Management of vestibular schwannoma in the elderly

The elderly population has been expanding and is expected to continue to do so in the future. This, together with advances in work-up for SNHL, led to an increase in the incidence of VS, with smaller tumor sizes and older ages at the time of diagnosis. One-third of VS exhibit growth, with an average growth rate of 2mm/year. Larger extracanalicular tumors are more likely to grow independent of patient age. Patients with higher baseline SDS fare better, and those managed conservatively have a higher preservation of facial function. Despite extensive research, standardized treatment for VS has yet to be implemented, especially in the elderly population, given the many individual variations. Watchful waiting is a reasonable option for smaller tumors, especially on initial follow-up, providing the highest rates of hearing and facial nerve preservation. An alternative option, which is especially advantageous in high-risk elderly populations, is radiosurgery, providing more than 94% tumor control rate with roughly 57% hearing preservation rate on long-term follow-up. Radiosurgery may be used alone or as an adjunct to microsurgery. Finally, microsurgery remains a feasible option for properly selected elderly patients with reasonable surgical risk, and large Koos grade 4 tumors generally not amenable to radiosurgery.