Endovascular treatment of ethmoidal dural arteriovenous fistulae (DAVFs) has become technically feasible, but its relative risks and benefits have not justified its use. We present a series of patients with ethmoidal DAVFs treated almost exclusively with surgery at an institution where expert endovascular therapy was available. Surgical risks, treatment efficacy, and patient outcomes were determined for comparison with published endovascular data. Sixteen patients with ethmoidal DAVFs were treated during a 17-year period from 1982 to 1999. In three patients, feeding arteries from the internal maxillary artery were embolized; no ophthalmic artery embolizations were performed. A low bifrontal surgical approach was used in most patients to expose, coagulate, and divide the fistulous site. Ethmoidal DAVFs were occluded grossly and angiographically in all 16 patients. There was no treatment-associated neurological morbidity, and clinical outcomes were good in all but one patient who was comatose initially. Review of our surgical experience with ethmoidal DAVFs as well as published endovascular results for these lesions suggests that endovascular management of ethmoidal DAVFs has a small but clinically significant risk to vision, is rarely effective in curing the fistula, and does not eliminate the need for surgery. In contrast, surgical management has no associated risk to vision, is highly effective at obliterating the fistula, and can contribute to good clinical outcomes in most patients. For these reasons, surgical management of ethmoidal DAVFs remains the treatment of choice.