Cholesterol granuloma is a lesion that develops as a result of an immune reaction to cholesterol crystals formed by the anaerobic breakdown of blood products. Although the incidence is extremely low, it is considered the most common pathology in the petrous apex area. The growth of this lesion is slow and asymptomatic until it compresses surrounding structures such as the inner ear and cranial nerves. Diagnosis requires detailed audiological and radiological evaluation with precise determination of the lesion's location and its relationship with adjacent neurovascular structures. It is often discovered incidentally, and in such cases, surgical treatment is not necessary but active surveillance is conducted, monitoring the size of the lesion and clinical presentation. In symptomatic cases, surgical treatment is indicated, with preference given to drainage procedures that do not require the removal of the lesion's wall. This is because a cholesterol granuloma is a pseudocyst that lacks a true epithelial lining. The decision regarding the surgical approach depends on the hearing status on the affected side, the localization of the lesion, the anatomical position of critical structures, and the surgeon's experience. In cases where hearing function is preserved, several surgical approaches can be used to spare the labyrinth, including the infracochlear approach. This surgical technique allows for a minimally invasive approach to the petrous apex and long-term drainage of the contents into the middle ear. Due to the abundance of neurovascular structures that limit the infracochlear compartment, attention and skill are essential in preventing complications.