Clin Geriatr Med 22 (2006) 677–686

Cochlear Implants
Sarah S. Connell, MD, Thomas J. Balkany, MD*
Department of Otolaryngology, University of Miami Ear Institute,
Miller School of Medicine, PO Box 016960, Miami, FL 33101, USA

Based on data from the National Center for Health Statistics, more than
2.2 million adults in the United States older than 70 have significant hearing
impairment, making hearing loss the third most common chronic health con-
dition affecting older adults [1]. An estimated 10% of individuals who have
sensorineural hearing loss experience impairment so advanced that conven-
tional amplification provides little benefit [2]. During the past 2 decades,
improvements in cochlear implant (CI) devices and surgical techniques
have made this form of aural rehabilitation a viable option for many geriatric
patients. This article reviews current applications for multichannel CIs in
elderly patients, the impact on quality of life, the evidence for safety and
effectiveness, and promising new approaches for future technologic direc-
tions in bilateral cochlear implantation and electric acoustic hearing.

Epidemiology and clinical features

In the Epidemiology of Hearing Loss Study (Beaver Dam, Wisconsin,
1993–1995 and 1998–2000), Cruickshanks and colleagues describe the risk
for incident hearing loss as greater for men than women. The average age
of onset was 65.9 years for men and 72.9 years for women [1]. This young
age of onset suggests that older adults face many years of life with hearing
impairment. The specific causes of presbycusis represent a combination of
the effects of years of use, exposure to noise, chemical exposure, and genet-
ically programmed biologic degeneration. Morphologic changes in humans
demonstrate age-related loss of inner and outer hair cells and supporting
cells, primarily from the basal turn of the cochlea.

* Corresponding author. Department of Otolaryngology, Miami Ear Institute, Miller

School of Medicine, PO Box 016960, Miami, FL 33101, USA.
E-mail address: Tbalkany@med.miami.edu (T.J. Balkany).

0749-0690/06/$ - see front matter Ó 2006 Elsevier Inc. All rights reserved.
doi:10.1016/j.cger.2006.04.003 geriatric.theclinics.com
678 CONNELL & BALKANY

Geriatric patients who have hearing loss often are burdened further with
the inability to communicate effectively because of cognitive impairment or
development of depression, independent of socioeconomic status. Patients
also experience tinnitus, poor voice monitoring, and difficulty using the tele-
phone. There are additional reports correlating hearing loss with social iso-
lation, poor self-esteem, and dementia. Despite the high numbers of people
afflicted with this disorder, only 25% of patients who could benefit from
hearing aids use them [3,4]. Unique to the older population is the effect of
hearing loss compounded by other perceptual deficits, including dementia,
visual impairment, or peripheral neuropathy. Overcoming age-related
changes in the auditory system, diminished communication abilities, and
coexisting medical and psychosocial problems, elderly adults with CIs
achieve excellent audiologic and quality-of-life measures.

History
Even though scientists in the 1700s were aware that electrical stimulation
could produce auditory sensation, it was not appreciated until 1957 that
some speech understanding was possible with electrical stimulation of the
cochlear nerve. In the 1980s, single channel CIs were accepted as safe and
efficacious therapy for individuals who had profound hearing loss. Since
then, improvements in microelectronics, battery technology, packaging,
and signal processing have broadened the application of this tool, such
that there are more than 80,000 (as of September 2005) CI users worldwide,
two thirds of whom are adults [5] (Steve Staller, personal communication,
2005).

Mechanism of cochlear implants

In humans, sounds are converted from mechanical to electrical energy
by hair cells within the cochlea. The CI serves to bypass this apparatus
and provide direct electrical stimulation to auditory neurons. A CI is a sur-
gically placed device that provides speech perception to individuals for
whom hearing aids are not useful. Environmental sounds are transformed
by a microprocessor into electrical signals, which are broadcast over multi-
ple electrode channels. These electrodes are placed into the cochlea in a way
that takes advantage of its tonotopic arrangement (ie, high frequencies are
present at the basal turn and low frequencies represented in the apex). CIs
work differently from hearing aids: hearing aids amplify sound. A CI, alter-
natively, transforms speech and other sounds into electrical energy that is
used to stimulate surviving auditory nerve fibers in the inner ear. Unlike
most hearing aids, CIs have internal and external components. A surgical
procedure is needed to place the internal processor component of the
implant.
 COCHLEAR IMPLANTS 679

Hearing aids send amplified sound through the outer and middle ear and
finally to the sensory receptor cells (commonly called hair cells) in the inner
ear. The function of the hair cells is to change (transduce) the sound energy
into electrochemical signals that are recognized by the hearing nerve. When
hair cells are damaged or dead, parts of the signal may be distorted, or may
not be sent to the hearing nerve at all. Because hair cell damage is by far the
most common cause of hearing loss, CIs bypass the damaged hair cells and
replace their function by converting sound energy into electrical energy that
can stimulate the auditory nerve directly. The nerve recognizes this stimula-
tion in much the same way normal sound is recognized, and the information
is sent along the nerve to the brain where meaning is attached.

Cochlear implant components

All CI devices consist of internal and external hardware. External compo-
nents are worn either behind the ear or on the body. They consist of a micro-
phone, a sound processor, batteries, and a transmitter that sends coded
electrical information and power to the internal parts. The internal compo-
nents, which are placed surgically underneath the skin, include a receiver
and an electrode array within the cochlea. Currently there are three CI de-
vices available: HiResolution Bionic Ear (Advanced Bionics Corp, Valencia,
California), Nucleus (Cochlear Americas, Englewood, Colorado), and
Combi 40/40 þ (Med-el, Innsbruck, Austria). Similarities include type of
components, such as body-worn and behind-the-ear sound processors.

Fig. 1. Mechanisms of CIs. (1) Sounds are picked up by the small, directional microphone
located in the ear-level processor. (2) The speech processor filters, analyzes, and digitizes the
sound into coded signals. (3) The coded signals are sent from the speech processor to the trans-
mitting coil. (4) The transmitting coil sends the coded signals as FM radio signals to the CI un-
der the skin. (5) The CI delivers the appropriate electrical energy to the array of electrodes,
which has been inserted into the cochlea. (6) The electrodes along the array stimulate the re-
maining auditory nerve fibers in the cochlea. (7) The resulting electrical sound information is
sent through the auditory system to the brain for interpretation.
680 CONNELL & BALKANY

Differences include size, weight, color, batteries, and number of intraco-

chlear stimulus contacts. The mechanisms of CIs are shown in Fig. 1.

Indications
The first step in the work-up of patients who have hearing loss is an audio-
gram. This battery of tests includes pure tone thresholds from 250 to 8000 Hz,
word recognition tests, speech reception thresholds, acoustic reflexes,
and tympanometry. The majority of hearing loss in elderly patients is senso-
rineural. In mild to severe loss, hearing aids can be an effective therapy for
social function, communication, and depression [6]. For those patients who
cannot benefit from hearing aids because of the configuration or magnitude
of their hearing loss or discrimination abilities, however, CIs are a good
option.
Audiometric criteria for cochlear implantation include bilateral severe to
profound sensorineural hearing loss and pure tone average threshold (500,
1000, and 2000 Hz) worse than 70 dB hearing level. Patients undergo rigor-
ous testing with appropriately fitted hearing aids and those who have less
than 50% open-set recognition on taped sentence material also are candi-
dates. High-resolution CT or MRI of temporal bones is performed to eval-
uate for cochlear ossification, the presence of a cochlear nerve, evidence of
prior ear surgery, and active mastoiditis. Patients should have no medical
contraindications to general anesthesia or any contraindications to surgical
intervention or postoperative follow-up. Absolute contraindications include
agenesis of the inner ear (Michel deformity), absence of the cochlear nerve,
and systemic illness precluding anesthesia or surgery (Box 1). Patients must
demonstrate psychologic stability and suitable motivation with realistic ex-
pectations for outcomes [7]. Selection criteria for choosing the ear are shown
in Fig. 2 [8].

Box 1. Current selection criteria for adult cochlear implantation

Moderate to profound bilateral sensorineural hearing loss
Less than 40% correct in best-aided condition on tape-recorded
test of open-set sentence cognition
No contraindications to surgical placement of internal device
and electrode array
Benefit from hearing aids less than expected from CIs
No medical contraindications to undergoing general anesthesia
Family support, motivation, and appropriate expectations
Absence of external or middle ear pathology or contraindication
to participation in postoperative follow-up or evaluation
 COCHLEAR IMPLANTS 681

Fig. 2. Considerations for selecting the ear to be implanted. aAfter candidate meets implanta-
tion criteria, demonstrates appropriate expectations and habilitation options. These are general
guidelines. Each patient must be evaluated individually. bAbsolute contraindications.

Surgery
Surgery to insert a CI usually requires 1.5 to 3 hours and can be per-
formed on an outpatient basis. With patients under general anesthesia,
a postauricular skin flap is elevated, a mastoidectomy is performed, and
the middle ear entered. The cochlea is opened and the electrode inserted.
The device is attached to the mastoid bone by suture. The wearable external
microphone, microprocessor, and battery pack are coupled to the implanted
device by radiofrequency transmission [7].

Rehabilitation
The initial fitting process requires that the number of functioning chan-
nels be determined and made operative and that the dynamic listening range
between threshold and comfort levels (upper level of the dynamic range) be
established. Further, each electrode must be balanced with the others for
pitch and loudness. This process is a substantial task for cooperative adults.
Stapedial reflexes are used successfully to determine comfort levels in
682 CONNELL & BALKANY

children as young as 2. Although this level may not be identical to the even-
tual comfort levels achieved, it does predict the general vicinity [7].

Complications
Device failures are reported to occur in less than 1% of cases and failed
devices can be replaced within the same ear without significant loss of ben-
efit [9]. Complications are rare and can include dehiscence of skin incision,
flap necrosis, improper electrode placement, dizziness, infection, facial nerve
stimulation or injury, or cerebrospinal fluid leak. No deaths from CI are
reported [10,11]. As humans age, general cognitive deficits and possible
increased risk for surgical complications are concerns. A retrospective
review, however, reveals no increased surgical risk. In comparison with
younger patients, those over age 50 had no increased incidence of device
extrusion, device malfunction, wound infection or dehiscence, flap-related
problems, or anesthetic complications. They performed slightly worse in
postoperative speech recognition scores but this could be explained by
decreased spiral ganglion cell count or central presbyacusis with cognitive
deficit [12].

Special consideration in elderly patients

Central auditory pathways
The elderly pose special considerations because of age-related degenera-
tion of the spiral ganglion cells and deficits in central auditory pathways.
Most often, the inner ear structures, the organ of Corti, and the stria vascu-
laris show the greatest changes. Schuknecht postulated four basic types of
presbyacusis: (1) sensory: organ of Corti hair cell degeneration; (2) neural:
cochlear nerve degeneration; (3) metabolic: atrophy of the stria vascularis;
and (4) mechanical: thickening of the basilar membrane. In addition to inner
ear changes, evaluation of brainstem auditory centers in elderly subjects
who have varying degrees of presbycusis reveals markedly smaller neural
cell size in deaf versus normal hearing controls [13]. Although there is con-
siderable variation, in general, advancing age is associated with an extensive
loss of sensory cells and support structures. These ears reveal complete de-
generation of the organ of Corti, particularly in the lower basal turn, with
associated mild degeneration of some auditory nerve fibers. In contrast,
the degeneration of the stria vascularis occurs primarily in the upper turns.
In spite of these changes, as a group, individuals older than 65 have CI use
characteristics similar to younger adult population [14].
Compromised healing
Patients who have impaired wound healing capabilities from immunosup-
pressive medications or underlying medical conditions are at an increased risk
 COCHLEAR IMPLANTS 683

for postoperative infection. In a study of patients who had liver and renal
transplants or sickle cell disease, however, cochlear implantation is shown
safe and effective. In a series of 13 CI patients who had chronic medical con-
ditions or prolonged used of immunosuppressive medications, only one de-
veloped a mild infection, which resolved with antibiotics. When considering
patients for cochlear implantation, the specific nature of their health prob-
lems and the overall medical and social situation of the patients should be
considered to determine if the routine travel, postoperative visits, and long-
term rehabilitation required are possible [15].

Acute otitis media

Adults receiving CIs once were considered to be at risk for meningitis re-
sulting from acute otitis media (AOM). CIs theoretically could create a po-
tential spread of infection into the cochlea along the electrode array. Clinical
studies demonstrate that the prevalence and severity of AOM are not in-
creased by cochlear implantation. Oral antibiotics are effective in the treat-
ment of postimplantation AOM, and there is no report of increased
incidence of labyrinthitis or meningitis. All CI patients are given pneumo-
coccal vaccination and preoperative intravenous antibiotics before implan-
tation to decrease the risk for meningitis [8].

Impact of hearing on the quality of life of older patients

The variability in outcomes with CIs is believed to be primarily the result
of patient factors. A shorter duration of deafness, longer duration of im-
plant use, and preimplantation hearing ability are predictors of postimplan-
tation speech perception. A direct link between spiral ganglion cell survival
and performance level is established. The etiology of deafness has been stud-
ied carefully and, in general, etiology does not seem to have an impact on
the auditory performance of adults.
Age at implantation for adults is not a major factor. The benefit experi-
enced by older adults is not significantly different from that of younger
adults, provided there are no other significant health issues. The age of onset
of deafness does have important implications, as people who learn speech
and language before becoming deaf adapt to CIs more quickly and achieve
open-set speech discrimination earlier than those who have not learned
speech and language.
When subjects have measurable residual hearing before implantation,
they perform better with CIs than those who do not. The amount of residual
hearing, however, does not predict postimplantation performance [16]. Sig-
nificant numbers of patients receive the secondary benefit of subjective tin-
nitus suppression after cochlear implantation [17]. The psychologic and
social impact of CIs in adults is positive. Psychologic studies show decline
in loneliness, reduction of depression, increase in self-esteem and indepen-
dence, reduced isolation, and improved job opportunities [18].
684 CONNELL & BALKANY

All adults who have functioning CIs are able to detect sound at lower in-
tensities than who have hearing aids alone and almost all are able to lip-read
better with auditory information provided by the implant. Many postlin-
gually deafened adults develop significant open-set word recognition ability
and more than half can converse to some degree on the telephone.
The cost of the device ranges from $24,000 to $37,572, and mean total
charge for unilateral implantation from time of implantation to 12-month
follow-up is $36,837 [19]. Preliminary studies of the cost-effectiveness of
CIs reflect a high value of this technology and procedure. Use of a cost
per quality-adjusted life-year (QALY) method enables the cost effectiveness
of selected medical technologies to be compared. CIs ($14,898/QALY) rank
at the most cost-effective levels along with three-vessel coronary artery
bypass grafts ($10,431/QALY) and a day of neonatal intensive care
($7,755/QALY) [7].

Advances in surgical therapy

CI technology has undergone a rapid and constant evolution since the de-
velopment of the devices in the early 1980s. Single channel devices gave way
to multichannel devices. External equipment has become smaller and more
versatile. Since the 1990s, users have been given multiple memory slots to
choose the best speech processing strategy. At this time, the majority of
adult implantees are able to conduct interactive telephone conversations.
Significant advances in surgical techniques in the past 5 years include re-
duction in surgical complications, improvements in skin flap design, elec-
trode fixation, and the ability to implant partially and fully ossified
cochlea. The overall surgical complication rate for cochlear implantation
has been reduced from 11% to 5% [7].

Future directions
Several developments currently are being tested clinically and may be-
come used widely in the next few years. The usefulness of bilateral cochlear
implantation has been investigated in adults. It is anticipated that in the
future the two implants will be integrated and will share a stimulation pro-
gram to minimize channel interaction and improve hearing in noisy environ-
ments and localization of sounds [8,20,21]. Development of perimodiolar
electrodes, implantable microphones, and rechargeable batteries promises
fully implanted devices in the future [11].
Implantation of adults with residual hearing requires preservation of ex-
isting neural elements. Patients who have residual low-frequency hearing in
conjunction with severe high-frequency hearing loss often do not hear well
with conventional hearing aids. These patients are unable to distinguish
high-frequency sounds, such as consonants, and have difficulty with speech
 COCHLEAR IMPLANTS 685

perception in noisy listening conditions. One solution is a hybrid electro/

acoustic stimulator (a short atraumatic electrode coupled to an implantable
hearing aid). In these experimental devices, severe to profound high-fre-
quency losses are treated electrically and mild to moderate low-frequency
losses are treated acousticallydthe ideal configuration for patients who
have presbyacusis [8,22,23].
Poor speech perception in noise and music appreciation in CI users
mainly is the result of their inability to encode pitch. The limited spectral
resolution and inaccurate encoding of low-frequency information are be-
lieved the main reasons for poor pitch perception performance. Shallow
insertion depth of present electrode arrays severely limits the transfer of
low-frequency spectral information via CI. In addition, current speech pro-
cessing strategies are unable to encode low-frequency temporal information.
Multiple studies suggest that additional fine structure information at low
frequencies allows for better encoding of pitch, which can improve music
appreciation and enhance speech recognition in competing backgrounds
[24]. Hence, those patients who are able to use both acoustic cues and elec-
trical stimulation reap the benefits of speech understanding with high-
frequency information from their CIs and speech perception in noise and
music appreciation from the low-frequency hearing in the more apical (non-
stimulated) portions of the cochlea.
Another area of current development is neural preservation in association
with implantation. Neurotrophins, molecular genetic techniques, and apo-
ptotic pathway blockers, delivered either preoperatively or through CI elec-
trodes, all are under study. If effective, more adults will be candidates to
benefit from CIs [8].

Summary
CIs are cost-effective auditory prostheses that safely provide a high-qual-
ity sensation of hearing to adults who are severely or profoundly deaf. In the
past 5 years, progress has been made in hardware and software design, can-
didate selection, surgical techniques, device programming, education and re-
habilitation, and, most importantly, outcomes. Cochlear implantation in the
elderly is well tolerated and provides marked improvement in auditory per-
formance and psychosocial functioning [25].

References
[1] Cruickshanks KJ, Tweed TS, Wiley TL, et al. The 5-year incidence and progression of hear-
ing loss. Arch Otolaryngol Head Neck Surg 2003;129:1041–6.
[2] Cheng AK, Niparko JK. Cost-utility of the cochlear implant in adults. Arch Otolaryngol
Head Neck Surg 1999;125:1214–8.
[3] Yueh B, Shapiro N, MacLean CH, et al. Screening and management of adult hearing loss in
primary care. JAMA 2003;289:1976–85.
686 CONNELL & BALKANY

[4] Dalton DS, Cruickshanks KJ, Klein BEK, et al. The impact of hearing loss on quality of life
in older adults. Gerontologist 2003;43:661–8.
[5] Koch DB, Staller S, Jaax K, et al. Bioengineering solutions for hearing loss and related dis-
orders. Otolarygol Clin N Am 2005;38:255–72.
[6] Yueh B, Souza PE, McDowell JA, et al. Randomized trial of amplification strategies. Arch
Otolaryngol Head Neck Surg 2001;127:1197–204.
[7] Balkany T, Hodges AV, Luntz MD. Update on cochlear implantation. Otolaryngol Clin
North Am 1996;29:277–87.
[8] Balkany TJ, Hodges AV, Eshraghi AA, et al. Cochlear implants in childrenda review. Acta
Otolaryngol 2002;122:356–62.
[9] Balkany TJ, Hodges AV, Gomez-Marin O, et al. Cochlear reimplantation. Laryngoscope
1999;106:351–5.
[10] Cohen NL, Hoffman RA. Complications of cochlear implant surgery in adults and children.
Ann Otol Rhinol Laryngol 1991;100:131–6.
[11] Cohen N, Waltzman S, Fisher SG. Department of Veterans Affairs Cochlear Implant Study
Group. A prospective, randomized study of cochlear implants. N Engl J Med 1993;328:
233–7.
[12] Chatelin V, Kim EJ, Driscoll C, et al. Cochlear implant outcomes in the elderly. Otol Neuro-
tol 2004;25:298–301.
[13] Schuknecht HF, Gacek MR. Cochlear pathology in presbycusis. Ann Otol Rhinol Laryngol
1993;102:1–16.
[14] Niparko JK, Kirk KI, Mellon NK, et al. Cochlear implant principles and practice. Philadel-
phia: Lippincott Williams and Wilkins; 2000.
[15] Odabasi O, Mobley SR, Bolanos RA, et al. Cochlear implantation in patients with compro-
mised healing. Otolaryngol Head Neck Surg 2000;123:738–41.
[16] Gates GA, Daly K, Dichtal WJ, et al. National Institutes of Health: Consensus Development
Conference statement: cochlear implants in adults and children. Bethesda (MD), May 15–17,
1995.
[17] Miyamoto RT, Bichey BG. Cochlear implantation for tinnitus suppression. Otolaryngol
Clin North Am 2003;36:345–52.
[18] Knutson JF, Schwartz HA, Bantz BJ, et al. Psychological change following 18 months of
cochlear implant use. Ann Otol Rhinol Laryngol 1991;100:877–82.
[19] Palmer CS, Niparko JK, Wyatt R, et al. A prospective study of the cost-utility of the multi-
channel cochlear implant. Arch Otolaryngol Head Neck Surg 1999;125:1221–8.
[20] Litovsky RY, Parkinson A, Arcaroli J, et al. Bilateral cochlear implants in adults and
children. Arch Otolaryngol Head Neck Surg 2004;130:648–55.
[21] Summerfield AQ, Marshall DH, Barton GR, et al. A cost-utility scenario analysis of bilateral
cochlear implantation. Arch Otolaryngol Head Neck Surg 2002;128:1255–62.
[22] Gstoettner W, Kiefer J, Baumgartner WD, et al. Hearing preservation in cochlear implanta-
tion for electric acoustic stimulation. Acta Otolaryngol 2004;124:348–52.
[23] Adunka O, Unkelbach MH, Mack MG, et al. Predicting basal cochlear length for electric-
acoustic stimulation. Arch Otolaryngol Head Neck Surg 2005;131:488–92.
[24] Kong Y, Stickney GS, Zeng F. Speech and melody recognition in binaurally combined
acoustic and electric hearing. J Acoust Soc Am 2005;117(3) Pt 1:1351–61.
[25] Hinderink JB, Krabbe PFM, van den Broek P. Development and application of a health-
related quality of life instrument for adults with cochlear implants: the Nijmegen Cochlear
Implant Questionnaire. Otolaryngol Head Neck Surg 2000;123:756–65.