A conservative approach to the management of acoustic neuromas in elderly patients has been used since 1971. Elderly patients without symptoms of brain stem compression are initially treated by observation and yearly radiographic imaging. A translabyrinthine radical-subtotal resection is performed if brain stem compression is present or if tumor is growing rapidly. Twenty-three patients, ages 65 to 86 years, had initial nonsurgical management of their tumors. Growth rates could be determined for 16 patients. Thirteen patients not requiring surgery had an average tumor growth rate of 0.6 mm/yr. Three patients with an average growth rate of 6.8 mm/yr eventually required surgery. No patient whose tumor was < 15 mm at initial evaluation has experienced brain stem symptoms or demonstrated rapid tumor growth. Twenty-four patients ages 65 to 86 years underwent planned subtotal tumor excision. Eighteen patients followed postoperatively for more than 1 year demonstrated an average rate of regrowth of tumor of 0.7 mm/yr.

An algorithm has evolved for the management of patients with acoustic neuroma. Decisions as to surgery vs. observation, surgical approach, and whether hearing preservation should be attempted depend on age, patient symptoms, size of the tumor, residual hearing, and degree of facial nerve involvement at the time of surgery. Conservative management is used for patients over 65 years of age. This consists of observation or subtotal resection through a translabyrinthine approach, depending on the absence or presence of brainstem signs or symptoms. In patients under 65 years of age, hearing preservation is attempted through the retrosigmoid approach in tumors 1.5 cm or less if pure-tone average is less than 30 dB and the discrimination score is greater than 70%. The translabyrinthine approach is our preferred approach for tumors of any size when hearing is not serviceable. A near-total excision is performed when the facial nerve cannot be separated from the tumor. The rationale for this algorithm in the management of 130 cases of acoustic neuroma over the past 17 years is presented.

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