Chronic suppurative otitis media (CSOM) is an advanced, persistent form of otitis media (OM) which is characterized by chronic inflammation of the middle ear cleft (MEC), in the presence of a non-intact tympanic membrane leading to frequent and recurrent otorrhea from the ear. CSOM is most prevalent in South East Asia and the Western Pacific and among indigenous populations of North America. The management of CSOM has two principal aims: First, to eradicate infection and hence reduce morbidity and mortality, second, to close the tympanic membrane perforation to reduce hearing loss and risk of reinfection of the middle ear (ME). Recognition of cases that are better managed surgically should be prompt to avoid delayed treatment and reduce morbidity. In some cases this means instituting treatment to stop discharge from the ear before it can be established whether the patient has either active mucosal chronic otitis media (COM) or active squamous COM (cholesteatoma) both of which require surgical intervention. Emerging evidence suggests that biofilms play an important role in the disease process.