In the course of restoration of the middle ear, routine histological examinations are initiated in many cases, although amiddle ear cholesteatoma can be clinically diagnosed in anormal case. To determine the correlation between the surgeons' diagnosis and that of the pathologist and comparison with literature data. To check the rate of unexpected diagnoses. Analysis of the costs and survey of German ENT clinics with regard to handling of the histological examination in suspected cholesteatoma. Retrospective evaluation of cholesteatoma cases of the ENT Department of the University Medical Center of Mainz from 2010-2015. Germany-wide postal survey of ENT clinics. In all, 449 operations for the rehabilitation of amiddle ear cholesteatoma, of which there were 312 (69.5%) first diagnoses and 137 (30.5%) recurrences. Ahistological examination was conducted in 78.6%. For first diagnoses, the sensitivity of the clinical assessment was 97.9%, specificity 10%, positive predictive value 96.3%, and negative predictive value 16.7%. Recurrences showed values of 100%, 40%, 97.1% and 100%. Unexpected malignant findings did not occur. This routine histological examination was performed by 58.6% of German ENT hospitals. Atotal of 80% of those questioned this to be useful. Ahistological examination cost an average of 14.06 €. Intraoperatively, there is ahigh degree of accuracy in diagnosing cholesteatoma. The cost factor of the histological examination is low and should not be the basis for the decision. The ear microscopy and the experience of the ear surgeon should be decisive for the decision for histological examination.