OBJECTIVE To investigate the efficacy of endoscopic approach with external ear flap and microscopic mastoid approach in the treatment of recurrent middle ear cholesteatoma caused by ear canal stenosis. METHODS? The clinical data of 60 patients (60 ears) with recurrent middle ear cholesteatoma due to ear canal stenosis who underwent surgery at the Affiliated Subei People"s Hospital of Yangzhou University from June 2021 to January 2024 were retrospectively reviewed. 29 cases underwent endoscopic external ear canal flap surgery (endoscopic group) and 31 cases underwent endoscopic breast insertion surgery (microscopic group). The relationship between the surgical time, postoperative pain, complications, and recurrence of ear canal stenosis and recurrent middle ear cholesteatoma was evaluated using endoscopic external ear canal flap surgery and endoscopic mastoid approach surgery. RESULTS There were no significant differences (p<0.05) in demographic, disease characteristics, complications, and recurrence rates between the otoscope group and the microscope group. There were significant differences in surgical time and postoperative pain VAS scores between the otoscope group and the microscope group, with the otoscope group taking less time, experiencing less pain, and having a greater advantage (p<0.05). CONCLUSION Endoscopic treatment of recurrent middle ear cholesteatoma with external ear canal flap is an effective surgical method, performed by experienced surgeons. Its efficacy is similar to that of endoscopic mastoid approach surgery, with less time and less pain.