Conclusion

The following factors can positively influence the reduced incidence of biofilm formation.
1. Strict asepsis,
2. Respecting the flap
3. Avoid using tie over (a better alternative is a snugly fitting periosteal pocket), treating hematomas at the earliest, giving adequate attention and proper treatment to otitis media with or without discharge.
Counselling regarding infection needs to happen as parents tend to take local treatment first which unknowingly leads to a delay before turning up at the cochlear implant centre. Polyhexanide and betaine surfactants are easily available and can be used against biofilms. However, we need more studies on biofilm management to make proper guidelines.
Conflicts of Interest: The authors have no conflicts of interest to declare.
Funds: This research did not receive any specific grant from any funding agencies in the public, commercial, or not for profit sectors
Acknowledgements: None
Data availability : data is available for review on request from the authors due to privacy/institutional ethical restrictions.
Ethical approval : The study was approved by the Institutional Ethics Committee