A large real-world study of cochlear implant users has found generally high levels of satisfaction with external audio processors, while also identifying a strong association between satisfaction and how long people use their devices each day.
Published September 7 in Frontiers in Psychology, the study analyzed responses from 861 cochlear implant users in Germany and the United Kingdom. Researchers examined satisfaction across wearing comfort, usability and social life, while also establishing population reference values that could help clinicians interpret individual patient scores.
The analysis used the Audio Processor Satisfaction Questionnaire (APSQ), a 15-item patient-reported outcome measure developed by MED-EL. The questionnaire asks users to rate different aspects of their processor experience on a 0-to-10 scale and can typically be completed in five to 10 minutes.
The researchers said monitoring satisfaction may provide clinicians with another way to identify problems that could eventually affect device use.
“For these reasons, it is imperative to monitor the degree to which the user is satisfied with their device,” the authors wrote.
Satisfaction High Overall, but Closely Associated With Daily Use
The median overall APSQ score was 8.7 out of 10, indicating relatively high satisfaction across the study population. Usability received particularly high ratings, with a median score of 9.6, compared with 8.6 for social life and 8.4 for wearing comfort.
Daily use was also high, with roughly three-quarters of respondents reporting that they used their audio processor for more than 12 hours per day. Importantly, satisfaction increased along with reported daily use.
After accounting for processor type, hearing configuration, gender and age, each one-point increase in the overall APSQ score was associated with approximately 44% higher odds of using the cochlear implant for at least three additional hours per day. Similar associations were found when the researchers examined the questionnaire’s individual satisfaction domains.
For clinicians, the finding suggests that patient-reported experience may provide useful information beyond traditional measures of speech recognition and auditory performance. A patient who is using a processor less than expected, for example, may have comfort, usability or lifestyle concerns that are not necessarily apparent from audiologic testing alone.
The researchers stressed, however, that the study does not establish whether satisfaction causes greater processor use or whether using the processor more leads to greater satisfaction.
“We emphasize that these are statistical associations only; we do not assert any causal relationship between these variables based on the findings presented here.”
Bimodal and SSD Users Show Some Differences
Hearing configuration emerged as another area of interest. The cohort included 255 bimodal users, representing approximately 30% of participants, along with bilateral CI users, unilateral CI users and people implanted for single-sided deafness (SSD).
Bimodal users had slightly lower satisfaction on the social-life subscale compared with bilateral CI users, although the difference was small. Their median overall APSQ score remained high at 8.7.
There was also evidence that practical aspects of processor experience may affect daily use among bimodal users. In models examining usability and wearing comfort, bimodal participants had significantly higher odds of shorter CI use compared with bilateral CI users. The odds of lower use were approximately 57% higher in the usability model and 53% higher in the wearing-comfort model.
The authors suggested that the pattern may point toward particular practical considerations for patients combining a cochlear implant with acoustic amplification in the opposite ear.
“The most parsimonious explanation is that bimodal users experience challenges that are related to practical and comfort issues,” the researchers wrote.
The effect was more pronounced among users with SSD. Compared with bilateral CI users, participants with SSD had 2.78 times the odds of using their implant at least three hours less per day. They also reported slightly lower overall satisfaction, although scores remained relatively high, with a median APSQ total score of 8.6.
The authors noted that people with SSD retain hearing in the opposite ear and therefore may be less reliant on their cochlear implant, which could contribute to differences in both satisfaction and daily use.
Processor Style May Matter for Everyday Comfort
The researchers also compared behind-the-ear (BTE) and off-the-ear (OTE) processors. Overall satisfaction was essentially similar between the two styles, although OTE processors received a small advantage on the usability subscale.
More noticeable differences appeared when respondents were asked about specific everyday situations. OTE users reported greater satisfaction when wearing glasses, with a median rating of 10 compared with 8 among BTE users. BTE users, meanwhile, reported greater satisfaction when wearing hats or other headwear, with median scores of 7.3 compared with 5.2 for OTE users.
No meaningful differences were identified for four other processor-related items, including general comfort, skin friendliness, stability on the head and ease of placement.
For counseling and processor selection, the findings illustrate how individual lifestyle factors — including whether someone routinely wears glasses or headwear — may influence satisfaction even when overall ratings between processor styles are similar.
New Reference Values Could Aid Clinical Follow-Up
One of the study’s primary contributions is the establishment of population reference values for the APSQ. These percentile-based norms may make it easier for clinicians to determine whether an individual patient’s satisfaction is broadly typical or substantially below that reported by other users.
The questionnaire does have a ceiling effect, with many respondents reporting scores near the top of the scale. That makes it more difficult to distinguish between patients who are highly satisfied and those who are extremely satisfied. However, the researchers also observed clearly lower scores among some users, suggesting the APSQ may be particularly useful for identifying individuals whose experience falls below the expected range.
The study has several limitations. Participation was voluntary, introducing the possibility of response bias, and daily processor use was self-reported rather than obtained through objective device datalogging. The reference population was also drawn from Germany and the UK, which may limit how broadly the population norms can be generalized.
Additionally, all six study authors were employees of MED-EL, which developed the APSQ and manufactured the audio processors included in the analysis. The authors reported that no financial support was received for the research or its publication.
Overall, the findings add to growing interest in patient-reported outcomes as a complement to conventional measures of cochlear implant performance. For clinicians, routinely asking how comfortable, manageable and socially compatible a processor is may help identify barriers to consistent use before they become more significant.
Reference: Billinger-Finke M, Hoppe DB, Koinig KA, Grandelis E, Connolly PF, Anderson I. (2026). User satisfaction with cochlear implant audio processors: population norms derived from a large-scale survey campaign. Frontiers in Psychology. 17:1817444. doi:10.3389/fpsyg.2026.1817444.
