Background: Cochlear implant (CI) surgery is traditionally performed under general anaesthesia (GA), yet increasing age and comorbidities of patients raises concerns about GA-related complications. Local anaesthesia (LA) offers reduced operative times, real-time patient feedback regarding hearing and balance, decreased postoperative nausea and vomiting, reduced disequilibrium, diminished postoperative confusion, and shortened hospital stays. A 2022 systematic review demonstrated significantly shorter surgical times with LA compared to GA for CI procedures. Aim: This retrospective study aims to enhance the reliability and generalizability of existing evidence regarding feasibility, safety, and outcomes of CI surgery performed under LA in very elderly patients. Methods: Ethics approval was obtained by the WSLHD HREC (ETH02089). Clinical data from consecutive patients aged 80 and older who underwent CI surgery under awake LA conditions at Westmead and Westmead Private Hospitals was analysed. Primary outcomes include duration of anaesthesia, operative time, postoperative analgesia requirements, postoperative disequilibrium, recovery time, admission duration, and adverse events with particular focus on postoperative confusion. Age- and sex-matched historical data from patients who received CI surgery under GA is used as a comparison group. Results: 16 additional procedures were eligible for the study (32 total). Primary outcome data is presented and compared against age- and sex- matched historical data from the same institutions. Conclusion: By substantially expanding the evidence base for CI surgery under LA in octogenarians, this study provides clinicians with more robust data to inform anaesthetic decision-making for elderly patients requiring cochlear implantation, potentially establishing LA as a safer, more acceptable standard of care for this growing population.