Conclusion: In cases of petrous apex cholesteatoma, radical removal should be prioritized over an unreasonable sparing of hearing or facial symmetry. Restoration of facial nerve function is achievable by reanimation procedures. Objectives: To analyze clinical manifestations, surgical findings, and postoperative functional results of petrous apex cholesteatoma. Methods: From 1995 to 2012, 34 cases of petrous apex cholesteatoma underwent operations. Clinical and surgical findings and postoperative functional outcomes were analyzed retrospectively. Results: Hearing loss was the most common symptom in 95% of patients, followed by otorrhea in 64% and facial palsy in 59%. Four patients had recurrent facial palsy. In eight (24%) patients petrous apex cholesteatomas were recurrent or iatrogenic in origin. The supralabyrinthine and massive type of petrous bone cholesteatoma were the most common types, followed by, infralabyrinthine-apical, infralabyrinthine, and apical. Among 18 cases with facial nerve paralysis, 8 underwent hypoglossal-facial nerve anastomosis, 4 underwent rerouting and end to end anastomosis, 3 of them did not undergo any treatment because of the duration of facial palsy (> 3 years), and another 3 patients for whom we had recommended facial-hypoglossal anastomosis did not accept the operation. There were no major complications. Recurrence was observed in two (5%) cases.