Adult patients with cholesteatoma who present with normal hearing create particular problems for the otologic surgeon. Whether the patient has active otorrhea or only asymptomatic physical findings, the potential of a destructive disease process exists for the future without any hearing deficit in the present. Selected considerations will be discussed including different forms of cholesteatoma, specific conditions of the ossicular chain and various findings at the time of surgery. Methods of ossicular reconstruction, hearing results and perioperative care will also be presented.