Introduction: Totally endoscopic ear surgery (TEES) is gaining in popularity globally and has revolutionized access to difficult areas in the middle ear cleft. It is, however, not without its own challenges and pitfalls and in some units is slow to be introduced into routine practice.

Methods: A prospective review and cohort study of all otological procedures performed by the senior author was undertaken and grouped according to technique from June 2013 to December 2020. Particular focus is given to our TEES procedures and we present our patient selection process, complication rates, and recurrence rates and follow up protocol. A non-systematic narrative literature review was undertaken.

Results: Just under one third of cholesteatoma cases were deemed appropriate for the TEES approach. At one year follow up, there was an 11.1% rate of recidivism. The complication rate was 0%.

Conclusion: The use of the endoscope is an invaluable tool in both middle ear surgery and training of junior doctors. It may also have economic benefits. Rigorous training and following a stepwise approach from simple procedures to more difficult is essential to overcome the learning curve associated with this technique.