Objective  To correlate preoperative high resolution computed tomography (HRCT) findings of the temporal bone with the degree of round window membrane (RWM) exposure observed during cochlear implant  surgery, and to establish an imaging-based predictive model to guide surgical approach selection in patients with sensorineural hearing loss.   Methods  A retrospective analysis was performed on 89 patients who underwent cochlear implantation at the People’s  Liberation Army 960th Hospital. Preoperative temporal bone high-resolution computed tomography (HRCT) scans were used to analyze and correlate with the intraoperative degree of RWM exposure. Based on the St. Thomas’ Hospital (STH) classification system, the cohort distribution was as follows, type Ⅰ (n=63), type Ⅱa (n=17), and type Ⅱb+Ⅲ (n=9). On the axial HRCT slice at the level of the round window niche, the following parameters were measured, including facial nerve to bony wall distance, the vertical distance from the anterior edge of the facial nerve’s vertical segment to the posterior edge of the external auditory canal’s bony wall; Facial nerve to membrane distance, the distance from the anterior edge of the facial nerve’s vertical segment to the midpoint of the RWM; Facial nerve point position, the vertical distance from the anterior edge of the facial nerve’s vertical segment to the basal turn of the cochlea. The measured parameters were analyzed for differences across age groups and STH classification types. An extension line from the anterior border of the vertical segment of the facial nerve, parallel to the external auditory canal was drawn, and the influence of its positional relationship on RWM. Finally, the preoperative predictions for the electrode insertion approach were compared with the actual surgical method  employed.  Results  A statistically significant difference was observed in the vertical distance between the anterior edge of the facial nerve’s vertical segment and the basal turn of the cochlea (P<0.05).The positional relationship between the round window and an extension line drawn anterior to the vertical segment of the facial nerve and parallel to the posterior wall of the external auditory canal had a statistically significant impact on round window membrane exposure (P<0.05). No statistically significant difference was found between the preoperatively predicted and the intraoperatively actual electrode insertion approaches (P>0.05).   Conclusion  Preoperative temporal bone HRCT measurements, specifically the vertical distance from the facial nerve to the cochlear basal turn and the positional relationship of a defined facial nerve extension line to the round window, can predict the difficulty of intraoperative RWM exposure, offering significant clinical utility for pre-surgical planning of the electrode insertion approach in cochlear implantation.