Hearing rehabilitation through cochlear implants and its wide surgical indications expansion has determined a rise in cases previously treated with a canal wall-down (CWD) timpanoplastly for various conditions. These patients may present unique surgical challenges due to altered anatomy and prior disease history. The absence of the posterior canal wall, associated meatoplasty, and potential for residual disease complicate standard surgical approaches. Subtotal petrosectomy (SP) is essential to ensure disease eradication and safe electrode insertion. Modifications in blind sac closure and receiver-stimulator positioning are required to reduce postoperative risks and optimize long-term imaging follow-up. Clinical judgment dictates whether a single or staged procedure is most appropriate.