Cochlear Implant Research Articles

The Effects of Home Language Use on Spanish Speech Measures in Bilingual Children With Hearing Loss Who Use Cochlear Implants and Their Peers With Normal Hearing.

The purpose of this study was to investigate how the amount of home language use between the primary caregiver and bilingual Spanish- and English-speaking children with hearing loss who use cochlear implants (CIs) versus their bilingual age-matched peers with normal hearing (NH) can impact speech outcomes in the home language. Thirty-four bilingual Spanish- and English-speaking children (17 CI users and 17 with NH) between the ages of 5;3 and 7;9 (years;months) participated in this study. Independent variables were the amount of home language use with the primary caregiver and hearing status, and dependent variables were vowels and consonants correctly produced and occurrence of selected phonological processes. The amount of home language use was ascertained from surveys, and the dependent measures were based on a single-word picture elicitation task. Bilingual children with CIs who are exposed to Spanish for more than 80% of the time via their primary caregiver performed better on Spanish segmental accuracy measures than those who are exposed to Spanish from only 20% to 50% of the time, specifically on vowels (partial η2 = .31) and consonants (partial η2 = .025). Children with NH outperformed children with CIs on all accuracy measures in Spanish. Preliminary results suggest the importance of language exposure through interactions with the primary caregiver for speech development in bilingual children. Future studies should investigate strategies to facilitate home language development in bilingual children with CIs, enabling them to reach their full potential.

Impact of Mask Type as Training Target for Speech Intelligibility and Quality in Cochlear-Implant Noise Reduction

The selection of a target when training deep neural networks for speech enhancement is an important consideration. Different masks have been shown to exhibit different performance characteristics depending on the application and the conditions. This paper presents a comprehensive comparison of several different masks for noise reduction in cochlear implants. The study incorporated three well-known masks, namely the Ideal Binary Mask (IBM), Ideal Ratio Mask (IRM) and the Fast Fourier Transform Mask (FFTM), as well as two newly proposed masks, based on existing masks, called the Quantized Mask (QM) and the Phase-Sensitive plus Ideal Ratio Mask (PSM+). These five masks are used to train networks to estimate masks for the purpose of separating speech from noisy mixtures. A vocoder was used to simulate the behavior of a cochlear implant. Short-time Objective Intelligibility (STOI) and Perceptual Evaluation of Speech Quality (PESQ) scores indicate that the two new masks proposed in this study (QM and PSM+) perform best for normal speech intelligibility and quality in the presence of stationary and non-stationary noise over a range of signal-to-noise ratios (SNRs). The Normalized Covariance Measure (NCM) and similarity scores indicate that they also perform best for speech intelligibility/gauging the similarity of vocoded speech. The Quantized Mask performs better than the Ideal Binary Mask due to its better resolution as it approximates the Wiener Gain Function. The PSM+ performs better than the three existing benchmark masks (IBM, IRM, and FFTM) as it incorporates both magnitude and phase information.

Tinnitus Suppression with Electrical Stimulation at the Most Basal Contact of the Cochlear Implant Electrode as a Model for Round Window Stimulation.

The objective of this research was to test whether efficient tinnitus suppression could be achieved by electrical stimulation of the single most basal electrode contact of a cochlear implant. This approach simulates the effects of electrical stimulation using a round-window electrode. The study was performed in 10 adult cochlear implant patients showing complete or almost complete tinnitus suppression during electrical stimulation with their standard fitting-MAP. In all patients, tinnitus appeared again when the implant was switched off. Five Nucleus implant (1 CI532, 4 CI24RE CA) users and 5 Mi12xx series with FLEX28 electrodes with at least 6 months of CI experience were included. Two types of stimulation were presented at the most basal CI contact: a constant pulse train and a modulated pulse train. The variation in pulse rates was low rate (100-300 pps) and high (≥900 pps), and the current level ranged from the C-level to less than the T-level for both stimulation types. The effect of acute electrical stimulation at the most basal electrode contact was compared to the effect obtained with multichannel stimulation with the patient's current fitting MAP. Electrical stimulation was paused between tests with different stimulation types until tinnitus returned to baseline intensity. Patients reported Visual Analog Scale (VAS) scores for tinnitus loudness and intrusiveness during normal CI use and for each single contact stimulation type. Eight participants perceived complete suppression with one or more stimulation patterns. In 2 patients, suppression was less efficient than full-band CI stimulation. Louder stimuli are generally perceived as annoying and less effective in reducing tinnitus. In FLEX28 patients, it was also possible to obtain full tinnitus suppression with current amplitudes under the thresholds for auditory perception (this was not tested in patients with the Nucleus device). In 8 of the 10 included patients, we were able to obtain complete or almost complete tinnitus suppression with electrical stimulation at only 1 most basal electrode contact. Therefore, round-window stimulation with a single electrode may be a potential treatment for tinnitus in patients with significant residual hearing. The long-term effects of this therapy should be confirmed in future studies.

Cochlear implants with dexamethasone-eluting electrode arrays reduce foreign body response in a murine model of cochlear implantation and human subjects.

The inflammatory foreign body response (FBR) following cochlear implantation (CI) can negatively impact CI outcomes, including increased electrode impedances. This study aims to investigate the long-term efficacy of dexamethasone eluting cochlear implant and locally delivered dexamethasone, a potent anti-inflammatory glucocorticoid on the intracochlear FBR and electrical impedance post-implantation in a murine model and human subjects. The left ears of CX3CR1 +/GFP Thy1 +/YFP (macrophage-neuron dual reporter) mice were implanted with dexamethasone-eluting cochlear implants (Dex-CI) or standard implant (Standard-CI) while the right ear served as unoperated control. Another group of dual reporter mice was implanted with a standard CI electrode array followed by injection of dexamethasone in the middle ear to mimic current clinical practice (Dex-local). Mouse implants were electrically stimulated with serial measurement of electrical impedance. Human subjects were implanted with either standard or Dex-CI followed by serial impedance measurements. Dex-CI reduced electrical impedance in the murine model and human subjects and inflammatory FBR in the murine model for an extended period. Dex-local in the murine model is ineffective for long-term reduction of FBR and electrode impedance. Our data suggest that dexamethasone eluting arrays are more effective than the current clinical practice of locally applied dexamethasone in reducing FBR and electrical impedance.

Evaluation of VOR function with vHIT in unilateral pediatric cochlear implant users

ObjectiveThe changes in the inner ear affect both the cochlea and the vestibule and these effects are observed after cochlear implantation surgery. The aim of the current study is to evaluate the effect of unilateral cochlear implant use on vestibulo-ocular reflex (VOR) in children. MethodsIn the current study, 29 cochlear implanted children, aged 7–18 years, were include as the study group and 32 children, in the same age range, were included with normal-hearing as the control group. vHIT was used to evaluate VOR and the results of unilateral CI users were compared with the control group. The study group was evaluated in two different situations: cochlear implant sound processor on (CI-ON) and cochlear implant sound processor off (CI-OFF). The data obtained in the evaluations were compared between the implanted ear and the non-implanted ear between the CI-ON and CI-OFF states within the study group and between the study group and the control group. ResultsWhen the CI-ON and CI-OFF conditions in the study group were compared, no significant difference was found (p > 0.05). Similarly, no significant difference was found between the implanted ear and the non-implanted ear (p > 0.05). Also, there was no significant difference in the comparisons between the study group and the control group (p > 0.05). ConclusionvHIT is a functional test method that can be used in children to test vestibular function after cochlear implant. vHIT is a comfortable test to use after cochlear implantation to demonstrate the functionality of the vestibular system. And it provides consistent results regardless of whether the speech processor is on or off.

Cochlear implant/MXene-based electroacoustic stimulation modulates the growth and maturation of spiral ganglion neurons

Cochlear implantation (CI) offers a dependable treatment for sensorineural hearing loss, with precision electroacoustic stimulation parameters showing great potential in improving auditory outcomes in CI patients. Here, we report the attachment of MXene into CI systems which effectively mimic the neural electrode interface due to MXene's excellent electrical conductivity and biocompatibility. Low-frequency short-term biphasic electrical pulses emitted by the MXenes-based CI promoted the outgrowth of spiral ganglion neuron (SGN) neurites and growth cones, substantially boosting the calcium activity in SGNs. This study lays a theoretical foundation for the precision medicine approaches in CI patient care, and informs the selection of materials for cochlear implant electrode materials in the future.

Impact of Cochlear Implant on the Quality of Life in Post Lingual Deafened Adult Population in Tertiary Care Centre

Impact of Cochlear Implant on the Quality of Life in Post Lingual Deafened Adult Population in Tertiary Care Centre

Antiviral Therapy for Congenital Cytomegalovirus Infection: Does It Prevent Late-Onset Sensorineural Hearing Loss?

Abstract Background Congenital cytomegalovirus (CMV) infection is the leading non-genetic cause of sensorineural hearing loss (SNHL) in children. While SNHL is often present at birth, as many as 20% of infants with congenital CMV infection may develop late-onset hearing loss beyond the neonatal period. Antiviral therapy improves hearing outcomes, but its effect on the occurrence of late-onset SNHL is not fully known. The objective is to describe the prevalence of SNHL at birth and late SNHL among infants and children with congenital CMV infection and assess the impact of antiviral treatment on the occurrence of late-onset SNHL. Methods From 2013 to 2022, infants with congenital CMV infection referred to the NEO-ID Clinic at Nationwide Children’s Hospital (NCH), Columbus, OH underwent complete evaluation including hearing testing. Pertinent demographic, clinical, audiologic, laboratory, and radiographic data were obtained and stored using an electronic database (REDCap). Infants with SNHL at birth or who developed late-onset SNHL beyond a month of age were identified and compared with respect to receipt of antiviral therapy in the neonatal period. Results During the 10-year study period, we enrolled 204 infants with congenital CMV infection: 75% (154/204) had symptomatic disease, while 25% (50/204) had clinically inapparent infection (normal physical examination, growth parameters, and evaluation). Overall, 30% (n=62) had SNHL at birth or on follow-up audiologic evaluation with the majority (95%, 59/62) having symptomatic disease. Of the 62 infants with SNHL, 29% (n=18) had late-onset SNHL in one (n=10) or both (n=8) ears at a median age of 19 months (IQR, 8.5-42 months). Of the 122 infants who received antiviral therapy initiated in the first month of age, 12 (10%) developed late-onset SNHL in one (n=7) or both (n=5) ears. All 12 had symptomatic congenital CMV infection, and 2 received cochlear implants in one ear. Of the 82 infants who did not receive any antiviral therapy, 6 (7%) developed late-onset SNHL (3, unilateral [2, symptomatic]; 3, bilateral [1, symptomatic]) and 2 received cochlear implant. There was no difference in the occurrence of late-onset SNHL in treated (10%) vs. untreated (7%) infants with congenital CMV infection (p=0.6). Conclusion In this cohort of mostly symptomatic infants with congenital CMV infection, antiviral treatment did not reduce the occurrence of late-onset SNHL. Further study on the impact of early antiviral therapy on severity of the SNHL is urgently needed to inform optimal treatment management.

Cognitive function and electrode mapping’s role in cochlear implant performance

Cognitive function and electrode mapping’s role in cochlear implant performance Amit Walia, Matthew Shew and Craig A. Buchman from Washington University School of Medicine, detail the role of cognitive function and electrode mapping in cochlear implant performance. In a previous article, we explored various factors influencing cochlear implant (CI) performance, including demographic, audiologic, and surgical variables, as well as the importance of cochlear health, as measured by electrocochleography. Beyond cochlear health, cognitive function, device function and surgical variables all play a role in performance. This section highlights the impact of cognitive function and device mapping to further refine and optimize CI outcomes.

Cochlear implant usage in single sided deafness and factors affecting usage

Objectives The primary objective was to examine duration of daily cochlear implant (CI) usage at 12 and 24 months post-operatively in single sided deafness (SSD). The secondary objective was to examine factors that could affect CI usage. Methods Retrospective cohort of patients with SSD who received CI from January 2015 to March 2020. CI usage was evaluated at 12 and 24 months. Hearing loss duration, tinnitus scores and signal-to-noise ratio (SNR) were correlated with CI usage at 12 months. Results Usage data was available for 54 patients at 12 months and 38 patients at 24 months. The mean usage was 8.2 h/day (SD 4.2) at 12 months, 7.0 h/day (SD 5.1) at 24 months. 5 out of 54 (9.3%) and 7 out of 38 patients (18.4%) were non-users at 12 and 24 months post-operatively. An improved mean SNR score from pre-operative 4.4 dB (SD 2.8) to – 0.70 dB (SD 4.2) at 12 months post-operative was positively correlated with CI usage at 12 and 24 months. Hearing loss duration and tinnitus scores were not associated with CI usage. Conclusions 18.4% of our patients were non-users at 24 months. Mean usage at 24 months was 7.0 h/day. Improved hearing in noise at 12 months was correlated with better usage.

Assessment of Cochlear Implant Rehabilitation Success by Speech-Language Therapists Using International Classification of Functioning, Disability and Health Criteria.

This study aims to introduce an assessment questionnaire based on the International Classification of Functioning, Disability and Health (ICF) to enable quantifiable clinical documentation. The questionnaire assists speech-language therapists (SLTs) in evaluating both non-audiological and audiological rehabilitation outcomes of patients with cochlear implants (CIs). Six SLTs were recruited to evaluate the effectiveness of CI care using ICF criteria. We carefully selected 20 pertinent ICF criteria, and SLTs received thorough training in how to apply them uniformly. A cohort of 48 patients was evaluated at three distinct time points: presurgery, postsurgery, and 6 months post-initial CI fitting. Patients underwent dedicated speech-language therapy sessions throughout the treatment course. A total of 144 complete datasets were scrutinized using a two-factor analysis of variance for ranks. Following CI care, patients exhibited substantial improvements in auditory perception, characterized by enhanced sound recognition and speech discrimination. Additionally, patients demonstrated improved attentional focus, proficiency in daily tasks and increased conversational engagement over time. Environmental factors, particularly sound perception, improved markedly, correlating with reported reductions in stress levels. Minimal changes were noted in stress management and communication techniques. Articulatory function, speech functions, and pain perception exhibited the least alteration. The data extracted from the ICF-based assessments underscore the vital significance of incorporating speech therapy-based metrics to evaluate both non-audiological and audiological factors in assessing the success of CI care within the SLTs domain. This approach proves to be highly relevant both in terms of demonstration and clinical applicability.

A qualitative exploration of the assessment process to cochlear implantation for children with hearing loss

Objective To explore the process of paediatric cochlear implant assessment, from referral to implantation, from the perspective of parents, cochlear implant professionals, and through observations of clinics. Design Qualitative approach, using grounded theory methodology. Study sample Twelve families with children under 5 years with permanent hearing loss referred for a cochlear implant or received an implant in the past year, and six professionals who refer or assess children for cochlear implants. Data collection involved interviews and ethnographic observations of assessment clinics. Results The core theme derived from interview and observation data related to the work of the cochlear implant assessment for families. The relationship between the work generated by the assessment process and capacity of parents to do the work provides a model to examine access to early implantation, consistent with the Burden of Treatment theory. We identified variation in terms of workload, relating to factors such as a child’s additional needs or number of appointments required, and in terms of capacity, relating to factors such as social circumstances or health literacy. Social, peer and professional support and information helped families manage the workload. Conclusions Findings have implications for delivery of paediatric cochlear implant services.

Correlation between the etiology of severe hearing loss and endolymphatic hydrops.

This study aimed to investigate correlation between the presence of endolymphatic hydrops(EH) and factors such as causes of hearing loss, patient age, duration of deafness, and results of vestibular function tests. We retrospectively reviewed medical charts of 128 ears of cochlear implantees who were not considered relevant to Meniere's disease. When comparing group with genetic variants of GJB2, SLC26A4, LMX1A and other genetic mutation group, the proportion of vestibular EH and cochlear EH found in group with genetic variants of GJB2, SLC26A4, LMX1A was significantly higher than group with other genetic etiology (p < 0.01) or the group with all the other causes of hearing loss (p < 0.01). The rate of vestibular and cochlear EH detection was higher in younger patients (41.5% and 35.4%) than in older patients (25.4% and 20.6%). A higher ratio of vestibular and cochlear EH was observed in patients with a longer duration of deafness (37.5% and 31.3%) than those with a shorter duration of deafness (29.7% and 25.0%). The group with vestibular EH showed a higher incidence of abnormal findings in the caloric test (42.9%) than the group without vestibular EH (28.2%). Patients with genetic variants of GJB2, SLC26A4, LMX1A, younger patients, those with longer deaf durations showed a higher prevalence of vestibular and cochlear EH, implying EH appears to be formed as a developmental disorder in association with a certain set of genetic variants, rather than a phenotypic marker as a result of severe to profound hearing loss.

Impact of Cochlear Implant Electrode Array Design on Post-Op Speech Perception.

Electrode array design may impact hearing outcomes in patients who receive cochlear implants. The goal of this work was to assess differences in post operative speech perception among patients who received cochlear implants of differing designs and lengths. Retrospective chart review. Tertiary Care Hospital. Patients (n = 129) received 1 of 9 electrode arrays, which were categorized by design: Lateral wall electrodes (n = 36) included CI522, CI622 (Cochlear Americas), Flex24, and Flex28 (Med El). Midscala electrodes (n = 16) included HiRes Ultra 3D (Advanced Bionics). Perimodiolar electrodes (n = 77) included CI512, CI532, CI612, and CI632 (Cochlear Americas). Speech perception was evaluated using consonant-nucleus-consonant (CNC) tests and at 3, 6, 12, and 24 months postimplantation. Perimodiolar electrodes showed significantly higher CNC scores compared to lateral wall electrodes at 6 and 24 months. Perimodiolar electrodes also outperformed midscala electrodes at 12 months. An inverse relationship was observed between electrode length and CNC scores noted at 6, 12, and 24 months. Perimodiolar electrode arrays, which tend to be shorter, demonstrated better speech perception outcomes compared to the longer lateral wall and midscala arrays at some timepoints. These findings suggest a potential advantages of perimodiolar electrodes for optimizing hearing outcomes.

Cochlear implantation for children with single-sided deafness: parents’ perspectives

ABSTRACT Historically, cochlear implantation is reserved for those with bilateral severe to profound hearing loss. However, indications have expanded to include Single-Sided Deafness (SSD) because of the known benefits of binaural hearing and the limitations of unilateral hearing, especially for children developing linguistic and cognitive skills. This study aimed to provide a qualitative perspective of lived experiences of children with SSD who use a cochlear implant (CI), as perceived and reported by their parents. An online questionnaire was developed and distributed to evaluate outcomes of cochlear implantation in children with SSD residing in New Zealand and the United States. Qualitative content analysis of open-ended questions identified themes, including: (1) motivating factors; (2) benefits of amplification; (3) challenges associated with the CI journey; and (4) advice to parents. Parents described benefits and challenges as a result of cochlear implantation, such as access to sound and academic and psychosocial development, as well as subjective improvements in spatial hearing, reduced listening fatigue, enhanced academic performance, and changes in quality of life. The difference that bilateral hearing makes to a child’s development is difficult to precisely define but parental insights offer valuable perspective to healthcare providers when considering what some consider an elective procedure.

A simple electrical circuit model for impedance spectroscopy with cochlear implant electrodes

Although cochlear implants are an established method of restoring hearing, they can have limitations such as increasing current spread and decreasing frequency resolution due to tissue growth around the electrode array. Impedance measurements in cochlear implants have become a versatile tool for intra- and post-operative diagnosis of cochlear implant state. However, most clinical devices use current pulse stimulation already available in the implants and analyze the voltage response in the time-domain and spread along the cochlea. To use the full potential of impedance spectroscopy in differentiating cell types, measurement over an extended frequency range is required. This study presents a simple electrical equivalent circuit for impedance spectroscopy with cochlear implants in a 2-pole configuration. The electrical equivalent circuit describes the electrical properties of the cochlear implant electrode and its electrochemical behavior at the electrode-electrolyte interface by comparing two non-linear bilayer models, Cole-Cole and Schwan-Faraday. The model is validated for four cochlear implant electrodes from four different manufacturers (MED-EL FlexSoft, AB HiFocus SlimJ, Oticon EVO, Cochlear Nucleus CI622) characterized by impedance spectroscopy between 5 Hz and 13 MHz. In the future, this electrical equivalent circuit may help to extract parameters for differentiating cell types around the cochlear implant electrode from an impedance spectroscopic measurement.

Subjective and functional outcome measures to evaluate performance of pediatric cochlear implant

BackgroundThe majority of research on the effects of cochlear implants has been on clinical evaluations of efficacy (hearing and speech skills and auditory thresholds). But it is unclear how much clinical efficacy metrics (speech, hearing, and language tests) actually demonstrate how beneficial cochlear implants (CI) are in everyday circumstances. In this study, we aim to assess the performance of a child’s current CI with both subjective and functional outcomes measures. Also, we aimed to assess factors affecting these outcomes after CI.MethodsThe study group included 45 cochlear-implanted children, and their chronological age ranges between 4 and 12 years. Children were divided according to their language age into three groups: group 1 (G1) includes15 children with a language age of less than 2 years, group 2 (G2) includes 15 children with a language age of 2 to less than 4 years, and group 3 (G3) includes 15 children with language age 4 to 6 years. Assessment was done in two sessions: one for phoniatric evaluation and another for audiological evaluation.ResultsCI enabled children to develop speech perception in a closed manner evidenced by the early speech perception (ESP) test with pattern perception being the easiest and monosyllabic words being the most difficult and the least to develop. Most children with CI were able to control their voice, to a lesser extent to use speech in meaningful use in social situations and to develop communication strategies in oral situations which were the least to develop, and this was evident by Meaningful Use of Speech Scale. Children with CI were able to acquire language, and their receptive language was better than expressive language, but their language age was below their chronological age.ConclusionThe cochlear implant is an effective rehabilitative tool for the treatment of prelingually deafened children, and this was evident by our results. A hierarchal approach of speech assessment according to the language age of the child and selection of age-appropriate speech perception test is very important to assess cochlear-implanted children Speech recognition had a high degree of variability. Early implantation age and increased duration of implant experience were the most important factors associated with good performance with CI, better speech perception, and better language outcomes.

Assessment of transparent alternative listening devices' effects on localization cues using head-related transfer function measurements

The past few years have seen a meteoric rise in technological advancements in the hearing health industry. New alternative listening devices, often referred to as "hearables", aim to become real "bionic ears" offering hearing protection, amplification, monitoring and even biosensing functionalities. With the recent approval of the "Over-the-Counter Hearing Aid Act" in the United States and the introduction of so-called "OTC" hearing aids, these alternative listening devices now have the potential to revolutionize the world of traditional auditory amplification. Since these devices may be used by individuals with hearing loss, it is important to consider how they might influence spatial auditory awareness. Therefore, this paper studies the effect of alternative listening devices on localization cues using the Head Related Transfer Function (HRTF). In this purpose, we measured the HRTFs on a Head and Torso Simulator (HATS) with and without digital listening devices. To evaluate the acoustic performance of these devices, the devices were set into their "acoustically transparent" mode. These measures enable a preliminary characterization of the effect of hearables and OTC devices on localization cues.

Adapting to non-human listening agencies

One central concept in soundscape studies has been that of an acoustic community, i.e. a group of people sharing an understanding of a listened environment, either acoustic or mediated. This understanding manifests in recognition of sound sources, their communicative function and their discoursive use in everyday life. The growing use of hearing aids, noise-cancelling headphones and other intelligent listening technology renders the soundscape more individual and at the same time introduces a non-human listening agency as a mediator to the individually calibrated soundscape. This raises conceptual and methodological questions of listening abilities in general and of how the listening experience is to be understood as taking place in a shared environment. To illuminate this problematic the paper will present as a case how listening through cochlear implants and their sound prosessors can be understood as a process of adaptation to a mediated acoustic community.

Changes in Outcomes Expectations During the Cochlear Implant Evaluation Process.

Patient expectations are a critical factor in determining cochlear implant (CI) candidacy. However, minimal data are available on how potential CI recipients develop their expectations and if expectations can be modified by providers. In addition, there is little insight into the resources patients use to inform their decision to undergo implantation. This project aims to assess (1) the role of the CI evaluation (CIE) process on patients' expectations, (2) the extent to which patients' pre-CI outcome expectations can be modified, (3) the information patients use to inform their expectations, and patients' preferences for the discussion/display of potential CI outcomes. Prospective mixed methods study of 32 adult CI patients undergoing CIEs. Outcome measures included: pre-CI Cochlear Implant Quality of Life-35 Profile scores (CIQOL-35 Profile); pre-CIE/post-CIE/day of surgery CIQOL-Expectations scores; post-CIE/day of surgery Decisional Conflict Scale (DCS) scores; and pre-CI aided CNC-word and AzBio sentence scores. Thematic analyses of key informant interviews with 19 potential CI recipients were also performed. In aim 1, CI CIQOL-Expectation domain scores remained essentially unchanged following the CIE when averaged across all participants (d = 0.01 to 0.17). However, changes in expectations were observed for many participants at the individual level. Regarding the second aim, participants with higher pre-CIE expectations showed a decrease in expectations following the CIE for all CIQOL domains except emotional and social (d = -0.27 to -0.77). In contrast, the only significant change in participants with lower expectations was an increase in expectations in the environment score from pre-CIE to the day of surgery (d = 0.76). Expectations remained essentially unchanged or continued to change in the same direction between the post-CIE and the day of surgery, narrowing the gap between participants with higher and lower expectations. Overall, participants demonstrated low overall conflict related to their decision to proceed with cochlear implantation (mean DCS of 11.4 post-CIE and 14.2 at time of surgery out of 100) but DCS scores were higher for participants with lower pre-CIE expectations (d = 0.71). In aim 3, key informant interviews demonstrated no differences between the low- and high expectation cohorts regarding resources used to develop their perception of CI outcomes. Potential CI recipients placed high value in talking with patients who had previously received a CI, and preferred discussing CI functional abilities via clinical vignettes described in the CIQOL Functional Staging System rather than by discussing speech recognition or CIQOL-35 Profile scores. The results of the present study suggest that, although overall expectations averaged across the cohort remained essentially unchanged, individual participants' pre-CI expectations can be modified and there is value in measuring these expectations using the CIQOL-Expectations tool to determine if they are realistic. This information can then be utilized during personalized counseling to present a more accurate representation of likely CI outcomes for each patient. Discussions between potential CI recipients and current CI users may also provide valuable information to inform their expectations. In addition, communicating potential CI benefits using CIQOL functional stages and associated clinical vignettes may result in more realistic patient expectations and support shared decision-making related to CI surgery.