The primary aim of treatment of cholesteatoma is to attain a dry, safe, stable ear, free of disease. Maintaining or improving hearing is important but the pursuit of a hearing result should not compromise this primary aim. This study reviews the long-term outcome of 133 patients, suffering from advanced disease, who underwent modified radical mastoidectomy between 1995 and 2000. Of these, 49 per cent had had previous mastoid surgery elsewhere. A dry, waterproof ear was attained in 95 per cent of patients. In 77 per cent of patients, hearing was unchanged or improved. In this period, there were two cases of significant post-operative loss in bone conduction, including one dead ear secondary to suppurative labyrinthitis. There were epithelial pearls on follow up in two per cent. These results indicate that when properly performed, modified radical mastoidectomy provides safe surgical access and clears disease with low recurrence rates while mostly maintaining or improving hearing.