Mucosal melanoma of the nasal cavity and paranasal sinus is always associated with poor prognosis, and 5-year overall survival does not exceed 40%. Our study aimed to compare the intraoperative conditions and prognosis of different surgical techniques to determine the optimum surgical approach for patients with mucosal melanoma of the nasal cavity and paranasal sinus. This was a retrospective analysis of 54 patients who received treatment at Beijing Tongren Hospital between January 2004 and December 2016. The patients were divided into two groups: those who received endoscopic surgery and those who underwent traditional open resection. The study analyzed the operative methods, the intraoperative conditions, and the prognosis of the patients. SAS JMP Pro software was used for statistical analysis of the data. There were 27 patients in the endoscopic surgery group and 27 patients in the open surgery group. Each group had the same distribution in terms of AJCC staging, with seven stage III, 12 stage IVA, and eight stage IVB patients in each group. There were statistically significant differences in operative time, complications, and cosmetic effects between the two groups, but no difference in local recurrence, disease-free survival, or overall survival. In the endoscopic surgery group and open surgery group, local recurrence rates were 14.81 and 11.11%, respectively, and metastasis rates were the same in both groups (40.74%). With regard to long-term prognosis, there was no statistically significant difference between the different surgical techniques, especially in terms of survival benefit. We believe that endoscopic surgery with protection of local function can be recommended for mucosal melanoma of the nasal cavity and paranasal sinus on the basis of its advantages in terms of shorter duration of surgery and fewer complications. In addition, it achieves better postoperative cosmetic effects with minimal scarring on the face of the patient, and thus improves postoperative quality of life.