Background: Excessive bleeding during middle ear surgery obscures the operative field and prolongs operative time. Dexmedetomidine, an α2 adrenergic agonist, reduces sympathetic outflow and may facilitate controlled hypotension and improved surgical field. Objective: To evaluate whether intraoperative dexmedetomidine reduces blood loss and improves surgical field quality in adult patients undergoing elective middle ear surgery under general anaesthesia. Design: Prospective, randomized, double blind, placebo controlled trial. Setting: Department of Anesthesia, 250 Beded General Hospital, Lalmonirhat, Rangpur, Bangladesh. Participants: Sixty ASA I–II adults (18–65 years) scheduled for tympanoplasty or mastoidectomy. Interventions: Patients were randomized (1:1) to dexmedetomidine (DEX) or placebo (PLC). DEX received a 1 µg·kg⁻¹ IV loading over 10 min followed by 0.4–0.7 µg·kg⁻¹·h⁻¹ infusion. PLC received volume matched saline. Anaesthesia was standardized. Main outcomes: Primary—total intraoperative blood loss (mL). Secondary—surgical field quality (Fromme Boezaart score), hemodynamics, opioid requirement, emergence profile, postoperative nausea/vomiting (PONV), and adverse events. Results: Mean blood loss was significantly lower with DEX vs PLC: 56 ± 22 mL vs 94 ± 35 mL; mean difference −38 mL (95% CI −53 to −23; p < 0.001). Median Fromme Boezaart score was 2 [IQR 2–3] vs 3 [2–4] (p = 0.004). Intraoperative heart rate was ~10 bpm lower with DEX; mean arterial pressure remained similar. Fentanyl consumption was reduced (85 ± 25 µg vs 120 ± 35 µg; p < 0.001). Time to extubation was modestly longer (9.2 ± 3.1 vs 7.6 ± 2.7 min; p = 0.03). Bradycardia requiring atropine occurred in 2/30 vs 0/30. PONV was less frequent with DEX (17% vs 37%; p = 0.09). Conclusion: Dexmedetomidine reduced blood loss and improved surgical field quality during middle ear surgery without clinically significant hypotension, with slightly prolonged emergence and occasional bradycardia.