The management options available for vestibular schwannoma (VS) have expanded and a nuanced approach to the decision making pathway is required. Patient factors influencing decision making include hearing status, tumor size and morphology, temporal bone anatomy, patient age and personal preferences. Each of these factors impact on the treatment algorithm and are used to recommend observation, radiosurgery or microsurgery. Each treatment choice is associated with benefits and risks which will be discussed in detail. Radiosurgery has been used for treatment of VS since the 1960s and is an excellent choice for some patients. The rationale and a description of treatment planning will be presented. The open surgical approaches with the risks and benefits will be explored including operative videos. The multidisciplinary team counseling the patient is often guided by their training and experience; the panel consists of members with diverse training and practice backgrounds who will explore differences of opinion on various treatment options. The components and dynamics of a successful skull base team will be discussed as well.