Cholesteatomatous chronic otitis media (COM) remains a significant health problem in developing regions, where delayed diagnosis predisposes patients to extensive bone destruction and intracranial complications. We report the case of a 38-year-old male with an approximately 9-year history of untreated left otorrhea (onset ~2009), progressive hearing loss, and previous cerebellar abscess and subdural empyema. High-resolution CT revealed bilateral cholesteatoma with extensive erosion of the mastoid, posterior fossa plate, and sinus plate, associated with a stable 11-mm posterior fossa empyema. The patient underwent canal-wall-down mastoidectomy with complete removal of cholesteatoma and reconstruction of the posterior fossa defect. No immediate neurosurgical intervention was indicated. This case illustrates the destructive potential of neglected cholesteatoma and highlights essential principles for safe surgical management of advanced disease.
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