EN
Learn more about the 60-60 guideline for cochlear implant referral, helping you understand when it might be time to explore cochlear implants instead of relying on traditional hearing aids.
While many individuals with hearing loss benefit substantially from hearing aids, these devices do not universally address all types of hearing impairments. For some, particularly when there is significant damage to the inner hair cells responsible for sound clarity, hearing aids may not suffice. In such scenarios, a cochlear implant could be a more effective solution. As hearing care professionals, we continuously assess and determine the best course of action for each patient, which sometimes involves considering a cochlear implant evaluation. Understanding the intricate workings of the human ear is essential in evaluating whether a cochlear implant or hearing aids are the most suitable for an individual.
The process involves reviewing a patient's audiogram and word recognition scores. Word recognition scores specifically gauge the ability to understand speech when appropriately amplified. If these scores are low, it likely indicates a deterioration of the inner hair cells, leading us to explore the possibility of a cochlear implant. We use the 60/60 guideline to determine whether to refer a patient for cochlear implant evaluation. This guideline is based on research and suggests that if a patient's better hearing ear has a pure tone average of 60 dBHL or more and a word recognition score of 60% or lower, they could be a candidate for cochlear implantation.
When we consider the extensive range of hearing loss causes—age, genetics, noise exposure, chemical exposure—the treatment that emerges as pivotal for over 90 percent of these cases is the use of hearing aids. Properly fitted and programmed, hearing aids are quite adept at boosting sounds to compensate for impaired outer hair cells in our ears.
Yet, hearing aids have their limitations, particularly when it comes to inner hair cells that dictate sound clarity. Once deterioration in these cells crosses a threshold, hearing aids may no longer suffice; this is when we might turn to cochlear implants as an alternative solution.
Understanding Hearing Loss and Treatment Options:
We assess this through Word Recognition Scores—the clarity of single syllable words repeated back in a test environment:
Taking into account your audiogram results, if your hearing aids reach prescriptive targets, they can effectively aid your hearing. However, we follow a simple guideline to determine whether a cochlear implant evaluation is needed—the 60/60 Guideline.
60/60 Guideline for Cochlear Implant Referral:
Research in otology and neuro-otology has shown that this guideline is quite predictive: adhering to this, you have a 76 percent chance of being a traditional cochlear implant candidate.
What This Means For Our Hearing Health:
This guideline aids us in understanding when to consider alternative treatments beyond hearing aids.
As leading experts in hearing care, we recognize that hearing aids are the primary treatment for the majority of hearing losses stemming from aging, hereditary factors, noise exposure, and toxic substances. They are expertly designed to compensate for diminished outer hair cell function in the cochlea by enhancing sound vibrations, ensuring that users can detect and process sounds effectively when properly fitted and programmed.
However, our expertise allows us to conclude that hearing aids have significant limitations. Specifically, they are considerably less effective at compensating for inner hair cell damage, which is crucial for sound clarity. When inner hair cells deteriorate beyond a certain threshold, hearing aids may not suffice to restore intelligibility in hearing. This limitation prompts us to evaluate whether a patient might benefit more from an alternative device, such as a bone-anchored hearing aid or a cochlear implant.
To that end, we meticulously assess your word recognition scores—percentages of correctly repeated single-syllable words in quiet after proper amplification. High word recognition scores suggest that inner hair cells are relatively intact, signifying that hearing aids could be beneficial. On the other hand, low scores indicate significant inner hair cell damage, which may warrant consideration of cochlear implants to improve clarity.
We apply the 60/60 guideline for cochlear implant referrals. This involves checking if the better ear has a pure-tone average (PTA) of 60 dBHL or greater and a word recognition score of 60% or less; if so, referral for a cochlear implant evaluation is recommended. While this criterion greatly simplifies the referral process for us, it also offers you a clear indication of when a cochlear implant might be more suitable than hearing aids.
Remember, meeting the 60/60 guideline is not a definitive indicator for cochlear implant candidacy, but rather a signal for potential evaluation. We advise that even if you meet the guideline and are dissatisfied with your hearing aids, you should engage in a thorough discussion with us—a team of audiologists and otologists—about the possibility of an implant. Conversely, if you are content with your hearing aid performance or have single-sided deafness, the guideline might not apply, and your current hearing aids might well be the best option for you.
Our ears are complex structures that function to collect sound and convert it into signals that our brain can understand. To thoroughly understand how this conversion happens, we leverage a 3D ear model for a better visual representation. Initially, sound enters through the ear canal, reaching the eardrum, where the journey to the inner ear begins. These vibrations are then transferred through the ossicles, three tiny bones in the middle ear. The ossicles serve as a bridge to the cochlea, the spiral-shaped organ responsible for hearing.
The cochlea, resembling a snail in shape, contains a fluid and a membrane that are set into motion by sound vibrations. Alongside this membrane are microscopic hair cells, known as outer hair cells, which amplify these vibrations. This movement is crucial as it triggers the inner hair cells, which then send the vibration signal up the auditory nerve and on to the brain, enabling us to hear.
Here is a simple breakdown of the ear's anatomy relevant to the hearing process:
The journey of a sound vibration from entering our ear to becoming a brain signal is a fascinating process that involves several steps. We shall focus on this specific sequence, starting from when sound enters the ear to when it is interpreted as sound in our brains.
The accuracy and precision of this process are critical for clear hearing. Hearing aids are designed to augment the function of the outer hair cells by enhancing the sound vibrations, thus improving the movement of the basilar membrane, provided they are fitted and programmed correctly. Nonetheless, they are not as effective in substituting for damaged inner hair cells, which are integral for sound clarity. When the function of these inner hair cells is significantly compromised, alternative treatments such as cochlear implants may be considered.
Our ability to decipher word recognition, based on percentages from hearing tests, can indicate the health of our inner hair cells. If the word recognition scores are low, indicating considerable inner hair cell damage, we may need to explore the possibility of a cochlear implant for better hearing clarity. If our word recognition scores are high, it suggests that our inner hair cells are relatively intact, and hearing aids could be a viable solution.
The 60/60 guideline proposed by researchers assists hearing care professionals in determining whether a cochlear implant evaluation is necessary. If our pure tone average (PTA) in the better hearing ear is 60 dBHL or above, and the word recognition score is 60% or below, it would be advisable to consider a cochlear implant candidacy evaluation. We must engage in discussions with our audiologist and otologist to explore the best options for our hearing health.
While hearing aids serve as a sufficient solution for the majority of hearing losses, they are not always successful for everyone. They typically enhance the function of outer hair cells in the cochlea to strengthen sound vibrations, which aids in hearing effectively. When these devices are correctly fitted and programmed, they can significantly improve hearing capability.
However, hearing aids have limitations, particularly when it comes to compensating for damage to the inner hair cells that are crucial for sound clarity. As our knowledge of the auditory system deepens, we understand that when inner hair cells are extensively damaged, cochlear implants might be the superior choice to restore clarity.
Cochlear implants bypass the damaged hair cells entirely by converting sound into electrical signals and directly stimulating the auditory nerve, which can result in clearer hearing for those with severe damage to the inner hair cells.
To determine if cochlear implants might be more appropriate than hearing aids, we consider a patient's word recognition scores—these are the percentages of single-syllable words correctly repeated back in a controlled environment after sound has been amplified appropriately.
Hearing Solutions
Hearing Aids
Function: Amplify sound to enhance remaining auditory function
Indication: High word recognition scores
Cochlear Implants
Function: Directly stimulate the auditory nerve
Indication: Low word recognition scores
We follow the 60/60 guideline for cochlear implant referral, which was proposed in a 2020 study published in Otology & Neurotology. The guideline stipulates that if a patient’s better hearing ear has a pure tone average (PTA) of 60 dBHL or above and a word recognition score of 60% or below, a referral for a cochlear implant evaluation is suggested.
To calculate PTA:
If a patient meets the 60/60 referral criteria, this doesn't guarantee cochlear implant candidacy, but it does warrant an evaluation. We've observed that:
Finally, if you're dissatisfied with your hearing aid performance and your test scores align with the 60/60 criteria, discussing a potential evaluation for a cochlear implant with us could be beneficial. Remember, even if criteria are met, satisfaction with current hearing aid performance can guide your decision on whether to explore cochlear implant options further.
When determining the need for referral to a cochlear implant evaluation, word recognition scores are a crucial factor. These scores represent the percentage of single-syllable words one can correctly repeat back under controlled conditions when properly amplified.
Word Recognition Score Interpretation:
To be more precise, let us consider the 60/60 Guideline for Cochlear Implant Referral based on a 2020 study published in Otology & Neurotology:
Then you should be referred for a cochlear implant evaluation. The PTA is calculated by taking hearing thresholds at 500 Hz, 1000 Hz, and 2000 Hz, adding them together, and then dividing by three.
Efficacy of 60/60 Guideline:
Remember, these guidelines do not guarantee candidacy for cochlear implants nor the necessity to undergo the procedure. If you have single-sided deafness or are content with your hearing aid performance despite meeting the criteria, cochlear implantation may not be applicable. The best course of action is an open discussion with your audiologist and otologist to understand your options thoroughly.
As hearing care professionals, it is essential for us to recognize when hearing aids may no longer be beneficial for certain types of hearing loss, particularly when it comes to inner hair cell damage. We advocate for the proper treatment, which in some cases, is a referral for a cochlear implant evaluation. Based on research in otology and neurotology, we've established a straightforward method to identify whether a cochlear implant may be more suitable than a hearing aid: the 60/60 guideline.
To explain this guideline, we consider two main factors:
The criteria for referral using the 60/60 guideline are as follows:
Then, a referral to a cochlear implant center for evaluation is warranted. This is based on evidence revealing a significant probability of candidacy for cochlear implants among individuals meeting these conditions. To demonstrate:
Criterion: 60/60 Guideline
Outcome: 76% chance of being a traditional cochlear implant candidate
Criterion: Above 60/60
Criteria: 94% did not meet traditional candidacy requirements
It's important to underline that these guidelines are aimed at identifying potential candidates for an evaluation, not for the determination of cochlear implantation itself. They do not apply in cases of single-sided deafness, which requires separate consideration. Always remember, the decision for cochlear implantation should be a collaborative process with your audiologist and otologist. If your hearing aids are not providing satisfactory clarity and you meet the 60/60 criteria, discussing a cochlear implant evaluation could be a fruitful step. However, if you are content with your hearing aids' performance, you may choose to continue their use.
When we are considering whether to refer a patient for a cochlear implant evaluation versus fitting them with another set of hearing aids, we assess the effectiveness of the hearing aids. Specifically, we look at the function of the inner hair cells. If damage to the inner hair cells is significant, a cochlear implant may be needed to restore clarity to hearing. Our assessment includes a detailed analysis of a patient's word recognition scores obtained from their hearing test.
Word recognition scores represent the percentage of single-syllable words that a patient can correctly repeat back in a quiet environment when they have been suitably amplified. High scores suggest that the inner hair cells are largely intact, making hearing aids an effective treatment. However, low word recognition scores indicate deteriorated inner hair cells, for which hearing aids may not be sufficient. This is as long as the audiogram shows measurable thresholds, denoted by the x's and o's, and the hearing aids can amplify sound enough to meet prescriptive targets.
The 60/60 guideline serves as a straightforward benchmark for referral. It states that if a patient's better hearing ear has a pure-tone average (PTA) of 60 dBHL or greater and a word recognition score of 60% or lower, referral for a cochlear implant candidacy evaluation is recommended. To calculate the PTA, we use the patient's pure-tone air conduction thresholds at 500 Hz, 1,000 Hz, and 2,000 Hz from the better ear, sum them, and divide by three.
A study published in the Otology & Neurotology journal in 2020 supports this guideline. The retrospective review of 529 patients undergoing cochlear implant evaluations found that those who met the 60/60 criteria had a 76% chance of becoming a traditional candidate for cochlear implants. Furthermore, 94% of those who did not meet the 60/60 criteria also did not meet traditional cochlear implant candidacy requirements.
As a result, the 60/60 guideline has become an essential tool for us to determine when a cochlear implant evaluation is more apt than another hearing aid fitting. If you match both criteria, you might benefit from a conversation with us about your satisfaction with your hearing aids. Remember, meeting the 60/60 guideline suggests candidacy for evaluation, but it is not a guarantee of becoming a cochlear implant candidate. The final decision will always be made in collaboration with your audiologist and otologist. If you have single-sided deafness, this guideline does not apply, but you might still be a candidate for a cochlear implant.
Ultimately, if you are content with your hearing aid performance, there's no obligation to switch. Yet, if you find yourself struggling despite your hearing aids and meet the 60/60 criteria, discussing the possibility of a cochlear implant evaluation with your doctor could be beneficial.
We understand that hearing aids are typically the best treatment option for most hearing losses due to age, genetics, noise exposure, and chemical exposure. However, we also acknowledge that there are instances where hearing aids are insufficient, particularly when the inner hair cells in the cochlea are damaged. In such cases, a cochlear implant may be necessary to improve clarity of hearing.
Our obligation as hearing care professionals is to determine the most beneficial course of treatment for our patients. This includes evaluating when a patient's hearing aids no longer provide the clarity needed, indicating a possible need for a cochlear implant evaluation.
Important considerations include:
To assist us in making this decision, we use the '60/60 guideline' as defined by a 2020 study. This guideline states:
Then, referral to a cochlear implant center for evaluation is recommended.
Evaluation for Cochlear Implant Candidacy:
We must also consider patient satisfaction with current hearing aids and the appropriateness of a cochlear implant based on individual circumstances, including single-sided deafness which has different criteria.
Data insights:
In summary, our role extends beyond fitting hearing aids; we must actively engage in discussions about potential cochlear implant evaluations, providing our patients with the opportunity for improved hearing experiences when conventional hearing aids are no longer adequate.
We often encounter patients with significant hearing loss and one question remains at the forefront: Are hearing aids sufficient, or is a cochlear implant more appropriate? To clarify this, it's important to assess the effectiveness of hearing aids against the damage to inner and outer hair cells in the cochlea.
For clarity, hearing aids amplify sound to assist outer hair cells and if they are well-fitted, they often do an excellent job. However, when it comes to the deterioration of inner hair cells, which significantly impacts clarity, hearing aids fall short, suggesting that cochlear implants may be a better alternative.
How do we determine where the damage lies? Through word recognition score percentages found in hearing tests, which indicate the effectiveness of inner hair cells. High percentages suggest that inner hair cells are relatively undamaged—signaling that hearing aids are a suitable option. Conversely, low percentages denote significant damage where cochlear implants may be necessary.
When to consider a cochlear implant? The '60/60 guideline' is informative here.
The 60/60 Guideline
Pure Tone Average (PTA): ≥60 dB HL
Word Recognition Score: ≤60 percent
Next Steps: Refer for cochlear implant evaluation
To calculate the PTA, we take thresholds at 500 Hz, 1000 Hz, and 2000 Hz from the better-hearing ear, sum them and divide by three. If the score is ≥60 dB HL and the word recognition score in that ear is ≤60 percent, referral for a cochlear implant evaluation is advised.
Research supports this guideline, demonstrating that candidates meeting the 60/60 threshold stand a 76% chance to be deemed traditional cochlear implant candidates. Meanwhile, those outside this criterion often fail to meet traditional candidacy requirements.
What does this mean for us in practice? If our patients fall within this 60/60 spectrum yet remain dissatisfied with their hearing aids, a discussion about cochlear implant evaluation could be highly beneficial. Remember, meeting the guideline does not equate to cochlear implant candidacy or a need to pursue one—this is determined by further evaluation and discussion with respective audiologists and otologists.
For patients with single-sided deafness or those content with their hearing aid performance, the 60/60 guideline may not be applicable, and hearing aids can continue to serve effectively.
Ultimately, if hearing aids are not meeting our patients' needs and they meet the 60/60 criteria, exploring cochlear implant evaluation might be a prudent course of action.
We understand the crucial role hearing aid technology plays in addressing a broad spectrum of auditory impairments, particularly those stemming from age, genetics, noise, and chemical exposure. It's paramount to recognize that these devices are highly effective in amplifying sound, thereby enhancing the movement of the basilar membrane in the cochlea, as long as they are fitted and programmed with precision.
Despite the benefits of hearing aids, there comes a point where they may not suffice, especially when inner hair cell damage compromises sound clarity. In these instances, we look to word recognition scores as an indicator of the health of inner hair cells. High word recognition score percentages signify that inner hair cells are significantly intact, validating the use of hearing aids as an effective treatment. Conversely, low percentages suggest a deterioration beyond the aid that hearing aids can provide, at which point we consider a cochlear implant.
The 60/60 guideline serves us as a straightforward method for determining the need to refer for a cochlear implant evaluation. This assessment relies on a pure tone average of 60 dBHL or higher combined with a word recognition score of 60% or below in the better hearing ear. Studies demonstrate a significant correlation between meeting these criteria and becoming a candidate for cochlear implantation, with a 76% likelihood observed in a 2020 research study.
As hearing care professionals, we continuously strive to provide optimal patient outcomes. Thus, our approach evolves to ensure that individuals who are not sufficiently benefitting from hearing aids, yet meet the 60/60 referral criteria, receive appropriate consultations for cochlear implants. However, we maintain that satisfaction with current hearing aid performance can be a valid reason to persist with these devices unless one expresses a preference for exploring implant options.
It is worth acknowledging that this guideline does not apply to cases of single-sided deafness, where different criteria are in place. Our goal is to support a well-informed decision-making process, encompassing individual patient needs and preferences through discussions with audiologists and otologists. This empowers you to make the most appropriate choice for your hearing health, whether it's to continue using hearing aids or to pursue a cochlear implant evaluation if you face persistent challenges.
You know, if your hearing loss is this bad, you should probably throw your hearing aids in The trash.
Hearing aids are the best and only treatment option for the vast majority of hearing losses. In fact, over 90% of hearing losses that are caused by things like age, genetics, noise exposure, and chemical exposure require the use of hearing aids. However, hearing aids are not effective for all types of hearing losses, and in some cases, you might need a bone anchored hearing aid or even a cochlear implant instead. Now, if you do not know what a cochlear implant is, I will link this video down in the description for you to check out so you can learn more about them. But in this video, I wanna talk about what a hearing in care professional is looking for when considering whether or not to refer you out for a cochlear implant evaluation instead of just fitting you with another set of hearing aids that aren't gonna work.
But before I do, if you could do me a huge favor and click the like button, I really appreciate it because it gets these videos in front of a bigger audience and why you're at it. If you have not yet hit that subscribe button with notification bell, go ahead and do that as well, because that ensures that you never miss one of my newly released videos and I release multiple new videos every single week. That being said, I really appreciate it. And now let me give you an understanding of how the human ear works. To help do that, I'm going to be using my 3D ear model. Now, sound is a vibration. When that vibration enters the ear, it travels down the ear canal to the eardrum. The eardrum takes that vibration and sends it through the three middle ear bones called ossicles and into the cochlea, which is your hearing organ.
The cochlea is this little coil right here, and it looks a little bit like a snail. Now, inside of that coil, you have a bunch of fluid and you have a membrane. When that vibration of sound enters in, it makes the membrane move. But you also have microscopic little hair cells all along that membrane called outer hair cells that take that vibration of sound and enhance it to make that membrane move even more. Now, this membrane moves enough, it triggers an inner row of hair cells that will take that vibration and send it up to auditory nerve to the brain. So you can hear hearing aids do a really good job of replacing the function of these outer hair cells to enhance the vibration of sound to create enough movement in the basler membrane. This is as long as those hearing aids are fit and programmed properly.
However, hearing aids are notoriously bad at replacing the function of the inner hair cells, which control the amount of clarity that you get from that sound when these inner hair cells deteriorate past a certain point. You need to consider cochlear implants instead of hearing aids if you want to restore clarity to your hearing. But how do you know if your hearing loss is caused by damage to the inner hair cells or the outer hair cells? Well, to find that out, we have to have a good understanding of your word recognition score percentages that you can find on your hearing test. Your word recognition scores are the percentages of single syllable words that you repeat back correctly to your tester in quiet when those words have been appropriately amplified. If these word recognition score percentages are, then your inner hair cells are largely intact, and hearing aids will be inappropriate treatment option for you.
However, if these percentages are low, then your inner hair cells have deteriorated to the point where hearing aids will no longer be as effective, as long as you have measurable thresholds on your audiogram indicated by the Xs and the OS, and hearing aids that are capable of amplifying sound loud enough to hit your prescriptive targets. So at what point should your hearing care professional refer you for an evaluation to determine if a cochlear implant is more appropriate than a hearing aid? Well, that's where the 60 60 guideline for cochlear implant referral comes into play. In a 2020 paper published in Otology and Neuro Otology, the researchers propose an extremely easy way to identify if you should be referred to a cochlear implant center for a cochlear implant candidacy evaluation. The whole premise of this guideline is that if your better hearing ear has a pure tone average of 60 D B H L or higher, and that same ear has a word recognition score of 60% and below, then you should be referred to a cochlear implant center for a cochlear implant candidacy evaluation.
Now, to easily calculate your pure tone average, otherwise known as your pta, you would take your pure tone air conduction thresholds from your better hearing ear at 500 hertz, 1000 hertz, and 2000 hertz, add them together and then divide by three. If this number is equal to or greater than 60 DB hhl, then you would meet the first half of the guideline. Now, if your word recognition score in that same year is that 60% or below, then you have technically met the second half of the 60 60 referral criteria, meaning that you could be referred to a cochlear implant center for a cochlear implant candidacy evaluation. In this retrospective review, researchers looked at data from 529 patients who participated in cochlear implant candidacy evaluations to see how many of them met the 60 60 referral criteria and ended up becoming a traditional candidate for cochlear implants.
When it was all said and done, the results were quite surprising. Candidates who met the 60 60 referral criteria had a 76% chance of becoming a traditional candidate for cochlear implants. However, of these individuals who did not meet the 60 60 criteria, meaning that they actually heard too good to be within this referral criteria, 94% of them did not meet the traditional candidacy requirements for a cochlear implant. This means that the majority of individuals who met this 60, 60 criteria ended up becoming traditional candidates for a cochlear implant on the hearing care professional side. This makes it really easy to know when we should be referring an individual for a cochlear implant evaluation rather than just fitting them with another set of hearing aids. So what does this mean for you? Well, if you happen to meet both of these criteria, it might be worth a conversation with your hearing care professional.
If you are just not satisfied with your performance with your hearing aids. Keep in mind that this guideline is intended to determine whether or not you should be referred for a cochlear implant evaluation. It does not guarantee that you'll become a candidate for a cochlear implant, and it does not mean that you should even get a cochlear implant. That is a discussion that you should be having with your audiologist and your otologist. Also, if you have a case of single-sided deafness, this criteria does not apply, and you may still be able to get a cochlear implant. And again, this is a discussion that you should be having with your doctors. At the end of the day, even if you do meet this criteria, but you're happy with your hearing aid performance, I say, go ahead and continue to use your hearing aids unless you feel like you'd rather get a cochlear implant instead. But if you continue to struggle with your hearing aids and you do meet this 60, 60 criteria, having a discussion with your doctor about getting a cochlear implant evaluation might be a really good idea.
Dr. Cliff explains why hearing aids whistle and provides practical solutions to eliminate feedback issues that many hearing aid users experience.
Read More
In our practice as audiologists, we emphasize the critical importance of precise hearing assessments and the use of real ear measurements (REM) to ensure optimal hearing.
Read More
Recent research has discovered that hearing loss treatment could in fact slow down the cognitive decline.
Read More
DID YOU KNOW that one-third of hearing loss cases are completely preventable?
Read More
Name-brand hearing aids, fit by a local hearing healthcare provider who follows Best Practices.
Best Practices ChecklistHearing Aid Buyer's Guide
