Ultrasound examinations are a standard procedure in the clinical diagnosis of many diseases. However, the efficacy of an ultrasound examination is highly dependent on the skill and experience of the operator, which has prompted proposals for ultrasound simulation systems to facilitate training and education in hospitals and medical schools. The key technology of the medical ultrasound simulation system is the probe tracking method that is used to determine the position and inclination angle of the sham probe, since this information is used to display the ultrasound images in real time. This study investigated a novel acoustic tracking approach for an ultrasound simulation system that exhibits high sensitivity and is cost-effective. Five air-coupled ultrasound elements are arranged as a 1D array in front of a sham probe for transmitting the acoustic signals, and a 5 × 5 2D array of receiving elements is used to receive the acoustic signals from the moving transmitting elements. Since the patterns of the received signals can differ for different positions and angles of the moving probe, the probe can be tracked precisely by the acoustic tracking approach. After the probe position has been determined by the system, the corresponding ultrasound image is immediately displayed on the screen. The system performance was verified by scanning three different subjects as image databases: a simple commercial phantom, a complicated self-made phantom, and a porcine heart. The experimental results indicated that the tracking and angle accuracies of the presented acoustic tracking approach were 0.7 mm and 0.5°, respectively. The performance of the acoustic tracking approach is compared with those of other tracking technologies.