<p>Chronic suppurative otitis media (CSOM) is a major cause of conductive hearing loss, particularly in low- and middle-income countries. Tympanoplasty aims to restore middle ear function, but postoperative hearing outcomes vary widely. The Middle Ear Risk Index (MERI) is a composite scoring system that quantifies disease severity and may help predict surgical and audiological outcomes. This study evaluated the correlation between preoperative MERI scores and hearing outcomes following tympanoplasty in patients with tubotympanic CSOM. In this prospective observational study, 110 patients undergoing primary type I tympanoplasty were enrolled. Preoperative MERI scores were calculated, and patients were categorized as mild (1–3), moderate (4–6), or severe (≥ 7). Pure-tone audiometry was performed preoperatively and at 6 months postoperatively to assess pure-tone average (PTA) and air–bone gap (ABG). Primary outcome was ABG closure; secondary outcomes included PTA improvement, functional hearing achievement (postoperative ABG ≤ 20 dB), and graft uptake. Correlation and multivariable regression analyses were performed. Higher MERI scores correlated significantly with poorer postoperative PTA and ABG (<i>p</i> &lt; 0.001). Functional hearing was achieved in 94.2% of mild, 83.3% of moderate, and 43.8% of severe MERI cases (<i>p</i> &lt; 0.001). MERI independently predicted postoperative ABG (<i>p</i> &lt; 0.001). MERI is a reliable preoperative tool for predicting hearing outcomes after tympanoplasty and assists in risk stratification and patient counselling.</p>