Aims <p>This study aimed to evaluate the effects of various preoperative and intraoperative parameters on surgical success and postoperative hearing improvement in pediatric COM cases.</p> Materials and methods <p>A prospective study was conducted over three years in a tertiary care teaching hospital in South India, enrolling 50 pediatric patients (&lt;14 years) undergoing surgical management for COM. Preoperative assessments included otomicroscopy, high-resolution computed tomography (HRCT) of the temporal bone, and audiometric evaluations. Patients underwent surgical management, and intraoperative findings, including ossicular erosion, middle ear mucosal status, and MERI (Middle Ear Risk Index) scores, were recorded. Postoperative outcomes were assessed at six months to one year, focusing on graft uptake, dry ear achievement, and audiometric improvement.</p> Results <p>The study included 50 patients with a median age of 11.5 years. Surgical success (dry ear) was achieved in 84% of cases, with 48% showing hearing improvement. Key factors associated with better hearing outcomes included the presence of adenoidal hypertrophy requiring preoperative adenoidectomy (p = 0.045), healthy middle ear mucosa (p = 0.036), and less extensive disease. Children undergoing CWU mastoidectomy had significantly better hearing outcomes (p = 0.023) compared to those undergoing CWD procedures.</p> Conclusions <p>This study highlights that while surgical success in pediatric COM is generally high, factors such as adenoidal hypertrophy, middle ear mucosal health, and disease extent significantly impact long-term hearing outcomes. Early management with appropriate surgical intervention, particularly in limited disease cases, yields favorable results in achieving dry ear and hearing improvement.</p>