Learning Objectives: The author will describe his experience with dealing with Indigenous Chronic Middle Ear disease in Northern Queensland, Australia. The management of this condition is co-ordinated with the collaboration of the “Deadly Ears” Program. “Deadly Ears” is an outreach program where otolaryngologists and supporting staff travel to rural and remote communities to provide primary intervention and screening. Most of the surgical management in the community involves adenoidectomy and myringotomy with or without ventilation tube insertion. Some simple tympanoplasties are performed in the community. A recent audit has found the repair rates are only 50%. The Authors practice involves providing a dedicated tertiary referral center and subspecialist Otologist support for the more at risk cases that are not treated in the community. By developing a non traditional public health frame work for referral and management, we have been able to achive a 90% attendance rate for surgical management. Considering the amount of chronic middle ear disease that we see, cholesteatoma is relatively rare. The majority of cholesteatoma disease is mesotympanic in nature with adhesive otitis media a rare finding. The majority of disease that is treated in this setting is Chronic Suppurative Otitis Media with dense granulation. This may be due to the active management that the “Deadly Ears” program provides that may change the nature of pathology. The Author treats all these cases aggressively with cartilage techniques as the mainstay of treatment. Age, air travel back to remote communities and active discharge in this setting has not made a difference to anatomical closure of disease. The author has developed a method of closure and packing that is simple for the local health care workers to manage in their remote community and allows for water exposure.