Background Pediatric cholesteatoma is an aggressive middle ear disease with high recurrence, making the choice between Canal Wall-Up (CWU) and Canal Wall-Down (CWD) surgery crucial yet controversial. Aim To evaluate clinically derived indications guiding the selection of CWU versus CWD techniques in children with cholesteatoma. Methodology A retrospective observational study was conducted on 43 pediatric patients at a tertiary care center in Gujarat, India, over two years. Clinical, radiological