CI Candidacy and Outcome Assessment

Question 1

Who performs assessments to determine CI candidacy?

Answer 1

An audiologist
A cochlear implant surgeon
An imaging specialist (e.g., a radiologist)

Question 2

What is the 60/60 guideline?

Answer 2

Patients should be referred if they have:
A best ear unaided monosyllabic word score ≤ 60% correct
An unaided PTA in their better ear that is ≥ 60 dB HL

Question 3

What is the purpose of a preop assessment?

Answer 3

To determine the patients candidacy for implantation

Question 4

What is the purpose of postop assessment?

Answer 4

To determine the functional benefits of cochlear implants

Question 5

Do patient and family expectations strongly influence satisfaction with outcome after implantation?

Answer 5

Yes

Question 6

What needs to be done during the comprehensive audiologic evaluation for candidacy?

Answer 6

Otoscopy
Acoustic immittance
Air conduction pure tone thresholds from 125 through 8000 Hz using insert earphones
A previous audiogram may be accepted, but testing is recommended if reliability is in question, hearing status may have changed, or the most recent evaluation is older than six months
Testing at 125 Hz should be included to assess hearing preservation and guide post-op amplification strategy and to support counseling by setting expectations about potential hearing loss

Question 7

Could the testing audiologist be different from the CI audiologist?

Answer 7

Yes

Question 8

Do we have to fit the patient with hearing aids and perform verification?

Answer 8

Yes
So the patients can try them to see if the patient receives benefit in speech understanding

Question 9

What are the steps for hearing aid verification?

Answer 9

Hearing aids should be optimally selected and fitted to maximize aided speech recognition performance
Perform a listening check and/or electroacoustic test to rule out internal noise or distortion
Use real-ear measurements to verify output matches prescriptive targets
If real-ear testing isn’t possible, use a 2-cc coupler for simulated verification
Verify output using a calibrated speech signal at 60/65 dB SPL, matching the level used in candidacy speech recognition testing
When the patient’s hearing aids are not appropriately fitted, clinic loaner devices should be programmed, verified, and used to ensure accurate aided results

Question 10

Does an aided assessment need to be performed?

Answer 10

Yes

Question 11

What is the test setup for the aided assessment?

Answer 11

Loudspeaker should be placed in the corner of the booth or on the side wall
Loudspeaker should be positioned at the same level as the listener’s head while seated (about 39 inches from the floor)
Patient seated 1 meter from the loudspeaker at 0 degrees azimuth
Minimum room size is 6ftx6ft

Question 12

Why does calibration during the aided assessment matter?

Answer 12

Speech discrimination scores are key criteria for candidacy.
Calibration ensures speech stimuli are presented at consistent, clinically relevant levels
Inaccurate presentation levels may lead to inappropriate CI referrals—either underqualifying or overqualifying patients
Standardized calibration enables reliable tracking of patient progress as they adapt to their hearing device(s)

Question 13

What does free-field calibration of speech stimuli require?

Answer 13

Input calibration - prevents distortion or clipping of the input signal
Output calibration - ensures that speech materials are presented in the SF at the intended level

Question 14

How do you perform input calibration?

Answer 14

A 1000 Hz calibration tone is used to calibrate the input level to the audiometer
External A and/or B sensitivity dials are adjusted to ensure that the VU meter reads 0 or slightly below during tone presentation
These controls should remain unchanged for the rest of the calibration and assessment process

Question 15

How do you perform output calibration?

Answer 15

A sound level meter (SLM) is used, with the microphone positioned 1 meter in front of the loudspeaker, at typical head height
The SLM should be set to A-weighting and fast response
The audiometer dial should be adjusted in 1-dB increments until the display reads the desired level

Question 16

What test battery is used for the aided speech recognition evaluation?

Answer 16

Minimum speech test battery (MSTB)
Originally introduced in 1996 by a committee of representatives (AAA, AAO-HNS, and 3 CI manufactures)
Original battery consisted of CNC, HINT in quiet, HINT in noise at +10, +5, or 0 dB SNR

Question 17

How was the MSTB developed?

Answer 17

The HINT was found to be inadequate for evaluating CI candidacy and outcomes
MSTB was revised in 2011 (MSTB-2) - included AzBio sentences in quiet and noise (SNR of 5 or 10), CNC, and BKB-SIN
In 2022, the Institute for Cochlear Implant Training (ICIT) assembled a panel of expert audiologists to revise the battery in light of expanded CI indications
The outcome was the release of MSTB-3 in Jan 2024

Question 18

What is the design of MSTB-3?

Answer 18

Designed to provide an evidence-based standardized battery that supports a streamlined protocol for all CI candidates - including traditional, SSD, and EAS users

Question 19

How is MSTB-3 different?

Answer 19

Revised test measured and presentation levels for determining CI candidacy
Defined as preop protocols tailored to traditional candidates, EAS, SSD, and those with asymmetric HL
Includes standardized report templated to promote consistency in clinical documentation and interpretation
Established a structured postop follow-up protocol to support outcome tracking
Emphasized clinical decision-making as a core component of the MSTB-3 framework

Question 20

What does MSTB-3 consist of?

Answer 20

CNC monosyllabic word test
AzBio sentence test in quiet and noise
Conditions: aided right ear only, aided left ear only, bilateral (as needed)

Question 21

What is CNC?

Answer 21

Consists of 500 test words, organized into 50-word lists.
Each word consists of three phonemes
Pt should be seated facing the loudspeaker used for stimulus presentation
Words should be presented at 60 dBA (Channel 1)
Scores should be obtained separately for each ear:
Right ear aided
Left ear aided

Question 22

What is AzBio?

Answer 22

Consists of 23 lists, each includes 20 sentences ranging from 4 to 12 in length
Each list includes 10 sentences spoken by two male talkers and 10 by two female talkers, all delivered in a conversational speaking style - gives a more realistic listening environment
Sentences are designed with minimal contextual cues to reduce predictability
10-talker babble is recorded on Channel 2 for evaluating performance in noise

Question 23

What is the test protocol for AzBio? (based on the MSTB-3)

Answer 23

In Quiet: sentences are presented at 60 dBA (Channel 1), front speaker
In noise: Sentences are presented at 65 dBA Channel 2), front speaker
Babble noise is presented at 55 dBA for +10 SNR or 60 dBA for +5 SNR

Question 24

Does the CNC serve as the primary measure for clinical decision making for determining candidacy?

Answer 24

Yes
But many insurers rely on open-set sentence recognition tests for coverage decisions (so the AzBio should be used to meet insurance requirements)

Question 25

According to MSTB-3, does the CNC and AzBio need to be administered in the patients best aided condition?

Answer 25

Yes The patient qualifies based on their best aided CNC score and the same test condition should be used for AzBio If the insurer defines "best-aided" as bilateral hearing aid use, AzBio testing should be conducted under bilateral aided conditions for coverage determination

Question 26

What is the CNC cut-off score for determining CI candidacy?

Answer 26

It is set at the discretion of the clinic Suggested cut-off scores from the literature include: 40% – Sladen et al. (2017) 50% – ACIA guidelines (Zeitler et al., 2023; Dunn, 2022) 60% – Perkins et al. (2023)

Question 27

What happens if the aided CNC score is above the clinics candidacy threshold?

Answer 27

The patient should be advised to return in one year for retesting Or earlier if hearing changes

Question 28

Why should we always start with CNC?

Answer 28

It can be used as a screener It should be the main test used for candidacy If AzBio is done first, the poor scores could be due to cognition rather than hearing loss (might have difficulty remembering all of the words)

Question 29

Is isolation of the test ear essential to ensure valid test results?

Answer 29

Yes, in those with residual hearing in the non-test ear

Question 30

How do you isolate the test ear in patients with residual hearing in the non-test ear?

Answer 30

Plug and muff approach, ideal for patients who struggle to process signal from masking noise Masking noise delivered via insert earphones to the better ear (ideal) Insert earphone + circumaural headphones; combines acoustic sealing with masking for enhanced isolation

Question 31

What are the current CI indications?

Answer 31

Traditional candidates EAS (electrical acoustic stimulation) SSD AHL

Question 32

Do you refer patients for a CI evaluation and assessment based on the 60/60 guideline?

Answer 32

Yes

Question 33

Do you use the second channel for CNC?

Answer 33

No, because your test doesn't require noise Can use the 2nd channel to put masking in the NTE to isolate the test ear if the residual hearing in the NTE is pretty good

Question 34

What condition do you start testing AzBio at?

Answer 34

10 dB SNR Stimulus at 65 dB HL After this you can do AzBio with different conditions to further assess hearing status (in quiet and/or 5 dB SNR) - to either make it more challenging or easier depending on how the patient performs on the initial test condition Then you can go on and test Az Bio with the patients everyday listening conditions (can be used for pre and postop comparison)

Question 35

Is the protocol the same for EAS and traditional candidates?

Answer 35

Yes

Question 36

What is the candidacy protocol for SSD and AHL?

Answer 36

Best aided CNC in ear to be implanted meets candidacy Test AzBio sentences (one full list) in the ear to be implanted in the best aided condition using 0 dB SNR (signal 65 dBA, noise 65 dBA) with signal front/noise to the better ear (S0NB) To further evaluate hearing status, test AzBio in everyday listening conditions using 0 dB SNR in signal front/noise front (S0N0) and signal front/noise poorer ear (S0NP)

Question 37

Does the MSTB-3 recommend that patient questionnaires be administered in conjunction with speech recognition testing?

Answer 37

Yes, to derive additional information regarding the patient's overall hearing performance Pre- and post-operative scores can be compared to further evaluate benefits derived from the use of the CI The results of the questionnaires should be reviewed to determine areas of listening that the patient is excelling or struggling with Results can be included in reports to insurers, reinforcing that a CI is likely to improve the patient’s hearing, daily function, and overall quality of life

Question 38

What are the questionnaires the are recommended by the MSTB-3 to be included during the pre-op evaluation?

Answer 38

Cochlear Implant Quality of Life (CIQOL-10 Global) Speech, Spatial and Qualities of Hearing Scale 12 (SSQ-12)

Question 39

What are some other questionnaires that can also be completed?

Answer 39

Tinnitus Handicap Inventory (THI) when pt reports tinnitus. Mental health screening tools: the General Anxiety Disorder-7 (GAD-7), Patient Health Questionnaire-9 (PHQ-9) Cognitive screening tools- recommended when cognitive concerns are present

Question 40

What should the clinician include in the report when reporting outcomes?

Answer 40

A comprehensive patient history A description of testing performed A clear delineation of scores A statement indicating whether a CI is recommended, and whether the patient qualifies for a CI based on their insurer

Question 41

Do you use the same codes that you would for evaluating someone for a bone conduction device?

Answer 41

Yes

Question 42

What is the goal of outcome assessments?

Answer 42

To ensure that a patient’s amplification — whether with cochlear implants and/or hearing aids — is appropriate and that the amplification is maximizing his or her auditory potential

Question 43

What are the two types of post-implant assessments?

Answer 43

Behavioral assessment Subjective assessment

Question 44

What are post-op behavioral measures used for?

Answer 44

To program the CI (if it isn't programmed optimally) The monitor the development of speech perception To provide an indication of auditory function or how the child is using their CI(s) to hear

Question 45

What is the post-op behavioral assessment protocol?

Answer 45

MSTB-3 recommended protocol Unaided audiometric thresholds (125-8000 Hz) in the implanted ear (AC and BC) Unaided thresholds in the non-implanted ear (for bi-modal listeners) Aided SF thresholds for the implanted ear (CI mapping should be optimized to achieve aided SF thresholds between 20 and 30 dB HL from 250-6000 Hz) Aided speech assessment Questionnaires to evaluate the perceived benefit and/or quality of life

Question 46

How do you assess speech perception during the post-op assessment according to MSTB-3?

Answer 46

Best aided CNC in the implanted ear in quiet (presented at 60 dB HL) Isolate the NTE as needed If the scores are poorer than expected, evaluate the programming and data logging Then these everyday listening condition with AzBio at 10 dB SNR (presentation at 65 dB HL) Then test AzBio in quiet or 5 dB SNR (to further evaluate status) Consider evaluation of non-implanted ear for candidacy by testing CNC in the best-aided condition and/or AzBio

Question 47

How often does MSTB-3 recommend that you perform a post-op testing?

Answer 47

3 months and 12 months, and then on a yearly basis after this If performance is suboptimal at 3 months, then consider additional testing before 12 months

Question 48

How do you examine bimodal benefit for those with CIs?

Answer 48

Compare performance on AzBio at 10 dB SNR using the CI-alone and CI + hearing aid in the non-implanted ear An improvement in performance with the CI + HA indicated bimodal benefit Minimal or no improvement may suggest limited benefit from bimodal use and should prompt consideration of the non-implanted ear as a potential CI candidate

Question 49

When doing a pre-op assessment on a child, should the parents be instructed to bring copies of all pertinent medical records to the appointment?

Answer 49

Yes

Question 50

What are the components of an audiologic evaluation during the pre-op assessment for pediatrics?

Answer 50

Case history Electrophysiologic assessment of auditory function Behavioral assessment of auditory function Hearing aid evaluation and assessment of aided auditory function Subjective assessment of communication and functional auditory abilities *May require more than one appointment to obtain all of these components

Question 51

What tests do you want to include in the electrophysiologic assessment for pediatrics?

Answer 51

Assessment of middle ear and, at a minimum, ipsilateral acoustic reflex testing OAEs provide valuable information for the cochlear implant evaluation to rule out ANSD Auditory brainstem response assessment (ABR) An audiologist may also consider auditory steady-state response assessment and cortical auditory evoked response assessment

Question 52

Should a cochlear implant ever be recommended without evaluating the auditory function through behavioral measures?

Answer 52

No, that is the standard Audiologists should attempt to evaluate a child’s audiometric thresholds for frequency-specific stimuli and speech using validated methods appropriate for infants and young children Behavioral testing helps ensure that candidacy decisions are based on accurate, age-appropriate auditory information

Question 53

What are the different types of behavioral testing that can be performed on pediatrics?

Answer 53

Behavioral observation Visual reinforced audiometry Conditioned play audiometry Conventional audiometry

Question 54

Is the speech recognition test only performed for the pre-op assessment when the child is old enough?

Answer 54

Yes, they cannot do it if they are not old enough to participate The audiologist should routinely evaluate the child’s ability to understand speech According to the FDA-approved indications for cochlear implantation, aided speech recognition should be evaluated in the best-aided condition

Question 55

Is there a universal protocol for evaluating speech recognition in pediatric CI candidates?

Answer 55

No Speech materials must be age-appropriate, as test suitability varies widely by developmental level. Commonly Used Tests - Ages 2–5 years (Closed-set tests): Early Speech Perception (ESP) NU-CHIPS Mr. Potato Head test Older than 5 (Open-set): Multisyllabic Lexical Neighborhood Test (MLNT) Lexical Neighborhood Test (LNT) Phonetically Balanced Kindergarten (PBK) Consonant-Nucleus-Consonant (CNC)

Question 56

Is there an obstacle present for post-op management of pediatric implant patients in gathering information from a child who is pre- or peri-verbal?

Answer 56

Yes There are several questionnaires which can be used to assess early hearing development in children using CI Such as LittlEARS (up to 24 months), the auditory skills checklist (up to 36 months), and PEACH (3-7 years)

Question 57

What is the pediatric minimum speech test battery (PMSTB)?

Answer 57

Developed by a collaborative group of experts in academia, clinical care, research, and industry Modeled after the MSTB for adults Provides a structured protocol to assess speech recognition in children who are being considered for implantation or already using CIs Calls for the assessment of speech recognition in quiet at multiple presentation levels and in noise Recommends the use of word and sentence materials Includes more speech recognition tests than the adult MSTB to accommodate the developmental variability in children Designed to assess children from infancy through adolescence Organized in a hierarchical format to guide test selection based on child’s abilities and age

Question 58

When do you transition to different measures in the PMSTB?

Answer 58

> or equal to 75-80% - transition to a more advanced measure < or equal to 25% - use a simpler measure 25-79% - indicates emerging skills, continue with current measure

Question 59

What is BabyBio?

Answer 59

Also known as the pediatric AzBio test Sentences in quiet and in noise An open-set sentence recognition measure developed for school-age children 5 years and older (appropriate for children who have a second-grade language level) Consists of 16 lists, each containing 20 sentences spoken by a female talker Sentences range from 3 to 12 words in length Scoring is based on the percentage of words repeated correctly Test may be presented in quiet (60 dBA) and in noise (65 dBA with a +5 dB SNR)

Question 60

What might SLPs assess during a language assessment for children?

Answer 60

Prelinguistic communication (eye contact, gaze patterns, gesture, pointing, vocalization, object manipulation, etc.) Linguistic communication to examine receptive and expressive vocabularies in sign or speech, beginning syntax, use of grammatical markers, and narration and conversation Pragmatic development

Question 61

What are the common assessment tools for SLPs to use for a language assessment?

Answer 61

The Rossetti Infant and Toddler Language Scale (Rossetti, 2005) The Cottage Acquisition Scales of Listening, Language, and Speech (Wilkes, 1999) MacArthur-Bates Communicative Development Inventory: Words and Gestures (MacArthur-Bates, 2007)

Question 62

What does cognitive and psychological assessment of children include?

Answer 62

Measurement of verbal and nonverbal intelligence Visual motor integration Attention Motor development Child behavior and parental stress *Will assess the child's ability to integrate information from the CI to understand

Question 63

What might an evaluation by an occupational therapist identify?

Answer 63

Subtle vestibular, tactile, or proprioceptive deficits that could affect the child’s ability to integrate auditory information, use language in a social context, engage with others, and gain control over body movement especially those of oral articulators

Question 64

Do we need to obtain CI aided audiometric thresholds in pediatrics post-op?

Answer 64

Yes Estimate minimum audibility for each ear to optimize CI maps Target aided sound-field thresholds of 20–25 dB HL (250–6000 Hz) for pediatric CI users Lower thresholds are not necessarily better! Test each ear separately in bilateral cases to fine-tune individual maps Monitor acoustic hearing in the implanted ear if residual hearing is present

Question 65

What is the aim of assessing speech recognition in pediatrics post-op?

Answer 65

To assess the effectiveness of the chosen habilitation strategy, hearing modality, as well as evaluating the efficacy of the current technology settings

Question 66

How do you perform a post-op speech recognition assessment on older children?

Answer 66

Use recorded materials and 60 dB presentation level. Multiple estimates of speech recognition *Ideally the same test as pre-op

Question 67

How do you perform a post-op speech recognition assessment on younger children?

Answer 67

Nonspeech measures can be used for postoperative assessment of children with limited skills. Parental questionnaires