Abstract: Objective: Middle ear cholesteatoma is a potentially destructive non-neoplastic lesion that erodes the adjacent bony structures and may lead to intraotologic and intracranial complications. This study evaluated the performance of ultra-high-resolution computed tomography (U-HRCT) in visualizing the bony destruction of intraotologic structures caused by middle ear cholesteatoma, using intraoperative findings as the reference standard, and to analyze its clinical efficacy from a surgical perspective. Methods: A retrospective analysis was performed on the data from 60 patients who were pathologically diagnosed with middle ear cholesteatoma at our hospital between February 2024 and February 2026. All the patients underwent preoperative U-HRCT. The imaging findings were compared with the intraoperative observations, and the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), accuracy, and kappa value of U-HRCT were calculated. Results: The sensitivity of U-HRCT for detecting the bony destruction of the scutum, tegmen tympani, malleus, incus, and semicircular canal wall was greater than 90% in all cases. Its identification of the destruction of the semicircular canal wall agreed perfectly with the intraoperative results (kappa = 1). The detection of the bony erosion involving the scutum, tegmen tympani, and malleus showed excellent consistency with the intraoperative findings (kappa > 0.8), whereas that of the erosion of the incus, stapes, and facial nerve canal achieved good consistency (kappa > 0.6). Conclusion: U-HRCT enables an accurate preoperative assessment of the bony destruction of the ossicles, facial nerve canal, and other structures caused by middle ear cholesteatoma and can assist surgeons in identifying potential high-risk conditions before surgery.