This is the first cost effectiveness modelling study looking at the three main treatment options for small to medium sized vestibular schwannomas. This study uses the widely accepted cost per quality adjusted life year (QALY) outcome measure to evaluate three hypothetical cohorts of adult patients receiving conservative, radiosurgery or surgical treatment. The model used finds initial conservative management to be the most cost effective treatment strategy available for small to medium sized vestibular schwannomas (extrameatal diameter less than 2cm). Slow growth allows two-thirds of these to never require aggressive treatment. Overall this strategy appears to offer more QALYs at a lower cost, yet overall quality of life data in this patient population continues to need evaluation.