Grade II and III (according to Sadé's classification) retraction pockets (RPs) in 40 ears of 30 children were excised transmeatally with simultaneous ventilation tube insertion. At a mean follow-up of 16.1 months, an intact tympanic membrane and mild, grade I retractions not requiring treatment were observed in 32 ears (80%). The mean air-bone gap had decreased from 22.4 to 9.7 dB. Two residual perforations and six recurrent grade II RPs were detected, all these eight ears undergoing further surgery. The second surgery solved both of the residual perforations and four of the six grade II recurrences. The age of the children did not influence the success rate, whereas bilateral pathology, a higher grade and more extensive RPs were associated with a higher rate of unsuccessful cases. A staging system is introduced to ease the selection of candidates with a good prognosis for this procedure.