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Acta Oto-Laryngologica, 2005; 125: 918 /919


International consensus on bilateral cochlear implants and bimodal

Second Meeting Consensus on Auditory Implants, 19 21 February 2004, Valencia, Spain

LLER (Germany), A. HUARTE

Panel: E. OFFECIERS (Belgium), C. MORERA (Spain), J. MU

(Spain), J. SHALLOP (USA) & L. CAVALLE (Spain)

Binaural hearing allows listeners with normal hearing to understand speech better in silence and noisy
conditions and is an essential requirement for spatial
hearing and sound localization. Other benefits of
binaural hearing are more natural hearing, reduced
listening effort and an improved quality of life.
The cortical projection of the ear is fundamentally
contralateral and only a small proportion of fibers in
the auditory neural pathway have homolateral cortical projection. This results in insufficient homolateral neural and cortical development in cases of
monaural stimulation.
Bilateral cochlear implantation
Bilateral cochlear implantation allows bilateral input
into the auditory system for adults and children who
suffer from severe-to-profound deafness. Bilateral
cochlear implantation may be considered if hearing
aids (HAs) do not provide appropriate stimulation of
the auditory system. It has been shown that bilateral
cochlear implants (CIs) restore fundamental aspects
of binaural hearing and provide the binaural advantages experienced by normal-hearing subjects.
Surgical techniques
The one-stage technique. Both ears are implanted
during a single surgical procedure. This procedure

is recommended for experienced CI surgeons and

centers, if appropriate and medically or surgically
possible. A one-stage procedure improves costeffectiveness.
The two-stage technique. With the two-stage technique, the two cochlear implantations are performed
during two different surgical procedures. The maximum delay between the two surgeries in order to
avoid contralateral cortical atrophy is not yet known.
The duration of deafness is not considered a
contraindication for bilateral cochlear implantation
because monoaural input may maintain some stimulation of the auditory pathways.
In children, a short interval between the 2
surgeries of B/6 /12 months enables prelingually
deaf children to achieve good performance with the
second implant within a few weeks, whereas a longer
time interval between the 2 surgeries makes additional training and rehabilitation necessary to avoid a
refusal to use the second CI. Although the time
interval between the 2 surgeries does not seem to be
as critical in postlingually deaf adults as in children,
it should not exceed 12 years.
The advantages of bilateral cochlear implantation
are as follows:
1. The better ear is always implanted. It is difficult
to predict which ear will give the best speech
understanding postoperatively.

Address for correspondence: Constantino Morera, Hospital Universitario La Fe, Avda. Campanar, 21, ES-46009 Valencia, Spain. E-mail:

ISSN 0001-6489 print/ISSN 1651-2551 online # 2005 Taylor & Francis

DOI: 10.1080/00016480510044412

International consensus on bilateral CIs and bimodal stimulation

2. It allows bilateral cortical stimulation and,
in children, the development of the central
auditory system during the critical period of
neural plasticity and language acquisition.
3. It can restore binaural hearing.


residual hearing and good performance with the HA

in the non-implanted ear.
Bimodal stimulation can offer additional advantages in terms of speech understanding in quiet and
noise, and some degree of sound localization. The
advantages of bimodal stimulation are as follows:

The disadvantages are as follows:

1. Procedure costs. Benefits of bilateral cortical
development when stimulating with bilateral
cochlear implants should be considered for
quantifying the actual benefit in terms of costeffectiveness.
2. It may make future techniques difficult or
impossible to use.
Bilateral cochlear implantation should be recommended in the following types of patient:
1. Those in whom the benefits obtained with one
CI is poor.
2. In Meningitis, that is developing cochlear
ossification the implantation should be performed as soon as possible to achieve full
3. Those who want to restore binaural hearing or
need it in order to remain in their chosen
4. Children with permanent bilateral profound
hearing loss. Special attention should be paid
to young children who are in their speech and
language acquisition periods.
Both CIs should be fitted and balanced with
regard to volume in order to optimize the results.
In the case of two-stage surgery, it is sometimes
advisable to switch off the first implanted CI for a
period of time in order to obtain stable CI performance and fitting on the second side. In general, the
fitting should aim to produce similar levels of
performance on each side.
Bimodal stimulation
Bimodal stimulation refers to the situation in which a
CI is implanted and a conventional HA is used in the
contralateral ear. It is used in patients who have

1. It stimulates the non-implanted ear.

2. It provides binaural advantages in patients with
residual hearing and good HA performance in
the non-implanted ear.
3. It does not require surgery in one ear.
4. It is cost-effective.
The disadvantages of bimodal stimulation are as
1. Obtaining a binaural advantage depends on the
residual hearing and HA performance in the
non-implanted ear. In young children it is
difficult to determine the hearing status of the
non-implanted ear.
2. Patients may refuse to use the HA in those cases
with poor HA performance.
3. Use of the HA and CI together can reduce the
performance achieved with the CI alone.
4. In cases with good HA performance, the results
obtained with the CI may be delayed. In these
patients it is recommended to stop using the
HA for a few weeks.
Bimodal stimulation should be recommended in the
following types of patient:
1. Those with residual hearing.
2. Those with good HA performance in the nonimplanted ear.
3. Those who want to restore binaural hearing.
4. All young children, because it is difficult to
determine the hearing status of the nonimplanted ear.
In order to optimize the results, the HA and CI
should be fitted and loudness should be balanced,
after CI activation, once the initial fitting has been