Perioperative complication rates in elderly cochlear implant recipients—a systematic review and meta-analysis

Introduction

The global population is ageing due to longer life expectancy, and a growing proportion of adults are aged 65 years and older. This trend is mirrored in Australia, where the number of people aged 80 and above is projected to more than double by 2050 (1-4). Hearing loss affects over 1.5 billion people worldwide (5), including more than 50% of adults by the age of 65 years and up to 80% of those older than 85 (6). In terms of severity, the number of individuals with moderate-to-profound hearing loss is projected to approach 700 million by 2050 (5,7).

Beyond its associated communication difficulties, hearing loss in the elderly is established as a major risk factor for cognitive decline (8,9). Longitudinal data show a dose-response relationship between hearing loss severity and incident dementia (10-12). Hearing loss has been identified as the largest single modifiable risk factor, accounting for an estimated 9% of dementia cases (6,13-19).

Cochlear implantation provides effective auditory rehabilitation for older adults with severe-to-profound hearing loss, improving speech perception, communication in noise and health-related quality of life (20-24). Elderly recipients show improvements in global cognition (18,20,25-27), memory and executive function (27-29), as well as reduced depressive symptoms and social withdrawal (30-32). These benefits directly address a major dementia risk factor while improving mental health and social engagement (18,33,34).

As candidacy criteria broaden, the pool of older adults who meet audiological criteria for cochlear implants is expanding (35). Procedure rates in adults aged 65 years and older have increased markedly over recent decades, including the largest growth among those aged 80 years and above (36). Growing elderly implant volumes necessitate detailed age-specific risk data, particularly as this population experiences higher baseline perioperative risks (37-40). Further, patient and referring clinician concerns for these risks are frequently cited as a barrier to implantation surgery (41,42). Existing systematic reviews, however, report aggregate rates across broad adult populations without stratifying specifically for elderly recipients (43,44), and research syntheses of older implant candidates specifically are limited to narrative or scoping reviews (45-47). To the authors’ knowledge, no prior systematic review and meta-analysis has focused on detailed perioperative complication rates in elderly cochlear implant recipients.

Robust age-specific data on perioperative complications are essential to guide patient selection, optimise perioperative management, and support balanced, evidence-based counselling during referral and informed consent (20,22,24,48-52).

The objective of this study was to systematically review and quantitatively synthesise perioperative complication rates among cochlear implant recipients aged 65 years and older, and, where data permitted, compare these rates with those in younger adults.

Methods

Study protocol and registration

The study is reported according to the PRISMA reporting guidelines (available at https://www.theajo.com/article/view/10.21037/ajo-2025-1-87/rc) (53). The review protocol was prospectively registered in the PROSPERO database (PROSPERO ID: CRD420251207956).

Literature search strategy

An index literature search was undertaken on 28^th August 2025 on MEDLINE, PubMed, Embase, CINAHL, Scopus, Cochrane Library, and Web of Science databases from database inception. To maximise currency of the evidence, the search was repeated on 18^th November 2025, prior to data analysis. The search strategy combined medical subject headings (MeSH) and keywords related to cochlear implants, elderly, and complications. In addition to hand-searching of reference lists, backward and forward citation searching was performed with Web of Science [Clarivate, London, United Kingdom (RRID: SCR_022706)], to ensure all relevant articles were included (54).

Inclusion and exclusion criteria

Selection criteria were established using the Patient/Population, Intervention, Comparator, Outcome, Timeframe framework, and included:

• Patients ≥65 years at the time of surgery;
• Undergoing primary cochlear implantation;
• With comparator cohorts of patients ≥18 years at the time of surgery, if present;
• Reporting outcomes of intra- and/or postoperative complications;
• With minimum follow up of 30 days postoperatively.

Stratification based on age ≥65 years at time of surgery was because this was the most common definition of elderly in the cochlear implant literature (21,24,50,55,56). Articles were included if they were original peer-reviewed reports with ≥10 patients aged ≥65 years, undergoing primary cochlear implantation, reporting perioperative complications with ≥30 days follow-up.

We required ≥10 elderly patients to ensure adequate precision for complication rate estimation while including smaller institutional series. We required ≥30 days follow-up to capture acute perioperative complications but included later complications as reported. Articles with and without younger adult cohorts were included. Where studies stratified by ages above 65 years, these were also included for subgroup analysis.

Articles were excluded if they:

Were a case report, case series, opinion article, editorial, conference abstract, non-human study, letter, meta-analysis or systematic review;

Did not have an available full text in English;

Did not report complication data for at least one complication category;

Reported complications, but did not report age-stratified complication data for elderly cohorts (minimum age ≥65 years);

Involved other major concurrent surgeries (e.g., acoustic neuroma removal);

Involved cohorts exclusively undergoing cochlear re-implantation.

Literature screening

Two reviewers independently screened titles/abstracts and reviewed full texts (M.L. reviewed all records; M.R. and D.K. served as secondary reviewers). A third reviewer (S.R.) resolved discrepancies when needed. This systematic review used Covidence (Veritas Health Innovation, Melbourne, Australia) [Research Resource Identifier, (RRID):SCR_016484] to manage the literature screening process (57).

Outcomes

The primary outcome of interest was the prevalence of intra- and postoperative complications by category. This included 30-day mortality, anaesthetic complications, discharge failure and re-admission, device related complications, falls and surgical complications, and are detailed in Table 1.

Surgical complications were stratified into major and minor using the classifications initially proposed by Hansen et al. 2010 (58), widely employed in large retrospective and prospective studies, systematic reviews, and case series to report and compare complication rates in both adult and paediatric populations (56,58-68). Major complications are typically defined as those requiring significant medical or operative intervention, device explantation, or resulting in permanent morbidity, while minor complications are those managed conservatively or with minimal intervention and without lasting sequelae. This approach was employed in this systematic review to maximise comparability of outcomes against the established literature.

Secondary outcomes of persistent vertigo, as a subset of interest within the minor complications category, and falls prevalence were also investigated.

Data extraction

Data extraction was performed independently by two investigators (M.L. extracted all records; M.R. and D.K. were secondary extractors), and used a pre-specified extraction template piloted on a sample of studies. A third reviewer (S.R.) resolved discrepancies as required. The following data were extracted from included studies:

Study author, year, design, country, setting;

Cohort age and sex information, co-morbidity prevalence data and American Society of Anesthesiologists (ASA) score;

Aetiology of hearing loss, duration of deafness and preoperative hearing thresholds;

Anaesthesia type, surgical approach and implant manufacturer;

Prevalence of intra- and postoperative complications.

Complication prevalence data were extracted either as whole-category rates (including explicit statements such as absence of major complications) or as counts of individual complications, which were summed to derive category-level prevalence; where only some complications within a category were reported and others were neither explicitly present nor absent, the study was included in quantitative analyses of a complication category only if at least half of its predefined component complications were reported per Table 1. Where there was insufficient information in the paper for extraction, corresponding authors were contacted.

Quality and risk of bias assessments

Included studies were appraised for quality and risk of bias by two independent investigators (M.L. and D.K./M.R.) using the Newcastle-Ottawa Scale (NOS) for assessing the quality of non-randomised trials in meta-analyses (69). For single-arm cohort studies where comparator-dependent items were not applicable, we scored only applicable items and reported the total score out of the reduced maximum. Overall risk of bias was categorised as low (scoring ≥70%), moderate (50–69%), or high (<50%). Discrepancies were resolved via consensus, and if necessary, consultation of a third independent investigator (S.R.).

Statistical analysis

Statistical analyses were conducted using the meta 8.2-1 package (RRID:SCR_019055) (70) within R Project for Statistical Computing (RRID:SCR_001905) (71). Studies were included in the analysis of each outcome on which they reported prevalence.

Primary analyses defined elderly as ≥65 years. Single-arm meta-analyses were used to pool absolute risks of each complication category in elderly cohorts where there were 10 or more studies. The threshold was selected in accordance with published methodological guidance (72) to ensure adequate precision of pooled estimates and sufficient power for assessment of publication bias via funnel plot asymmetry and Egger’s regression test for small-study effects, and for meta-regression analyses examining sources of heterogeneity. Subgroup analysis was performed for specified age thresholds (≥70, ≥75 and ≥80 years) when four or more cohorts were present in that stratum, as per published guidance (72). Elderly and younger study cohorts were included in every subgroup for which they qualified.

Where studies reported both elderly and younger adult cohorts, we additionally performed two-arm comparative meta-analyses to estimate risk ratios (RRs) for elderly versus younger adults for each complication category. Comparative pooling was only undertaken when at least four studies with at least one event in either arm were available (72). If meta-analyses included at least 10 studies, we assessed risk of publication bias using funnel plots and Egger’s regression.

Random-effects models were prespecified for all meta-analyses, as our aim was to estimate average effects across studies of various design, patient demographic characteristics and study setting (73). Pooled absolute risks and RRs were estimated using inverse-variance random-effects models. Between-study variance (τ²) was estimated using restricted maximum likelihood. We reported τ², Cochran’s Q and P value, I², and 95% confidence intervals (CIs) calculated using Hartung-Knapp adjustments. Continuity correction of 0.5 was used for zero events.

Sensitivity and heterogeneity analysis

For single-arm meta-analyses where there were at least 10 studies, we also performed exploratory random-effects meta-regression of elderly cohorts to examine whether complication risk increased with age: absolute risks in elderly cohorts were regressed against the central cohort age (reported mean, or approximated from median and interquartile range where necessary) for all outcomes. Meta-regression was not applied to comparative RRs because there were too few two-arm datasets with non-zero events.

For comparative two-arm meta-analyses, pre-specified sensitivity analysis examined robustness of findings using leave-one-out influence analyses and high risk-of-bias sensitivity analyses.

Certainty of evidence assessment

The Gradings of Recommendations Assessment, Development and Evaluation (GRADE) framework was employed for assessment of evidence certainty of the primary outcomes (74).

Results

Literature search

The search identified 9,301 records in total, comprising 9,299 records from electronic databases and 2 additional records from citation searching. After deduplication, 3,605 unique records underwent title and abstract screening, of which 3,130 were excluded. Full texts were sought for 475 records; 9 could not be retrieved. The remaining 466 articles progressed to full text analysis. In total, 41 studies were included. The study selection process is depicted in the PRISMA flow diagram (Figure 1), and the full electronic data queries are provided in Appendix 1.

Figure 1 PRISMA diagram. CDSR, Cochrane Database of Systematic Reviews; CENTRAL, Cochrane Central Register of Controlled Trials; PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

Study characteristics

Forty-one studies (6,374 elderly implant recipients and 5,904 younger comparators) were included in the analysis and are detailed in Table 2.

Thirty-five were retrospective and six prospective, and all employed a case-control or cohort design, with publication years ranging from 2000 to 2025, and collectively represented Level III and IV evidence according to the Oxford Centre for Evidence-Based Medicine (110). Three studies were based on registry data, and the remaining studies were institutional series. Twenty-one studies included younger adult comparators.

Of the 15 studies that reported on surgical approach, six studies reported cochleostomy (52,83,91,96,100,102), six studies reported a round window approach (77,95,96,103,109,111), and four reported limited mastoidectomy without further specification (82,84,93,112). One study used only local anaesthesia with conscious sedation (LA-CS) (106), and six studies included both general anaesthesia (GA) and LA-CS (22,84,90,102-104).

Baseline demographic and clinical characteristics of elderly and younger cohorts, pooled across studies, are summarised in Table 3.

Single-arm meta-analyses were performed for all outcomes where there were ≥10 studies reporting that outcome. Although 21 studies included younger comparator cohorts, the age cut-offs defining elderly versus younger recipients varied across studies: 8 studies used ≥65 years, 6 used ≥70 years, 3 used ≥75 years, and 3 used ≥80 years. Consequently, when stratifying by age threshold, few studies were available for comparative analyses at each stratum. Combined with sparse events for certain outcomes, two-arm meta-analyses comparing elderly versus younger recipients were only possible for minor surgical complications and anaesthetic complications.

Primary outcomes

Across all studies, there were no reports of mortality within 30 days of surgery. Across all complication categories, because most studies did not report whether complications clustered within individuals, each event was treated as affecting a separate patient; the reported prevalence estimates should therefore be interpreted as conservative upper bounds for the proportion of patients experiencing at least one complication.

Major surgical complications

In single-arm analyses of elderly cohorts, absolute risks of major complications were consistently low: 2.43% for ≥65 years old cohorts (95% CI: 1.73–3.41%; I²=0.0%), and between 1.2–1.9% for higher age strata (Figure 2).

Figure 2 Single-arm meta-analysis of prevalence of major surgical complications. CI, confidence interval.

The most prevalent major surgical complications for the ≥65 group were wound dehiscence (9 events across 33 studies), cerebrospinal fluid leak (4 events across 33 studies), mastoiditis (3 events across 34 studies), flap necrosis (3 events across 33 studies), and persistent facial nerve injury (3 events across 32 studies). The pooled counts of all complications across included studies are detailed in Appendix 2.

Minor surgical complications

Minor complications were prevalent in 22.27% of patients ≥65 years old (95% CI: 16.06–30.02%; I²=85.9%), and rates were between 18.15–21.94% for higher age strata, but with higher heterogeneity (I² = 85.6–88.3%) (Figure 3A).

Figure 3 Meta-analysis of minor surgical complications. (A) Single-arm meta-analysis of prevalence of minor surgical complications; (B) two-arm meta-analysis of minor surgical complications between elderly and younger comparator cohorts. CI, confidence interval; RR, risk ratio.

The most prevalent minor surgical complications for the ≥65 group were vertigo (283 events across 35 studies, including 151 transient, 112 persistent, and 20 unspecified), wound infection (35 events across 34 studies), and postoperative pain events (34 events across 32 studies). Of the vertigo events, transient cases (151 events) outnumbered persistent cases (112 events); persistent vertigo is reported separately as a secondary outcome below. Transient vertigo was the single largest contributor to the overall minor complication rate, and the aggregate estimate of 22.27% should be interpreted with this in mind, as a substantial proportion of events were self-limiting vestibular symptoms rather than complications requiring active intervention.

Two-arm comparative meta-analyses for minor surgical complications were performed at ≥65 and ≥70 years thresholds (Figure 3B). At ≥65 years, six studies (194 elderly recipients with 50 events versus 201 younger recipients with 45 events) showed no significant difference in minor complication risk between elderly and younger adults (RR 1.18, 95% CI: 0.78–1.77, P=0.3518; I²=0.0%).

At ≥70 years, five studies (219 elderly recipients with 48 events versus 320 younger recipients with 43 events) demonstrated a significantly higher risk of minor complications in elderly recipients (RR 1.64, 95% CI: 1.04–2.60, P=0.0401; I²=0.0%). For this age stratum, however, leave-one-out sensitivity analysis showed that the statistical significance was lost when omitting any one of three studies (50,101,103), although the direction of effect remained consistent (RR range 1.55–1.83). Full results of leave one out analyses are detailed in Appendix 3.

Insufficient studies were available for comparative analyses at ≥75 and ≥80 years thresholds.

Anaesthetic complications

Absolute anaesthetic complication risk was 3.08% at ≥65 years (95% CI: 2.19–4.33%; I²=31.9%), remaining similar across age strata though with greater heterogeneity (I²=51.9–68.9%) (Figure 4A).

Figure 4 Meta-analysis of anaesthetic complications. (A) Single-arm meta-analysis of prevalence of anaesthetic complications; (B) two-arm meta-analysis of anaesthetic complications between elderly and younger comparator cohorts. CI, confidence interval; RR, risk ratio.

The most prevalent anaesthetic complications for the ≥65 group were postoperative delirium (11 events across 31 studies), arrhythmia (7 events across 32 studies), and cerebrovascular complications (7 events across 33 studies).

For anaesthetic complications, two-arm comparative meta-analysis was performed only at the ≥65 years threshold (Figure 4B). Four studies (141 elderly recipients with 7 events versus 132 younger recipients with 0 events) demonstrated a significantly higher risk of anaesthetic complications in elderly recipients (RR 4.58, 95% CI: 1.99–10.53, P=0.0101; I²=0.0%). However, this estimate is derived from a small number of events and required continuity correction due to zero events in the younger arm; it should be regarded as hypothesis-generating rather than confirmatory, and the relative risk and its CI should be interpreted with considerable caution. Leave-one-out sensitivity analysis showed effect direction and magnitude remained stable (RR range 4.02–5.79), but statistical significance was sensitive to individual study inclusion, with omission of either of two studies (91,96) resulting in borderline non-significance. The consistent direction of effect across all iterations supports an increased anaesthetic complication risk in elderly recipients, though the precise magnitude remains uncertain.

Comparative analyses at higher age thresholds were not performed due to insufficient studies (k<4).

Discharge failure and re-admission

Discharge failure prevalence was 3.46% for ≥65 years (95% CI: 2.18–5.46%; I²=59.4%) (Figure 5). Rates were similar across age strata (2.32–2.97%; I²=70.9–84.6%). Within the ≥65-years-old group, there were 136 re-admissions within 30 days across 21 studies, and 6 postoperative admissions to the intensive care unit across 21 studies.

Figure 5 Single-arm meta-analysis of prevalence of discharge failure and re-admission. CI, confidence interval.

Device complications

For cohorts ≥65 years old, the prevalence of device-related complications was 4.21% (95% CI: 2.99–5.91%; I²=54.3%). Prevalence in higher age strata was similar, ranging from 4.24-5.00% with substantial heterogeneity (I²=59.9–66.6%) (Figure 6).

Figure 6 Single-arm meta-analysis of prevalence of device-related complications. CI, confidence interval.

Secondary outcomes

Persistent vertigo

Persistent vertigo rates, defined as lasting at least 30 days post implantation, ranged from 6.08–8.50% across age strata with no clear age-related trend: 6.08% at ≥65 years (95% CI: 4.24–8.66%; I²=55.9%), 7.52% at ≥70 years (95% CI: 4.78–11.62%; I²=59.3%), 8.50% at ≥75 years (95% CI: 5.21–13.57%; I²=63.3%), and 7.27% at ≥80 years (95% CI: 4.88–10.68%; I²=21.8%) (Figure 7).

Figure 7 Single-arm meta-analysis of prevalence of persistent vertigo. CI, confidence interval.

Falls

Only six studies reported falls as an outcome (84,88,90,94,107,108), and so single-arm meta-analyses were not performed. Instead, pooled prevalence estimates are presented in Table 4. Mean follow-up for these studies was 6.5 months. Pooled fall rates increased progressively with age: 4.21% (27 out of 642) in patients aged <65 years, 7.68% (211 out of 2,746) at ≥65 years, 8.39% (206 out of 2,456) at ≥70 years, 9.74% (115 out of 1,181) at ≥75 years, and 9.87% (111 out of 1,125) at ≥80 years. Given the significant reporting bias identified across outcomes in this review, these estimates should be interpreted as likely lower bounds for true fall event prevalence in elderly cochlear implant recipients. The elevated rates among patients ≥70 years suggest fall-related complications may represent an important age-associated perioperative concern, though these unadjusted estimates should be interpreted cautiously given potential heterogeneity in fall ascertainment across studies.

Meta-regression

Meta-regression analyses examined whether mean cohort age predicted complication rates within the elderly stratum. Age was not a significant predictor for any outcome (all P>0.19), with regression coefficients small and CIs spanning zero. Residual heterogeneity remained substantial for minor surgical complications (I²=84.7%), discharge failure (I²=72.1%), and persistent vertigo (I²=60.6%), indicating that factors other than chronological age drive between-study variability. These findings suggest that within elderly cochlear implant candidates of the included studies, advancing age alone does not meaningfully predict perioperative risk. Full results are presented in Appendix 4.

Risk of bias in studies

Risk of bias assessments were performed on the included studies utilising the NOS for assessing the quality of non-randomised studies in meta-analyses (Figure 8). Overall, 27 studies were judged to have a low overall risk of bias, 10 a moderate risk, and two, a high risk. Most cohorts were representative of the target elderly CI population, with adequate ascertainment of exposure and clear outcome definitions, and with adequately representative comparator cohorts when present. Several studies had limited information on length or completeness of follow-up, particularly for late or minor complications.

Figure 8 Newcastle-Ottawa scale risk of bias assessment.

Risk-of-bias sensitivity analyses was performed by excluding high risk studies across two-arm meta-analyses. Neither of the high risk of bias studies were included in the two-arm meta-analyses, and consequently the risk-of-bias sensitivity analyses results were identical to those of the original analysis.

Reporting biases

Assessment of risk of bias due to missing results was conducted using Egger’s regression test for outcomes with ≥10 studies. Egger’s test showed statistically significant asymmetries for all outcomes tested. For remaining outcomes with fewer than 10 studies, including two-arm meta-analyses, formal testing was not performed due to insufficient power. Qualitatively, reporting bias was of significant concern, as many studies would report only major complications or certain domains of interest within the established reporting framework in the literature. The full reporting bias assessments are detailed in Appendix 5.

Certainty of evidence assessment

The certainty of evidence was assessed using the GRADE framework, with results presented in Table 5. Beginning from low due to observational study designs, evidence certainty ranged from ‘very low’ for minor surgical complications and discharge failure, to ‘low’ for other outcomes. Inconsistency due to heterogeneity between studies was the primary reason for downgrading across outcomes.

Discussion

Summary of main findings

This meta-analysis demonstrated that cochlear implantation in elderly adults carries low major surgical, anaesthetic, and device-related complication rates, in addition to low rates of discharge failure and re-admission; each of these complication categories carried an absolute risk of ≤5.00% for all age strata. Minor surgical risks, however, are more prevalent, affecting 22.27% of patients over 65 years of age, though this estimate carries very low certainty of evidence given the substantial heterogeneity observed across included studies (I²=85.9%). Comparative analyses between younger adults and elderly cohorts suggested increased event prevalence of minor surgical and anaesthetic complications; however, these estimates carry low certainty of evidence, and the statistical significance was not robust to leave-one-out analyses. While these findings support cochlear implantation as an appropriate intervention for carefully selected elderly candidates, the relative risks compared to younger candidates requires further investigation before firm conclusions can be drawn. When using these estimates for patient counselling, it should be noted that the reported rates represent conservative upper bounds, as complications could not be confirmed as affecting distinct individuals across all included studies.

Reported complication rates in mixed-age cochlear implant series provide a useful benchmark for interpreting the findings of this review in the context of the broader adult population. In these mixed-age series, pooled estimates suggest a major surgical complication prevalence of approximately 2–3% (43,44,46,58-61,63,64,68,113-117), minor complications between 11–12% (46,58,64,68,114), which included persistent vestibular symptoms at 3.9% (43), and device-related complications of 3.4% (67,118). Discharge failures and re-admissions, anaesthetic complications and falls were rarely described.

While major surgical complications and device-related complications in the elderly were comparable to those in the mixed-age literature, the minor complications prevalence of 18.15–22.27% observed in this review is substantially higher than the 11-12% reported in mixed-age cochlear implant series. Vertigo of any duration was the largest contributor to the total minor surgical complication rate in our included studies, and transient vestibular symptoms, in particular, accounted for a substantial proportion of the elevated aggregate minor complication estimate. Readers should therefore interpret the overall minor complication rate cautiously, recognising that it reflects a heterogeneous category in which self-limiting events predominate. However, the prevalence of persistent vertigo (6.08-8.50% across age strata) was consistent with a prior meta-analysis reporting an approximately 7.4% incidence in mixed-age populations (119). This suggests that the elevated minor complication rate may be driven by transient vertigo and other minor surgical complications rather than persistent vestibular dysfunction alone. Some cochlear implant studies have proposed peripheral vascular disease and skin atrophy in elderly patients as predisposing factors for wound complications (52,120,121), which may contribute to elevated minor complication rates in this population. The present review, however, was not adequately powered to systematically investigate the specific causes underlying the higher minor complication rates observed in elderly recipients, and most included studies did not report sufficient granularity in complication categorisation to permit detailed sub-analysis or comparative meta-analysis. Further research with standardised, comprehensive complication reporting is needed to clarify the relationship between age and specific categories of minor surgical complications.

Anaesthetic complications were infrequent but showed a possible age signal, with higher event prevalence in elderly recipients (RR 4.58, 95% CI: 1.99-10.53); this estimate is based on sparse data with zero events in younger comparator cohorts in some studies, carries low certainty of evidence, and should be considered hypothesis-generating rather than confirmatory. The incidence rising from 3.2% at ≥65 years to 3.65% at ≥80 years should be interpreted with appropriate caution. Despite this increase, absolute rates remained well below baseline elective surgical anaesthetic risks of 10-20% in octogenarians (38,122,123), likely reflecting the less invasive nature of cochlear implant surgery compared to other elective procedures, though patient selection bias may contribute. While insufficient data precluded comparison of general versus local anaesthesia with conscious sedation, emerging evidence suggests local anaesthesia may reduce complications in selected elderly patients (120,121,124).

An important consideration for generalisability is whether the included elderly cohorts represent typical candidates with severe-to-profound hearing loss or reflect selection bias toward healthier patients proceeding to implantation. Pooled comorbidity prevalence across the included elderly cohorts showed notable variation compared with population-level estimates. For the ≥65-years-old cohorts, several comorbidities were comparable to figures reported in the literature, including respiratory disease (10.62% vs. 10.6%) (125-127), arrhythmia (14.86% vs. 13–15%) (128,129), and other cardiovascular disease (33.89% vs. 26.8%) (130,131). Other pooled comorbidity prevalences within the included studies were markedly lower, such as hypertension (46.45% vs. 60–80%) (132-134), diabetes (13.99% vs. 23–33%) (135,136), and chronic kidney disease (5.68% vs. 25–30%) (137-140).

These differences may suggest selection bias toward less comorbid elderly candidates proceeding to cochlear implantation, though this interpretation is limited by the nature of pooled prevalence estimates across heterogeneous studies and an absence of comorbidity adjustment in comparative analyses. Further research is required to determine whether selection bias differences exist between elderly patients who proceed to cochlear implantation and those with profound hearing loss who do not.

With regards to falls, this review found that they are substantially under-reported in the cochlear implant literature. The pooled absolute event prevalence estimates across all included studies revealed an incidence of only 9.35–9.45% of a fall post implantation for patients ≥75 years old. Similarly, pooled estimates of vestibular dysfunction should be regarded as likely lower bounds, given the significant reporting bias identified and the tendency of included studies to report only selected outcomes. Compared to the annual baseline risk of a fall of 28.5% and 34–37% for 75- and 80-year-old groups respectively according to national registry level data (141,142), this suggests under-reporting of falls in the elderly cohorts of the included studies. Much of the falls data in our review comes from registry studies which risk failing to capture complications. One single-centre study, Wong et al. [2016], found that in elderly cochlear implant patients, 38.7% had pre-existing subjective imbalance, 12.7% had a fall in the year prior to surgery, and 13.3% had a fall in the year following surgery (108).

Falls in elderly patients carry significant risk of increased morbidity and reduced quality of life (143-147). Further studies into the postoperative incidence of falls in elderly cochlear implant recipients, and its relation to vertigo, are warranted. Such information is essential to informing patient selection, and development and implementation of suitable vestibular rehabilitation in higher risk cochlear implant candidates.

Limitations

The main limitations in the current literature on complication rates of cochlear implantation in elderly patients are the predominance of retrospective, single-centre cohort studies, modest sample sizes, variable follow-up durations and heterogeneity in the definition and reporting of complications. As one of the central limitations of this review, reporting bias was statistically significant across all outcomes formally assessed using Egger’s regression; the true burden of minor complications and falls in particular is likely underestimated given the tendency of included studies to report only major events or a narrow subset of outcomes. The marked discrepancy between pooled fall event prevalence estimates and population-level registry data further illustrates the extent of outcome under-ascertainment in this literature.

Despite an established and widely used framework for categorising cochlear implant complications (58,67), many studies reported only major events or a narrow subset of outcomes. Furthermore, while transient and persistent vertigo were reported as distinct categories across included studies in keeping with the Hansen et al. 2010 framework, the majority did not provide explicit definitions; of the six studies that did (49,85,87,90,93,111), all defined transient vertigo as resolving within less than 30 days, consistent with the pre-specified threshold in Table 1, though this variability in explicit reporting should be acknowledged. Adverse events such as persistent vertigo, although classified in the framework as a minor surgical complication, can carry substantial morbidity in older adults, and how this burden translates into clinically consequential outcomes such as falls requires further investigation. Subsequently there was significant publication bias associated with all outcomes formally assessed.

Few studies reported comorbidities or perioperative risk scores, and none adjusted for these factors in comparative analyses. We were therefore unable to identify high-risk subgroups or account for residual confounding by frailty, comorbidity, and patient selection, which may differ substantially between elderly and younger cohorts.

Most studies did not stratify complications by narrow age bands within elderly cohorts, limiting comparative analyses to broad thresholds (≥65, ≥70, ≥75 years). This precludes determination of whether complication risk increases within each stratum and limits precise risk characterization for the oldest candidates.

Because most studies did not report whether complications clustered within individuals, we treated each event as affecting a separate patient, which may overestimate the proportion with at least one complication but provides a conservative upper bound for patient risk counselling.

Future research

Future research should address three priorities. First, multicentre prospective registries with standardised complication reporting—including minor surgical complications, anaesthetic events, falls, and vestibular symptoms—stratified by narrow age bands (65–74, 75–84, ≥85 years) would enable precise risk estimation in the oldest candidates, and allow for robust comparison of RRs between elderly cohorts compared to younger patients. Vestibular symptom reporting in particular would benefit from more granular subgroup characterisation, including distinction between intermittent and constant symptoms, new onset versus pre-existing dysfunction, and transient versus permanent vestibular sequelae. Such information is essential for informing patient selection and for the development and implementation of appropriate vestibular rehabilitation and fall-prevention strategies in higher-risk cochlear implant candidates.

Second, studies should report validated comorbidity measures, such as ASA classification or Charlson index, to identify high-risk subgroups requiring targeted perioperative management.

Third, ongoing work into the feasibility and safety of cochlear implantation under local anaesthesia with conscious sedation in high-risk elderly patients will help clarify whether this approach can safely mitigate some of the anaesthetic risk burden in this cohort (84,122,123,148-150).

Existing reviews on older cochlear implant recipients are narrative or scoping in nature and, while concluding that implantation is generally safe and effective, do not provide age-stratified quantitative estimates of complications (45-47). A further avenue for future research would be systematic comparison of cochlear implantation complication rates against those of other comparable otological procedures, focusing on shared outcomes such as wound dehiscence, wound infection, persistent facial nerve injury, and cerebrospinal fluid leak. Our findings support continued offering of cochlear implantation to carefully selected elderly candidates, including very old adults, with particular attention to anaesthetic risk assessment and vestibular/fall-prevention strategies.

Conclusions

Cochlear implantation in elderly adults is associated with low rates of major surgical, anaesthetic, and device-related complications, and these rates are comparable to those of mixed-age adult cohorts reported in the broader literature. Given the very low certainty of evidence for minor surgical complications and the limited data available for falls, further investigation is needed to more reliably characterise these risks in elderly cochlear implant recipients. Careful anaesthetic assessment is of particular importance given the low certainty evidence suggesting increased anaesthetic risk in elderly recipients. Clinicians should maintain heightened attention to vestibular symptoms and fall risk. The existing evidence included in this meta-analysis indicates cochlear implantation should continue to be offered to suitable older adults given its risk profile and its substantial benefits for communication, cognition, and quality of life.

Acknowledgments

The authors are thankful to Prof. Mari Botti for her assistance in proofreading the manuscript.

At time of manuscript submission, preliminary abstracts have been submitted for consideration at the Australasian Society of Otolaryngology Head and Neck Surgery (ASOHNS) Annual Scientific Meeting (20-22 March 2026, Hobart, Australia), and the Royal Australasian College of Surgeons (RACS) Annual Scientific Congress (30 April – 3 May 2026, Perth, Australia).

Footnote

Reporting Checklist: The authors have completed the PRISMA reporting checklist. Available at https://www.theajo.com/article/view/10.21037/ajo-2025-1-87/rc

Peer Review File: Available at https://www.theajo.com/article/view/10.21037/ajo-2025-1-87/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://www.theajo.com/article/view/10.21037/ajo-2025-1-87/coif). J.M.G. received consultancy fees for workshops, research and design, and expert opinions from Cochlear Ltd. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

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