Juvenile nasopharyngeal angiofibroma is a combined vascular and fibrous neoplasm that most commonly affects prepubertal and adolescent boys. These tumors have traditionally been managed with open surgery, but interest in endoscopic resection-particularly for small tumors-has increased in recent years. To the best of our knowledge, no comparative study of open and endoscopic approaches for treating large, locally advanced tumors has been previously published in the literature. We conducted a retrospective study of 42 males, aged 6 to 21 years (mean: 13 ± 2.1), who had been treated for histologically proven and locally advanced juvenile nasopharyngeal angiofibroma with either open surgery (n = 29) or endoscopic excision (n = 13). Our two primary outcomes measures were local control and surgical morbidity. We found that the endoscopic approach was as good as or better than open approaches for patients with large tumors.