The principal objectives of acoustic neuroma surgery in the order of priority are absence of mortality and neurological morbidity, total removal of the lesion, preservation of facial function, and preservation of hearing. The aim of this work was to evaluate the selection criteria and the therapeutic strategy for hearing preservation in acoustic neuroma management. This retrospective study included 436 consecutive patients referred to our department for an acoustic neuroma. The population comprised 365 patients (84%) treated surgically, 66 patients (15%) managed conservatively, and 5 irradiated patients (1%). The mean age was 54 years (range: 13-87). The mean follow-up period was 24 months (range: 1-120). The surgical approaches were translabyrinthine in 294 (81%), retrosigmoid in 37 (10%), and through the middle fossa in 34 cases (9%). Approaches preserving the labyrinth were employed in patients aged less than 60 years with lesions measuring <or=2 cm and a serviceable hearing (pure tone average <50 dB and speech discrimination score >or=50%). A serviceable hearing was preserved in 53% of the cases with a serviceable hearing in 44% of the cases. Postoperative normal or subnormal facial function was obtained in 72 to 98% of cases depending on tumor size. Two cases (0.5%) of recurrence were reported. In conclusion, our surgical strategy based on age, tumor size and pre-operative hearing function permitted hearing preservation in 50% of selected cases, a high rate of facial function preservation and a low risk of recurrence.