Introduction: The management of acoustic neuroma has changed over the years, early diagnosis together with improved imaging facilities & the availability of different management options have raised patients’ treatment expectations. There is in addition an abundance of information on the internet. Three main therapeutic options are available: Surgery, radiotherapy, and conservative management or "watch(Scan) & wait". We report our experience in the multidisciplinary management of acoustic neuroma at our dedicated skull base clinic over the past 20 years.

Methods: From 1990 to 2010, we have maintained a database of patients presenting to our multidisciplinary skull base clinic. This contains in excess of 500 patients. these have been divided into groups of 1-4 each comprising of 5 year periods. Data was also acquired from retrospective chart review. Hearing was assessed according to the Gardner-Robertson classification & facial nerve function was assessed according to the House-Brackmann Grade. Maximum Tumour Dimension (MTD) was classed as the longest measurable distance on a single image on T2 MRI.

Results: There was a linear increase with time in the proportion of preoperative patients with serviceable hearing.This trend is statistically significant.Tumour size became significantly smaller year on year.This may correspond to observed change in the clinical presentation of acoustic neuroma. Our experience is that though surgery remains the cornerstone of management, Its overall contribution is falling, whilst increasingly more cases are being managed with radiotherapy and conservative management. Factors associated with a decision to operate were Age <65 Tumour size> 25 mm Servicable hearing at presentation

Conclusions: There has been an evolution in the management of acoustic neuroma as witnessed over the past 2 decades. We are seeing smaller tumors & fewer cases with hearing and or CN VI dysfunction. There has been a trend towards greater use of stereotactic radiotherapy and in a "watch & wait "policy. Microsurgical emphasis has shifted to facial nerve & hearing preservation where possible.

Patient Care: Our research will aid current & future generations of physicians guide patents treatment choice in acoustic neuroma. Learning from past experience can shorten the steep "learning curve" for the young neurosurgeon and facilitate better patient selection.

Learning Objectives: There has been an evolution in the management of acoustic neuroma as witnessed over the past 2 decades. We are seeing smaller tumors & fewer cases with hearing and or CN VI dysfunction. There has been a trend towards greater use of stereotactic radiotherapy and in a "watch & wait "policy. Microsurgical emphasis has shifted to facial nerve & hearing preservation where possible.

References: Stereotactic radiosurgery, microsurgery, and expectant management of acoustic neuroma: basis for informed consent. Wackym PA. Otolaryngol Clin North Am. 2005 Aug; 38(4):653-70. The natural history of untreated sporadic vestibular schwannomas: a comprehensive review of hearing outcomes. Sughrue ME, Yang I, Aranda D, Lobo K, Pitts LH, Cheung SW, Parsa AT. J Neurosurg. 2010 Jan;112(1):163-7. Facial nerve outcome after microsurgical resection of vestibular schwannoma. Marouf R, Noudel R, Roche PH. Prog Neurol Surg. 2008;21:103-7.