Objective To explore the predictive value of the Middle Ear Risk Index (MERI) and tympanic membrane conditions for the prognosis of patients with chronic otitis media.Methods A total of 100 patients with chronic otitis media, admitted to the Second Affiliated Hospital of Air Force Medical University from January 2022 to March 2023, were enrolled and categorized based on the MERI score into a good prognosis group (n = 77) and a poor prognosis group (n = 23). General data were compared between the two groups, and logistic regression analysis was used to identify factors affecting poor prognosis in patients with chronic otitis media. Receiver operating characteristic (ROC) curves were constructed to analyze the predictive efficacy of poor prognosis.Results The poor prognosis group showed higher instances of eustachian tube dysfunction, tympanic membrane bleeding, tympanic membrane fibrosis, and tympanic membrane thickening, as well as higher MERI scores compared to the good prognosis group (P <0.05). Multivariate logistic regression analysis indicated that eustachian tube dysfunction [O^R = 7.482 (95% CI: 1.086, 51.570)], tympanic membrane bleeding [O^R = 9.476 (95% CI: 1.354, 66.321) ], tympanic membrane fibrosis [O^R = 7.679 (95% CI: 1.518, 38.840) ], tympanic membrane thickening [O^R = 7.228 (95% CI: 1.296, 40.322) ], and high MERI scores [O^R = 2.867 (95% CI: 1.473, 5.579) ] were significant factors influencing poor prognosis in patients with chronic otitis media (P <0.05). ROC curve results showed that the combined prediction of tympanic membrane bleeding, tympanic membrane fibrosis, tympanic membrane thickening, and MERI score yielded an area under the curve (AUC) of 0.951, with a sensitivity of 91.3% (95% CI:0.720, 0.989) and a specificity of 92.2% (95% CI:0.838, 0.971). The AUC for tympanic membrane bleeding was 0.701, with a sensitivity of 73.9% (95% CI:0.516, 0.898) and a specificity of 66.2% (95% CI:0.546, 0.766); for tympanic membrane fibrosis, the AUC was 0.774, with a sensitivity of 78.3% (95% CI:0.563, 0.925) and a specificity of 76.6% (95% CI:0.656, 0.855); for tympanic membrane thickening, the AUC was 0.711, with a sensitivity of 69.6% (95% CI:0.471, 0.868) and a specificity of 72.7% (95% CI:0.614, 0.823); and for the MERI score, the AUC was 0.879, with a sensitivity of 69.6% (95% CI:0.471, 0.868) and a specificity of 92.2% (95% CI:0.838, 0.971).Conclusion The middle ear risk index and the condition of the tympanic membrane are effective predictors of prognosis in patients with chronic otitis media.