The middle fossa approach is useful for the removal of small acoustic tumors when hearing preservation is possible. This approach provides complete exposure of the contents of the internal auditory canal and positive facial nerve identification. Because access to the posterior fossa is limited, the middle fossa approach is most appropriate for tumors with less than 5 mm extension into the cerebellopontine angle. With the introduction of gadolinium-enhanced magnetic resonance imaging, very small acoustic tumors are diagonosed more frequently, and the middle fossa approach is well-suited for the removal of these tumors.