The patient came to the clinic 19-July-2014 complaining of CSF leak after trauma 10 years ago with recurrent episodes of meningitis for 5 years. Remission took place, but the last 2 months got CSF leak from the left nostril. CT-scan done 19-June-2014 bad quality, not informative.

On examination; the patient is neurologically free, except the episodes of the CSF leak with headache and decreased hearing left ear. The patient was sent for thorough investigations: MRI 22-July-2014 showing CSF pocket in the eroding left middle fossa. CT-scan with with reconstruction using ORS Visual showing the bony destruction reaching the cochlea of the left pyramid.

Osteoplastic craniotomy immediately above the left ear with reflection of the flap anterior. Extradural approach to the subtemporal area. The old fracture of the anterior part of the petrous bone exposed. It was necessary to perform also intradural approach to inspect the structures intradurally. There was a huge bony defect in the posterior part of the left cavernous sinus. The left oculomotor nerve was seen running under the defect. There was a huge fossa anterior to the foramen ovale, through which the left V1 was running. The dural defect was filled with muscle harvested from the temporal muscle and glue used to keep the muscle in place. This was done to avoid mechanical trauma to the running left oculomotor nerve running under. Using bone granules 5 ml the cavity anterior to the foramen ovale and the bone defect in the petrous bone were filled snuggly extradurally to prevent any other unseen defects. Glue was applied over the bone granules. The dura was closed water-tightly and routine closure of the wound.

Smooth postoperative recovery. The patient was sent to the ICU for 12 hours observation.

The patient has CSF leak from the old bony fracture of the left middle ear reaching the Eustachian tube and eroding the entire left middle fossa. All the suspected sources of the CSF leak must be dealt accordingly.