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We report a combined otoneurosurgical approach in the treatment of a patient with meningitis due to an arachnoid cyst, extending through the dura and petrous bone into the middle ear. The combination of mastoid surgery and temporal craniotomy including opening the dura was necessary to determine the nature of the problem, excise the disease and repair the defects.Two recent cases at our Institution of cerebrpspinal otorhinorrhea and chronic ear disease illustrate the difficulty in carrying out definitive repair of dural defects from within the mastoid cavity. Case 2 had three bouts of menmgitis and two brain abscesses separated by 25 years. Case 3 had eight bouts of meningitis in 19 years.The authors recommend an otoneurosurgical team approach in patients with cerebrospinal otorhinorrhea permitting treatment of the temporal bone, dura and brain.