Three cases of brain abscess caused by Actinomyces israelii are reported which were successfully treated by burr hole aspiration and a short course of antibiotics (3-4 weeks). The clinical response of the patients, as well as the serial serum C-reactive protein levels and CT findings were used as a guideline for stopping antimicrobial therapy relatively early. Introduction Fifty per cent of brain abscesses in adults and 25 per cent of those in children are otogenic in origin. The current neurosurgical options are to drain the abscess repeatedly through burr holes or to excise it completely with the capsule. We successfully managed 10 cases of brain abscess by draining through the transmastoid route. The technique and its advantages are discussed. Material and methods The patients underwent surgery at two different institutions. Computed tomography scanning and magnetic resonance imaging were performed, along with diffusion-weighted imaging and in vivo proton magnetic resonance spectroscopy. The abscesses were drained via a transmastoid route. Results In eight cases, ear disease and brain abscess were treated in a single-stage procedure. In the remaining two cases, residual brain abscess was excised subsequently by our neurosurgical colleagues. Conclusions Transmastoid drainage of pus can successfully treat mastoid disease and brain abscess in a single surgical intervention. Residual abscess can be subsequently excised, with relatively reduced morbidity. Repeated needling is also avoided with this approach. Diffusion-weighted imaging and proton magnetic resonance spectroscopy are helpful.