An acoustic neuroma, also called a vestibular schwannoma, is a usually benign and slow-growing tumour arising from the sheath of the eighth cranial nerve, which carries hearing and balance signals from the inner ear to the brain. It sits in a narrow canal between the ear and the skull cavity, and because it grows in a tight space its symptoms begin early and quietly: gradual hearing loss in one ear, ringing in that same ear, and a sense of unsteadiness or dizziness on rapid movement. As it enlarges it may press on neighbouring nerves and cause facial numbness or weakness of facial movement. The most neglected symptom is hearing loss in one ear. Many patients attribute it to wax, a cold or ageing and postpone assessment for years. The practical rule is that any hearing loss or ringing in one ear but not the other deserves a hearing test and medical assessment, because a difference between the two ears is not a coincidence. Diagnosis rests on audiometry together with dedicated MRI of the inner ear region and the angle at the base of the skull, which is the study that reveals small tumours invisible on ordinary CT. There are three management pathways, and choosing between them is not a matter of personal preference: surveillance with repeated imaging, microsurgical removal, or targeted stereotactic radiotherapy delivering a concentrated dose aimed at stopping growth. Small tumours without troublesome symptoms may be monitored for years, because some never grow or grow extremely slowly; surveillance is a considered plan that commits you to precise imaging dates, not simply waiting. Large tumours, those pressing on the brainstem, and those causing deteriorating balance may need intervention. The limits of treatment must be understood before deciding. Neither surgery nor radiation restores hearing that has already been lost; the goal is to protect what remains and to halt tumour growth, not to recover the past. Tinnitus may persist after treatment and may not improve, and unsteadiness needs balance rehabilitation and weeks of exercises rather than time alone. There is a risk to the adjacent facial nerve that varies with tumour size, location and treatment type, and it is discussed openly before consent. The tumour type is only finally confirmed by histopathology when surgery is performed. Decisions here are made by a team of neurosurgeon, ENT surgeon, audiologist, radiation oncologist and radiologist. Suitability for any pathway is determined by clinical examination, audiometry, imaging, and the patient's age and general condition, not by online reading or by another patient's experience.
Procedure steps
- 1
Audiometry and clinical examination
Assessment begins with full audiometry comparing both ears and measuring speech understanding, together with examination of balance, eye movement, and facial nerve function and sensation. The patient is asked about the order and speed of symptom onset and about tinnitus and dizziness, because the pattern guides imaging and reveals other conditions that mimic the tumour.
- 2
Dedicated imaging and sizing
Contrast-enhanced MRI with thin sections through the internal auditory canal is requested to define the tumour's position, size and relationship to the brainstem and facial nerve. The measurement is recorded precisely so it can be compared with future scans, since a difference of a few millimetres separates a stable tumour from one that is growing and needs intervention.
- 3
Structured surveillance when chosen
For small tumours with few symptoms the decision may be surveillance with imaging and audiometry at defined intervals, initially close together and later spaced out if the tumour proves stable. The signs that justify an earlier review are explained, and the patient is asked not to postpone imaging merely because they feel no change.
- 4
Microsurgery or targeted radiation
When intervention is needed, microsurgical removal is performed through an approach chosen according to size and hearing status, with electrical monitoring of the facial nerve, and a small part may be left deliberately to protect that nerve. The alternative in selected cases is concentrated stereotactic radiation aimed at halting growth without opening the skull.
- 5
Rehabilitation and long-term follow-up
Balance rehabilitation starts early with daily exercises that train the brain to compensate, and hearing is reassessed to consider hearing-aid options if appropriate. Imaging follow-up continues for years after any treatment choice, and facial movement and eye dryness are monitored if the facial nerve has been affected.
Before the procedure
Bring all previous audiograms and MRI scans as digital files, because comparing hearing and tumour size over time is the basis for choosing between surveillance and intervention. Tell your doctor exactly when the hearing loss began and whether it was gradual or sudden, whether the tinnitus is in one ear, and when the dizziness started and whether it is true spinning or unsteadiness. Mention any numbness or weakness of half the face, dry eye, or change in taste. Report all your medicines, especially blood thinners, and any drug or contrast allergy or kidney problem. Tell the team if you have a pacemaker, a nerve stimulator, or metal that prevents MRI. Stop smoking early if surgery is being considered. If the procedure is surgical, follow fasting instructions to the hour and arrange someone to stay with you and drive you home. Before consenting, ask three direct questions: what is the goal of treatment, what is its expected effect on my hearing, and what is the risk to the facial nerve?
After the procedure
After surgery expect headache, fatigue and unsteady walking for some days; walk with help at first to avoid falls, keep the wound clean and dry, and avoid forceful nose blowing, heavy lifting and air travel until your doctor allows it. Do your balance exercises every day, because they are what restores steadiness; do not expect balance to improve with rest alone. After radiotherapy the tumour may remain visible on scans while inactive, and may even swell slightly for a time, which does not mean failure. If the facial nerve is affected, protect the eye with prescribed drops and cover it during sleep, because corneal dryness threatens sight. **Go to the emergency department immediately if you have: sudden hearing loss in either ear; sudden weakness of one side of the face; a severe headache that worsens or wakes you from sleep with repeated vomiting; severe drowsiness or confusion; clear fluid leaking from the nose, ear or wound; fever with a stiff neck; or severe spinning dizziness with vomiting that will not settle.** Do not postpone follow-up scans in the years after treatment.
Expected duration
Audiometry usually takes twenty to forty minutes and MRI thirty to sixty minutes. Under surveillance, scans are typically repeated every six to twelve months at the team's discretion. Microsurgery generally requires four to eight hours with a hospital stay of three to seven days, while a stereotactic radiation session is usually completed within a single day.
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