Endoscopes have revolutionised otitis media surgery in recent years and are increasingly used in the surgical management of cholesteatoma, sinus tympani pathology and facial nerve surgery. Despite this, the development of endoscopic myringoplasty and how this compares to its microscopic counterpart have received relatively little attention. This study aimed to assess exactly that, by directly comparing endoscopic with microscopic myringoplasty for similarly sized and positioned tympanic membrane perforations. Sixty patients were recruited and randomised between the two groups (30 endoscopic and 30 microscopic). Endoscopic myringoplasty was always performed transcanal with tympanomeatal flap elevation in all cases. On the other hand, microscopic myringoplasty was performed via a postaural approach. The use of an endoscope (0º or 30° 4mm rigid endoscope) proved to offer numerous advantages over microscope use. Firstly, no patient in the endoscopy group required canalplasty as adequate exposure of the margins of the perforation (even when very anterior) and visualisation of the incudostapedial joint complex were easily achieved with the endoscope and without the need for any posterosuperior canal wall curettage. This was despite four patients in the endoscopic group having significant canal overhangs. This was not the case in the microscopic myringoplasty group where all five patients with significant canal overhangs required canalplasty to obtain adequate exposure of the tympanic annulus and four also required curettage of the posterosuperior canal wall to obtain visualisation of the incudostapedial joint complex. Moreover, all patients in the endoscopy group (30/30) reported excellent cosmetic outcomes as the incision scar was well hidden in the hairline whereas the equivalent percentage in the microscopic group was 25/30 with the remaining five patients reporting it as only satisfactory due to the associated scar. No difference was observed in graft uptake rates which were 83.3% in both groups. The hearing outcomes were comparable between the two techniques and endoscopic myringoplasty was well received by the residents being trained in the technique. In summary, this study, albeit small, illustrates the promising role that endoscopic myringoplasty has to play as it achieved improved cosmesis, comparable tympanic membrane perforation and air-bone gap closure rates to microscopic surgery without the need for canalplasty and postaural incision even in the presence of major canal overhangs.