OBJECTIVE: To evaluate hearing preservation (HP) outcomes for patients with small sporadic vestibular schwannomas (VS) who elect to undergo microsurgical resection. STUDY DESIGN: Retrospective study. SETTING: Tertiary single-academic institution. PATIENTS: Individuals 18 years or older with small sporadic VS (≤15 mm) who underwent microsurgical resection from 2018 to 2023. INTERVENTIONS: Microsurgical resection via a middle cranial fossa (MCF) or retrosigmoid (RS) approach. MAIN OUTCOME MEASURES: Postoperative HP (word recognition score ≥ 50%) and facial nerve function. RESULTS: Of the 230 consecutive patients with small sporadic VS who elected to undergo microsurgical resection, hearing was preserved in 61% of patients. When stratified by tumor size, patients with tumors ≤10 mm had a 72% hearing preservation rate. On multivariate analysis, the most important prognostic factors for hearing preservation were the presence of preoperative vertigo (OR, 0.33
95% CI, 0.17-0.52) and tumor size. Patients with tumors between 0 to 5 mm and 5.1 to 10 mm had 3.62 higher odds (95% CI, 1.39-9.4) and 2.52 higher odds (95% CI, 1.30-4.9) of hearing preservation, respectively, when compared to patients with tumors that were larger than 10 mm. At the time of last follow-up, a House-Brackmann (HB) 1 or 2 was maintained in 95% (n = 218) patients. CONCLUSIONS: Microsurgical resection for patients with small VS is associated with good hearing preservation and excellent facial nerve outcomes. Because larger tumor size portends poorer hearing outcomes, for patients who elect to undergo microsurgical resection for hearing preservation, proactive surgical intervention when tumors are ≤10 mm should be considered to increase the likelihood of hearing preservation.