Surgery that eliminates the open radical cavity takes three forms: obliteration (cavity fill-in, reconstruction (canal wall defect repair), or ablation (external canal closure). The evolution of each variety is reviewed in detail and a personal series of 240 cases is discussed. These included obliterations and reconstructions employing porous hydroxylapatite ceramic implants. Larger defects required Grote implants, but high facial ridge cases were managed with attic defect plates and limited canalplasty. Canal repair success rates improved with the use of the middle temporal flap to improve canal wall vascularity Residual cholesteatoma has been prevented by staged surgery, and recurrent disease has been virtually abolished by aggressive prevention techniques which employ drum reinforcement with finely shaven cartilage-perichondrium composite grafts. Ossiculoplasty procedures included 85 Plastipore columellas, 107 Oval-Top hydroxylapatite/Teflon columellas and, more recently, 17 Spanner malleus-stapes/footplate assemblies. Earlier poor results have been succeeded by more satisfactory levels. Since 1990, the air-bone gap has been closed to within 10 dB in 33% of cases and to within 20 dB in 66% of cases. Studies using SPITE (surgical, prosthetic, infection, tissues, and eustachian) adverse indicators have demonstrated high levels of pathology in elimination cases, when compared with nonelimination series. The SPITE studies have also demonstrated the reduction of pathology levels by staged surgery. Elimination surgery now provides permanent relief from the problem cavity in all but a few cases.