AJA
Research Article
Evidence-Based Recommendation for
Bilateral Cochlear Implantation in Adults
Agnes Aua,b and Richard C. Dowella,b,c
Purpose: Most adult cochlear implant (CI) users in
developed countries benefit from the use of a hearing aid
in conjunction with their implant device (bimodal hearing).
Benefits have also been documented for the use of
bilateral CIs for speech perception in quiet, localization,
and speech perception in noise. This study attempted
to quantify speech perception results for bimodal and
bilateral CIs in adults and provide a guide for those
considering a 2nd CI.
Method: Speech perception outcomes were reviewed for
1,394 adults with acquired hearing loss who received a CI at
the Melbourne Cochlear Implant Clinic between 2000 and
2015.
B
inaural hearing provides improvements in speech
perception and localization over monaural hear-
ing, even for listeners with hearing impairment
(Dwyer, Firszt, & Reeder, 2014; Illg, Bojanowicz, Lesinski-
Schiedat, Lenarz, & Büchner, 2014; Litovsky, Parkinson,
& Arcaroli, 2009; Morera et al., 2012). For those with a
cochlear implant (CI), binaural hearing can be accessed using
a hearing aid (HA) in the nonimplanted ear (bimodal stim-
ulation) or with a second CI (bilateral implantation), depend-
ing on the degree of hearing loss in the contralateral ear.
Binaural hearing provides crucial interaural timing
and intensity difference cues that enable the typical listener
to localize sound sources. The auditory system is able to
use the acoustic differences between the two ears to perceive
the location and direction of sound sources on the horizontal
a
The HEARing Cooperative Research Center, Melbourne, Victoria,
Australia
b
Department of Audiology and Speech Pathology, The University
of Melbourne, Victoria, Australia
c
Cochlear Implant Clinic, Royal Victorian Eye and Ear Hospital,
Melbourne, Victoria, Australia
Correspondence to Agnes Au: agnes.au@unimelb.edu.au
Editor-in-Chief: Gabriella Tognola
Received November 21, 2018
Revision received March 20, 2019
Accepted March 26, 2019
https://doi.org/10.1044/2019_AJA-HEAL18-18-0183
Publisher Note: This article is part of the Special Issue: Select Papers
From the Hearing Across the Lifespan (HEAL) 2018 Conference.
American Journal of Audiology • Vol. 28 • 775–782 • October 2019 • Copyright © 2019 American Speech-Language-Hearing Association
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Results: Bimodal and bilateral users significantly outperformed
unilateral CI users on consonant–vowel–consonant word
recognition in quiet. For the bilateral group, word recognition
scores with the 1st CI were predictive of 2nd CI word
scores. The analysis suggested that bimodal users who
were gaining less than 19% benefit from the nonimplanted
ear were likely to perform better with a 2nd implant.
Conclusions: CI users who score less than 19% on
consonant–vowel–consonant words in the nonimplanted
ear have a good chance of benefiting from a 2nd implant.
Consideration of many other factors including age, hearing
goals, medical factors, and the risk to residual hearing also
needs to play a part in recommending a 2nd CI.
plane (Middlebrooks & Green, 1991). Speech perception in
the presence of background noise is also improved for those
listening with two ears. The acoustic shadow created by the
head increases the signal-to-noise ratio at the ear furthest
from the sound source, giving an average binaural benefit
of approximately 3 dB depending on the frequency content
(Bronkhorst & Plomp, 1992). Furthermore, the central
auditory system can combine the different signals arriving
at each ear to decrease the overall effects of noise, in a
process referred to as binaural “squelch” or unmasking
(Carhart, 1965).
Hearing an auditory signal with two ears gives rise
to binaural redundancy and provides another small 1- to
2-dB advantage in speech intelligibility (Cox, DeChicchis,
& Wark, 1981; MacKeith & Coles, 1971). Binaural loud-
ness summation is a particular case of binaural redundancy
and refers to the increase in loudness from hearing a sound
in both ears instead of one. This loudness increase can vary
from the equivalent of 3 dB to as much as 10 dB for higher
level sounds (Dermody & Byrne, 1975; Haggard & Hall,
1982).
A review of the literature by Ching, Van Wanrooy,
and Dillon (2007) showed that both bimodal and bilateral
CI users are able to derive some benefit from the combined
effects of head shadow, binaural unmasking, and redundancy,
although performance is still not comparable to that of
typically hearing listeners (Chang et al., 2010; Kerber &
Disclosure: The authors have declared that no competing interests existed at the time
of publication.
775
Seeber, 2012; Litovsky, 2011). The efficacy of binaural
unmasking, in particular, is limited for both bimodal and
bilateral users by the inability of the hearing devices to
deliver precise interaural timing difference cues. No clear
evidence was found to support the benefit of one mode
over the other due to differences in methodologies across
the studies that were included, but complementarity was
considered one particular advantage of bimodal over bi-
lateral stimulation. This refers to the combined use of low-
frequency information from the HA and high-frequency
information from the CI and has been found to improve
the sound quality of speech as well as music perception in
bimodal listeners who have some residual low-frequency
acoustic hearing (Ching, Incerti, & Hill, 2004; Kong, Stickney,
& Zeng, 2005; Tyler et al., 2002). A review by van Hoesel
(2012) contrasted the benefits of bilateral implantation
and bimodal hearing by describing the distinct spatial
listening advantages provided by a contralateral CI and
the complementary information provided by the contra-
lateral HA.
What is clear is the significant benefit provided by a
binaural fitting (whether bimodal or bilateral) over unilateral
CI use. Bimodal hearing provides significant speech under-
standing and localization benefits over HA alone or CI alone
(Morera et al., 2012; Schafer, Amlani, Seibold, & Shattuck,
2007), particularly when speech and noise are presented from
the front, although it appears that the degree of benefit may
depend on the integration of the two modalities (Yoon, Shin,
Gho, & Fu, 2015). Some studies suggest that part of the
variability in bimodal outcomes may be attributed to indi-
viduals with better hearing thresholds in the mid–high
frequencies where there may be some conflicting information
between the HA and the CI (Mok, Galvin, Dowell, &
McKay, 2010; Mok, Grayden, Dowell, & Lawrence,
2006).
Dunn, Tyler, Oakley, Gantz, and Noble (2008)
compared bilateral and unilateral implant outcomes for
73 individuals matched on duration of deafness and age
at implantation. They found that bilateral CI users performed
significantly better on tests of speech perception in quiet and
localization testing compared to unilateral CI users. A follow-
up study comparing 30 bilateral and unilateral CI users on
speech perception in noise found the same result, supporting
the hypothesis that bilateral implantation generally provides
binaural advantages over unilateral implantation (Dunn
et al., 2010).
Given that many previous studies have explored these
binaural benefits in the paediatric population, a more re-
cent study by Yoon, Shin, and Fu (2012) aimed to develop
second side implantation criteria for adult CI users by
directly comparing 12 bimodal and 13 bilateral adult listeners.
They found a binaural benefit for the bilateral group, but
only when compared with the bimodal subgroup who had a
contralateral aided pure-tone average > 55 dB HL at fre-
quencies ≤ 1 kHz (Yoon et al., 2012). Based on these findings,
they recommended that a second CI would be appropriate
for adult bimodal users with poor aided thresholds ≤ 1 kHz
in the nonimplanted ear. However, current CI selection
776 American Journal of Audiology • Vol. 28 • 775–782 • October 2019
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criteria are more commonly based on speech perception
scores, given the limited correlation between pure-tone
thresholds and CI performance (Rubinstein, Parkinson,
Tyler, & Gantz, 1999), and the findings in that study were
also limited by the small sample size.
Although the choice of bilateral implantation is rela-
tively unambiguous when there is no residual hearing to
consider (and cost is not a factor), there are currently no
evidence-based recommendations regarding the potential
benefit of a second CI for adults with more useful acoustic
hearing in the nonimplanted ear—a growing CI candidate
population in recent years (Plant, van Hoesel, McDermott,
Dawson, & Cowan, 2016). The current study aimed to
quantify speech perception results for a large group of adult
bimodal and bilateral CI users to provide a practical guide
for those considering a second CI.
control group: UNilat
exp groups; bimodal
Method and bilateral
Speech perception scores were reviewed for 1,394 adults
with acquired hearing loss who received a CI at the Royal
Victorian Eye and Ear Hospital Cochlear Implant Clinic,
Australia, between 2000 and 2015. This unselected cohort
included 487 who used their first CI alone (unilateral), 640
who used their first CI with a contralateral HA (bimodal),
and 267 who went on to receive a second CI (bilateral).
Monosyllabic word scores from the 3-month postimplanta-
tion time point provided the most complete dataset for this
cohort and were used as the outcome measure.
Pre- and postoperative speech perception ability was
assessed using open-set monosyllabic consonant–vowel–
consonant (CVC) words, scored for percentage correct
(Peterson & Lehiste, 1962). A phonemically balanced list
of 50 CVC words, recorded in Australian English, was
presented auditory alone at 65 dB SPL to each participant
from a loudspeaker at a distance of 1 m and 0° azimuth.
Postoperative speech perception performance was assessed
in the first side CI alone (CI1) for all three groups, whereas
binaural speech perception ability was also assessed for
both the bimodal (CI+HA) and bilateral (CI+CI) users.
For the purpose of this study, the contribution of the
contralateral HA for bimodal users was calculated as the
difference between CI+HA and CI1 (denoted HA benefit
henceforth), whereas the benefit of a second CI (CI2) com-
pared to a contralateral HA was calculated by comparing
bilateral and bimodal word scores—that is, the difference
between CI+CI and CI+HA (denoted CI2 benefit). CI2
benefit was only assessed for a smaller subgroup of bilateral
users (n = 92) who were bimodal users prior to receiving a
second CI. This allowed a direct comparison between the
two binaural modes of hearing and addresses the clinical
question of whether recommending a second CI for an indi-
vidual would provide them more binaural benefit than a
contralateral HA. In contrast, bilateral benefit is simply the
difference between CI+CI and CI1—the additive binaural
benefit of a second CI used in conjunction with CI1.
Statistical analyses were performed using R (Version
3.5.0; R Core Team, 2018) and RStudio (Version 1.1.453;
RStudio Team, 2016). The rpart package (Therneau &
Atkinson, 2018) was used to generate and plot regression
trees through recursive partitioning, based on the method
originally described by Breiman, Friedman, Olshen, and
Stone (1984). This recursive partitioning technique attempts
to identify groupings of the data based on the predictors
that show meaningful differences in outcomes. At the end of
this process, a regression tree is generated with terminal nodes
describing the average response value for each statistically
significant split that is chosen by the algorithm (Strobl,
Malley, & Tutz, 2009). All other figures were generated using
ggplot2 (Wickham, 2009).
Results
An exploratory analysis of group differences in age
at implantation and duration of deafness was conducted,
given that both variables have been found to be related to
CI outcomes in the past (Blamey et al., 2013; Dowell, 2016;
Green et al., 2007). A one-way analysis of variance showed
a significant group effect (unilateral, bimodal, and bilateral) on
mean age at first implant, F(2, 1408) = 64.3, p < .001, and
post hoc Tukey comparisons revealed significant differences
between all three groups. There was also a significant group
effect on mean duration of deafness in the first implanted
ear, F(2, 1274) = 9.5, p < .001, with post hoc comparisons
revealing that the bimodal group had a significantly longer
mean duration of deafness compared to the unilateral and
bilateral groups.
Figure 1 shows best aided 3-month postimplantation
CVC word scores for the three different groups, with a
one-way analysis of variance revealing significant group
differences, F(2, 1120) = 98.5, p < .001. Post hoc pairwise
comparisons confirmed that bimodal CI users performed
significantly better than unilateral users, whereas bilateral
users significantly outperformed both groups. A wide range
of performance was seen for all three groups. Descriptive
statistics for the three groups are presented in Table 1.
A Pearson product–moment correlation coefficient
was used to first explore the relationship between CI1 and
CI2 for the bilateral group, revealing a significant positive
correlation, r = .67, p < .001. The scatter plot in Figure 2
summarizes this relationship, showing that those who had
a better result with CI1 tended to have a positive result with
CI2 and that CI1 word scores predicted approximately
45% of the variance in CI2 word scores, F(1, 169) = 139.2,
p < .001.
For the subgroup of 92 bilateral users who were pre-
viously bimodal users, CI+HA word scores were significantly
correlated with CI+CI word scores, r = .70, p < .001,
accounting for approximately 48% of the variance. However,
looking at binaural speech perception scores alone can
often mask a relatively large contribution from CI1, as
demonstrated in Figure 3, where a better bimodal or bilateral
word score was generally associated with a CI1 word score
≥ 75%. It is suggested that the clinical recommendation for
a second CI should be made relative to HA benefit—in
other words, optimizing the binaural benefit provided by
the nonimplanted ear.
Accordingly, a recursive partitioning algorithm with
cross-validation was used to generate a regression tree for
CI2 benefit based on HA benefit, 3-month CI1 word scores,
age at implantation, and duration of deafness. Of the four
variables selected, only HA benefit and 3-month CI1 word

Figure 1. Box and whisker plots showing significant group differences in mean consonant–vowel–consonant (CVC)
word scores between unilateral (n = 487), bimodal (n = 640), and bilateral (n = 267) CI users (“***” p < .001). The open
circle represents the mean, the black line in the center of each box represents the median, and the lower and upper
hinges represent the first and third quartiles, respectively. The two whiskers extend to no further than 1.5 × interquartile
range; values outside of this range are outliers and are plotted individually.

Au & Dowell: Evidence-Based Recommendation for Bilateral CIs 777

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Table 1. Descriptive statistics for unilateral (n = 487), bimodal (n = 640), and bilateral (n = 267) CI users.

Unilateral Bimodal Bilateral

Variable M SD Min Max M SD Min Max M SD Min Max

Age at implant (years) 63.1 16.9 18.4 93.1 67.9 14.1 19.2 93.4 55.5 14.5 18.5 88.4
Duration of HL (years) 14.5 13.9 0.0 67 18.1 15.2 0.3 81 14.8 12.7 0.2 60
3-month CVC words (%) 31.5 24.1 0.0 95 47.6 25.5 0.0 100 64 22.4 0.0 100

Note. HL = hearing loss; CVC = consonant–vowel–consonant.

scores were found to be significant predictors and were
retained in the final regression model, F(2, 89) = 26.57,
p < .001, adjusted R2 = .36. The regression tree is plotted
in Figure 4, and the partitioning rules can be summarized
as follows:
For CVC word scores:
CI2 benefit = −7.1% when HA benefit ≥ 19%
CI2 benefit = 9.4% when HA benefit < 19% and
CI1 ≥ 45%
CI2 benefit = 22.9% when HA benefit < 19% and
CI1 < 45%
These results show that, for this group of bilateral
users, those who were previously receiving more than 19%
benefit from their contralateral HA saw a decline in binaural
performance of around 7% post-CI2. Those who were
deriving less than 19% benefit from their contralateral HA
gained significant benefit from CI2, depending on the speech
perception ability of CI1. Based on this finding, a second
CI can therefore be recommended in the clinical setting
when a contralateral HA is found to be providing < 19%
benefit to CI1 in tests of binaural word perception.
In clinical situations where CI1 and bimodal word
perception scores are not available, it may be more practical
to use preoperative word scores to predict the benefit of
CI2. For the 640 bimodal CI users, a Spearman correlation
found HA benefit to be significantly correlated with best
preoperative word score, whether this was from the ear to
be implanted, the contralateral ear, or binaurally, rs = .45,
p < .001 (see Figure 5). Furthermore, a linear regression analy-
sis found that the best preoperative word score was a signif-
icant predictor of HA benefit and accounted for around
28% of the variance, F(1, 638) = 248.4, p < .001.
With HA benefit as the outcome measure, the best
preoperative word scores were recursively partitioned as shown
in Figure 6. The terminal nodes show a mean HA benefit
of 9.2% for those who had a best preoperative word score
< 42%, whereas the mean HA benefit was 26% for those
scoring ≥ 42% preoperatively. In comparison, the mean
bilateral benefit at 3 months post-CI2 was 19.4% for the
bilateral group, which suggests that the proportion of
bimodal users who had a best preoperative word score of
< 42% may derive more binaural benefit from a second
CI.

Figure 2. Scatter plot of cochlear implant alone (CI1) word scores and second cochlear implant (CI2) word scores at 3 months postimplantation
for bilateral users (n = 267). A Pearson product-moment correlation coefficient revealed a significant positive correlation, r = .67, p < .001. The
line and shaded area represent the linear regression fit and 95% confidence interval.

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Figure 3. Scatter plot of 3-month cochlear implant plus hearing aid (CI+HA) and 3-month CI+CI word scores for bilateral users showing a
significant positive correlation, r = .70, p < .001 (n = 92). The size of each circle represents the approximate 3-month CI1 word score for that
particular individual. As shown in this scatter plot, a better bimodal or bilateral word score was generally associated with a CI1 word score ≥
75%. The line and shaded area represent the linear regression fit and 95% confidence interval.

Furthermore, it can be shown that predicted HA
benefit is 19.3% when a best preoperative word score of
42% is used with the regression equation shown in Figure 5.
This audiological criterion thus corresponds neatly with the
earlier finding that a second CI can be recommended for those
who are deriving < 19% benefit from a contralateral HA,
and provides another metric for predicting bilateral benefit
when CI1 or bimodal word scores are clinically unavailable.
Discussion
Speech perception scores from a large unselected
cohort were quantified to investigate second CI benefit and
develop an audiological criterion for recommending second
side cochlear implantation in postlingually deafened adults.
Mean performance on CVC word perception was 31.5%
for unilateral CI users, 47.6% for bimodal users, and 64%
for bilateral users, indicating that significant benefit was
obtained for bimodal and bilateral CI use even with a speech
test that did not utilize spatial cues. In addition, results
from the bilateral group showed that those with good CI1
outcomes also tended to do well with CI2. It can be assumed
that the binaural benefits seen in this study are due to the
listening advantages provided by binaural redundancy and
loudness summation (Cox et al., 1981; MacKeith & Coles,
1971). The significant advantage of binaural over monaural
hearing in this study supports the findings from previous

Figure 4. Regression tree with hearing aid (HA) benefit and 3-month(3MTH) cochlear implant alone (CI1) word scores as predictors of second
cochlear implant (CI2) benefit for n = 92. Terminal nodes depict average CI2 benefit and number of observations within each node.

Au & Dowell: Evidence-Based Recommendation for Bilateral CIs 779

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Figure 5. Scatter plot of best preoperative word score and hearing aid (HA) benefit at 3 months postimplantation for bimodal users (n = 640).
A Spearman correlation revealed a significant positive relationship, rs = .45, p < .001. The line and shaded area represent the linear regression
fit and 95% confidence interval.
research (Dunn et al., 2010; Morera et al., 2012; Schafer
et al., 2007) and provides further evidence for the provision
of binaural hearing where possible.
The findings from this study also demonstrate the need
to assess the contribution of the two ears separately when
considering a second CI, given that binaural speech scores
can be inflated by good speech perception in CI1. In this
study, HA benefit was used to describe the contribution of
the contralateral HA, whereas CI2 benefit represented the
benefit of a second CI in addition to what the contralateral
HA was providing in the bimodal listening condition.
A relatively large dataset of bimodal CI users who
went on to receive a second CI allowed a direct comparison
between the two modes of binaural hearing. It was revealed
that individuals who were receiving more HA benefit were
less able to benefit from a second implant; similarly, those
who already had good CI1 outcomes did not show much
bilateral benefit from CI2 due partly to ceiling effects on
Figure 6. Regression tree with terminal nodes showing mean hearing
aid benefit of 9.2% for those scoring < 42% preoperatively in the
best listening condition and mean hearing aid benefit of 26% for
those scoring ≥ 42%.
780 American Journal of Audiology • Vol. 28 • 775–782 • October 2019
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performance. The groups who gained significant bilateral
benefit were those who did not derive much HA benefit
and were also not progressing as well with CI1; for this
group, the mean CI2 benefit was 23% in CVC word scores.
It is important to consider these findings when counseling
individuals on realistic expectations of what a second side
CI may provide.
Previous studies have found preoperative residual
hearing to be a significant predictor of CI outcomes (Blamey
et al., 2013; Dowell, 2012). Thus, for situations where CI1
or bimodal speech perception scores are unavailable, an indi-
vidual’s best preoperative word score may also be used to
predict and discuss expected bilateral benefit. In this study, a
lower best preoperative word score was associated with less
HA benefit, indicating that a second side CI may be more
beneficial for these bimodal users. The findings from the
current study are supported by those of Blamey et al. (2015),
who also compared outcomes for a large cohort of bilateral
and bimodal listeners using basic speech audiometry and
found that a second CI was likely to be indicated for those
with very low preoperative performance. This may be more
relevant in cases where simultaneous bilateral implantation
may be an option.
Other predictors of CI outcomes in previous studies
include age at implantation and duration of deafness (Blamey
et al., 2013; Dowell, 2016; Green et al., 2007), but these
were not found to be significant predictors of bilateral
benefit in the current study. However, the bimodal group
had a significantly longer duration of deafness compared
to the other two groups, whereas the bilateral group was
significantly younger. It is therefore difficult to draw any
conclusions from this study about which mode of binaural
hearing provides the greater benefit.
 It is noted that, due to the inherent limitations of clinical
data, tests of spatial listening or localization ability were
not used to assess binaural benefit. It would also be of inter-
est in the future to explore bilateral and bimodal differences
in music perception and sound quality, as this would likely
have an impact on the recommendation for a second CI.
More importantly, patient preference has been found to be
a sensitive measure of benefit and should be taken into
consideration, particularly when adaptive measures of binau-
ral hearing are not readily available (Gifford & Dorman,
2019). A further limitation of this study was that speech
perception scores from 3 months postimplantation were used
as the outcome measure, which may not be representative
of the long-term speech perception outcomes of this cohort,
particularly given that duration of CI experience has been
found to be a significant predictor of CI outcomes in the
past (Blamey et al., 2013).
Conclusion
The findings from this study present clear audiological
guidelines that can be applied in the clinical setting when
considering second side cochlear implantation. In summary,
it is proposed that a second CI may be recommended for a
postlingually deafened adult when
the best preoperative word score is < 42% or
the difference between CI+HA and CI1 is < 19%.
Consideration of many other factors including age,
hearing goals, medical factors, financial costs, individual
preference, and the risk to residual hearing also need to
play a part in recommending a second CI.
Acknowledgments
We gratefully acknowledge Sylvia Soong for data collection
and the Royal Victorian Eye and Ear Hospital Cochlear Implant
Clinic for assessing and recording the data.
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