This study aims to evaluate the surgical outcomes and clinical differences of elderly vestibular schwannoma (VS) patients (> 65 years), compared with non-elderly patients, focusing on baseline characteristics, preoperative symptoms, postoperative facial and auditory functions, and quality of life. A retrospective study was conducted on 59 elderly and 59 non-elderly patients, matched 1:1 by tumor size. All patients underwent retro-sigmoid microsurgery performed by the same neurosurgical team during the period from December 2018 to September 2023. Data including demographics, imaging findings, clinical symptoms, hearing, facial nerve function, and surgical outcomes were collected. Regular follow-up was conducted to assess postoperative recovery. Elderly patients had a longer disease course (median: 36 months) and a higher proportion with poor preoperative ASA scores (P < 0.001). Hearing loss was the most common symptom in the elderly group (n = 47, 79.7%), who were also more likely to have hydrocephalus (15.3%, P = 0.027) and balance disorder (25.4%, P = 0.006). Gross total resection rates were significantly lower in elderly patients (55.9% vs. 78.0%, P = 0.011). Postoperative and follow-up facial nerve function showed no statistical difference between groups, but hearing preservation was poor in both. Compared to non-elderly patients, elderly patients had longer disease courses, more preoperative symptoms, and slower postoperative recovery. Despite poorer general conditions and more comorbidities, advanced age should not be a contraindication for surgery, as long-term outcomes are favorable when individualized patient factors are considered.