Meningitis is an inflammation of the brain membranes and spinal cord. Bacterial meningitis etiology has been changed in recent decade due to H. Influenza (HIB), S. pneumonia and Meningococcal vaccination 12. It has different risk factors such as; head trauma, immune suppression, central nervous shunts, cerebrospinal fluid fistula/leak, neurological diseases , alcoholism, sinusitis, otitis media, pharyngitis, bacterial pneumonia, sickle cell disease, and congenital defects, age, social factors, exposures to pathogens, immunocompromising factors and drug usage 34567 cerebrospinal fluid analysis and culture is the best way for meningitis diagnosis. Some of the most complications that are associated with meningitis is; brain edema, hydrocephalus, infarcts, cerebral herniation and focal infection. They all need cranial CT scan for diagnosis 8.

An encephalocele is a rare congenital neural tube defect. It happens when brain tissues protrude through a hole in the skull. Temporal bone encephaloceles manifest either as a mass or cerebrospinal fluid (CSF) in the middle ear or mastoid or both. Temporal lobe encephalocele is a rare disease. It is estimated about 1/3000 to 1/350009. There are two main etiologies for the temporal lobe encephalocele; acquired (traumatic fracture, radiation, erosions, tumors, etc.) and congenital skull base defects 10. Temporal lobe encephalocele does not have any specific signs and symptoms; so the diagnosis is with delay most of the time. The patient should expect a lot of complications such as seizures, abscess, meningitis and venous infarction, if remain untreated.

A 10 years old boy was refered to Rasul Akram Hospital (tertiary hospital) in Tehran, Iran . The clinical presentation was headache, vertigo, and intermediate coughs for one week. The frontal and bitemporal headache intensified by head bending, just one-time fever before admission. He received Co-amoxicalve and diphenhydramine in out-patient. There wasn’t any pain relief by using the drugs and due to the headache worsening and vomiting he was taken to the clinic for serum therapy. His drug was changed to azithromycin. The day after serum therapy he had delirium and gradually leads to loss of consciousness (LOC), was intubated in first hospital, then referred and admitted in PICU of Rasool Akram hospital. In the admission day, he had a fever (39/1), pulse rate=114, respiratory rate=17, blood pressure=116/76. Pupils were in normal size and had reaction to light and his deep tendon reflexes (DTR) were decreased, no kerning or Brudzinski sign. Course crackles in both lungs and downward Babinski reflexes were found in his examination. He was self-extubated about four hours after admission to PICU and was oxygenated by nasal cannula without any decrease in O2 saturation.

An encephalocele usually happens when brain tissue herniates through a dural defect of the skull. Temporal bone encephaloceles show either as a mass or cerebrospinal fluid (CSF) in the middle ear or mastoid or both.

Cerebrospinal fluid otorrhea and temporal lobe encephaloceles (TLEs) including the tegmen tympani also mastoide are infrequent. neurotologic conditions that have become more common in the past 10 years. 11

Cerebrospinal fluid otorrhea and TLE come with serious aftermaths such as meningitis and brain abscesses, including conductive hearing loss and chronic middle ear effusion. 12

All temporal bone CSF usually occur through the tegmen (tympani or mastoideum) and through the temporal lobe dura. Posterior fossa plate that leak over the cerebellum are not common. 13

CSF leaks that are secondary to head trauma are well documented. It usually resolves spontaneously or with lumbar drainage within 1 to 2 weeks after the incident. 14

Usually, Preparatory radiographic evaluation begins with a high-resolution computed tomography (CT) of the skull base. A magnetic resonance imaging (MRI) study is helpful to display for the presence of an encephalocele and may confirm that the effusion has a similar signal characteristic as CSF. If CT and MRI are non-diagnostic, other imaging formats such as a radionucleotide cisternogram study could be helpful. 15 The gold standard confirmatory test for a CSF fistula is the presence of beta-2 transferrin in the fluid that was used as a sample. 16

A more frequent discovery is a soft compressible mass in the mastoid cavity comming off the tegment that may mimic a blue dome cyst or cholesterol granuloma. 17 Less frequent presentations include meningitis and seizures 18^17.

MRI is the gold standard technique for detecting brain tissue herniation in middle ear cavities. The involved tissue is shown as a mass iso-intense in all sequences in MRI. Hypo intense in T1 and hyper intense in T2 with diffusion weighted sequences 25 is seen in cholesteatoma and cholesterol granuloma appears hyper- intense in both T1 and T2. Administration of contrast only will show granulation tissues 24.

CT scan is the other technique for diagnosis. It is so much important to detect the size and location of the involved bones with high resolution computer tomography; but there is a defect with that which cannot detect the solidarity of soft tissues. It has limitation in detecting granulation, cholesteatoma, cholesterol granuloma or other soft tissue masses inside the middle ear cavity. 1920212223

Different surgical techniques now are available. Repairing the whole layers (bone and soft tissue) is more effective than the only repair in soft tissue, due the increased risk of recurrence 2526.

Middle cranial fossa craniotomy (MCF), trans mastoid and combined MCF/trans mastoid are one of the surgical techniques for temporal bone CSF-L which reduces the risk of meningitis, conductive hearing loss and otorrhea 27.

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