<p>Tympanic membrane (TM) perforation is a frequent consequence of chronic otitis media and a major cause of conductive hearing loss. Although the relationship between perforation size and hearing loss is well recognized, the independent contribution of perforation site remains controversial. To assess the influence of the size and site of central pars tensa tympanic membrane perforations on the severity of conductive hearing loss using objective planimetric and audiometric evaluation. This cross-sectional observational study included 100 patients aged ≥ 15 years with dry central pars tensa perforations and pure conductive hearing loss. High-resolution endoscopic images were analyzed using digital planimetry to quantify perforation size, which was categorized as small (&lt; 25%), medium (25–50%), large (50–75%), or subtotal (&gt; 75%). Perforation site was classified as anterior central, posterior central, central malleolar, or subtotal/big central. Hearing thresholds were assessed using pure-tone audiometry. Statistical analysis included one-way ANOVA with post-hoc Tukey testing and multiple linear regression. Mean air conduction thresholds and air–bone gaps increased progressively with perforation size (<i>p</i> &lt; 0.001), with subtotal perforations producing the greatest hearing loss. Posterior central and subtotal perforations demonstrated significantly higher hearing thresholds compared to anterior and central malleolar perforations (<i>p</i> &lt; 0.001). Multivariable regression analysis confirmed perforation size and site as independent predictors of hearing loss after adjustment for age and sex (adjusted R² = 0.58). Both the size and site of tympanic membrane perforation significantly influence the degree of conductive hearing loss. Larger and posteriorly located perforations result in greater auditory impairment. Objective quantification of perforation characteristics using digital planimetry enhances prognostication, patient counselling, and prioritization of surgical intervention.</p>