Learning Objectives: Petrous Bone Cholesteatomas are very challenging lesions and require a thorough knowledge of skull base anatomy and surgical techniques for their management. Here we describe a unique case of a 44 year old male patient with a Massive Petrous Bone Cholesteatoma (according to the Sanna classification) encircling the petrous Internal Carotid Artery. This was excised using a Combined Transotic and Infratemporal Fossa Approach type B Approach to expose the anteromedial portions of the vertical tracts of the carotid. The cavity was closed by abdominal fat with a blind sac closure of the external auditory canal. The patient is free of disease after a 4 year follow-up.