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True cholesteatomas developing medial to the labyrinth and facial nerve with extension into the petrous apex are uncommon lesions. More recent techniques of total matrix removal and obliteration require the otoneurosurgeon to be knowledgeable of intratemporal facial nerve mobilization techniques. Total cholesteatoma matrix removal and obliteration may obviate the need for frequent care of the exteriorized cavity. However, these procedures can be associated with extensive recurrence from residual disease and close radiographic follow-up is a necessity. We review our experience with ten cases of petrous apex keratoma treated with both techniques. Six cases were managed with an exteriorization technique and four patients underwent subtotal petrosectomy with obliteration. Advantages, disadvantages, and complications of both methods are presented and guidelines for selecting a particular approach are suggested.