Background: The subject of cholesteatoma in the middle ear is a highly intricate area of study in the field of otology, which has sparked numerous research studies and discussions across the globe. However, despite all the research and debates, there remains a significant lack of agreement among experts regarding many aspects of cholesteatoma. Aim of the work: This study aims to compare between the hearing outcome and recidivism [recurrence or residual] of canal wall up [CWU] and canal wall down [CWD] mastoidectomy in cholesteatoma. Patients and Methods: This randomized comparative prospective study involved eighty-six adult patients with acquired cholesteatoma divided into two equal groups; Group A: included patients who undergo CWU mastoidectomy, and Group B: include patients who undergo CWD mastoidectomy. Follow up for at least 12 months using otoendoscop, PTA, as well as DWI-MRI. Results: Air-bone [AB] gap and AC threshold improved significantly in both groups after surgery. However, the improvement was significantly better in the CWU group compared to the CWD group [P=0.025 for AB gap and 0.039 for AC threshold]. Regarding recidivism, the CWD group had less recurrence rate than CWU group [4 vs. 9], but with no significant difference [P=0.11]. Conclusion: The CWU group has demonstrated superior results in terms of hearing improvement compared to the CWD group. However, the CWD technique showed better outcomes in terms of preventing the recidivism of cholesteatoma.