I confess to an initial hesitation when I requested this book for review. Let us face it, the literary output of the world's medical publishers has slackened off with the pandemic, but Plural has proved a worthy exception to that. Even so, I did fear that this would prove of far more relevance to the intellectual discipline of the audiologist, who does after all carry out so much of the assessment for cochlear implantation, than to the simple surgeon, who is tasked with inserting the device. I was quickly reassured that this is for our otological readership too.

Again, I thought the opening chapter on the US Food and Drug Administration's role in determining candidacy would be of little relevance to a UK readership, but, undeterred, I read on. It was actually quite fascinating to read of the work of the Food and Drug Administration, despite central funding that amounts to less than $10 per head of the US population. The rest of their income, of course, comes from the industry, as user fees for premarket reviews of new technology, or even granting approval to device modifications or indications. For the latter, I now appreciate how the delays and costs involved discourage manufacturers from revising their labelled indications for cochlear implantation (e.g. to the less severely deafened or children under 12 months of age). The minefield to be negotiated proved interesting even before I read of the right of clinicians to decide their own criteria ‘off label’. An early table in this book showed how the three manufacturers do vary in their indications for cochlear implantation, let alone the place of Medicare and insurers. This chapter did surprise me with its international relevance. A good start then.

The second chapter, on adult cochlear implantation candidate selection obviously emphasised the role of the audiologist, but did introduce the social worker, the psychologist and, of course, the surgeon. A very similarly styled chapter followed for paediatric cochlear implantation selection, and I liked the ‘catchy’ titles such as ‘Thinking Beyond the Criteria Checklist’. Both chapters carried a lengthy discussion entitled ‘Utility of Predictive Variables for Post-operative Outcomes’, which included age at cochlear implantation, neural pathway integrity or the aetiology of hearing loss. A chapter on the role of the speech and language pathologist in paediatric cochlear implantation assessment certainly illustrated the number of measures available. In 4 tables, I counted no fewer than 38 measures, which is maybe telling us that the jury is still out on the best option?

Now, the fifth chapter is a ‘pearl’ for the surgeon reader, as it explores the clinical implications of variable anatomy. The surgical approach is explained in a manner accessible to any member of the team, whether wielding a drill or not, but the chapter then offers detailed discussion of the challenges of varied cochlear length, shape, or orientation in the temporal bone. There is excellent coverage of ‘suboptimal outcomes’, a nice phrase I feel, for problems such as tip fold-over, scalar translocation, lateralisation or shallow insertion. There is advice regarding their detection and correction. The author stresses the role of post-operative imaging, if only for personal quality control, and of per-operative electrophysiological testing. I was most impressed by the topicality of the references cited here (and elsewhere indeed), which were as recent as 2018 or 2019.

The final chapters naturally concentrate on post-operative testing and rehabilitation, but there is some very nice coverage of how cochlear implantation may yet evolve, in chapters such as ‘Nontraditional Candidates for Cochlear Implantation’ and ‘What Does the Future Hold and What Might We Be Missing?’ These titles speak for themselves as being essential for any member of the cochlear implantation team.

This is then an attractive softback book, at a very reasonable price, which has a relevance to a surgical reader just as much as to any other member of the multidisciplinary team. I will admit though that it was the ‘pearl’ chapter noted above that I reread a second time.