Cholesterol granulomas of the temporal bone without clinical symptoms of chronic otitis media may result from an indolent inflammatory process caused by a congenitally blocked group of air cells. A unique case of giant bilateral cholesterol granulomas of the temporal bone is presented to support this theory. Management allowed bilateral surgical removal with hearing preservation. The differentiation between cholesterol granuloma, giant cholesterol cyst and other lesions of the temporal bone is discussed. The presumed pathogenesis of this condition is reviewed.