Objective To investigate the postoperative effect of hydroxyapatite reconstruction of the lateral wall of the epitympanic recess or the posterior wall of the external auditory canal in transcanal endoscopic atticotomy for cholesteatoma. Methods A total of 40 patients with epitympanic cholesteatoma who underwent surgical treatment in the Department of Otolaryngology of our hospital from January 2018 to January 2025 were selected as the research subjects. According to the random number table method, they were divided into the control group and the study group, with 20 patients in each group. The control group used tragal cartilage-perichondrium to reconstruct the lateral wall of the epitympanic recess or the posterior wall of the external auditory canal, and the study group used hydroxyapatite for reconstruction. The tympanic membrane healing, air-bone gap at different frequencies and postoperative dry ear time were compar ed between the two groups. Results The good healing rate of the tympanic membrane in the study group was higher than that in the control group, and the tympanic membrane perforation rate was lower than that in the control group (P <0.05). After treatment, the air-bone gaps at 0.5, 1.0, 2.0, and 4.0 kHz in the two groups were lower than those before treatment (P <0.05), but there was no significant difference in the air-bone gaps at 0.5, 1.0, 2.0, and 4.0 kHz between the two groups after treatment (P >0.05). The postoperative dry ear time in the study group was shorter than that in the control group (P <0.05). Conclusion In transcanal endoscopic atticotomy, hydroxyapatite and tragal cartilage-perichondrium are comparable in improving the hearing of patients when reconstructing the lateral wall of the epitympanic recess or the posterior wall of the external auditory canal, but hydroxyapatite has shorter postoperative dry ear time and better tympanic membrane healing effect, which is more advantageous.