The use of alternative techniques for cochlear implantation is indicated in unusual cases where the standard procedure would not be suitable. The authors of this study highlight the various reasons as to why an alternative technique might be sought, and go on to compare the potential complications associated with each approach. The classic technique of mastoidectomy, followed by posterior tympanotomy and cochleostomy, for placing the electrode, remains the most commonly used technique. It is a reliable technique that can be easily and safely performed by experienced surgeons, but not without risk of injury to the external auditory canal, chorda tympani and facial nerve. Patients with temporal bone abnormalities will often benefit from the use of an alternative technique. Of the 38 patients in this study who were operated on using alternative techniques following preoperative or intraoperative findings, 13 patients were operated on with a suprameatal approach and 18 with a transcanal approach. Resection of the bony part of the external ear canal and reconstruction was performed in seven patients. Postoperative complications included wound infection, haematoma, chorda tympani injury, and tympanic membrane perforation. Cochlear implantation is an effective method in the rehabilitation of patients with bilateral total hearing loss. This study highlights that the standard procedure is not appropriate for all patients, such as those with temporal bone abnormalities. The authors suggest that surgeons performing cochlear implantation should be aware of these variations and should be able to confidently perform alternative implant techniques.