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COCHLEAR IMPLANTS
HUGH J. MCDERMOTT
The University of Melbourne
East Melbourne, Australia
1. HEARING AND DEAFNESS
Figure 1 is a sectional diagram of the human auditory
anatomy. (The figure includes components of a typical co-
chlear implant system, which will be described later.) The
pinna, at the left, directs airborne sound via the external
ear canal to the tympanic membrane, or eardrum. Sound
pressure waves produce vibration of the eardrum, which is
coupled to the cochlea, or inner ear, by means of three ar-
ticulated bones, known as ossicles. The cochlea is a spiral-
shaped structure containing fluid in several chambers
separated by membranes. Acoustic vibrations generate
oscillatory motion of structures inside the cochlea. The
physical properties of the internal cochlear structures re-
sult in a mechanical filtering characteristic that distrib-
utes this motion spatially in accordance with the
frequency content of incoming acoustic signals. High-
frequency sounds produce most movement near the base
of the cochlea, where vibrations are introduced from the
886 COCHLEAR IMPLANTS
Figure 1. Cutaway diagram showing a right human ear and a
cochlear implant. Behind the pinna (external ear) at the left is the
sound processor. The transmitting coil, above the pinna, is
aligned with the receiving coil of the device implanted under
the skin. The electrode array lies inside the spiral-shaped cochlea
shown at the lower right. A separate lead connects the receiver-
stimulator to an extracochlear electrode that has been placed im-
mediately above the receiving coil. Also shown are the external
ear canal leading from the pinna to the eardrum, and the ossicles
that couple sound vibrations from the eardrum to the inner ear.
(This figure is available in full color at http://www.mrw.intersci-
ence.wiley.com/ebe.)
ossicular chain, whereas lower frequencies produce max-
imal activity at places closer to the cochlear apex.
The motion of the structures inside the cochlea is trans-
duced into neural signals by approximately 15,000 hair
cells that are distributed regularly around the spiral.
Sound vibrations apply shearing forces to projections,
known as stereocilia, on the hair cells. Deflections of the
stereocilia initiate a sequence of electrochemical events
that result in the production of action potentials in audi-
tory neurons. These action potentials are conveyed from
the cochlea by fibers of the auditory nerve to neural pro-
cessing centers in the brainstem. Ultimately, these signals
Microphone
Signal
amplification and
conditioning
Electrode array
Figure 2. The main functional blocks of a
typical cochlear implant system.
modulate neural activity in the auditory cortex of the
brain, where hearing sensations are perceived.
In sensorineural hearing impairment, a partial or total
loss of hair cells usually occurs. Damage to, or loss of, hair
cells causes a loss of hearing sensitivity because the me-
chanical vibrations created in the cochlea by sound waves
are not represented in neural excitation patterns. The hair
cells tend to be more susceptible to permanent damage
from various causes than most other structures in the ear
that are essential for hearing. Some common causes of
hair-cell damage include prolonged exposure to excessive
levels of noise, diseases such as meningitis and otosclero-
sis, head trauma, and treatment with certain antibiotic
drugs. Once destroyed, hair cells in humans do not regen-
erate (although hair-cell regeneration is observed to occur
in some other species). However, many of the primary au-
ditory neurons survive even in cases of total hair-cell loss.
Therefore, it is possible to create hearing sensations even
in an ear that is profoundly or totally deaf as a conse-
quence of extensive loss of hair cells by stimulating audi-
tory neurons directly with electric currents. The purpose
of a cochlear implant (CI) is to generate electric stimuli
that are appropriately controlled to convey useful infor-
mation about sounds, and that do not cause major unde-
sirable side effects even with chronic application.
2. DESIGN OF COCHLEAR IMPLANT SYSTEMS
Although many different designs of CIs have been de-
scribed over at least the past three decades, all designs
have general features in common. The components of a
typical CI system are shown in Fig. 2. All implant systems
pick up sound signals with a microphone, which is usually
packaged in a small enclosure that is worn on the users
pinna, as with conventional hearing aids of the behind-
the-ear type. An electric signal representing the variation
of air pressure associated with airborne sound waves is
conveyed from the microphone to an electronic signal pro-
cessor. The processor is designed to convert selected fea-
tures of acoustic signals into a pattern of electric nerve
stimuli that will provide useful hearing sensations to the
implant user. Considerable flexibility is available to de-
signers of sound processing circuits and algorithms, which
has led to the development and evaluation of a number of
distinct processing schemes. Functional details of the
User-specific
stimulus parameters
Stimulus
Estimation of
parameter encoding
signal spectrum
and transmission
Data decoding
Stimulus
and power
production
generation
Inductive
link

most important schemes that are currently in use are pre-
sented later.
In most cases, the output of the sound processor con-
sists of a digital code specifying the parameters of the
electric stimuli to be delivered to the implanted electrode
array. The code is usually conveyed to the implanted de-
vice via an inductive link (see Fig. 2). The link operates on
the same principle as a transformer, and comprises two
coils of wire separated by the skin overlying the implant.
An electric current flowing in the external coil magneti-
cally induces a secondary current in the implanted coil.
The currents are modulated by the transmitter circuit of
the sound processor to represent the encoded information
specifying the required electric stimuli. An integrated cir-
cuit in the implant, often called the receiver-stimulator,
demodulates the signal obtained from the subcutaneous
coil. In addition, the inductive link serves to provide elec-
tric power to the implanted electronics and hence to the
electrodes. The power is extracted by rectifying and
smoothing the modulated alternating current induced in
the implanted coil. This technique obviates the need for a
power source, such as a battery, in the implant. The ab-
sence of an implanted battery helps to ensure that, after
the device has been implanted, no further surgical inter-
vention should be necessary throughout the lifetime of the
implant user.
2.1. Implanted Components
A typical implantable device, including a receiver-stimu-
lator and electrode array, is illustrated in Fig. 3. The re-
ceiver-stimulator decodes the information transmitted by
the external sound processor, which specifies parameters
such as the onset time and magnitude of the stimulus to be
generated, and the particular electrodes that are to con-
duct the stimulus current. To prevent unintended stimu-
lation, the receiver-stimulator contains circuits to check
that the received code is free from errors, and that ade-
quate power is available from the inductive link to gener-
ate the required stimulus. Thus, little chance exists that
the implant will be activated incorrectly or unexpectedly
as a result of poor coupling between the coils, or the re-
ception of electromagnetic fields generated by devices
Figure 3. Photograph of a cochlear implant, showing the re-
ceiving coil with magnet at center, the electronics package, the
intracochlear electrode array, and the separate extracochlear
electrode. (This figure is available in full color at http://www.mrw.
interscience.wiley.com/ebe.)
COCHLEAR IMPLANTS 887
other than the sound processor, which is one advantage
of implanting a relatively complex receiver-stimulator
rather than connecting the signal received from the im-
planted coil directly to the stimulating electrodes. How-
ever, the latter technique has been employed in some
simple CI systems, and some of its characteristics are dis-
cussed further later.
In many recent implant systems, the receiver-stimula-
tor has the additional capability of transmitting informa-
tion outward for external analysis and monitoring. Such
information might include measurements of the electrical
impedances of the electrodes, or an indication of the state
of the internal power supply. This information can be used
to diagnose faults in the implant, or to minimize the
amount of power that the sound processor needs to trans-
mit for a given user. The power requirements depend on
various individual factors including the thickness of the
skin separating the transmitting coil from the receiving
coil, which affects the coupling efficiency of the inductive
link. When measurements of the electrical state of the
implanted components are available externally, it is pos-
sible for the transmitter of the sound processor to be ad-
justed automatically to provide the minimum required
power, and thus to maximize the lifetime of the battery.
The output of the receiver-stimulator is usually a pre-
cisely controlled electric current that is directed to one or
more of the implanted electrodes. In the majority of exist-
ing implant systems, the stimulus waveform is usually a
symmetric, biphasic, rectangular pulse (Fig. 4, top). This
waveform comprises two intervals, or phases, of equal du-
ration, during each of which current flows through the
selected electrodes. The phases may be separated by a
short time during which no current flows. The insertion of
such an inter-phase gap can reduce the current required
to produce an audible sensation, at the expense of a small
increase in the overall stimulus duration. Current flows in
opposite directions during the two phases, but with equal
magnitudes. Therefore, the total charge transferred
CURRENT
0
CURRENT
TIME
Figure 4. Two types of stimulating waveform generated by co-
chlear implants. At the top is a series of two biphasic current
pulses. Each pulse comprises two intervals, or phases, during
which a constant current flows between the active electrodes.
These phases are separated by a brief zero-current interval. The
direction of current flow is reversed between the two phases. At
the bottom is an example of an analog stimulus.
888 COCHLEAR IMPLANTS
through the electrodes during the first phase (i.e., the
product of current and phase duration) is equal to the
charge transferred in the reverse direction during the sec-
ond phase. This cancellation of the charge delivered by the
electrodes within each stimulating period has been shown
to minimize damage to neurons and other tissues in the
vicinity of the electrodes, and to prevent corrosion of the
electrode materials. Two widely used methods of ensuring
that the charge is balanced accurately between the phases
are to couple the electrodes to the stimulator via capaci-
tors, which prevent accumulation of charge on the elec-
trodes as a consequence of any nonzero net current flow,
and to connect the electrodes together whenever the stim-
ulator is not delivering current (i.e., at all times between
successive pulses). The latter technique helps to dissipate
any residual charge remaining in the electrode circuit af-
ter the completion of a biphasic pulse, and is often applied
in implanted stimulators regardless of whether coupling
capacitors are also used. However, some stimulators that
are designed to drive a large number of electrodes may not
incorporate coupling capacitors, because such components
tend to be bulky and would require a relatively large im-
plant package.
The safety of the electric stimulus for chronic applica-
tion is also promoted by using the smallest possible cur-
rents and pulse durations. Both the current and the pulse
duration (as well as other parameters of the stimulation)
affect the loudness of electrically induced sensations. Gen-
erally, increases in either of these parameters increase the
number of auditory neurons that are activated or the rate
at which neural action potentials are produced. At least
two additional ways of increasing the susceptibility of
neurons to the stimulation exist. First, the electrodes
can be placed closer to the surviving auditory neurons.
Second, the configuration of the electrodes can be selected
to increase the spatial distribution of the stimulus cur-
rents and thereby to excite a larger number of neurons.
These aspects of electrode design are discussed further
below.
In general, however, the current levels that can be gen-
erated by existing implants range from a few microamps
up to a few milliamps, and the pulse durations range from
tens to hundreds of microseconds per phase. The inter-
phase gap (see Fig. 4, top) is usually less than 50 ms long.
In some receiver-stimulator designs, the stimulus cur-
rents are related by a nonlinear function to the digital
code that is transmitted from the sound processor. For ex-
ample, each step in the current-level code might result in a
proportional (rather than absolute) change in the magni-
tude of the electrode current. This design derived from an
early finding that the loudness of sensations produced by
an implant was related to the current magnitude approx-
imately by a mathematical power function; thus, loudness
can be controlled more regularly when currents are chan-
ged by a constant ratio rather than in fixed absolute steps.
For a particular electrode in a given implant user, the
range of currents (or pulse durations) that encompasses
the widest useful range of loudness is always much
smaller than the full range that the receiver-stimulator
can generate. As numerous individual factors affect the
range of currents that may be required in a specific
instance, and the effects of many of these factors cannot
be predicted accurately before the device is implanted, re-
ceiver-stimulators must be designed with enough spare
capacity to function correctly in any potential user. In
most CI users, the range over which currents (or pulse
widths) vary on each electrode is typically about 520 dB.
In the design of receiver-stimulators, the electrical im-
pedance of the electrodes is an important consideration.
The impedance of a pair of metal electrodes immersed in a
conductive fluid can be represented approximately by the
equivalent circuit shown in Fig. 5. The circuit includes
capacitive and resistive elements whose values depend on
various parameters, such as the surface area and material
of the electrodes and the electrical properties of the fluid.
It is difficult to predict the precise impedance of electrodes
after implantation, and it is also known that the imped-
ance can vary over time. For stimulation with constant
currents, changes in the electrode impedance cause corre-
sponding changes in the voltage. Fortunately, neurons are
much more sensitive to the local current intensity than to
the voltage at the electrodes, so moderate impedance
changes generally have little effect on the sensations per-
ceived by the implant user. However, the maximum cur-
rent and pulse width that can be applied on a particular
electrode are affected by that electrodes impedance. As
can be inferred from the circuit of Fig. 5, the onset of a
current pulse (see Fig. 4, top) produces an abrupt increase
in the voltage across the electrode pair. The voltage
increases smoothly during the first phase of the pulse
while the capacitance is charged, and reaches a maximum
at the end of the first phase. For the current generator in
the receiver-stimulator to maintain the intended constant
current throughout the pulse, it is essential that this
E1
from
receiver-
stimulator
E2
Figure 5. Simplified equivalent circuit of an intracochlear elec-
trode pair. The nodes labeled E1 and E2 at the left are driven by
the current generators of the stimulator. Each parallel R/C com-
bination represents the metal-fluid interface for each electrode,
and the resistance on the right represents the current path within
the cochlear tissues.

maximum voltage be less than a limit known as the com-
pliance voltage, which is slightly less than the power sup-
ply voltage of the receiver-stimulator. The supply voltage
varies among implant devices, and can also be affected by
factors such as the thickness of the skin separating the
sound processors transmitting coil from the receiving coil,
but is usually around 12 V.
It is possible with some recent implant systems to
check postoperatively that all electrodes are operating
within their limits of compliance. If it is found that some
stimuli are causing compliance to be exceeded, the prob-
lem can be eliminated in most cases by reducing the stim-
ulus current, which will usually require an increase in
the pulse width or a change of the electrode configuration
(e.g., from bipolar to monopolar). Characteristics of these
and other types of electrode configurations are described
below.
A final requirement for the safe long-term use of coch-
lear implants is that the materials from which the devices
are constructed be biocompatible and structurally and
chemically stable. Studies investigating the properties of
candidate materials in the biological environment have
identified a number of suitable metals, ceramics, and
polymers. Electrodes and connecting wires are usually
fabricated from platinum or an alloy having similar char-
acteristics. Electrode carriers and the protective jacket
surrounding the implanted package are made from med-
ical-grade silicone rubber compounds. The package itself
is often constructed using titanium or ceramic materials
and is hermetically sealed to prevent fluids contacting
the electronic components inside. The use of appropriate
materials, combined with the intensive testing of implan-
table devices during and after manufacture, have gener-
ally succeeded in maintaining postoperative failure rates
at acceptably low levels.
2.2. Stimulating Electrodes
In early CIs, the primary objective was to deliver currents
to the entire surviving population of auditory neurons in
people whose degree of deafness was so severe that
they could not perceive sound no matter how much am-
plification was attempted using conventional hearing
aids. Often a single electrode was placed near to the neu-
ral population, with the electric circuit being completed
through a second electrode that was located at a remote
site. In one device, which was implanted in a relatively
large number of people mainly in the 1970s and 1980s, the
single active electrode was inserted into the basal region
of the cochlea through an opening created surgically at or
near the round window (1). An upgraded version of this
device, manufactured by AllHear Inc. (2), is the only de-
vice presently available from a commercial manufacturer
that does not have the capability of stimulating on multi-
ple electrodes.
Although the use of a single active electrode may be
attractive, mainly because of the relative simplicity of
both the surgery and the stimulator electronics, great
advantages exist in being able to stimulate different sec-
tors of the population of surviving auditory neurons with
some degree of independence. As mentioned earlier, in the
COCHLEAR IMPLANTS 889
normal cochlea, an orderly relationship exists between the
frequencies of sounds and the location of maximal excita-
tion of auditory neurons. The essence of this relationship
is that high frequencies produce most activity in neurons
that innervate hair cells near the base of the cochlea,
whereas lower frequencies activate neurons that inner-
vate hair cells located at more apical positions. This tono-
topic organization applies not only to hair cells, but also to
the cell bodies and dendrites of auditory neurons. There-
fore, even in cases of profound sensorineural deafness, in
which there may be few or no surviving hair cells, it is still
possible for a CI to take advantage of the tonotopic orga-
nization of auditory neurons with a suitably designed ar-
ray of electrodes. Generally such arrays comprise many
discrete electrodes mounted on a carrier that can be in-
serted into the fluid-filled interior of the cochlea through
the round window, or through an artificial opening near
the round window (see Fig. 1). When an array is inserted
deeply into the cochlea in this way, electrodes near the tip
preferentially stimulate neurons that would normally
have responded best to low-frequency sounds, whereas
electrodes nearer the cochlear base stimulate neurons
that would normally have been responsive to higher-fre-
quency sounds.
For this principle to be effective in practice, it is impor-
tant that the current delivered by each electrode can stim-
ulate exclusively a nearby subpopulation of the available
neurons. If excessive spatial overlap exists among the
groups of neurons that respond best to each member of a
set of closely spaced electrodes, then it is unlikely that the
auditory percepts produced by activation of each electrode
will be distinct. Such an electrode array would provide
little advantage over an array having fewer electrodes,
particularly from a perceptual point of view. The question
of how many electrodes should be provided in a CI is a
complex one, and some of the issues involved are beyond
the scope of this article. However, if benefit is to be ob-
tained from implanting many, rather than few, electrodes,
it is essential that the spatial distribution of the current
delivered by each electrode be restricted to distinct groups
of the available neurons, which is the rationale for the
trend in recent CI developments for electrode arrays to be
positioned closer to the modiolus at the center of the co-
chlea, and therefore closer to the cell bodies of the auditory
neurons.
Regardless of the location of the electrodes, different
ways exist in which multiple electrodes can be configured
to deliver stimulating currents to the auditory neurons.
The three main configurations available with existing de-
vices are illustrated in Fig. 6. The monopolar electrode
configuration comprises an active electrode that is located
close to the target auditory neurons and a second electrode
(sometimes referred to as the indifferent or ground
electrode) that is located relatively far from the neurons
(Fig. 6, left). The indifferent electrode typically has a
larger surface area than the active electrode, and may
serve as the current return path for many discrete active
electrodes. In multiple-electrode implants employing
monopolar stimulation, it is important that the active
electrodes be located close to the target neurons so that
each electrode may stimulate a perceptually distinct
890 COCHLEAR IMPLANTS
Monopolar Bipolar Common ground
Figure 6. Three electrical configurations of the stimulating elec-
trodes: monopolar (left), in which current flows between an in-
tracochlear electrode and a remote electrode; bipolar (center), in
which current flows between two intracochlear electrodes; and
common ground (right), in which current flows between one in-
tracochlear electrode and all other electrodes.
subpopulation of neurons. The electric current distribu-
tions associated with each electrode become more over-
lapping at increasing distances from the active electrodes,
and would be completely indistinguishable at locations
close to the indifferent electrode.
To improve the spatial separation of stimulating cur-
rents in multiple-electrode implants, bipolar stimulation
is often used. In the bipolar configuration, currents are
passed between two electrodes, both of which are located
relatively close to the auditory neurons (Fig. 6, center).
The decrease in current density with distance from a bi-
polar electrode pair is much steeper than the decrease as-
sociated with an electrode used in the monopolar
configuration. Theoretically, therefore, the spatial selec-
tivity of bipolar electrodes should be better than that of
monopolar electrodes. However, psychophysical studies
have shown that the perceptual distinctiveness of elec-
trodes is not related exclusively to whether bipolar or
monopolar stimulation is applied (3).
Several variations exist on the bipolar electrode config-
uration that can provide practical benefits in some cir-
cumstances. In one variation, the separation between the
two active electrodes (called the spatial extent) can be
increased, which results in a reduction of the stimulus
current required to produce an audible sensation because
more auditory neurons are in the path of the current. (For
the same reason, threshold currents are generally lower
with monopolar stimulation than with bipolar stimula-
tion.) Another variation on the bipolar configuration in-
volves mounting the electrodes on their carrier in an
arrangement that directs the current along approximately
a radial, rather than longitudinal, path. Currents that are
aligned radially with respect to the cochlear spiral are
more efficient at producing action potentials in nerve cells
than currents flowing in other directions, and thus radial
bipolar electrode pairs should, at least in theory, provide
better selectivity and lower thresholds than alternative
electrode configurations.
A third type of electrode configuration is known as the
common ground stimulation mode (Fig. 6, right). In this
configuration, one active electrode is selected, and all of
the remaining intracochlear electrodes are used together
as the return path for the stimulating current. In some
functional respects, the common ground arrangement is
intermediate between the bipolar and monopolar configu-
rations. One advantage of the common ground config-
uration is that its use can minimize the adverse effects
of electric short circuits within the electrode array.
Unfortunately, such short circuits occur occasionally, and
can occur intermittently as well as permanently. Their oc-
currence is associated with the need, in multielectrode
arrays, for many, very thin wires to be packed closely to-
gether in passing between each active electrode and the
implanted receiver-stimulator. When short circuits occur
with a bipolar electrode configuration, the threshold cur-
rents can be much lower than expected, because, in effect,
the spatial extent of the electrode pair is larger than in-
tended. Use of the common ground configuration circum-
vents this problem, and therefore it is often selected in
situations where there are known short-circuits between
some electrodes, or where an intermittent short circuit is
suspected.
A variation on the common ground electrode configu-
ration is used in the COMBI 40 implant, manufactured
by the company MED-EL (4). The standard intracochlear
electrode array comprises 12 pairs of electrodes. However,
rather than employing the bipolar configuration, the
MED-EL device treats 12 of the electrodes (one from
each pair) as a common current return path for each of
the remaining 12 electrodes. Like other implant manufac-
turers, MED-EL provides modified electrode arrays for
special situations, such as cases where surgical access to
the cochlea is restricted.
In some CI designs, the way in which electrodes are
configured to deliver stimulation can be selected at any
time by transmitting appropriate data to the receiver-
stimulator. For example, in the CI24 series of devices,
manufactured by Cochlear Limited (5), there are 22 in-
tracochlear electrodes mounted longitudinally on a flexi-
ble carrier that is inserted into the scala tympani of the
cochlea, and two additional electrodes that are located
outside the cochlea (see Fig. 3). The 22 intracochlear elec-
trodes can be configured in a common ground or bipolar
arrangement without the use of the extracochlear elec-
trodes. In the bipolar configuration, any two electrodes
can be selected to form a stimulating pair, so that all spa-
tial extents possible within the limits imposed by the ge-
ometry of the electrode array are available. In addition,
monopolar configurations can be selected using any of the
intracochlear electrodes in combination with either or
both of the extracochlear electrodes. In principle, a differ-
ent configuration could be selected for each pulse of stim-
ulation to be generated, although in practice the use of the
same configuration for all active electrodes is more usual.
2.3. Stimulating Waveforms
Previously, the constant-current, biphasic pulse was de-
scribed briefly, because it is the most widely used stimu-
lating waveform in existing CI devices. As illustrated in
Fig. 4 (top), this waveform can be defined completely using
only four parameters: the current level, the pulse onset
time, the duration of the two phases, and the time interval
separating the phases. To generate each pulse of stimula-
tion, data specifying these parameters, and the particular
electrodes to be activated, must be transmitted to the im-
planted receiver-stimulator. In part because this small
number of data parameters can be represented in digital
form relatively compactly, the complexity and the electrical

power consumption of both the external sound processor
and the implant can be kept to manageable levels, even
when stimulation at high pulse rates is required. Existing
receiver-stimulators have maximum pulse-rate capabili-
ties of about 15100 kHz. However, research has shown
that different waveshapes can have different effects when
neural tissue is stimulated electrically. Some CI devices
have the capability for delivering waveforms other than
rectangular biphasic current pulses to the electrodes.
These waveforms are generally referred to as analog derstand speech, as discussed further later. In normal
waveforms, because in some CI systems, the stimulus
waveform represents a continuously varying waveform de-
rived from the microphone signal, usually after some pro-
cessing such as filtering (see Fig. 4, bottom). However, it is
also possible to generate nonrectangular waveforms by
specifying the current to be delivered to the active elec-
trodes at each of a number of discrete time instants. With
this technique, employed in certain existing receiver-stim-
ulators, it is feasible to construct an approximation to any
desired nonrectangular waveform while retaining the
practical advantages of digital encoding of the data trans-
mitted to the implant.
One way of avoiding nearly all restrictions on stimulus
waveshape is to provide a direct connection between the
external sound processor and the implanted electrodes,
rather than an implanted receiver-stimulator driven via a
transcutaneous inductive link. Such a percutaneous con-
nector was used with the Ineraid CI, which is now obso-
lete (6). This system relied on a plug and socket to connect
the body-worn electronics with each of 8 (6 intracochlear, 2
extracochlear) electrodes. Although an arrangement of
this type is extremely flexible in terms of stimulus wave-
forms and electrode configurations, it has three serious
disadvantages. First, the permanent protrusion of the
connector through the skin increases the risk of infection
and local tissue damage. Second, it is difficult to fabricate
a reliable connector of acceptable size for use with a large
number of implanted electrodes. Third, the visibility of the
connector would be undesirable to many potential users of
CIs. Nevertheless, percutaneous connectors are valuable
for short-term use in research investigating the percep-
tual characteristics of stimuli with parameters outside the
range that can be generated by existing CIs.
For small numbers of implanted electrodes, it is possible
to provide a separate inductive link for each intracochlear
electrode pair. This technique was used in previous single-
channel (1,7) and 4-channel (8) devices, and is used in the
present AllHear single-channel system (2). Generally, the
inductive links in these devices convey analog waveforms
to the electrodes by modulating a radio-frequency carrier.
The process of demodulating the signal received by the
implant is much less complex than decoding digital data,
and therefore the implanted electronic circuitry is simple
and consumes very little power. The AllHear system is dis-
tinctive in that it employs a relatively low carrier fre-
quency (16 kHz) and delivers the amplitude-modulated
carrier waveform directly to the stimulating electrode
without demodulation. An advantage of using multiple in-
ductive links in the devices with more than one active elec-
trode is that independent, analog stimulating waveforms
can be delivered to the active electrodes simultaneously.
COCHLEAR IMPLANTS 891
However, the large physical volume required for both the
external transmitting coils and the implanted receiving
coils renders the multiple-link technique impractical for
large numbers of electrodes.
Whether stimulating with analog waveforms confers
perceptual benefits over stimulating with simple rectan-
gular pulses is a research question that is presently unre-
solved. Sound-processing schemes using each technique
have provided many users of CIs with the ability to un-
hearing, the mechanical stimulation of hair cells by vibra-
tions resulting from the variations in pressure associated
with acoustic signals produce action potentials in auditory
neurons. As action potentials are all-or-nothing events,
good reason exists to suggest that the use of brief current
pulses to stimulate auditory neurons directly can convey as
much information about sound signals as can nonrectan-
gular waveforms. On the other hand, it is well known that,
in normal hearing, auditory neurons that innervate the
cochlea at sites distributed along the length of the basilar
membrane convey information about incoming acoustic
signals concurrently. Based on this fact, it seems reason-
able that CIs that can stimulate several locations in the
cochlea simultaneously might provide perceptual advanta-
ges over devices that are restricted by design to present
stimulation on multiple electrodes nonsimultaneously.
2.4. Simultaneous Stimulation
As mentioned above, CIs that employ a percutaneous con-
nector, or several independent inductive links, to convey
stimuli to multiple intracochlear electrodes are inherently
capable of providing stimulation with analog waveforms
simultaneously to several subpopulations of auditory neu-
rons. Some implant designs have achieved similar capa-
bilities using a single inductive link and digital encoding
of stimulus parameters. In general, these devices contain
a complex receiver-stimulator that converts data specify-
ing the required pattern of stimulation into a set of stim-
ulating currents that are delivered to the selected active
electrodes independently. For example, the HiRes CI sys-
tem, manufactured by Advanced Bionics Corporation (9),
is capable of receiving data that specifies the current to be
delivered by up to 16 independent electrodes simulta-
neously. The rate at which these data can be processed
is high enough to permit the currents on the active elec-
trodes to be modified approximately every 12 ms. Alterna-
tively, data can be transmitted to the implant that
specifies nonsimultaneous stimulation. Bipolar and mono-
polar electrode configurations are available.
Numerous technical problems still need to be overcome
to enable simultaneous stimulation to be produced on
multiple electrodes without undesirable side effects. One
important problem derives from the summation of cur-
rents within the cochlea. As mentioned above, for the use
of multiple electrodes to be beneficial perceptually, it is
essential that the subpopulations of auditory neurons that
are excited by each electrode be at least partially non-
overlapping. With a monopolar electrode configuration,
currents produced simultaneously by several electrodes
combine in the conductive fluids and tissues surrounding
892 COCHLEAR IMPLANTS
the electrode array and the target population of neurons.
The occurrence of such current summation means that the
effects of the stimulation produced by each electrode are
dependent in a complex manner on the currents produced
by all other electrodes that are active at overlapping
times. In the Clarion device (10), some degree of indepen-
dence among the simultaneously active electrodes is
achieved by delivering currents to the electrodes while
they are configured as bipolar pairs, with the members of
each pair closely spaced. In addition, the stimulator cir-
cuitry is designed to prevent currents destined for a par-
ticular electrode pair from flowing to any other electrodes
that are active at the same time.
In addition to the potential perceptual benefits deriving
from the simultaneous activation of subpopulations of au-
ditory neurons at distinct sites, a further reason for pro-
viding simultaneous stimulation capabilities in CIs is to
exploit some of the effects of current summation. For ex-
ample, it is possible in theory to create stimulating cur-
rent distributions that are more restricted spatially than
those resulting from a bipolar electrode configuration by
employing three intracochlear electrodes simultaneously.
In this tripolar configuration (sometimes referred to as
quadrupolar), a central electrode is used to deliver current
that is returned in equal parts by the two adjacent elec-
trodes. In practice, the tripolar configuration can be cre-
ated by activating simultaneously two bipolar electrode
pairs that share one central electrode. Experimental stud-
ies suggest that tripolar stimulation may result in en-
hanced spatial selectivity in the target subpopulation of
auditory neurons by comparison with bipolar (or monopo-
lar) stimulation. The same principle can, of course, be ap-
plied to any larger number of electrodes to produce a
particular current density distribution along the length of
the cochlea. Whether this would provide perceptual ben-
efits to implant users in comparison with stimulating at
only one site at a time has not yet been determined.
To summarize, the development of CI devices and the
evaluation of their performance over time has enabled
some general principles of good implant design to be iden-
tified. First, better perceptual performance is likely to be
obtained if multiple electrodes are used rather than a sin-
gle electrode. Secondly, it is preferable for the stimulating
electrodes to be located relatively close to the target audi-
tory neurons, and in an arrangement that enables the to-
notopic organization of the cochlea to be exploited. Third, it
is possible to provide substantial perceptual benefit to im-
plant users by stimulating with rectangular current pulses
delivered sequentially to multiple electrodes, although the
use of analog stimulus waveforms or simultaneous stimu-
lation may also be worthwhile. Research has also shown
that the degree of benefit obtained by deaf individuals from
CIs depends very heavily on the methods used to process
sound signals and to generate stimulation patterns that
represent those sounds. This topic is discussed below.
3. SOUND PROCESSING FOR COCHLEAR IMPLANTS
The evolution of design of the implantable components of
hearing prostheses has been accompanied by continual
Figure 7. Photograph of a complete cochlear implant system,
including the external sound processor (left), the implantable de-
vice (center), and a programming interface unit (right). (This fig-
ure is available in full color at http://www.mrw.interscience.
wiley.com/ebe.)
improvements in the design of sound processors (which at
present must be worn externally by implant users). One
recent CI system is illustrated in Fig. 7, showing three
main components: a sound processor, designed to be worn
behind the ear; the implantable receiver-stimulator and
electrode array; and a programming interface that enables
the sound processor to be connected to a computer. A large
number of distinct sound processing schemes have been
developed and evaluated for CIs so far (11). For various
reasons, it is not realistic to rank implant systems or
sound processor techniques in a strict order of perfor-
mance. For example, different designs have been shown to
provide comparable levels of benefit to individual implant
users, and furthermore, considerable variability exists in
the benefit users may obtain from the same devices and
processing schemes. Nevertheless, three broad categories
of sound-processing schemes (often referred to as strate-
gies) can be identified. Most of the successful strategies
that have been developed for a particular implant device
can also be used by people implanted with a different de-
vice, at least in principle, by changing or reprogramming
the sound processor. In spite of the commercial rivalries
among device manufacturers, many fundamental princi-
ples of sound-processing schemes are similar across sys-
tems in each category. In the following, certain superseded
techniques, including those employed in single-channel CI
systems, are not described in detail.
3.1. Feature-Extracting Strategies
One early and distinctive approach to the design of sound
processors was taken by researchers at the University of
Melbourne, Australia, and the CI manufacturer Cochlear
Limited (formerly Nucleus Limited) (5). Initially, this ap-
proach focused on providing implant users with specific
information about speech sounds. A limited set of acoustic
features of the speech signal that were known to be im-
portant for speech recognition was identified. Stimuli rep-
resenting some parameters of those features were
generated by delivering trains of nonoverlapping pulses
to a small number of electrodes selected from an intra-
cochlear array of 22 electrodes. In an evolving series of
designs, the number of features represented was increased
progressively, resulting in improvements in the average

Stimulus
BPF encoder
4 - 6kHz
BPF
2.8 - 4kHz
Acoustic to electric
level conversion
BPF
2 - 2.8kHz
Input
signal
F2 F2 frequency to
estimator electrode conversion
F1 F1 frequency to
estimator electrode conversion
F0 F0 frequency to pulse
estimator rate conversion
Voicing Active electrode
detector selection
speech perception of implant users. The ultimate in this
series of sound processors was the Multipeak (or
MPEAK) strategy (12), a block diagram of which appears
in Fig. 8.
For vowels and other voiced speech sounds, the fre-
quency spectrum of the acoustic signal is characterized by
a number of broad peaks that are associated with reso-
nances in the vocal tract. Two of these peaks correspond to
the first two formants (known as F1 and F2). As the lower
formants carry information that enables many speech
sounds to be recognized, parameters describing them
were estimated in the MPEAK strategy. The frequency
ranges of the acoustic signal associated with F1 and F2
were extracted by bandpass filters, and the corresponding
amplitudes were estimated by means of envelope detec-
tors. The center frequencies of the formant peaks were
estimated by measuring the periods of the waveforms
passed by the filters using zero-crossing detectors. These
frequency estimates were converted to the locations of the
active electrodes, such that an apical set of electrodes was
assigned to F1 (which has a range of about 300 to 800 Hz)
and a basal set of electrodes was assigned to F2 (which has
a range of about 800 to 2800 Hz). Three additional band-
pass filters and envelope detectors estimated the ampli-
tude of the incoming signal in three higher frequency
regions (2.02.8, 2.84.0, and 4.06.0 kHz). These filters
were assigned to three fixed electrodes near the basal end
of the array. Each of the five amplitude estimates was
converted to a stimulation level using an instantaneous
nonlinear function, as described further later. However,
only four of the above feature estimates were used to con-
trol stimulation on four active electrodes in each stimulus
period, and the positions of only the electrodes represent-
ing the frequencies of F1 and F2 were variable. Unlike
most other modern sound-processing schemes, which
COCHLEAR IMPLANTS 893
Output
data to
cochlear
implant
Figure 8. Functional block diagram of the
Multipeak (MPEAK) speech-processing scheme.
stimulate at a constant pulse rate, the stimulation period
in MPEAK depended on whether voicing (i.e., vibration of
the speakers larynx) was detected in the input signal. If
so, the fundamental frequency (F0) of the speech signal
was estimated, and the stimulus period was set equal to
the inverse of F0. The four pulses presented within the
period represented F1, F2, and the lower two of the three
high-frequency bands. If voicing was not detected, a stim-
ulation rate of about 250 Hz was used, and the four pulses
presented in each period represented F2 and all of the
three high-frequency bands.
Although research studies demonstrated that feature-
estimating schemes including MPEAK could provide
many implant users with information sufficient to enable
the recognition of most speech sounds, feature estimation
has several inherent disadvantages. A major problem is
that it is technically difficult to obtain accurate estimates
of the relevant parameters of speech signals in a real-time
processor, especially in unfavorable conditions. Situations
with high levels of background noise, multiple speakers,
or signals with parameters outside the expected ranges
(such as music and environmental noises) can result in
unreliable performance. These considerations led to the
development of alternative processing schemes (described
later), which were also designed to present information
about prominent spectral features of sounds, but did not
rely on the assumption that those spectral features were
always associated with speech.
3.2. Simultaneous Analog Schemes
Analog sound-processing schemes have been used success-
fully in several earlier CI systems (1,7,8). At present, a
scheme of this type, called Simultaneous Analog Stimula-
tion (10), is available as a programming option in CI
894 COCHLEAR IMPLANTS

BPF Level
information about speech is present. Typical center fre-
4 control 4 quencies are 0.5, 1.0, 2.0, and 4.0 kHz. The signal passed
Input by each filter is amplified by an adjustable amount, and
signal finally delivered to the corresponding electrode. When the
(after BPF Level Output sound processor is fitted to an implant user, the gain in
AGC) 3 control 3 signals to each of the final stages of the processor is adjusted to pro-
cochlear duce appropriate loudness when speech (and other
implant
BPF Level sounds) are picked up by the microphone. One important
2 control 2 electrodes
characteristic of processing schemes of this type is that the
waveforms of the signals in each of the bandpass filters
BPF Level (rather than the amplitudes of those signals envelopes)
1 control 1 are used as the basis of the electric stimuli produced by
the electrodes. As mentioned previously, the simultaneous
Figure 9. Functional block diagram of the Compressed Analog
delivery of multiple analog current waveforms by an array
(CA) sound-processing scheme.
of intracochlear electrodes can lead to undesirable inter-
actions that adversely affect the auditory perception of
some implant users. Part of the rationale for the develop-
systems manufactured by Advanced Bionics Corporation ment of nonsimultaneous pulsatile schemes was to pre-
(9). A generic block diagram of a sound processor employ- vent such interactions.
ing simultaneous analog stimulation with four channels is
shown in Fig. 9. Sounds picked up by the microphone are
3.3. Nonsimultaneous Pulsatile Schemes
converted to electric signals that are amplified and com-
pressed using an Automatic Gain Control (AGC) circuit. A block diagram of a widely used sound-processing strat-
The compression reduces the dynamic range of electrical egy known as Continuous Interleaved Sampling (CIS) is
levels in an attempt to match the relatively narrow range shown in Fig. 10. As the name implies, the CIS technique
of stimulus levels that is acceptable for the implant user. presents current pulses cyclically to a number of elec-
This range is delimited by the minimum level at which trodes such that only one electrode (at most) is conducting
hearing sensations are just audible, and by the maximum current at any time instant. In a CIS system, much of the
level that produces a comfortable loudness. As a result of processing of microphone signals is similar to that em-
this reliance on reducing the dynamic range of signals be- ployed in a generic simultaneous analog scheme as de-
fore delivery to the electrodes, an early version of this type scribed above. An initial version of a CIS processor was
of processing strategy was known as the compressed an- developed for use with the Ineraid CI, and provided one
alog scheme (6). The compressed signal is divided into four bandpass filter for each of the six intracochlear electrodes
partially overlapping frequency bands by a bank of band- available in that device (13). A CI system developed pre-
pass filters. The filters have center frequencies that are viously in Paris, France, also used a CIS-like processing
usually spaced approximately uniformly on a logarithmic scheme (14). In that system, the levels of signals in each
scale encompassing the frequency spectrum in which most of 12 bandpass filters modulated the levels of pulses

BPF
6

BPF
5
Acoustic to electric
level conversion
BPF
Input
4
signal

BPF
3 Stimulus
encoder
Output
BPF data to
2 cochlear
implant

Figure 10. Functional block diagram of the Constant rate

BPF pulse generator
Continuous Interleaved Sampling (CIS) 1
sound-processing scheme.

presented in a nonoverlapping cyclical sequence to an in-
tracochlear array of 12 electrodes. At present, CI systems
based in part on this relatively early work are manufac-
tured by Laboratoires MXM in France (15). Versions of
CIS processors have been developed for implants with dif-
ferent numbers of active electrodes and corresponding
bandpass filters, and with several variations to the de-
tails of the signal processing. However, the main func-
tional blocks shown in Fig. 10 are common to all CIS
implementations.
In the figure, a six-channel processor is shown. Al-
though the bank of bandpass filters is similar to that em-
ployed in the analog scheme (Fig. 9), CIS has additional
processing in each frequency channel, and introduces a
pulse generator to control the stimulation sequence. Each
of the bandpass-filtered signals is processed by a detector
circuit, such as a rectifier and low-pass filter, to extract the
envelope of the waveform. These envelope signals are
sampled at regular times determined by the pulse gener-
ator, and their amplitudes are converted to stimulation
levels by means of an instantaneous nonlinear function.
As described further below, this amplitude conversion
function ensures that a suitable range of acoustic signal
levels is perceived by the implant user to have appropriate
loudness. An example of an amplitude-modulated stim-
ulus pulse train, similar to the waveform that a CIS
scheme would present on each electrode, is shown in
Fig. 11. The rate at which stimulus pulses are delivered
to the electrodes varies among implementations of the CIS
scheme, and is limited in any case by the capabilities of
the implanted receiver-stimulator. In typical CI systems,
pulse rates of at least 800 Hz per electrode are applied,
although in some instances either much higher or slightly
lower rates have been used successfully. Studies investi-
gating the perceptual effects of different pulse rates with
CIS schemes (and with other nonsimultaneous pulsatile
strategies) have found that the use of higher pulse rates
does not always result in better performance.
Another sound-processing scheme that is widely used
at present is sometimes described generically as the n-
of-m scheme, which is because n outputs of m bandpass
filters are represented by electric pulses in each stimula-
tion period, with nom. An initial version of this scheme
was called the Spectral Maxima Sound Processor (SMSP)
(16). Modified versions of this strategy have been devel-
oped for use in commercial CI systems, including the
SPEAK and ACE schemes of the Nucleus CI system
manufactured by Cochlear Limited, Australia. As with
CURRENT
TIME
COCHLEAR IMPLANTS 895
CIS, several variations of this type of processing have been
developed, although the main functional principles are
similar in all existing practical implementations.
A block diagram of the ACE scheme appears in Fig. 12.
The bandpass filters and envelope detectors are function-
ally similar to those used in other sound-processing
schemes, such as CIS (Fig. 10). However, a relatively large
number of filter channels is provided, with each channel
assigned tonotopically to each intracochlear electrode
available in the implant. The filters have partially over-
lapping frequency responses. Typically, 20 filters encom-
pass a frequency range of about 150 Hz to 10 kHz. In each
stimulation period, the outputs of the envelope detectors
are compared, and the channels with the highest short-
term amplitudes are identified. The number of channels
selected is limited, usually to approximately eight chan-
nels. The amplitudes of these channels are converted to
appropriate levels of stimulation using an instantaneous
conversion similar to that used in other nonsimultaneous
pulsatile schemes (described further below). The period of
stimulation, within which the eight selected electrodes are
activated, varies among implementations of this type of
scheme. Stimulation rates as low as 250 Hz per electrode
have been found to provide satisfactory performance for
many implant users (17), although evidence exists that
higher rates (up to at least 2.4 kHz per electrode) are often
beneficial (18). Other parameters, such as the number and
design of the bandpass filters, and the number of channels
selected in each stimulation period, can also be adjusted.
In general, if the number of electrodes available for
stimulation is small, and therefore the number of corre-
sponding bandpass filters is also small, then there may be
no advantage in selecting channels dynamically. For ex-
ample, if only six electrodes are available, use of the CIS
scheme, in which the outputs of all six filters are repre-
sented in each period, might be most appropriate. How-
ever, if the number of available intracochlear electrodes is
large (up to 22 in some existing implant devices), present-
ing stimulation on a periodically changing subset of elec-
trodes may be advantageous. In particular, because the
overall stimulation rate possible for any nonsimultaneous
pulsatile scheme is limited by the capabilities of the im-
planted receiver-stimulator, it may be effective to distrib-
ute the rate among a relatively small number of
electrodes, rather than activating all electrodes cyclically,
which may improve the representation of relatively fast
amplitude modulations in the signals passed by each
bandpass filter. Furthermore, selecting only the filters
Figure 11. Example of a stimulating current
waveform comprising a train of biphasic
pulses with amplitudes modulated to repre-
sent a time-varying analog signal (dotted
line).
896 COCHLEAR IMPLANTS
Input
signal
Figure 12. Functional block diagram of the
Advanced Combination Encoder (ACE or
SPEAK) sound-processing scheme.
that contain the highest short-term amplitudes can reduce
the amount of background noise presented to the implant
user in some conditions. For example, in the common sit-
uation where high-level speech is mixed with a spectrally
broad, relatively low-level noise, the filters with the high-
est amplitudes may contain primarily the spectral fea-
tures that carry most speech information (such as the
peaks corresponding to the first few formants), rather
than components of the noise.
3.4. Stimulation Level Control
All sound-processing schemes that generate nonsimulta-
neous pulsatile stimulation incorporate a conversion func-
tion to relate the amplitude of each stimulus pulse to a
corresponding level derived from the incoming acoustic
signal. Psychophysical studies of the way loudness varies
as a function of stimulus amplitude have suggested that,
for a steady pulse train with other parameters held con-
stant, a change in loudness by a given ratio occurs when
the electric current changes by a ratio rather than by an
absolute amount (19). This relationship is comparable
with the well-established corresponding relationship for
normal hearing, in which a doubling (or halving) of loud-
ness occurs when acoustic intensity is increased (or de-
creased) by approximately 10 dB (20). To produce a similar
relationship between loudness and acoustic intensity for
CI users, a nonlinear function is applied that converts
acoustic intensity into the current amplitude of the stim-
ulus pulses. Although the shape of this function varies
among sound-processor implementations, and in some
cases can be altered during the fitting of a sound proces-
sor to suit the CI user, the general form of the function is
typically logarithmic, which means that a ratio change in
acoustic intensity (i.e., a change by a constant number of
decibels) produces a ratio change of stimulus current.
BPF
n
Selection of bands
with highest levels
BPF
4
Acoustic to electric
BPF level conversion
3
BPF Stimulus encoder
2
Output
data to
cochlear
BPF Constant rate implant
1 pulse generator
The overall range of currents allowed on any electrode
in each implant user is determined when the sound pro-
cessor is fitted. The lowest current, at which a sound is just
audible, is generally called the threshold or T-level. Usu-
ally a higher current, at which the sensation is loud but not
uncomfortable, is also estimated, and is often called the C-
level. The values for the T- and C- levels vary as a function
of pulse width, pulse rate, electrode configuration, and
other parameters. They may vary widely across electrodes
in a given implant user, and even more widely among im-
plant users. However, the ratio between the current at the
C-level and the current at the T-level is much smaller than
the overall range of T- and C- levels observed among a
large population of implant users. That ratio, known as the
electrodes dynamic range, is often less than about 10 dB
(i.e., a ratio of about 3:1).
In contrast, the dynamic range of acoustic intensities
for normal hearing is generally at least 90 dB. In most ex-
isting sound processors for CIs, it is not practical to pro-
vide a dynamic range as large as that at the microphone
input, which is because electrical noise in the microphone,
preamplifier, and related circuits usually prevents sounds
with levels near the threshold for normal hearing (ap-
proximately 0 dB SPL) from being detected reliably. At the
other extreme, acoustic levels above about 90 dB SPL are
considered uncomfortably loud by many people with nor-
mal hearing. In many CI sound processors, high input
levels (e.g., above about 70 dB SPL) are held to a constant
level by a fast-acting compression limiter. This limiter
helps to prevent overloading and consequent distortion in
the filters and other sound-processing stages of the sys-
tem. Thus, the effective dynamic range of signals at the
microphone input of CI systems may be restricted to only
approximately 30 dB in some sound-processor designs, al-
though the dynamic range can be much wider (e.g., 60 dB)
in other existing systems.

The compression of the dynamic range at the audio in-
put of the sound processor to be compatible with the much
smaller dynamic range needed for the electric stimuli pro-
duced at the implanted electrodes can be performed in two
stages. The first stage is wide dynamic range compression,
which has been used successfully in hearing aids and
other amplification systems for many years. This type of
compression employs an amplifier with automatic gain
control (AGC). The AGC acts to reduce the variation in
output level when a change in input level occurs. For ex-
ample, with a compression ratio of 2:1, a change in input
level of 10 dB would result in a change in output level of
5 dB. The speed at which gain changes can occur in re-
sponse to changes in level is defined in terms of an attack
time and a release time. In a typical compressor, the at-
tack time (defined as the time for the AGC to respond to a
level increase of 25 dB) is about 25 ms and the release
time (response time for a level decrease of 25 dB) is about
50200 ms. Longer release times, up to several seconds,
are used in some systems. Generally, AGC circuits are de-
signed to reduce overall variations in the average level of
signals while preserving the size of relatively rapid level
changes, mainly because more rapid level changes convey
information important for the recognition of speech
sounds.
The second stage of compression is provided by the
amplitude conversion function that is applied to signals
after they have been filtered and their envelopes have
been estimated. Although this conversion is often de-
scribed as being instantaneous, time constants are inher-
ent in the envelope-estimation process. Those time
constants are usually much shorter than the release
time of typical AGC circuits. For example, if the envelope
detectors comprise a rectifier followed by a low-pass filter,
time constants of a few milliseconds are typical.
The approximately logarithmic relationship between
loudness and the current amplitude of pulsatile stimula-
tion has led to the use of a nonlinear scale of currents in
some implantable receiver-stimulators. In these devices,
the digital amplitude parameter transmitted to the re-
ceiver-stimulator results in changes of current by a con-
stant ratio when the parameter changes by a constant
number of steps. The parameter is referred to as current
level, and causes the stimulus current magnitude to vary
over a wide range across the range of possible values of the
level parameter. For example, in the CI24 implant man-
ufactured by Cochlear Limited, the current-level param-
eter has 8 bits, and therefore 256 discrete steps. The
stimulus current in this device ranges from approximately
10 mA to 1.75 mA, with each step corresponding to a
change in the current of 2%.
As the overall range of currents required to ensure that
T- and C- levels can be obtained on all electrodes in every
implant user is much wider than the current range needed
on any individual electrode, it may be necessary to select
an appropriate stimulus pulse width when the users
sound processor is fitted. The width of the pulses affects
the loudness of sensations in much the same way as the
current amplitude. Generally, it is desirable to use the
minimum possible pulse width, because this both maxi-
mizes the overall rate at which pulses can be delivered by
COCHLEAR IMPLANTS 897
the implant, and minimizes the power consumption of the
receiver-stimulator. However, it can happen that C-levels
are unattainable with the minimum pulse width avail-
able, either because the highest possible current does not
produce sensations that are loud enough, or because of
insufficient voltage compliance at the output of the re-
ceiver-stimulator (as explained previously). In these cases,
the pulse width can be increased, and the T- and C- levels
redetermined. In certain implant systems, the appropriate
setting of T- and C- levels is simplified by the use of a sin-
gle level parameter that varies both the current and pulse
width together. For example, in some of the CI systems
manufactured by Cochlear Limited, this parameter is re-
ferred to as stimulus level. By this means, a stimulus-level
parameter having a relatively small number of discrete
steps can vary the total charge per phase of the stimulus
pulses (i.e., the product of current amplitude and pulse
width) over a wider range than is possible when either
current or pulse width is varied separately. In a sound
processor programmed to use the stimulus-level rather
than the current-level parameter, the output of the am-
plitude conversion function is modified to produce stim-
ulus levels, but the effective shape of the function is
generally not changed.
If it is preferable to keep the pulse width fixed (ideally
to a relatively small value that maximizes the possible
stimulation rate), an alternative way of reducing the cur-
rent required to elicit appropriate sensations at the T- and
C- levels is to change the configuration of the active elec-
trodes. For example, changing from a bipolar to a mono-
polar configuration, or increasing the spatial extent with a
bipolar configuration, will reduce the current require-
ments. Furthermore, the current requirements are lower
for electrodes that are located closer to the auditory neu-
rons. In general, T- and C- levels can be obtained with
shorter pulse widths using monopolar electrodes designed
to lie close to the modiolus of the cochlea than when using
bipolar electrodes on an array that is inserted more loosely
into the scala tympani.
The detailed design of both the AGC that compresses
input signals and the amplitude conversion function that
controls stimulation levels differ among implant systems,
and several research studies have investigated the effects
of modifying them (21,22). To maximize the perceptual
performance of a sound processor, and in particular to
maximize the intelligibility of speech, two requirements
are important. First, the minimum acoustic level that is
audible (i.e., the input level just producing stimulation at
the T-level) must be low enough to ensure that all infor-
mation-carrying components of the speech signal can be
perceived by the implant user. Second, changes in level
above the minimum input level must be perceptible, at
least over the range of acoustic levels present in speech
signals. Whether these requirements are met fully in a
sound processor depends not only on the operation of the
AGC and the amplitude conversion function, but also on
the sensitivity of the microphone. Usually, the sensitivity
can be adjusted by the user with a manual control. Some
types of AGC, particularly those with large compression
ratios or long release times, may reduce the need for man-
ual sensitivity adjustments to compensate for variations
898 COCHLEAR IMPLANTS
in the overall level of input signals. When the input signal
is speech, and its average level is constant, the relatively
rapid fluctuations in intensity at each frequency must be
perceived by the implant user to maximize intelligibility.
These fluctuations encompass at least 30 dB (23). There-
fore, even in the absence of wide dynamic range compres-
sion at the input of a sound processor, the range of levels
applied to the amplitude conversion function is at least
30 dB. As the average level of speech and other sounds can
also vary widely, it is advantageous for the sound proces-
sor to be able to control the level of stimulation as a func-
tion of acoustic intensity over a range greater than 30 dB.
However, increasing the amount of compression applied
by the instantaneous amplitude conversion function may
be less effective than increasing the compression applied
by the slower-acting AGC at the input of the sound pro-
cessor. This is because excessive instantaneous compres-
sion may reduce the amount of information available to
implant users in the form of rapid changes in stimulation
level, which are known to convey important speech cues.
In contrast, increasing the compression in the AGC circuit
while maintaining a relatively long release time constant
has the advantage of reducing the range of average levels
to be processed by the instantaneous conversion function
without affecting the size of these rapid level changes.
4. THE FUTURE OF COCHLEAR IMPLANTS
This article has focused on aspects of the design and func-
tion of sound processors and implantable stimulators that
are specific to existing cochlear implant hearing prosthe-
ses. Other practical aspects are common to alternative
technologies that have been developed to assist people
with a hearing impairment, particularly acoustic hearing
aids. In both hearing aids and CIs, there has been a trend
toward smaller devices, accompanied by a progression
away from analog electronic circuitry toward the use of
digital signal processing. These changes have succeeded in
reducing the size of devices and in improving their per-
formance. With CIs, pocket-sized sound processors have
been superseded by smaller and more cosmetically accept-
able devices that are packaged in enclosures that can be
worn comfortably on the pinna, as with many high-pow-
ered acoustic HAs. This trend is likely to continue until it
is practical for all the components of a hearing prosthesis
to be implanted in the body, obviating the need for any
visible external devices in normal use.
The ability of CI users to understand speech without
any visual cues varies widely. Research has found that
adults who have acquired a hearing loss after develop-
ment of spoken language skills are more likely to obtain
satisfactory performance from a CI than adults whose
hearing impairment occurred pre-linguistically. Some
evidence also exist that deaf children may obtain greater
benefits if they receive a CI at the earliest feasible age. At
present, the majority of CI recipients can converse easily
in quiet conditions, especially when some contextual in-
formation is available. In such situations, many users of
the latest systems can communicate face-to-face or via the
telephone almost as well as people with normal hearing.
However, even for the most successful CI users, under-
standing speech in the presence of high levels of back-
ground noise is much more difficult than for listeners with
normal hearing. The use of a directional microphone can
provide substantial benefit, provided that some spatial
separation exists between the signal of interest and the
unwanted noise. The simultaneous use of implants in both
ears can also be advantageous in noisy situations (24). In
general, CI recipients obtain inadequate performance
from currently available devices when listening to music
or environmental sounds. Research has shown that iden-
tification of melodies, musical instruments, and common
nonspeech noises is usually unsatisfactory, and many CI
users report experiencing minimal enjoyment from listen-
ing to music (25).
A recent development that promises to alleviate many
of the above problems, at least for people with certain
types of hearing impairment, is the implantation of ears
that have some usable acoustic hearing (26). Typically,
hearing loss affects sensitivity to sounds at high frequen-
cies more than at low frequencies. In some cases, the high-
frequency impairment is so severe that conventional
acoustic aids provide no benefit, although sufficient low-
frequency hearing remains that the person can perceive
many sounds with appropriate acoustic amplification.
Such people may elect to receive a cochlear implant to ob-
tain information about high-frequency signals via electric
stimulation. If the low-frequency acoustic hearing can be
substantially preserved in the implanted ear (or the op-
posite ear), it is possible for combined acoustic and electric
stimulation to provide more auditory information than
either a hearing aid or a cochlear implant could provide
when used separately. In some clinics, a special short elec-
trode may be used in these cases to minimize damage to
the apical region of the cochlea where low-frequency
sounds are transduced (27). Although research with com-
bined acoustic and electric stimulation is relatively new,
experimental results suggest that it can be highly benefi-
cial for certain people with hearing impairment, particu-
larly for understanding speech in noise and for listening
to music (28). In the future it is likely that increasing
numbers of people with partial, rather than total, hearing
loss in both ears will become successful users of cochlear
implants.
Acknowledgment
This work was supported financially by the Garnett Passe
and Rodney Williams Memorial Foundation. The images
in Figs. 1, 3, and 7 were provided by courtesy of Cochlear
Limited, NSW, Australia. The remaining figures, except
for 5 and 9, were first published in Ref. 25, and are repro-
duced by permission of Westminster Publications r 2004.
BIBLIOGRAPHY
1. W. F. House and J. Urban, Long term results of electrode im-
plantation and electronic stimulation of the cochlea in man.
Ann. Otol. Rhinol. Laryngol. 1973; 82:504517.
2. AllHear. (2003, March 24). Home page. (online). Available:
http://www.allhear.com/.