Beyond speech perception: contemporary landscape of language agnostic hearing assessment

Speech perception testing remains the dominant framework for cochlear implant (CI) outcomes assessment, yet its reliance on language introduces two fundamental limitations. Mechanistically, speech recognition performance reflects a composite of peripheral auditory encoding, cognitive processing, and linguistic knowledge, obscuring the contribution of each. Practically, language-dependent testing systematically underserves patients with limited English proficiency, prelingually deafened children, and others for whom verbal response formats are not viable. Language agnostic hearing tests (LAHTs) assess auditory function without requiring linguistic processing, offering a more precise probe of the auditory periphery and central encoding pathways and a more equitable framework for diverse populations. This narrative review was conducted via a systematic search of PubMed, MEDLINE, and Embase and examines the evidence for LAHTs across three domains: psychoacoustic resolution measures (spectral, temporal, and spectrotemporal), naturalistic stimulus measures (environmental sound identification, music perception, and phoneme discrimination), and electrophysiologic measures. Across the adult CI and hearing impairment literature, psychoacoustic measures demonstrate consistent, moderate-to-strong correlations with speech recognition outcomes. Spectral ripple discrimination and the Spectrotemporally Modulated Ripple Test (SMRT) predict speech outcomes in both English-speaking and non-English-speaking populations, though their validity at higher ripple densities is constrained by signal aliasing in CI processors. The Audible Contrast Threshold (ACT) has achieved clinical deployment for hearing aid fitting, and environmental sound identification deficits documented by the Familiar Environmental Sounds Test reveal safety-relevant dimensions of auditory function that speech batteries do not capture. In prelingually deafened children, the expected correlations between psychoacoustic resolution and speech recognition are largely absent, suggesting qualitatively distinct auditory reorganization that current measures incompletely characterize. Across domains, LAHT-speech correlations are real but partial: these measures predict speech outcomes without replacing them, and their relationship to patient-reported quality of life remains uninvestigated. The evidence supports integrating LAHTs as complementary tools in clinical practice and research, with the greatest immediate utility in candidacy screening, outcomes characterization in linguistically diverse populations, and mechanistic investigation of device and patient factors underlying outcome variability.