To explore the efficacy of modified intact canal wall mastoidectomy combined with tympanoplasty in the treatment of elderly middle ear cholesteatoma and its influence on hearing recovery. Methods The clinical data of 118 elderly patients with middle ear cholesteatoma admitted to the hospital were retrospectively analyzed from March 2017 to March 2021, and the patients were divided into 58 cases in intact canal wall group and 60 cases in modified group according to the surgical methods. The patients in the intact canal wall group underwent intact canal wall mastoidectomy combined with tympanoplasty, and the patients in the modified group performed modified intact canal wall mastoidectomy combined with tympanoplasty, and the patients were followed up for 12 months after surgery. The surgical status, clinical efficacy, hearing recovery and postoperative complications were analyzed in the two groups of patients. Results The surgical time in modified group was longer than that in intact canal wall group while the dry ear time was shorter than that in intact canal wall group, and the secondary surgery rate and postoperative recurrence rate were lower than those in intact canal wall group while the total effective rate of treatment was higher than that in intact canal wall group (P＜0.05). At 12 months after surgery, the air conduction level, bone conduction level and air-bone gap of the two groups were all reduced compared with those before surgery (P＜0.05), but there were no statistically significant differences between the groups at the same time point (P＞0.05). The incidence rates of postoperative complications of patients in modified group within 12 months after surgery were lower compared to intact canal wall group (P＜0.05). Conclusion Modified intact canal wall mastoidectomy combined with tympanoplasty has a definite efficacy in the treatment of elderly middle ear cholesteatoma. It is helpful for the hearing recovery of patients, and has fast dry ear, low recurrence rate and few postoperative complications, therefore it is worthy of clinical promotion