The middle fossa approach is indicated for procedures requiring access to the internal auditory canal, structures within the temporal bone, and adjacent structures. This is one of the three main approaches for the surgical repair of tegmental defects causing cerebrospinal fluid (CSF) leak. The middle fossa approach allows for an optimal view of the middle fossa floor for larger or multiple defects, ease of graft placement, and avoidance of the removal of ossicle to access the tegmen. Surgical intervention for CSF leak is indicated when conservative management fails or when spontaneous closure of a defect is unlikely. In this case, a middle fossa approach is used to surgically close a tegmen defect causing CSF otorrhea refractory to conservative management. This case highlights the step-by-step surgical techniques involved in this procedure including the surgical approach to expose the tegmen defect, repair of the tegmen defect using temporalis fascia and a bone graft, and craniotomy repair and closure.