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Objective: To evaluate the incidence of intratympanic membrane cholesteatoma (ITMC) in patients after tympanoplasty with the underlay technique., Design: Retrospective study., Setting: Ear, nose, and throat department, Tabriz University of Medical Sciences, Tabriz, Iran., Patients: A total of 1121 patients with central tympanic membrane perforation were evaluated after tympanoplasty., Interventions: Tympanoplasty was performed with the underlay technique using temporal facial graft., Main Outcome Measure: The patients were followed up to assess the postoperative incidence of ITMC., Results: During the follow-up period of 5 years, ITMC was observed in 9 patients (0.8%). Of these 9 patients, 8 were asymptomatic and had intact tympanic membranes. The asymptomatic cases were detected 1 to 2 years after surgery during routine follow-up examinations. Only 1 of 9 patients had otorrhea, which was due to a posterior perforation away from the location of the ITMC. The most common site of the ITMC was near the umbo., Conclusions: Even after tympanoplasty with underlay technique, ITMC may develop between the layers of the tympanic membrane. The most common location of these cholesteatomas is near the umbo, which may be the result of insufficient removal of the residual squamous epithelium from the handle of the malleus. The cholesteatomas are usually asymptomatic and can be detected during routine follow-up examinations 1 to 2 years after surgery. Although ITMCs are usually noninvasive in nature, a review of the literature revealed that in rare cases they can also show a rapid and invasive growth pattern. Early detection and removal of these asymptomatic cholesteatomas during routine postoperative follow-up examinations can prevent their progression as well as consequent residual problems and complications.