<p>Adenoid hypertrophy is a well-documented cause of conductive hearing loss and speech-language delays in children, primarily due to its effect on Eustachian tube function and middle ear ventilation. While adenoidectomy is widely practiced, comparative outcomes with conservative therapy remain under-investigated in certain populations. To evaluate the impact of adenoidectomy on hearing thresholds and speech-language development in children with adenoid hypertrophy, in comparison to standard non-surgical medical management. This prospective observational study was conducted at a tertiary care center in North India over 12 months. Fifty children aged 3–10 years with radiologically confirmed adenoid hypertrophy and audiometric evidence of conductive hearing loss were enrolled. Group A (<i>n</i> = 33) underwent adenoidectomy; Group B (<i>n</i> = 17) received medical therapy. Outcome measures included pre- and post-intervention pure tone audiometry (PTA), tympanometry, radiographic grading, nasal obstruction index, and standardized speech-language assessments using REELS and the Linguistic Profile Test. IQ screening was performed to exclude neurocognitive delay. Following adenoidectomy, the proportion of children achieving normal hearing thresholds (air-bone gap &lt; 10 dB) increased from 18.2% to 66.6% in Group A (<i>p</i> &lt; 0.001). Normal (Type A) tympanograms rose to 84.8% postoperatively. Significant gains in age-appropriate speech and language scores were observed in the surgical group (<i>p</i> &lt; 0.01), whereas the medical group showed minimal change across parameters. In this cohort, adenoidectomy was associated with clinically and statistically significant improvements in hearing and speech-language metrics compared to conservative therapy. Surgical intervention may be considered in children with persistent symptoms, radiologically significant hypertrophy, and audiometric evidence of middle ear dysfunction, after excluding other causes.</p>