Auditory neuromas originate from the neurohypophyseal portion of the auditory nerve, mostly in the vestibular branch. The tumor is a neoplasm of Schwann cells, and the correct name should be auditory nerve Schwannoma or auditory nerve sheath tumor. Extraosseous auditory neuromas may protrude into the vicinity of the pontocerebrum and pontocerebrum and push to the opposite side, and may force the cerebellum to shift upward or downward, forming a cerebellar cone. The tumor continues to grow and may extend superiorly to the cerebellar curtain and, in a few cases, to the greater occipital foramen. The cerebral nerve at the pontocerebellar angle is often stretched and thinned by the tumor of the auditory nerve. In the later stages of growth, auditory neuromas outside the posterior cranial fossa are bound to cause increased intracranial pressure, which is mainly due to the formation of hydrocephalus. Hydrocephalus is mostly caused by the obstruction of cerebrospinal fluid circulation in the cerebral pool due to tumor compression, and may also be combined with obstruction of the aqueduct or the fourth ventricle. Indications: Auditory nerve syringomyelia in the internal auditory tract and pontocerebellar horn. (1) A 5-6 cm vertical incision is made at the posterior border of the mastoid process. The incision is made under the muscle and periosteum to expose the superior and inferior collateral ligaments, and the occipital bone is revealed by dissecting the two sides of the incision with a stripper. (2) A circular bone groove of 3 cm in diameter is made behind the sigmoid sinus with an electric drill. The free bone fragment inside the groove was taken and immersed in saline for preservation. The edges of the groove are trimmed with biting forceps to form a round bone window, and a T-shaped meningeal incision is made in the window. The meningeal flap is turned up and sutured to the muscle at the window, and the soft tissue is retracted with a pulling hook. At this time, 20% mannitol (250-500 ml) is administered as a drop to shrink the brain tissue and lower the cranial pressure. Dry frozen meninges or fibrin membranes (or saline cotton sheets) are taken and applied to the cerebellar surface for the purpose of protecting the cerebellum. (3) Reach into the brain plate and gently pull the cerebellum apart. The cerebellum is too delicate to withstand the direct pressure of the metal brain plate and must be covered with a membrane-like item as a pseudomeningeal to replace the dura for protection from cerebellar compression, edema or hemorrhage. (4) Bluntly detach the arachnoid membrane between the cerebellum and the posterior aspect of the rock bone to access the pontocerebellar horn. The overflowing cerebrospinal fluid is aspirated away. For tumors with smaller tumors, separation can be performed between the arachnoid and tumor envelope. Gently traction on the tumor may lead to the facial auditory nerve and the anterior inferior cerebellar artery off the lower part of the brainstem. Careful peeling may remove the entire tumor. If there are more adhesions and the facial nerve near the brainstem is not accessible, it is advisable to cut open the envelope and reduce the size of the tumor before separation. Tumors that enter into the internal auditory canal can be peeled off after grinding the posterior wall of the internal auditory canal with electric drill, but most of them are pulled out by traction. (5) Removal of larger auditory neuroma (diameter >2cm) should be performed slowly and carefully, firstly, the pericardium should be cut open and intrapericardial resection should be performed. The upper and lower poles of the intraperitoneal tumor are then removed to locate the facial nerve and cochlear nerve. Outside the internal auditory portal, the facial nerve is often located anteriorly and inferiorly to the tumor, and the cochlear nerve is located posteriorly and inferiorly to the tumor. If the tumor is stretched intraoperatively and bradycardia occurs, it indicates that the brainstem is affected by external forces and there is likely adhesion between the tumor and the brainstem. The change of heart rate during surgery is a dangerous warning sign, so it is advisable to temporarily terminate the surgery and closely observe the change of heart rhythm. Whether to continue the operation should be decided according to the patient’s age, tumor blood supply and brainstem adhesions. (6) After tumor removal and adequate hemostasis, remove the dry-frozen meninges or coverings made of other materials. Before repairing the meningeal fissure, a layer of fascia (taken from the temporalis muscle or broad fascia) is lined under the meninges. The meningeal fissure is sutured while crossing the fascia to enhance the degree of bridging of the fissure and to completely prevent cerebrospinal fluid leakage. The bone fragment is filled over the bone window and the skin incision is sutured. Caution: Pay attention to timely management and prevention of complications, which are closely related to the size of the auditory neuroma, the proficiency of the surgical operation, and the patient’s general condition. One of the serious complications that occur immediately after surgery is the formation of an intracranial hematoma due to bleeding. The early sign of intracranial hematoma formation is a reflex blood pressure surge caused by increased cranial pressure, which is followed by an emergency return to the operating room or in the intensive care unit to open the wound, remove the clot, and stop the bleeding completely under the operating microscope. Another serious complication is cerebral edema, which should be monitored intensively and, if necessary, some of the infarcted cerebellar tissue should be removed. Cerebrospinal fluid leakage is most often caused by inadequate filling and repair of the surgical cavity or by inadequate suturing, but most can be terminated after the skin wound has healed. Excessive cerebrospinal fluid flow or prolonged failure to stop will require reoperative management. In addition, prolonged surgical retraction of the cerebellum or removal of the external cerebellar hemispheres can cause cerebellar pathology such as dysmotility, tremor, or poor distance discrimination. Surgical removal or injury to the facial nerve can cause peripheral facial palsy and predispose to exposure to corneal infection. Disruption of the anterior inferior cerebellar artery is one of the most dangerous complications and can lead to ischemic infarction of the brainstem and death. In individual cases, involvement of the anterior inferior cerebellar artery can cause arterial spasm, which is also a threat to the brainstem. In recent years, the use of microsurgical techniques and new surgical approaches for the removal of auditory neuromas has significantly improved surgical safety and reduced surgical mortality. Surgical mortality varies with the size of the tumor, ranging from 0%-2% for small auditory neuromas and less than 10% for large auditory neuromas, in which the sub-removal rate is reduced to less than 10%. The rate of facial nerve function preservation has improved significantly, with 94% for small tumors, 93% for medium tumors, and 65% for large tumors (Glasscock, 1978). In the elderly, complications and mortality rates of auditory neuroma surgery are quite high. From the reports of Cushing in 1917, Oliverona in 1940, Ednard in 1951, Pool in 1957 and Ditullio in 1978 on the removal of auditory neuromas by suboccipital approach, there was only 1 patient over 70 years of age out of 1100 cases. Since auditory neuroma is a slow-growing benign tumor, the aim of surgery for auditory neuroma in elderly patients should focus on reducing cranial pressure and preserving function. Therefore, intraperitoneal resection of the tumor is usually performed. The tumor contents in every corner of the envelope should be removed as much as possible, especially in the posterior cranial fossa, and as far as possible from the facial nerve and brainstem until the envelope is atrophied. However, in the vicinity of the internal auditory meatus and Bill’s septum near the facial nerve and brainstem, the removal should be limited. After removal of intraperitoneal tumor, the brainstem, cerebellum and trigeminal nerve can be decompressed, hydrocephalus and meningeal signs can be relieved, and postoperative headache can be significantly reduced, and facial muscle movement can be preserved. In conclusion, we should try to remove all the auditory neuromas in young people, while in elderly people, the purpose of removing auditory neuromas is to spend the rest of one’s life in peace and happiness. Postoperative management: (1) Pay attention to the observation of the mental state, pupils, blood pressure and heart rate, and understand the occurrence of intracranial hematoma and intracranial infection. (2) Apply antibiotics and prevent infection. (3) Apply mannitol in appropriate amount after surgery to avoid high intracranial pressure.