<p>Mastoid pneumatization patterns and ossicular integrity play an essential role in the pathophysiology and management of chronic otitis media (COM). Although these factors are clinically important, the association between mastoid aeration and ossicular erosions remains inadequately understood. To evaluate the correlation between mastoid pneumatization patterns and ossicular erosions in tubotympanic and atticoantral types of COM, and to assess the relationship between tympanic membrane retraction and mastoid aeration. This prospective observational study, conducted over 18 months, included 60 patients with COM who underwent radiological evaluation X-ray form mucosal COM and high-resolution computed tomography of the temporal bone for squamosal COM, followed by surgical exploration. Diagnostic nasal endoscopy to assess Eustachian tube function. Mastoid pneumatization was categorized as pneumatic, diploic, or sclerotic. Intraoperative findings documented ossicular integrity and Statistical analysis using chi-square and Fisher’s exact tests determined correlations between pneumatization patterns and ossicular erosions. Affected ears showed predominantly sclerotic mastoids (61.7%), while unaffected ears were mainly pneumatic (51.7%). Ossicular erosion occurred in 60% of patients, with the incus most frequently involved (23.3%). Although mastoid pneumatization differed between ears, its correlation with ossicular erosion was not significant (<i>p</i> = 0.303). Nasal endoscopy findings significantly correlated with unaffected-side mastoid pneumatization (<i>p</i> = 0.027), highlighting nasopharyngeal involvement. Differences in mastoid pneumatization between affected and unaffected ears are clear in COM, but pathology type influences ossicular erosion more than aeration. The significant link between nasopharyngeal findings and mastoid aeration underscores the need to assess Eustachian tube dysfunction in COM management.</p>