<p>This study investigates the correlation between cochlear aperture, internal auditory canal (IAC) dimensions, and intraoperative neural response telemetry (NRT) as predictors of cochlear nerve health in pediatric patients. We focused on children with normal cochlear structures to minimize anatomical variability and isolate functional outcomes related to nerve integrity. A cross-sectional study was conducted at a tertiary care center. Seventy-eight children under 15 years of age with bilateral severe-to-profound sensorineural hearing loss and normal inner ear anatomy (confirmed by high-resolution CT and MRI) underwent cochlear implantation. Intraoperative NRT thresholds at basal, mid, and apical cochlear regions were recorded to assess cochlear nerve function. Cochlear aperture diameter and IAC width (porus, mid, fundus) and length were measured from imaging. Pearson correlation coefficients and linear regression models were used to analyze associations between inner ear dimensions and NRT thresholds. Weak and statistically insignificant correlations were observed between all the inner ear dimensions and NRT thresholds. The strongest correlation was noted between basal thresholds and IAC diameter at the porus (− 0.19). Regression analysis demonstrated that cochlear aperture and IAC measurements have minimal predictive value for NRT thresholds. The low R² values indicate that these anatomical dimensions alone are weak predictors of cochlear nerve health. This study disagreed with the notion that cochlear aperture and IAC dimensions predict cochlear nerve health in paediatric patients. The weak correlations highlight additional factors, such as genetic and developmental influences, that play a significant role in cochlear nerve function.</p>