Cholesteatoma has attracted many studies seeking to uncover its nature and the pathogenesis of related diseases. However, no researchers have explored the mitochondrial bioenergetics of cholesteatoma. The aim of this study was to investigate the energy demand and differential mitochondrial respiration profiles between keratinocytes in external auditory canal (EAC) skin and cholesteatoma samples cultured in normoxic (20% O 2 ) and hypoxic (5% O 2 ) conditions. Enhanced cellular proliferation of both types of keratinocytes was found in hypoxia compared to normoxia. In 20% O 2 conditions, cholesteatoma keratinocytes exhibited less mitochondrial mass, lower ATP levels, and significantly lower basal oxygen consumption rate (OCR) and reserve capacity compared to normal skin keratinocytes. In contrast, in hypoxic conditions, cholesteatoma keratinocytes showed markedly higher levels in maximal OCR and reserve capacity, as well as lower proton leak OCRs, compared to normal skin keratinocytes. Hypoxia induced the reverse mitochondrial bioenergy profile from that in normoxia between these two types of keratinocytes, implying that an adaptive change of mitochondrial respiration to oxygen fluctuations may develop in cases of cholesteatoma. Such adaptation in response to hypoxic conditions may play a role in explaining the pathogenesis of acquired cholesteatoma.Cholesteatoma derives from an abnormal growth of the keratinizing squamous epithelium, which consists of a thin layer of stratified squamous epithelium (matrix) and an adjacent subepithelial connective tissue layer (perimatrix) 1 . The enzymatic activity from matrix components (such as collagenase, plasminogen, and N-acetyl-β-hexosaminidase), the local chronic inflammation-recruited osteoclasts, and the inflammatory mediators concomitant with the disease are responsible for its destruction of the bony external auditory canal (EAC) and ossicular chain 2-7 , resulting in refractory otorrhea and progressive hearing loss. Moreover, vertigo and balance dysfunction can be associated when the labyrinth is involved. Although surgical treatment can cure such disease, a wide range of recidivism rates, from 4 to 61%, has been reported [8][9][10] ; thus, the long-term eradication of cholesteatoma remains a great challenge for otologists.Previous studies have investigated whether there is an interaction between cholesteatoma and normal skin of the EAC by comparing their gene regulation, biochemical presentation, and cytokine secretion. Cholesteatomas exhibit increased expression of epidermal growth factor receptor (EGFR), transforming growth factor-α (TGF-α), c-jun, and c-myc, accompanied by a significant upregulation of inflammation-related genes and downregulation of several tumor suppressor genes [11][12][13][14][15][16][17][18][19] . Using whole human genome DNA microarray analysis, the expression profiles of cholesteatomas were demonstrated to mimic those of metastatic tumors and chronically inflamed tissue 14 . The more extensive expression of hyperproliferation-associated cy...