Cochlear implants are a surgical option for hearing loss that cannot be adequately treated with conventional hearing aids. There are specific criteria to be a candidate for a cochlear implant, determined by your audiologist and surgeon. There are three FDA-approved manufacturers of cochlear implants, and often your cochlear implant center will leave the decision of which device to pursue in your hands.

This article will outline the most current offerings from each manufacturer to help you make the decision on the best cochlear implant for your needs.

What Is A Cochlear Implant?

A cochlear implant is a medical device designed for people who have too much hearing loss to receive adequate benefit from traditional hearing aids. Cochlear implants are a treatment option for patients of all ages, from babies who receive a diagnosis of hearing loss at birth all the way up through elderly adults who are healthy enough for surgery.

So, what is the difference between hearing aids vs. cochlear implants? Hearing aids use the traditional sound pathway of normal hearing but provide amplification based on the degree of hearing loss. 

Cochlear implants, on the other hand, are creating a new pathway for hearing. An electrode array is inserted directly into the cochlea to essentially take the place of the tiny hair cells responsible for sending auditory signals to the brain. These hair cells are damaged or dysfunctional in a person with considerable hearing loss, and they are unable to regenerate. The electrode array essentially takes the place of these hair cells to directly stimulate the auditory nerve. The external portion of the cochlear implant, known as the sound processor or speech processor, picks up sound and transmits it to the electrode array, which stimulates the auditory nerve and the brain.

Image credit: Sick Kids

Who Is A Candidate For Cochlear Implants?

If you are currently using hearing aids and noticing that you are struggling, it might be time to have a cochlear implant evaluation. It is possible that you simply need adjustments to your existing hearing aids to account for a change in hearing loss, or your hearing loss may have progressed to the point of cochlear implant candidacy. There are two main parts of the evaluation to determine candidacy for a cochlear implant. The first is the diagnostic hearing test. Candidates for cochlear implants typically present with severe to profound hearing loss in children, and moderately severe to profound hearing loss in adults. The second part of the evaluation is discrimination ability with appropriately fit hearing aids. The audiologist needs to be able to show that, even with hearing aids, a patient is missing a large percentage of meaningful speech. There are a couple of different tests, some of which use single monosyllabic words and others which use sentences, which are presented to the patient in the soundproofed booth with their hearing aids on. The performance on these tests needs to be below a certain percentage in addition to the results on the audiogram in order to be considered a candidate for a cochlear implant. 

If a patient is deemed an audiological candidate, they would also need to be seen by a surgeon to determine medical suitability for surgery. The surgeon is an otologist or neuro-otologist, meaning they have had special training in ear surgery. The procedure takes place under general anesthesia, so the patient must be healthy enough to be put under. The surgeon will also make a referral for a CT scan in order to examine the anatomy of the inner ear within the temporal bone. For some patients, and especially for children, the surgeon may also recommend an MRI. A CT scan shows bone, while an MRI shows soft tissue. Depending on the etiology of hearing loss, the surgeon may or may not need both types of images. The surgeon may also make a recommendation for the best cochlear implant electrode type based on your anatomy.

I’m A Candidate, What Should I Consider Before Getting A Cochlear Implant?

Depending on where you are located, you may have one cochlear implant center or several. Some centers offer all three devices, while others only offer one or two. Additionally, some centers provide two external sound processors with your kit so that you have a backup device, while others are known as single processor centers. These are important factors to consider if you do have the flexibility in your region to choose your center. 

If you are an audiological and medical candidate for a cochlear implant, the surgery and devices should be covered by your insurance. Depending on the insurer, there may be some co-pays or out-of-pocket expenses, but the majority should be covered. Prior to getting surgery, you can work with your cochlear implant center and your chosen manufacturer to learn exactly what you might be responsible to pay out of pocket. All of the companies have insurance and reimbursement teams to assist patients and professionals with working through this process.

Who Makes Cochlear Implants?

1. Advanced Bionics

AB is the only American cochlear implant company, founded in 1993 and based in Valencia, CA. Since 2009, they are under the umbrella of Sonova, a Swiss hearing healthcare organization, and they partner closely with Phonak for much of the directional microphone technology, accessories, and bimodal fitting (one hearing aid and one cochlear implant). The newest processors from Advanced Bionics are on the Marvel platform, with the Naida M processor designed for adults and Sky M designed for children.

This processor incorporates much of the tried-and-true technology from Phonak hearing aids, including their AutoSense OS scene analyzer for automatic adjustments as the patient transitions into different listening environments. This processor also offers made-for-all Bluetooth connectivity, meaning you can directly stream from any Bluetooth device. As mentioned, AB and Phonak have partnered to offer a full bimodal system with the Naida Link M hearing aid, which communicates directly with the processor. AB also benefits from the Phonak partnership in the offering of Roger assistive listening devices, and there is a fully waterproof case as an accessory option, as well.

As far as internal devices, the most current implant is the HiRes Ultra 3D. This internal device is compatible for 3T MRI due to unique internal magnet technology allowing pain-free and hassle-free MRI. Advanced Bionics has two options for electrode arrays: Mid-Scala and SlimJ. While the manufacturer will likely be the patient’s choice, the surgeon typically makes the selection regarding which electrode array from the manufacturer to implant. Both the Mid-Scala and the SlimJ were designed to be as atraumatic to the cochlea as possible; one is a pre-curved array meant to literally sit in the middle of the scala tympani, while the SlimJ is a lateral wall design. Many surgeons and CI centers have a strong preference for a certain electrode design, while others make the decision based on the patient’s hearing and results of pre-operative imaging.

Advanced Bionics also advertises a fully upgradeable internal device, meaning that any future external sound processors will be backward compatible. Think about this like the routine software updates pushed to your smartphone- your internal device can support any software updates or new hardware that becomes available.

2. Cochlear Americas

Cochlear is an Australian company founded in 1984, with Cochlear Americas headquarters located in Denver, CO. Cochlear was the first to market, and they have the largest share of cochlear implant patients worldwide. The newest processor from Cochlear is the Nucleus 8.

The Nucleus 8 is the smallest cochlear implant processor on the market. It is a Made-for-iPhone device with some streaming capabilities to non-Apple products. Cochlear has a partnership with ReSound to offer bimodal streaming options with a compatible ReSound hearing aid and accessories. Cochlear also offers an all-in-one processor (Kanso), which does not have a portion that sits on the ear but rather the entire processor sits on the magnet site. 

Cochlear’s newest internal device is the Profile Plus implant. Cochlear designs perimodiolar electrodes, meaning they tend to “hug” the internal wall of the cochlea. The philosophy here is that the stimulation is closest to the target area. Cochlear also offers a “hybrid” electrode array, specifically designed for patients who have considerable low-frequency hearing. This shorter electrode array will only target the area of the cochlea with considerable hearing loss, and the patient can receive electrical stimulation in this area and continue to use their acoustic hearing where it is still viable. Cochlear’s internal devices are 3T MRI compatible.

3. Med-El

Med-El is an Austrian company founded in 1986, with American headquarters in Durham, NC. Med-El was also the first company to offer an all-in-one processor. The current iteration is called the Rondo 3 and offers wireless charging. Their newest processor is the Sonnet 2, which is their smallest and lightest processor and offers some streaming capability via an audio accessory that is a sort of “sleeve” attached to the processor. Med-El is not partnered with any hearing aid company for bimodal solutions, but rather state that patients can continue using whatever hearing aid they are currently comfortable with during the candidacy phase on the opposite ear. 

Image credit: Cochlear Implant Help

Med-El was first to market with an MRI-compatible internal device. There are some restrictions on head placement in the MRI machine with this device, but most imaging can be carried out without magnet removal. Med-El uses lateral wall electrode arrays of varying lengths. Their philosophy with internal devices is “complete cochlear coverage,” the belief that a longer electrode array with widely spaced electrodes will offer more natural quality of the frequencies of speech. That said, Med-El does offer a hybrid electrode array for those with considerable low-frequency hearing ability.

Advanced BionicsCochlear AmericasMed-El
Newest processorNaida/Sky MarvelNucleus 8/Kanso 2Sonnet 2/Rondo 3
Internal devicesHiRes Ultra 3DProfile PlusSynchrony 2
Electrode designsPre-curved and lateral wallPre-curvedLateral wall
MRI Compatibility3T3T3T
Streaming capabilityFully Bluetooth compatibleCurrently Made-for-iPhone, will be upgradeable for Bluetooth LE Requires AudioStream accessory on Sonnet 2 processor
Bimodal optionsNaida Link M or Sky Link M specifically designed to work with implant, ear-to-ear communication and bimodal fitting formulaBimodal streaming with compatible GN ReSound hearing aid via accessoriesNo specific bimodal recommendations
Accessory optionsCompatible with all Phonak accessories, including RogerCompatible with Cochlear and GN ReSound accessoriesAudioStream sleeve
Waterproof capabilityWaterproof case (AquaCase) for processor with IP 68 rating, uncovered microphonesWaterproof case (Aqua+) with IP 68 rating for Nucleus or KansoWaterWear for Sonnet 2 or Rondo 3 processors with IP 68 rating, reusable with change to adhesive strip
Community supportBionic Ear AssociationCochlear FamilyHear Peers
Warranty10 years on internal, 5 years on external10 years on internal, 5 years on external10 years on internal, 5 years on external

They All Sound Great; How Do I Choose?

One of the best steps to take going through the cochlear implant journey is to talk with other recipients. Each of the three companies has a community of recipients and family members and you can be paired with a mentor to talk through your experience. Each of the manufacturers also has local representatives who are able to meet with you in person or virtually to specifically talk through the options from their respective companies and can even help you fill out your order form if you choose to move forward with that device, to ensure that you make the most of your package.

All of the companies have excellent technology, and you will more than likely find success with whatever device you choose. That said, there might be certain reasons to choose one over another. Most adults receive one cochlear implant and continue to use a hearing aid on the contralateral ear, so bimodal compatibility may be a deciding factor. If you are concerned about dexterity issues, you can practice battery removal and other daily activities with the device to see which style feels the most comfortable to you. You may also make a decision based on certain technology regarding hearing in noise, waterproof capability, or Bluetooth streaming.

Making the decision to pursue a cochlear implant is the most important one. The device that you go with is a big choice because hopefully you will be married to that company forever! You certainly want to feel confident in putting your trust in the right company. Use the manufacturers and the providers at your center as resources and know that you can’t make a wrong choice so whichever device you choose will be the best cochlear implant for you.

erin edwards aud
Clinical Audiologist at Towson University | + posts

Erin Edwards received her Doctor of Audiology degree from Towson University in 2015 and her Ph.D. in Education and Leadership from Pacific University in 2022. She has worked with patients of all ages in a variety of settings and has a specific interest in cochlear implants, the relationship of hearing loss and dementia, and interdisciplinary healthcare.

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