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Chronic otitis media, unlike trauma, seldom leads to the development of tension pneumocephalus. Rarely, it occurs as a complication of mastoid surgery. A Melanesian woman sought treatment for loss of speech, hemiparesis, and headache 4 weeks after undergoing canal-down mastoidectomy for cholesteatoma. The tension pneumocephalus was decompressed urgently by aspirating air via a cannula through the burr hole, and the mastoid cavity was obliterated. She recovered completely. Twelve additional patients with postmastoidectomy pneumocephalus reported in the literature are reviewed.