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Objective To show the efficiency of using transmastoid atticotomy (TMA) endoscopy on the outcome of ossiculoplasty in patients with cholesteatoma. TMA is often performed as part of the surgical management of patients with middle ear cholesteatoma extending to the epitympanum. TMA can also be used as an access for endoscopic view to confirm the right alignment and stability of the ossicular prosthesis because the reconstruction of the tympanic membrane will obscure the visualization of the prosthesis. Methods A retrospective study was done at a tertiary referral institute, including 133 ears with cholesteatoma that underwent canal wall‐up tympanomastoidectomy (CWU) with ossicular reconstruction using titanium prosthesis between August 2013 and August 2015. Post packing of the ear canal and position, stability, and axis of the prosthesis were checked using endoscope positioned in the attic through TMA. A postoperative pure‐tone average air–bone gap (ABG) of 20 dB or less was considered as a successful hearing result. Results are compared with historical control groups. Results Of the 133 ears, 88 patients underwent reconstruction with partial ossicular replacement prosthesis (PORP), whereas the rest (45 patients) had total ossicular replacement prosthesis (TORP). A postoperative ABG ≤ 20 dB was obtained in 77.4% of all the patients (79.5% for PORP; 73.3% for TORP). Conclusion Endoscopic assessment of the ossicular prosthesis via the attic, after repositioning of the tympanomeatal flap and packing the ear canal, decreases the risk of immediate ossiculoplasty failure and improves the functional outcome after ossicular chain reconstruction in cholesteatoma surgery. Level of Evidence 4 Laryngoscope, 129:2754–2759, 2019

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