Cochlear implantation represents the preferred rehabilitative strategy in advanced otosclerosis unresponsive to conventional treatments. The affection of critical middle ear areas in otosclerosis must be considered in those cases, and a proper counseling regarding the expectations and a proper preoperative radiological study are of utmost importance. Surgical challenges may arise during such procedures and may include cochlear ossification, increased risk of cerebrospinal fluid leak, and facial nerve stimulation. Based on ossification severity, approaches range from standard posterior tympanotomy to subtotal petrosectomy (SP), particularly in type 3 or cavitary forms. SP offers broader access for electrode insertion and drill-out when necessary.