The aim of the present study is to document and analyze the ossicular chain preservation rate in patients affected by acquired primary cholesteatoma with epitympanic involvement and with preoperative intact ossicular chain. A retrospective case series in a tertiary university referral center. From January 2006 to February 2010, at the Otolaryngology Department of the University Hospital of Modena, 68 patients affected by acquired primary cholesteatoma with attic involvement underwent exclusive endoscopic transcanal tympanoplasty. In April 2010, we performed a retrospective chart and video review of these patients. Patients in whom the ossicular chain was found to be intact and not involved by the pathology at the beginning of the operation were included in the study. A cholesteatoma staging was introduced based on tympanic subsite involvement by pathology. Out of 68 patients affected by acquired primary cholesteatoma and who underwent exclusive endoscopic transcanal tympanoplasty, 23 had intraoperative integrity of the ossicular chain (17 male and 6 female subjects; mean age, 40 yr) and were included in the study. An inverse correlation was found between number of subsites involved and chain preservation (Spearman rank correlation coefficient, r = -1; p = 0.017). Medial attic involvement was the factor that most negatively influenced the likelihood of chain preservation. Middle ear endoscopic techniques may increase the likelihood of ossicular chain preservation during cholesteatoma surgery. Medial attic involvement and a high number of subsites involved represent the most significant negative factors for chain preservation. The rate of residual disease requires more thorough evaluation in the future to validate the results.