Objective: To evaluate the effect of surgery on survival in patients with stage I nasopharyngeal carcinoma (NPC), since the role of surgery in the initial treatment of patients with stage I NPC. Methods: Patients with stage I NPC diagnosed from 2004 to 2015 were collected from the Surveillance, Epidemiology, and End Results (SEER) database. The 1:1 propensity score matching (PSM) method was performed to ensure the balance of baseline characteristics and minimize the confounding in this study. Chi-square test was also used to compare baseline characteristics of the patients. Kaplan-Meier method and log-rank test were used to compare the overall survival (OS) and carcinoma-specific survival (CSS) among the subgroups. Univariate and multivariate Cox proportional hazard regression were applied to determine independent prognostic factors. Results: After 1:1 PSM, a total of 258 patients were included, 129 of whom underwent surgery. Kaplan-Meier analysis showed that in all patients with stage I NPC, surgical patients showed significantly superior 5-year OS than non-surgical patients (78.8% vs 62.7%, P=0.009). And, in the subgroups analysis, the surgery alone group, radiotherapy alone group and surgery plus radiotherapy group showed similar 5-year OS (68.1%, 69.1%, 82.9%, P=0.318) and CSS (84.9%, 88.5%, 92.8%, P=0.358). In multivariate Cox regression analysis, we identified that surgery (HR=0.450, 95%CI: 0.284 to 0.714, P=0.001) was significantly associated with better OS. And, age, grade, histology, radiotherapy, and the number of primary tumors were also independent prognostic factors for stage I NPC. Conclusion: The present study highlights the positive effect of surgery on the survival of patients with stage I NPC. It indicates that surgery may become a potential initial treatment option for patients with stage I NPC.