Purpose <p>This prospective, non-randomized intervention study aimed to compare hearing outcomes and patient satisfaction between stapedotomy and hearing aid rehabilitation in individuals with untreated otosclerosis.</p> Methods <p>A total of 134 adults diagnosed with otosclerosis were recruited from four Swedish clinics. Participants self-selected treatment after receiving standardized information: 91 chose stapedotomy and 43 opted for hearing aids. Hearing outcomes were assessed pre- and one year post-intervention using pure tone audiometry, sound field (SF) warble tones, and speech reception thresholds (SRT) in noise using the Hagerman matrix test. Patient satisfaction was also evaluated.</p> Results <p>Baseline audiometric thresholds were similar between the two groups. At follow-up, stapedotomy resulted in greater low-frequency SF threshold improvements at 250 and 500&#xa0;Hz (<i>p</i> &lt; 0.001 and <i>p</i> = 0.002, respectively), and significantly better SRT in noise (<i>p</i> = 0.004). Subjective satisfaction was high in both groups, but was significantly greater among stapedotomy recipients (<i>p</i> = 0.019).</p> Conclusion <p>Stapedotomy was associated with better speech-in-noise recognition, low-frequency hearing gain, and patient satisfaction compared to hearing aids in otosclerosis patients, although both treatments were effective. Treatment choice should consider individual clinical profiles, patient preferences, and potential risks, as stapedotomy is associated with more serious adverse effects despite superior auditory outcomes.</p>