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Introduction: Hearing preservation is invariably a consideration when exploring treatment options for acoustic neuromas. We reviewed the long-term hearing results of patients who were treated using 1) hyperfractionated stereotactic radiotherapy (HSR), 2) hearing preservation tumor excision surgery (HPTES), and 3) expectantly (no treatment). Methods and Materials: Single institution retrospective chart review of 42 patients managed with HSR (1993-2003), 113 patients in whom HPTES was carried out, and 86 patients who were untreated (1974-2003). Hearing levels were graded according to the Gardner-Robertson classification. Results: The percent of patients managed with HSR initially who had serviceable hearing (class 1-2) was 68.8%. This fell to 6.7% in the follow-up interval. Of the group treated with HPTES, 100% had preoperative serviceable hearing. This dropped to 15.9% in the follow-up interval. The percent of patients managed expectantly who initially had serviceable hearing was 77.3%. This dropped to 33.3% during the follow-up interval. Mean follow-up periods were 4.0, 9.5, and 6.8 years in the HSR, HPTES, and expectant groups, respectively. Conclusions: Hearing acuity statistically worsened over the long term ( P < .01) in all three groups. There was a significant proportion of patients in whom hearing deteriorated from serviceable to nonserviceable hearing ( P < .01) during the follow-up interval. The decline was most significant in the groups treated with HPTES and HSR compared with the group treated expectantly ( P < .05). Hearing outcomes, in our experience, continue to be poor, but this is especially so in patients treated with HPTES or HSR. [ABSTRACT FROM AUTHOR]