<p>To evaluate and compare the efficacy of temporalis fascia and tragal perichondrium in underlay tympanoplasty type I, with particular attention to graft uptake and hearing improvement across small, medium, and large tympanic membrane perforations. A prospective study was conducted on 60 patients aged 15–45 years with tubotympanic CSOM and conductive hearing loss. Patients were randomly assigned to two groups: Group I received temporalis fascia grafts, and Group II received tragal perichondrium. Perforations were categorized by size, and postoperative outcomes were assessed on days 30 and 90 using otoscopy, otoendoscopy, and pure tone audiometry. Statistical significance was determined using chi-square and t-tests (p &lt; 0.05). Maximum number of patients, that is, 25 (41.66%) were from the age group of 15–25 years. The mean age of all the cases together was 28.63 years with a standard deviation of 8.34 years. On 90th day, successful graft uptake in small, medium, large perforations in Group I was 87.5%, 84.6% and 77.77% and in Group II was 91.6%, 90.9% and 71.42% respectively. The average AC threshold change in small, medium, large perforations in Group I was 11.46 ± 1.64 dB, 15.51 ± 5.58dB and 15.93 ± 4.93 dB and in Group II was 9.03 ± 3.01 dB, 10.61 ± 4.36 dB and 10.47 ± 6.64 dB respectively. The mean ABG closure change in small, medium, large perforations in Group I was 11.25 ± 4.77 dB, 13.97 ± 3.93 dB and 14.63 ± 3.88 dB and in Group II 8.75 ± 4.81 dB, 10.16 ± 4.36 dB and 9.29 ± 5.92 dB respectively. Temporalis fascia and tragal perichondrium are both effective in tympanoplasty. Trgal perichondrium is better suited for small to medium perforations, but temporalis fascia may offer an advantage in larger defects due to better structural and acoustic properties.</p>