How does a cochlear implant work and who is a candidate?
A cochlear implant restores access to spoken language by stimulating the auditory nerve, and candidacy depends on how little speech a person understands with hearing aids rather than hearing loss severity alone.
Covers: This page explains the basic function of a cochlear implant, including its external and internal components and how it converts sound into electrical signals that stimulate the auditory nerve. It also covers the general candidacy criteria for adults and children, such as degree of hearing loss and speech perception scores, but does not provide personalized medical advice or detailed surgical or programming procedures.
Also answers: How do cochlear implants work? · Who qualifies for a cochlear implant? · Cochlear implant candidacy criteria · What does a cochlear implant do?
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The short answer
Interpretation AI-prepared starting mapA cochlear implant is a device that restores access to spoken language by bypassing damaged hair cells and stimulating the auditory nerve directly with electrical signals; candidacy is not a single cut-off but a judgement about how little speech a person understands with well-fitted hearing aids. In adults, the widely used "revised 60/60 rule" frames…12345
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At a glance
The picture in numbers
Live · updated just now
- Before implantation8.2%
- After implantation53.9%
21.5 percentage points
65 dB HL
lower boundary supported
80 dB HL
appropriate per one review
88–96 dB HL
used in two studies
The evidence behind it
6 sources- Reviews of many studies2
- Other studies and data4
When it was published
Newest from 2024
| Source | Kind | Year |
|---|---|---|
| American Cochlear Implant Alliance Task Force: Recommendations for Determining Cochlear Implant Candidacy in Adults | Other studies and data | 2023 |
| Determining cochlear implant candidacy in children with residual hearing: A scoping review | Reviews of many studies | 2024 |
| Cochlear implantation outcomes in adults: A scoping review | Reviews of many studies | 2020 |
| Speech and Language Outcomes in Adults and Children with Cochlear Implants | Other studies and data | 2022 |
| Candidacy for Cochlear implantation: Validating a novel Cochlear implant candidacy calculator against gold‐standard, in‐clinic audiometric assessments | Other studies and data | 2022 |
| Identification of Pure-Tone Audiologic Thresholds for Pediatric Cochlear Implant Candidacy | Other studies and data | 2018 |
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Be the first to voteIn brief
A cochlear implant works by stimulating the auditory nerve directly, giving access to spoken language rather than amplifying sound.6
InterpretationAdult candidacy centres on aided speech perception, with the "revised 60/60 rule" used to decide who should be referred for formal evaluation.1
Evidence-backedA high-frequency PTA of 65 dB HL or worse plus a word score of 50% or lower identified adult candidates with 0.90 accuracy and 0.94 sensitivity in one validation study.2
Evidence-backedAverage adult word perception improved from 8.2% to 53.9% after implantation, with self-reported benefit up 21.5 percentage points.3
Evidence-backed
Have you or a family member ever been evaluated for a cochlear implant?
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What it means for you
Which fits you?
Pick the situation closest to yours. Each answer says what it rests on.
If you are an adult with bilateral hearing loss and struggle to understand speech even with well-fitted hearing aids
the revised 60/60 rule is the current framing for referral to a cochlear implant centre for formal evaluation, where each ear is assessed separately.1
Evidence-backedIf you want a rough sense of whether your audiogram and word scores put you in candidate territory
a high-frequency PTA of 65 dB HL or worse together with a word discrimination score of 50% or lower matched clinical candidacy with 0.90 accuracy in one validation study; a 70% word-score threshold was chosen to catch more potential candidates at the cost of more false positives.2
Evidence-backedIf you are an adult of any age with limited aided speech perception and are weighing whether implantation is worth it
across 102 studies with more than 10 participants, average word perception rose from 8.2% to 53.9% and self-reported benefit improved by 21.5 percentage points, though individual outcomes vary widely.3
Evidence-backedIf you are deciding about implantation for a child with residual hearing
audiologic thresholds of roughly 65–80 dB HL PTA are discussed in the literature, with one review supporting 80 dB HL or greater as appropriate — lower than many national and manufacturer guidelines — and other areas of functioning should also be weighed.54
Evidence-backedIf you are told your hearing loss is not severe enough to qualify
practice varies, with some providers using outdated criteria and others exceeding current labelled indications, so a second opinion at a specialist implant centre may be reasonable.1
Evidence-backedIf you are a clinician or family weighing hearing loss severity alone as the deciding factor
the validity of using hearing loss severity as a criterion for implantation has not been demonstrated, so aided speech perception should carry weight.3
Evidence-backedThe full explanation
Interpretation AI-prepared starting mapA cochlear implant is a device that restores access to spoken language by bypassing damaged hair cells and stimulating the auditory nerve directly with electrical signals; candidacy is not a single cut-off but a judgement about how little speech a person understands with well-fitted hearing aids. In adults, the widely used "revised 60/60 rule" frames referral for formal evaluation, and a validation study found that a high-frequency pure-tone average (PTA) of 65 dB HL or worse plus a word discrimination score of 50% or lower identified clinical candidates with 0.90 accuracy, 0.94 sensitivity and 0.82 specificity (thresholds relaxed to 70% word score to favour sensitivity). Averaged across 102 studies with more than 10 participants, adult word perception rose from 8.2% to 53.9% after implantation and self-reported benefit improved by 21.5 percentage points. For children, evidence supports audiologic thresholds around 65–80 dB HL PTA, with one review concluding that thresholds of 80 dB HL or greater would be appropriate — lower than many current national and manufacturer guidelines.12345
- Evidence 20
- Interpretation 3
The full story · 3 chapters
01
How a cochlear implant works
AI summary:The implant bypasses damaged hair cells to stimulate the auditory nerve directly, and average adult word perception rose from 8.2% to 53.9% after implantation.
Evidence-backed: A cochlear implant is described as a significant engineering and medical milestone in treating hearing loss for both adults and children. Rather than amplifying sound as a hearing aid does, it provides access to spoken language by delivering electrical stimulation to the auditory system, which is why it is discussed alongside basic questions about how spoken words are recognised and how spoken language develops.6
Interpretation: The device has external and internal parts: a sound processor worn outside the body and an implanted component that stimulates the auditory nerve, with the external part converting incoming sound into signals the internal part delivers as electrical pulses. The sources summarised here describe the technology at this level and focus on what it achieves and where it falls short, rather than on surgical or programming detail.6
Evidence-backed: What the implant buys in practice is measurable. Across 102 adult studies with more than 10 participants, average word perception improved from 8.2% before implantation to 53.9% after, and self-reported benefit rose by 21.5 percentage points. The same review concludes that implantation benefits the majority of adults of any age who have limited aided speech perception.3
Evidence-backed: Benefits are not uniform. Implant users face specific limitations and issues, and outcome variability is described as a major clinical problem that motivates new assessment tools and interventions for people who do poorly.6
02
Who is a candidate: adults
AI summary:Adult candidacy turns on aided speech perception, with the revised 60/60 rule guiding referral and one validation study finding 0.90 accuracy for a PTA and word-score combination.
Evidence-backed: Adult candidacy is framed around how well a person understands speech with hearing aids, not around hearing loss severity alone. The American Cochlear Implant Alliance Task Force stresses treating each ear individually and applying a "revised 60/60 rule" when deciding who should be referred to a CI centre for formal evaluation. The task force notes that clinical practice varies, with some providers using outdated criteria and others exceeding current labelled indications, so only a fraction of people who could benefit actually receive an implant.1
Evidence-backed: A validation study of a candidacy calculator against in-clinic audiometry, in 132 patients of whom 54 had single-sided deafness and 114 were clinically determined to be candidates, found that a high-frequency PTA of 65 dB HL or worse combined with a word discrimination score of 50% or lower performed well: accuracy 0.90, sensitivity 0.94, specificity 0.82. To favour sensitivity over specificity the authors chose a word-score threshold of 70%, which they suggest could raise awareness of candidacy and reduce the burden of hearing loss.2
Evidence-backed: The task force recommendations were developed by literature review and clinical consensus rather than by a formal level of evidence, and they emphasise a standardised testing protocol delivered by a team, with individualised patient care.1
Evidence-backed: One caution cuts against a purely audiometric view: although many adults with severe-to-profound hearing loss also have poor aided speech perception, the validity of using hearing loss severity as a criterion for implantation has not been demonstrated.3
03
Who is a candidate: children
AI summary:For children, reviews support audiologic thresholds around 65–80 dB HL PTA, lower than many current guidelines, with other areas of functioning also considered.
Evidence-backed: For children, the audiologic debate is about where the threshold sits. A scoping review of seven articles found that hearing levels better than the moderately severe to severe range (65–90 dB HL) tend to be supported as candidacy criteria, with recommended lower boundaries ranging from 65 to 80 dB HL pure-tone average. That review identified no specific assessment protocols, though it flagged the Speech Intelligibility Index and the Pediatric Minimum Speech Test Battery as decision-making tools for borderline configurations.5
Evidence-backed: A separate review of 21 critically appraised studies, narrowing to 10 for data extraction, found two studies that set audiologic thresholds: 80 dB HL or greater on a 4-frequency PTA based on speech perception and auditory performance subtests, and 88 and 96 dB HL based on a speech perception subtest. In 8 of 18 outcome measures, children with profound hearing impairment using implants performed similarly to children with severe impairment using hearing aids; implant users did better on a picture-naming test and a speech perception in noise test. The authors concluded that thresholds lower than those in current national and manufacturer guidelines — 80 dB HL or greater — would be appropriate.4
Evidence-backed: Both paediatric reviews agree that audiologic thresholds are only part of the picture: it is widely recommended that other areas of functioning also be considered, and most recommendations rest on expert opinion, clinical expertise and general paediatric implant outcomes rather than evidence specific to children with residual hearing.5
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What to remember
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Adult candidacy centres on aided speech perception, with the "revised /60 rule" used to decide who should be referred for formal evaluation.
A high-frequency PTA of dB HL or worse plus a word score of 50% or lower identified adult candidates with 0.90 accuracy and 0.94 sensitivity in one validation study.
Average adult word perception improved from to 53.9% after implantation, with self-reported benefit up 21.5 percentage points.
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- 1American Cochlear Implant Alliance Task Force: Recommendations for Determining Cochlear Implant Candidacy in AdultsThe Laryngoscope (Zeitler et al.)Published Jul 12, 2023Checked Oct 15, 2026
“However, clinical practice is variable, with some providers using outdated criteria and others exceeding current labeled indications. As a results, only a fraction of those persons who could benefit from CI technology receive it. This document summarizes the current evidence for determining appropriate referrals for adults with bilateral hearing loss into CI centers for formal evaluation by stressing the importance of treating each ear individually and a "revised 60/60 rule". By mirroring contemporary clinical practice and available evidence, these recommendations will also provide a standardized testing protocol for CI candidates using a team-based approach that prioritizes individualized patient care. This manuscript was developed by the Adult Cochlear Implantation Candidacy Task Force of the American Cochlear Implant Alliance using review of the existing literature and clinical consensus. LEVEL OF EVIDENCE: N/A Laryngoscope, 134:S1-S14, 2024.”
- 2Candidacy for Cochlear implantation: Validating a novel Cochlear implant candidacy calculator against gold‐standard, in‐clinic audiometric assessmentsLaryngoscope Investigative Otolaryngology (So et al.)Published May 10, 2022Checked Oct 15, 2026
“Of the resulting 132 patients, 54 presented with single-sided deafness (SSD), and 114 were clinically determined to be CI candidates. ROC AUC analyses identified optimal thresholds of high-frequency PTA ≥65 dB and word discrimination score ≤ 50%. To maximize sensitivity at the expense of specificity, diagnostic thresholds of high-frequency PTA ≥ 65 dB and word discrimination score ≤ 70% were chosen, which yielded accuracy, sensitivity, specificity, and ROC AUC of 0.90, 0.94, 0.82, and 0.88, respectively. The novel online CI Candidacy Calculator exhibits high sensitivity and accuracy, and moderate specificity. The calculator may thereby be useful in increasing awareness of potential CI candidacy, increasing prevalence of CIs, and decreasing the burden of hearing loss.”
- 3Cochlear implantation outcomes in adults: A scoping reviewPLoS ONE (Boisvert et al.)Published May 5, 2020Checked Oct 15, 2026
“A total of 4182 abstracts were screened against inclusion criteria, and of these, 603 full-texts were further screened. After exclusion of non-eligible articles, 201 articles were included in the first part of this scoping review. The majority of these articles were case series or comparative studies without a concurrent group, and had small sample sizes. Data synthesis conducted with the 102 articles with more than 10 participants highlighted that the average word perception ability improved from 8.2% to 53.9% after implantation. Self-reported benefit improved by 21.5 percentage points. Despite broad inconsistencies in measurement, research design, and reporting across articles, it is evident that cochlear implantation is beneficial to the majority of adults of any age who have limited aided speech perception abilities. While many adults with severe-to-profound hearing loss may also have poor speech perception abilities with hearing aids, the validity of using hearing loss severity as a criterion for cochlear implantation has not been demonstrated.”
- 4Identification of Pure-Tone Audiologic Thresholds for Pediatric Cochlear Implant CandidacyJAMA Otolaryngology–Head & Neck Surgery (Kleijn et al.)Published May 24, 2018Checked Oct 15, 2026
“Title and abstract screening of 2822 articles resulted in selection of 130 articles for full-text review. Twenty-one studies were selected for critical appraisal, resulting in selection of 10 articles for data extraction. Two studies formulated audiologic thresholds (in dB HLs) at which children could qualify for cochlear implantation: (1) at 4-frequency pure-tone average (PTA) thresholds of 80 dB HL or greater based on speech perception and auditory performance subtests and (2) at PTA thresholds of 88 and 96 dB HL based on a speech perception subtest. In 8 of the 18 outcome measures, children with profound HI using cochlear implants performed similarly to children with severe HI using hearing aids. Better performance of cochlear implant users was shown with a picture-naming test and a speech perception in noise test. Owing to large heterogeneity in study population and selected tests, it was not possible to conduct a meta-analysis. Conclusions and Relevance: Studies indicate that lower audiologic thresholds (≥80 dB HL) than are advised in current national and manufacturer guidelines would be appropriate as audiologic candidacy criteria for pediatric cochlear implantation.”
- 5Determining cochlear implant candidacy in children with residual hearing: A scoping reviewInternational Journal of Pediatric Otorhinolaryngology (Pignac et al.)Published Jan 3, 2024Checked Oct 15, 2026
“A total of seven articles (two reviews and five primary studies) were included in the final analysis. Hearing levels better than the moderately severe to severe range (65-90 dB HL) tend to be supported as audiological candidacy criteria for pediatric CI. Recommendations for candidacy consideration based on audiologic thresholds range from 65 to 80 dB Hl pure-tone average as the lower boundary. Our review did not identify any specific assessment protocols. However, additional decision-making considerations related to borderline hearing loss configurations and assessment tools (the Speech Intelligibility Index and the Pediatric Minimum Speech Test Battery) were identified. There is limited information regarding specific assessment protocols for children with residual hearing. The literature is primarily focused on guidelines related to audiologic criteria, although it is widely recommended that other areas of functioning should also be considered. Most recommendations appear to be based on expert opinion, clinical expertise, and evidence from overall pediatric CI outcomes rather than empirical evidence targeting children with residual hearing.”
- 6Speech and Language Outcomes in Adults and Children with Cochlear ImplantsAnnual Review of Linguistics (Tamati et al.)Published Jan 14, 2022Checked Oct 15, 2026
“Cochlear implants (CIs) represent a significant engineering and medical milestone in the treatment of hearing loss for both adults and children. In this review, we provide a brief overview of CI technology, describe the benefits that CIs can provide to adults and children who receive them, and discuss the specific limitations and issues faced by CI users. We emphasize the relevance of CIs to the linguistics community by demonstrating how CIs successfully provide access to spoken language. Furthermore, CI research can inform our basic understanding of spoken word recognition in adults and spoken language development in children. Linguistics research can also help us address the major clinical issue of outcome variability and motivate the development of new clinical tools to assess the unique challenges of adults and children with CIs, as well as novel interventions for individuals with poor outcomes.”
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Open questions
Why do implant outcomes vary so much between individuals, and which candidacy or assessment factors predict who will do well?
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What assessment protocols should be used for children with residual hearing, given that no specific protocols were identified?
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Should hearing loss severity itself be a candidacy criterion, given that its validity for implantation has not been demonstrated?
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How should the 65 dB HL and 80 dB HL audiologic thresholds be reconciled across adult and paediatric guidance?
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