Objective To explore the feasibility of treatment of middle ear cholesteatoma in young children with transcanal totally endoscopic ear surgery so as to guide the pathway of clinical diagnosis and treatment.Methods The young children (≤ 6 years old) with middle ear cholesteatoma treated by transcanal totally endoscopic surgery in our department from April 2016 to March 2021 were selected as the object of study. The general data, degree of the lesion, intraoperative condition, postoperative complications, hospital stays, and recurrence were statistically analyzed. The feasibility and strategy of transcanal totally endoscopic surgery in young children were analyzed.Results A total of 26 children were included, their average age was 4.1±0.9 years old, and the youngest was 1.9 years old. There were 19 boys (73.1%) and 7 girls (26.9%). Of them, 21 cases were congenital cholesteatoma (80.8%) and 5 were acquired cholesteatoma (19.2%). According to EAONO/JOS staging, there were 8 cases of stage I (30.8%), 17 cases of stage II (65.4%), 1 case of stage III (3.8%), and none of stage IV. Multi-angle otoendoscopes were used in 12 cases. The intraoperative bleeding was 1.0(1.0, 2.0) ml. The length of operation was 85.0(50.0, 110.0)minutes, and the postoperative hospital stay was 2.0(2.0, 5.0)days. Intraoperative dissociation of chorda tympani nerve was achieved in all cases. After operation, 3 cases had short-term vertigo, one had temporary mild facial movement asymmetry, and no other complications were found. Recurrence occurred in one.Conclusions Transcanal totally endoscopic ear surgery can be performed for middle ear cholesteatoma in young children. The extension of cholesteatoma to the posterior tympanum, epitympanum, and the entrance of the tympanic sinus requires aid of multi-angle oto-endoscopes for observation. With obvious advantage of clear observation of fine structure, otoendoscope can effectively protect the structure of the middle ear.