Summary Cochlear implantation is the standard treatment for severe to profound hearing loss. However, implantation trauma and underlying disease may lead to on-going degeneration of auditory neurons and impairment of implant function. Targeted therapeutics to control inflammation, prevent implantation trauma and protect auditory neurons are an unmet clinical need specifically for treating patients with residual hearing. Cell-based approaches including the sealing of the round window membrane with biological tissue releasing growth factors and factors supporting wound healing will be introduced. Such sealing approaches can provide benefit specifically to the basal turn where implantation trauma is most pronounced. Preclinical results will be presented on novel cell and exosome-based treatment strategies for the inner ear. Long-term clinical experience with biohybrid implants coated with cells for the provision of a variety of nutrients and immunomodulative factors throughout the cochlea will be presented. Finally, the use of an inner ear catheter in humans to apply drugs and cells into more apical regions of the cochlea will be discussed.