Conclusions: We consider that the transmastoid-epitympanum approach to decompression of the geniculate ganglion, without a craniotomy, combining the advantages of middle cranial fossa and transmastoid extralabyrinthine approaches, is simple, minimally invasive, safe, and effective, with little postoperative hearing change. It can be employed in some cases of facial palsy due to temporal bone fracture (TBF) and middle ear cholesteatoma (MEC) in accordance with the range of facial paralysis, facial nerve electrophysiology, and imaging guidance. Objective: To evaluate the efficacy of geniculate ganglion decompression of the facial nerve by the transmastoid-epitympanum approach. Methods: Thirty cases of facial palsy were reviewed, including patients with TBF and MEC. All the patients were evaluated by routine preoperative tests including high-resolution computed tomography (HRCT), audiometry, and electroneuronography, and were treated by transmastoid-epitympanum decompression. The negative effects on auditory function were recorded. Results: The mean percentage facial function improvement (House-Brackmann grade I-II) was 88% in TBF and 100% in MEC. The negative effects on auditory function were less than 10 dB in most cases.