Learning Objectives: Understanding the burden of cholesteatoma in the developing world. Consideration of optimum management strategies in resource poor settings.

Chronic Otitis Media and its effects include hearing loss, reduced Quality of Life (QoL) and life threatening complications. These are major public health problems in developing countries. Many reviews include data from small or old studies and make generalisations that may now be inaccurate. The prevalence of cholesteatoma in most developing countries is unclear. It appears to be less frequent in some populations such as parts of Africa and S America, but much commoner in others such as SE Asia. Understanding of Otitis Media and COM has taken major steps forward in recent years. Risk factors and causes are generally agreed, but those specifically for cholesteatoma are less clear, in a developing country context. Some factors are amenable to targeted public health and primary care interventions and some countries have seen reducing incidence of COM and its complications. Prevalence studies of COM rarely distinguish between types of COM such as mucosal central perforations and cholesteatoma. Often the skills and materials required for diagnosis are lacking in under resourced health systems. Most agree that the treatment of cholesteatoma requires surgery. The complications of cholesteatomatous COM are usually considered more severe than mucosal COM. Both can be life threatening and many cases of ‘safe’ COM can also benefit from surgery. In poor resource settings with few specialists, how can patients be identified and surgery delivered? Do out reach camps play a useful part? Extensive disease is common and late stage, often worse than commonly seen by specialists from developed centres. What forms of surgery are most cost effective and safe to teach? Can developed nations partner in the development and training of local specialists?

After over 30 years experience in such settings, principally in Nepal I hope to open up some of these questions.