Audiology Services
A cochlear implant bypasses the damaged part of the inner ear and stimulates the hearing nerve directly. It is not a louder hearing aid and it does not work the same way. It is also not a last resort any more: the referral criteria have moved substantially, and the most common mistake we see is people waiting years longer than they needed to.
We run cochlear implant candidacy evaluations here and we program implants after activation. The surgery itself is done by an ENT surgeon at an implant centre, and we work alongside them. If you are wondering whether this conversation applies to you, the starting point is a current hearing evaluation with speech testing, not a guess.
At a glance
- A cochlear implant bypasses the damaged inner ear and stimulates the hearing nerve directly; it is not a more powerful hearing aid.
- Referral is now recommended far earlier than it used to be — a pure-tone average of 60 dB HL with 60% speech understanding is enough to warrant evaluation.
- Medicare widened its coverage criteria in 2022 to sentence recognition scores of 60% or less, so an assessment made before then used a stricter rule.
- Outcomes depend heavily on how long the ear has been deaf and on wearing the processor consistently after activation.
When hearing aids are no longer enough
The clearest sign is a gap between volume and clarity. You are not asking people to speak up so much as asking them to repeat, because sound arrives at a reasonable level and still does not resolve into words. Telephone calls become guesswork. Groups become impossible while one-to-one in a quiet room still works. Importantly, this judgement is made with hearing aids that have been verified against prescriptive targets — an unverified fitting can look like a cochlear implant candidacy question when it is really a programming problem, which is why real-ear verification comes first.
The 60/60 referral guideline
Cochlear recommends a simple screen for when to refer: a pure-tone average of 60 dB HL or worse and speech understanding of 60% or less should prompt a full candidacy evaluation, a threshold under which 96% of patients meeting 60/60 turned out to be candidates. The point of the guideline is that it fires far earlier than the old instinct of waiting for profound deafness. We explain it in more detail on our page about the 60/60 rule. Meeting it does not mean you will be implanted; it means the question is worth asking properly.
What the candidacy evaluation involves
More than a hearing test. We measure hearing in both ears, aided and unaided, and the part that decides most of it is recorded sentence testing in the best-aided condition — how much connected speech you actually understand with your hearing aids working properly. That is the number Medicare and the manufacturers' criteria are written around. Beyond the audiology, candidacy involves imaging of the inner ear, a medical assessment of fitness for surgery, and a realistic conversation about expectations and about the rehabilitation that follows. We do the audiological workup; the imaging and surgical assessment happen at the implant centre.
What the criteria actually say
Medicare changed its coverage criteria in September 2022, widening the threshold to scores of 60% or less on recorded open-set sentence recognition in the best-aided condition, up from the previous 40%. That single change made a large group of people eligible who had been told for years that they were not bad enough. If you were assessed before 2022 and turned down, you were assessed against a different rule, and it is reasonable to ask to be reassessed.
Surgery, activation and the work afterwards
The operation is performed by an ENT surgeon and is generally day surgery or a single overnight stay. The implant is not switched on at the time of surgery — activation happens a few weeks later, once healing has progressed, and that is where we come back in. Early sound through an implant is commonly described as mechanical, thin or robotic, and it changes over weeks and months as the brain adapts. Programming is not a single appointment but a series, with the map adjusted repeatedly over the first year. This rehabilitation is the part that determines the outcome, and the people who do best are the ones who wear the processor all day from the start. We work with established implant centres in the Bay Area and will make the referral, then handle the programming here so your ongoing care stays local.
What an implant does and does not restore
It does not restore normal hearing, and we would rather say that now than have you discover it at activation. What the evidence supports is substantial gains in understanding speech, particularly in quiet and on the telephone, for people whose hearing aids had stopped delivering clarity. Music often remains less satisfying than speech. Two factors consistently predict a better outcome: how long the ear has been without useful hearing, and consistent daily use afterwards. A long-deafened ear implanted decades later generally does less well than one implanted within a few years, which is the practical reason not to wait and see.
Implants, hearing aids and one-sided loss
Using a hearing aid in one ear and an implant in the other is common and usually encouraged, since the brain does better with input from both sides. For people deaf in one ear only, the FDA approved cochlear implantation for single-sided deafness in 2019, and it is the only option that makes the deaf ear itself work again rather than routing sound to the other side — see our page on single-sided deafness and CROS. Serious general health problems or dementia do not automatically rule out an implant, but they change the balance of benefit against the demands of surgery and rehabilitation, and that is a decision made with the surgical team and the family together.
Where to start
With a proper evaluation, and with hearing aids that have been verified. If your current devices have never been checked with real-ear measurement, that is the first thing to fix, because it is not unusual for clarity to improve enough that the question recedes. If it does not, we will run the candidacy workup and tell you plainly what we find. Call 650-342-9449 — 88 N. San Mateo Drive in San Mateo, or 1008 Laurel Street in San Carlos. Bring your current hearing aids and your most recent audiogram, and if you have been assessed for an implant before, bring that report too.
Frequently asked questions
A few questions worth asking
How do doctors decide between a hearing aid and a cochlear implant?
By whether amplification still produces clarity. If well-fitted, verified hearing aids give you volume but not words — particularly for connected speech and on the telephone — a cochlear implant becomes the question. The decision rests on recorded sentence testing in the best-aided condition rather than on the audiogram alone.
What are the signs my hearing loss is too severe for hearing aids?
You hear that someone is speaking but cannot make out what they said, even at a comfortable volume. The telephone becomes unusable. Group conversation stops being difficult and becomes impossible. Subtitles become essential. If that describes you and your hearing aids have been properly verified, it is time for a candidacy evaluation.
What does the cochlear implant candidacy evaluation involve?
Full hearing testing in both ears aided and unaided, and recorded sentence recognition testing with your hearing aids working properly — that last measure carries most of the weight. Beyond the audiology there is imaging of the inner ear and a medical assessment of fitness for surgery, which happen at the implant centre. We perform the audiological workup and refer for the rest.
Do cochlear implants restore normal hearing?
No, and anyone who tells you otherwise is overselling. They restore access to speech for people whose hearing aids no longer deliver clarity, and the gains in understanding conversation and using the telephone can be substantial. Sound is different rather than simply louder, music is often less satisfying than speech, and the brain takes months to adapt.
Does it matter how long I have been deaf?
Yes, and it is one of the strongest predictors of outcome. An ear that has been without useful hearing for a long time generally does less well than one implanted within a few years, because the hearing pathways lose the stimulation they depend on. This is the main argument against waiting to see how things go.
Can I use a hearing aid and a cochlear implant at the same time?
Yes. Wearing an implant on one side and a hearing aid on the other is common and generally encouraged, since the brain works better with input from both ears. We program the implant and fit the hearing aid so the two work together rather than against each other.
Can someone with dementia or other health problems still get an implant?
It is not an automatic exclusion, but it changes the calculation. Surgery and the months of rehabilitation afterwards both ask something of the patient, and the benefit has to be weighed against that. Against it: untreated hearing loss makes cognitive and communication difficulties worse, so doing nothing is not a neutral choice. This is a decision for the surgical team, the family and the patient together.
Will a cochlear implant stop the ringing in my deaf ear?
Often it reduces it, and tinnitus improvement is one of the outcomes measured in the research rather than just an anecdote. It is not guaranteed and it should not be the sole reason to have surgery. If tinnitus is your main complaint, we would treat it in its own right first — see tinnitus therapy.