Syndromic patients can have severely anomalous anatomy significantly challenging conventional cochlear implant (CI) surgery. This case report describes a 20‐year‐old with brachio‐oto‐renal syndrome with a severely anomalous facial nerve completely covering the round window and preventing a traditional posterior tympanotomy CI. This is the first report to illustrate the performance of an endoscopic trans‐canal bony cochleostomy with insertion of the CI performed via a “microfacial recess.” We describe the performance of an endoscopic trans‐canal bony cochleostomy and a modification of the conventional wide posterior tympanotomy usually performed into a 1 mm “microfacial recess,” which allowed a full insertion to take place. Laryngoscope, 134:4806–4809, 2024