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Objective: To present a new surgical concept, functional middle ear and mastoid surgery (FMMS), which is aimed to improve the results of chronic ear surgery in the 21st century.

Setting: Tertiary Care Center Study Design: Clinical Prospective Study. Methods: A surgical roadmap, based on a new clinico-radiological staging system (TMC) of middle ear cholesteatoma, is outlined.

Patients: 120 patients of tympanomastoid cholesteatoma were included in this study. They were preoperatively staged, operated by (FMMS) system, followed up and results reported. Results: Anterior tympanotomy was done in all the cases. Intact canal wall mastoidectomy was done in 79 percent, while open mastoidectomy was performed in 11 percent, and no mastoidectomy was required in 10 percent of the cases. Residual and recurrent cholesteatoma was found in 6.7 percent (6/95) of cases, all after Intact canal wall (ICW) mastoidectomy. The overall (n= 120) pre-and post-operative (at least 12 months after surgery) four frequency PTA-ABG were 33.40±7.22 dB and 12.42±5.6 dB.

Conclusions: Due to the changing trends in the presentations of chronic ear disease, as well as the advances in its diagnosis and treatment, FMMS presents a logical surgical solution for tympano-mastoid cholesteatoma in the 21st century It stresses the fact that the middle ear should be the primary target of otosurgeons to clear pathology and reconstruct the hearing mechanism. Mastoidectomy is performed, only if necessary, to approach the middle ear posteriorly and to clear pathology extensions if needed.