Comparative Efficacy and Safety of Dexmedetomidine and Esmolol in Functional Endoscopic Sinus Surgery (FESS): A Systematic Review and Meta-analysis

Background Functional Endoscopic Sinus Surgery (FESS) requires precise hemodynamic control to maintain a clear surgical field and minimize bleeding. Dexmedetomidine and esmolol are commonly used for this purpose, but their relative efficacy and safety has not been systematically evaluated. Objective To assess the relative efficacy and safety of dexmedetomidine and esmolol in patients undergoing FESS. Methods A systematic review and meta-analysis of randomized controlled trials was conducted. PubMed, Embase, Scopus, Web of Science, Cochrane, ClinicalTrials.gov and grey literature were searched to August 2025. Random-effects models were applied for pooled analyses in R software, version 4.5.1. Certainty of evidence was assessed using the GRADE approach. Results Eighteen trials (1056 participants, mean age 29.24 to 40.12 years, ASA I-II) were included. Both agents achieved comparable control of intraoperative blood loss (MD -1.18 mL, 95% CI: [-2.99 to 0.63], low-certainty). Esmolol resulted in faster emergence (MD 3.13 minutes shorter; 95% CI: [2.64 to 3.63], low-certainty), while dexmedetomidine prolonged time to first rescue analgesia (MD 27.83 minutes longer; 95% CI: [26.41 to 29.26], moderate-certainty) and time to modified Aldrete > 9 (MD 2.68 minutes longer; 95% CI: [2.26 to 3.11], low-certainty). Dexmedetomidine increased bradycardia risk (RR 3.96, 95% CI: [1.62 to 9.65], low-certainty) and dry mouth but reduced postoperative nausea and vomiting (RR 0.26, 95% CI: [0.10 to 0.73], low-certainty). Conclusion Moderate-to-low certainty evidence suggests both dexmedetomidine and esmolol may be effective for hemodynamic control during FESS. Esmolol may have quicker emergence and recovery, whereas dexmedetomidine may result in longer analgesia and less postoperative nausea, but increased bradycardia risk. Agent selection should consider patient needs and recovery priorities. Further high-quality trials are needed to strengthen the evidence base.