES, a cochlear implant is a good option, the time to move is NOW.  For adults who are long-term hearing aid users, why wait to reap the benefits in quality of life and ease of communication that the CI can offer?  For children, every month without full, complete access to sound is taking precious time away from a brain ready to soak up listening and language.  Going back and forth and delaying a CI will only make the rehabilitation harder when that ear, used to dealing with the sound from a hearing aid, has to re-learn how to hear with a cochlear implant.


WHO should you consult?  If you feel that a cochlear implant could benefit you or your child, the first step is to speak with your audiologist.  If he/she is primarily experienced in hearing aids, it may be time to seek a second opinion.  You want an audiologist with plenty of cochlear implant experience who is an aggressive advocate for his patients.  Studies also show that borderline candidates who work with otolaryngologists whose primary focus is cochlear implantation receive cochlear implants more frequently than patients whose ENTs are  generalists2.


Speaking from clinical experience, I have seen many children who are borderline candidates for any number of reasons (speech perception is “too good” with hearing aids, auditory neuropathy cases, kids who are perceived as “great performers” with their hearing aids) go on to receive cochlear implants and do remarkably well with them.  We must remember that hearing aids simply amplify sound but still drive that sound through a fundamentally compromised system (the cochlea of someone with sensorineural hearing loss).  Even if the sound is louder, that cochlea still has damage and is not performing 100%.  And when we amplify sounds loud enough, we often run into issues with feedback and distorting the sound.  For these children, moving to a cochlear implant (or two) has made a world of difference.  Anecdotes are not evidence, though, and more research is needed to support our clinical judgment that, for many borderline hearing aid users, the cochlear implant is the right choice.



1 Madell, J. R. and Gifford, R.  Expanding Criteria for Cochlear Implantation.  AudiologyNOW 2010.

2 Tobey, E. (2010, February 16). The Changing Landscape of Pediatric Cochlear Implantation : Outcomes Influence Eligibility Criteria. The ASHA Leader.

Written by

Elizabeth Rosenzweig MS CCC-SLP LSLS Cert. AVT is a Listening and Spoken Language Specialist Certified Auditory Verbal Therapist. She provides auditory verbal therapy, aural rehabilitation, IEP advocacy, consultation, and LSLS mentoring for clients around the world via teletherapy. You can learn more about Elizabeth's services on her Website or Facebook.



November 14, 2013 at 11:00 pm

Hi, I loved your article!! My daughter, born with severe-to-profound hearing loss was one of those tricky border line cases. She has worn hearing aids since she was 10 weeks old and was a very good hearing aids user. Thanks to AVT and the guidance of skilled professionals, her speech and general development were coming along just like a hearing kid. However our consultant still believed that CI was the way to go. We weren’t sure so we had her assessed in three hospitals and, in the end, she was implanted in last May, when she was almost 20 months old. Needless to say that it was the best decision we ever too! She can hear just so well with her CIs and her speech is improving every day!


November 20, 2013 at 2:53 am

Thanks for the kind words, Stella! I’m so glad the CI has helped your daughter!



December 13, 2013 at 12:11 am

My son is 23 months old and has behind-the-ear hearing aides. His hearingloss is mild/moderate in the higher frequencies. It *should* not be a huge issue, but he does not speak at all. He’s terrible about wearing his aides, because he can’t stand to have anything in his ears.

It’s gotten to a point we don’t put them in at all anymore, since we couldn’t tell the difference between him with or without aides. He acts like he cannot hear you, even though we know he can. He pulls the aides out, chews them up and you’re left to try and find the pieces somewhere in the house.

He will be having an Autism screening soon, as we suspect that may have something to do with his complete lack of communication, even after receiving 6 months of EI therapy.

Would a child like that qualify for an implant? Due to behavior, rather than severe hearing issues.


January 2, 2014 at 4:12 pm

Before determining whether or not your son could benefit from cochlear implants, it is important for him to be using hearing aids to their fullest potential to determine whether or not he benefits. I would recommend a consultation/evaluation with an autism specialist to get the behaviors under control so you can see his true abilities with the hearing aids, and then go forward with CI candidacy, if necessary. We have to peel back the layers of “what is behavior-related?” and “what is hearing-related?” to make the best decision.


June 26, 2014 at 5:35 am

my son is a borderline case as well, and I’m dilemma to CI or not CI.
His aided for 4kHz is 45 db and other freq are at 30-35 dB. His speech is clear except the high frequencies sounds. I don’t know if it is because he doesn’t hear it well or because of wrong place/manner.
And I’m also confused with HINT test result given to me. I used to read that they give scores in percentage. What my audiologist told me is that my son can repeat sentences in quiet when sounds presented at 57dB. I guess that is not good enough and he should be a CI candidate?
Pls advice.

July 1, 2014 at 10:38 pm

Good question! Aided hearing at 45dB at 4000Hz is not sufficient for your son to have access to speech sounds in quiet and in noise. At that level, he will only hear them if the speaker is close, loud, and in a quiet environment. That is not a good recipe for learning speech and language. In addition, I’m assuming that his hearing above 4000Hz is at 45dB or poorer, and there is lots of important consonant information above the 4000Hz level. Yes, HINT scores should be given as a percentage correct. I’m wondering what the audiologist’s cut off is? Does she mean he gets 50% correct at 57dB? 80% correct? Either way, if he needs speech to be at 57dB to hear it, that means he’s missing a lot of conversational and soft speech. I would get a second audiological opinion, because, to me, without know the specifics of his case, it seems like there are strong indicators that he could benefit from a CI.

[Please note that advice offered is general in nature and is not a substitute for the services of your personal hearing healthcare professionals]


July 1, 2014 at 11:53 pm

Apart of formal tests we took, I also noticed my son could not detect /s/ sound at distances more than 3 feet. He can detect other Ling sounds at 10 feet, but not /s/ sound.

Thank you for the information. It gives me some points to discuss/ask the audiologists.I should ask my audiologist for the cut-off.

My audiologist primarily handle Hearing aids users and was an ENT just like you said in your post.

Knowing the limitations in term of experiences and tests that the audiologists may have,I have to find information by myself to be more informed and to prompt/question the audiologists.

I think it’s time for me to seek second opinion too.