<p>This narrative review synthesizes evidence regarding the impact of sclerotic mastoid on outcomes following tympanoplasty. A total of eight studies, including retrospective cohort studies, prospective cohorts, comparative studies, and one randomized controlled trial, were analyzed. Patients with chronic suppurative otitis media undergoing tympanoplasty with or without mastoidectomy were included. Across studies, graft success rates in sclerotic mastoid cases ranged between 71 and 90%, while hearing improvements typically averaged 7–13 decibels. Functional hearing success ranged from 69 to 82%. Comparative analyses consistently demonstrated no statistically significant advantage of adding mastoidectomy in sclerotic ears, with outcomes such as graft uptake and hearing gain remaining similar between tympanoplasty alone and tympanoplasty with mastoidectomy. One study demonstrated superior graft uptake in well-pneumatized mastoids compared to sclerotic mastoids (88.8% vs. 71.4%, p = 0.047), indicating that mastoid aeration may have some influence on outcomes. Pediatric findings suggested mastoid volume influenced anatomical but not functional success. Overall, the evidence suggests that sclerotic mastoid does not inherently compromise tympanoplasty outcomes, and routine mastoidectomy is not supported. However, study heterogeneity, variable reporting, and limited randomized evidence necessitate caution in interpretation.</p>