Purpose <p>This study aimed to compare cochlear function in patients with chronic suppurative otitis media (CSOM) with and without cholesteatoma and to identify clinical predictors of mixed hearing loss.</p> Methods <p>A retrospective comparative study conducted at the Otorhinolaryngology Department, Benha University Hospitals, Egypt, from April 2024 to April 2025. Sixty-two patients with unilateral CSOM and complete audiologic and radiologic data were included, comprising 30 with cholesteatoma and 32 without. Evaluations included pure-tone audiometry, speech reception threshold (SRT), speech discrimination score (SDS), and temporal bone computed tomography. Cholesteatoma severity was staged using the EAONO/JOS classification. Multivariate regression analyses were performed to identify factors associated with mixed hearing loss and air- and bone-conduction pure-tone averages (PTA), with bone-conduction PTA serving as a surrogate for cochlear involvement.</p> Results <p>Disease duration was significantly longer in the cholesteatoma group (<i>P</i> = 0.023), while other baseline characteristics were comparable. Hearing metrics (PTA, SRT, SDS) did not differ significantly between groups. Multivariate analysis identified advancing age and longer disease duration as independent predictors of mixed hearing loss, whereas the presence of cholesteatoma was not.</p> Conclusion <p>Cholesteatoma was associated with longer disease duration but was not independently associated with measurable cochlear involvement, based on the audiometric measures and cross-sectional design employed. Age and disease chronicity were the primary determinants of audiometric patterns compatible with cochlear involvement, underscoring the importance of early diagnosis and timely management.</p>