Vestibular schwannoma

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

Last reviewed: 5 Aug 2025

Last updated: 15 Sep 2023

Vestibular schwannoma is a histologically benign, generally slow-growing tumor that may remain stable for long periods on follow-up magnetic resonance imaging scans after initial detection.

Progressive unilateral sensorineural hearing loss is the most common presenting symptom, followed by tinnitus and intermittent dizziness; hemifacial numbness or pain may occur less frequently.

Larger tumors may cause headaches, ataxia, and obstructive hydrocephalus and may rarely be life threatening.

Diagnosis is confirmed by gadolinium-enhanced magnetic resonance imaging of the head.

Management includes observation (active surveillance), focused radiation (stereotactic radiosurgery or radiation therapy), or surgery.

Decision-making regarding tumor management is mainly based on the presenting tumor size, detection of growth during active surveillance, provider bias, baseline patient function (e.g., hearing status), and patient preference.

Definition

A vestibular schwannoma is a histologically benign, usually slow-growing tumor that develops from the vestibular divisions of the vestibulocochlear nerve, typically presenting with unilateral sensorineural hearing loss.[1][2] Vestibular schwannomas are also called acoustic neuromas; however, the term "acoustic neuroma" is a misnomer because the tumor actually grows from the vestibular component of the vestibulocochlear nerve, rather than from the cochlear or acoustic division, and is pathologically a schwannoma. Although most tumors are now diagnosed at a smaller size in people with less severe symptoms compared to the pre-magnetic resonance imaging era, some tumors are still only detected after growing quite large and may result in brainstem compression and hydrocephalus.[3]

History and exam

Key diagnostic factors

asymmetric hearing loss
progressive episodes of dizziness
tinnitus

Full details

Other diagnostic factors

difficulty localizing sounds
headache
facial numbness
facial weakness
diplopia on lateral gaze
nystagmus
loss of balance and coordination difficulties
slower blink
swallowing difficulties
gait disturbances
hydrocephalus
papilledema
increased intracranial pressure

Full details

Risk factors

neurofibromatosis-related schwannomatosis

Full details

Diagnostic tests

1st tests to order

audiogram
T1-weighted MRI using gadolinium-based contrast
contrast-enhanced head CT

Full details

Tests to consider

auditory brainstem reflexes

Full details

Treatment algorithm

ONGOING

small tumor (Koos grades 1-2)

medium tumor (Koos grades 3-4, tumor size <3 cm)

large tumor (Koos grade 4, tumor size >3 cm)

Contributors

Authors

Michael J. Link, MD

Professor

Departments of Neurologic Surgery and Otorhinolaryngology

Mayo Clinic

Rochester

Disclosures

MJL is an author of a reference cited in this topic.

Matthew L. Carlson, MD

Professor

Departments of Neurologic Surgery and Otorhinolaryngology

Mayo Clinic

Rochester

Disclosures

MLC is an author of a reference cited in this topic.

Acknowledgements

Dr Michael J. Link and Dr Matthew L. Carlson would like to gratefully acknowledge Dr Ryojo Akagami, the previous contributor to this topic.

Disclosures

RA has been reimbursed for instructing at a dissection course by Stryker and gives yearly lectures at a Canadian resident review course. RA was an expert panelist at a session on vestibular schwannomas at the 2019 NASBS meeting.

Peer reviewers

Rick Friedman, MD, PhD

Professor of Otolaryngology and Neurosurgery

UC San Diego

La Jolla

Disclosures

RF declares that he has no competing interests.

Iain Swan, MD, FRCS

Senior Lecturer in Otolaryngology

Honorary Consultant Otolaryngologist

Glasgow Royal Infirmary

Glasgow

Disclosures

IS declares that he has no competing interests.

Patrice Tran Ba Huy, MD

Department of Otorhinolaryngology-Head and Neck Surgery

AP-HP

Hopital Lariboisiere

Service ORL

Universite Paris 7

Paris and Laboratoire des Réseaux Sensorimoteurs

Paris

France

Disclosures

PTBH declares that he has no competing interests.

Peer reviewer acknowledgements

BMJ Best Practice topics are updated on a rolling basis in line with developments in evidence and guidance. The peer reviewers listed here have reviewed the content at least once during the history of the topic.

Disclosures

Peer reviewer affiliations and disclosures pertain to the time of the review.

References

Our in-house evidence and editorial teams collaborate with international expert contributors and peer reviewers to ensure that we provide access to the most clinically relevant information possible.

Key articles

Goldbrunner R, Weller M, Regis J, et al. EANO guideline on the diagnosis and treatment of vestibular schwannoma. Neuro Oncol. 2020 Jan 11;22(1):31-45.Full text Abstract

Ren Y, Chari DA, Vasilijic S, et al. New developments in neurofibromatosis type 2 and vestibular schwannoma. Neurooncol Adv. 2021 Jan-Dec;3(1):vdaa153.Full text Abstract

Lin VY, Stewart C, Grebenyuk J, et al. Unilateral acoustic neuromas: long-term hearing results in patients managed with fractionated stereotactic radiotherapy, hearing preservation surgery, and expectantly. Laryngoscope. 2005 Feb;115(2):292-6. Abstract

Pollock BE. Management of vestibular schwannomas that enlarge after stereotactic radiosurgery: treatment recommendations based on a 15 year experience. Neurosurgery. 2006 Feb;58(2):241-8. Abstract

Darrouzet V, Martel J, Enee V, et al. Vestibular schwannoma surgery outcomes: our multidisciplinary experience in 400 cases over 17 years. Laryngoscope. 2004 Apr;114(4):681-8. Abstract

Roland JT Jr, Fishman AJ, Golfinos JG, et al. Cranial nerve preservation in surgery for large acoustic neuromas. Skull Base. 2004 May;14(2):85-91.Full text Abstract

Reference articles

A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.

Differentials
- Meningioma
- Epidermoid cyst
- Facial nerve schwannoma
More Differentials
Guidelines
- EANO guideline on the diagnosis and treatment of vestibular schwannoma
- Guidelines on the management of patients with vestibular schwannoma
More Guidelines
Patient information
Tinnitus
More Patient information
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Vestibular schwannoma

Summary

Definition

History and exam

Key diagnostic factors

Other diagnostic factors

Risk factors

Diagnostic tests

1st tests to order

Tests to consider

Treatment algorithm

small tumor (Koos grades 1-2)

medium tumor (Koos grades 3-4, tumor size <3 cm)

large tumor (Koos grade 4, tumor size >3 cm)

Contributors

Authors

Michael J. Link, MD

Disclosures

Matthew L. Carlson, MD

Disclosures

Acknowledgements

Disclosures

Peer reviewers

Rick Friedman, MD, PhD

Disclosures

Iain Swan, MD, FRCS

Disclosures

Patrice Tran Ba Huy, MD

Disclosures

Peer reviewer acknowledgements

Disclosures

References

Key articles

Reference articles

A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.

Differentials

Guidelines

Patient information

Log in or subscribe to access all of BMJ Best Practice

Log in or subscribe to access all of BMJ Best Practice

Log in to access all of BMJ Best Practice