Temporal bone fractures (TBFs) occur in up to 20% of patients who sustain a skull fracture, and they may result in a range of complications, including hearing loss, balance disturbance, facial nerve palsy, and cerebrospinal fluid leak. Unfortunately, sensorineural hearing loss is a common sequela following TBF, especially in individuals with otic-capsule violating fractures. For patients with severe to profound sensorineural hearing loss (SNHL) after TBF, cochlear implantation (CI) is the primary option for auditory rehabilitation (Table 1). Known labyrinthine changes following TBF, such as intracochlear fibrosis and new bone formation, raise concerns regarding the feasibility of proper CI electrode insertion and postoperative audiometric outcomes. In this Triological Society Best Practice, we address the question: Are cochlear implants a viable option following a temporal bone fracture? 12.6 (1.7–35), 1 case unknown Preoperative mean audiogram threshold: 96.57 (90–106), mean implant-aided audiogram threshold: 44 dB (40–50), postoperative BKB: 71 (44–100) Camilleri et al.'s study in 1999 was among the first to describe CI outcomes in a cohort of postlingually deafened patients following TBF.1 The authors describe seven cases of profound hearing impairment following either single-sided (n = 1) or bilateral deafness (n = 6) due to TBF. All patients were implanted with a Nucleus 22 (Nucleus 22: Cochlear Limited, Sydney, Australia) channel or Ineraid (Ineraid: Symbion, Inc., Salt Lake City, UT, USA). Six of the seven patients (86%) had a hearing threshold of 40 to 50 dB nine months following activation. The average postoperative Bench-Kowel-Bamford word recognition score was 71% (range, 44%–100%). Of note, the one patient without improved auditory rehabilitation performance had the longest duration of total deafness prior to implantation (35 years) compared to the remainder of the cohort (mean = 2.5 years). The authors also reported postoperative facial nerve stimulation in two patients that was addressed by implantation in the contralateral ear. In a retrospective case review, Greenberg et al. highlighted clinical challenges and predictors for CI outcomes in patients following blunt head trauma.2 They reviewed 25 patients with head trauma from 1984 to 2009. Of this cohort, 11 underwent CI, eight of whom had TBF (n = 4 for bilateral TBF). Five out of the eight patients with CI following TBF had transverse fractures on the side of implantation. The average City University of New York sentence test score, 1-year postimplant, was 66% (range, 16%–100%). Sixty percent (n = 3) had 1-year postimplant open sentence scores comparable to the non-TBF CI population. Although limited by a small sample size, the authors comment that the location of the fracture may play a role in post-CI auditory rehabilitation success, as two of the five cases with CI had postimplant speech discrimination scores less than 25. Despite the findings that some patients may perform poorly, the authors conclude that open-set speech recognition scores in the TBF CI population can still be consistent with those achieved by the non-TBF CI population. In one of the largest retrospective case studies to date, Khwaja et al. similarly found that CI is an effective method of auditory rehabilitation in profoundly deafened patients following TBF.3 The authors describe the outcomes of 23 patients with CI following head injury, including 16 TBF cases. Although the authors did not perform separate analyses in TBF versus non-TBF CI cases, the mean duration of deafness was 12 years, larger than previous studies. The postimplantation Bench-Kowel-Bamford speech perception scores were 64% in quiet and 61% in noise, similar to CI audiometric performance in patients without head injury. Injury to the otic capsule did not influence CI performance on bivariate correlation analysis, although they noted that obliteration of the cochlear lumen increases the technical difficulty of implantation and may increase the risk of an incomplete insertion. In a study that investigated bilateral TBFs, Vermeire et al. examined the role of cochlear implantation.4 In four patients with bilateral profound SNHL following bilateral TBF, patients were implanted with a unilateral cochlear implant. Following implantation, three of the four patients had excellent speech recognition at the time of follow-up (7–96 months), with an overall mean Nederlandse Vereniging voor Audiologie score of 63% (range, 24%–95%). Additionally, the mean postoperative hearing threshold was 28 dB HL. Similar to Camilleri et al., the authors of this study suspected that the poor outcome in one patient was likely due to the relatively increased length of deafness prior to CI (5.25 years) compared to the other cases, which were less than 2 years. Bilateral disruption of the cochleovestibular nerve is a potential indication for auditory brainstem implantation (ABI) instead of CI. In a direct comparison of CI versus historic ABI auditory outcomes in bilaterally deaf patients following head trauma, Medina et al. retrospectively reviewed 14 CI cases. In this cohort, nine patients had a TBF (six bilateral, three unilateral).5 At the time of last follow-up (mean = 53 months), all patients had useful open-set speech perception, and in secondary CI following failed ABI, all had better audiometric results compared to the ABI. In this study, the authors also performed a literature review that examined ABI following head trauma. The authors identified three reports detailing seven total patients. Of these cases, three patients failed satisfactory open-set sentence recognition at 1-year follow-up. Of those with satisfactory auditory rehabilitation results following ABI, the authors note a clear advantage in outcomes following CI compared to ABI. Studies examining CI following TBF consistently demonstrate successful auditory rehabilitation; however, outcomes may be variable. Patients who were implanted years after trauma appear to have worse outcomes than peers implanted earlier, following the general trend of CI outcomes. Additionally, although CI for single-sided deafness as a result of head injury has been performed, more research is needed to further assess outcomes. The current literature raises a host of anatomic features, such as cochlear ossification and testing, including promontory stimulation, that may help to predict outcomes; however, the majority of the studies were not primarily designed to address these questions. There are a host of limitations of the current studies and several variables that remain underinvestigated. The articles also utilized different speech discrimination testing, making comparisons challenging. In addition, the studies were not sufficiently designed to delineate how preoperative imaging, fracture location, promontory stimulation, and time to implantation may influence outcomes. These studies also tended to group together head injury patients, with and without fractures, limiting direct analysis of patients with TBF. In summary, as a best practice, there is sufficient evidence to advocate for CI after TBF. However, specific timing of implantation and patient selection criteria need to be further delineated in future studies. All studies were retrospective case reviews (level 4).