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

Comparative Efficacy and Safety of Dexmedetomidine and Esmolol in Functional Endoscopic Sinus Surgery (FESS): A Systematic Review and Meta-analysis | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Comparative Efficacy and Safety of Dexmedetomidine and Esmolol in Functional Endoscopic Sinus Surgery (FESS): A Systematic Review and Meta-analysis Saad Arsalan Wasti, Areesha Wasti, Muhammad Ali Abid, Hammad Javaid, and 6 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8501577/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract 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. Dexmedetomidine Esmolol Meta-analysis Functional Endoscopic Sinus Surgery FESS Figures Figure 1 Figure 2 Figure 3 Introduction Functional Endoscopic Sinus Surgery (FESS) is a surgical technique designed to improve sinus drainage and ventilation by removing obstructed tissue in diseased sinuses ( 1 ), with chronic rhinosinusitis being its most frequent indication ( 2 ). Despite its advantages, FESS carries potential risks, including bleeding, injury to surrounding structures such as CSF rhinorrhea, dural tear, optic nerve injuries, and anesthesia-related complications to name a few, all of which can impact patient outcomes ( 3 ). Surgical field visualization is an important factor that can prevent complications. Intraoperative blood loss can obstruct the surgical field, prolong the operative time, and increase the risk of surgical complications due to a poor surgical field ( 4 ). Thus, effective perioperative management is essential to minimize these risks and enhance both surgical outcomes and patient safety. Strategies to minimize perioperative stress and prevent complications during FESS include anesthetic agents ( 5 ), achieving controlled hypotension and heart rate ( 6 ), and perioperative positioning of the patient in the reverse Trendelenburg position ( 7 ). Anesthetic agents like opioids, benzodiazepines, propofol, and inhalational anesthetics, though helpful in ensuring sedation and pain control, are associated with risks, including respiratory depression, hemodynamic instability, and postoperative nausea and vomiting. The idea behind controlled hypotension is that it could reduce intraoperative blood loss, improve surgical field quality, and reduce operative time. Various agents used for this purpose include β-blockers, α-2 agonists, vasodilators such as nitroglycerin and sodium nitroprusside, and some anesthetics like propofol and sevoflurane, which have the added benefit of blood pressure reduction despite sedation. Our systematic review and meta-analysis aim to compare the efficacy and safety of two such agents: Dexmedetomidine and Esmolol. Dexmedetomidine, an α2-agonist, provides sedation, analgesia, and controlled hypotension by reducing norepinephrine release via brainstem α2-receptor activation ( 8 ). Esmolol, an ultra-short-acting beta-blocker, is frequently used to manage intraoperative hemodynamic fluctuations. Though individual studies compare the safety and efficacy of these drugs in FESS, pooled evidence in the form of a systematic review and meta-analysis is lacking. This review aims to address that gap. Methods We conducted this systematic review and meta-analysis in line with the Cochrane Handbook for Systematic Reviews of Interventions ( 9 ), and reported it according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist of 2020 ( 10 ). This review is registered on the Open Science Framework (OSF) (Registration DOI: 10.17605/OSF.IO/UZEF6 ) ( 11 ). Ethical approval was not needed for this review, as already published, publicly available data were utilized. Data Sources and Search Strategy: We searched the PubMed, Embase, Scopus, Web of Science, Cochrane and ClinicalTrials.gov from inception to August 28, 2025. Additional studies were identified through citation chaining and searching websites. The detailed search strategies for each source are provided in Supplementary Table S1 . The search string consisted of three search terms: i) Functional Endoscopic Sinus Surgery; ii) Dexmedetomidine; and iii) Esmolol. Study Selection Process: All retrieved records were imported into Rayyan ( 12 ) for screening. After removing duplicates, two reviewers independently screened titles, abstracts, and full texts according to pre-specified inclusion and exclusion criteria. Disagreements were resolved by a third reviewer. Eligibility Criteria: Inclusion criteria were: 1. Adult patients undergoing functional endoscopic sinus surgery (FESS); 2. Usage of dexmedetomidine as intervention; 3. Comparison with esmolol as control; 4. Reporting relevant efficacy and/or safety outcomes; 5. Randomized controlled trials (RCTs) by design. Exclusion criteria were: 1. Studies enrolling animals or patients undergoing procedure other than FESS; 2. Not using dexmedetomidine as intervention; 3. Not comparing to esmolol; 4. Not reporting relevant efficacy and/or safety outcomes; 5. Other study designs such as case reports, reviews, and case series. Data Extraction: Four reviewers independently extracted data using pre-piloted sheets, such that data from each study were extracted by two reviewers. Discrepancies were resolved by discussion or, if needed, by a third reviewer. Extracted data included study characteristics, intervention details, and patient demographics, and outcome data. Risk of Bias Assessment: Two reviewers independently assessed risk of bias using the Cochrane Risk of Bias 2 (RoB 2) tool. Risk of bias was judged per outcome for seven key endpoints: intraoperative blood loss, emergence time, time to first rescue analgesia, time to modified Aldrete score > 9, and incidences of hypotension, bradycardia, and postoperative nausea and vomiting. Disagreements were resolved by consensus or, if needed, by a third reviewer. Certainty of Evidence: Certainty of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. Certainty was rated as high, moderate, low, or very low. The primary domains for downgrading the quality of evidence are risk of bias, inconsistency, indirectness, imprecision, and publication bias. Findings were organized and summarised using the GRADEpro software. Statistical Analysis: Statistical analyses were conducted in R (version 4.5.1) using a random-effects model. For continuous outcomes, mean differences (MD) with 95% confidence intervals (CIs) were calculated, and for dichotomous outcomes, risk ratios (RR) with 95% CIs were calculated. Heterogeneity was assessed using the χ 2 and I 2 statistics. Sensitivity analyses were performed using a leave-one-out approach, and subgroup and meta-regression analyses were conducted to explore heterogeneity. Publication bias was assessed for outcomes with ≥ 10 studies by funnel plots. For outcomes with fewer studies, publication bias was not formally evaluated due to limited statistical power. Results Study Selection Process The literature search yielded a total of 102 records through databases and registers. 39 duplicates were removed and the remaining articles were screened on the basis of title-abstracts and then full-texts. 11 studies met the eligibility criteria and were included. From other sources (website and citation searching), 109 records were screened and 7 studies met the inclusion criteria. In total, 18 studies were included in this systematic review and meta-analysis ( 13 – 30 ). The detailed study selection process is outlined in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flowchart (Fig. 1) . Characteristics of Included Studies This systematic review and meta-analysis included a total of 18 randomized controlled trials, comprising 1,056 participants. The studies were published between the years 2013 and 2025. All studies were parallel-group, single-center trials; most were conducted in India (k = 15), followed by Egypt (k = 2) and Bangladesh (k = 1). All trials compared dexmedetomidine, administered intravenously, to esmolol, also administered intravenously, in functional endoscopic sinus surgery (FESS). The most common dosing regimen for dexmedetomidine was a loading dose of 1 µg/kg given over 10 minutes, followed by a maintenance dose of 0.4–0.8 µg/kg/hr. For esmolol, the most common regimen was a loading dose of 1 mg/kg given over 1 minute, followed by a maintenance dose of 0.4–0.8 mg/kg/hr. Mean participant ages varied from 29.24 ± 1.38 years to 40.12 ± 11.9 years. The American Society of Anesthesiologists (ASA) physical statuses of the included participants were ASA I-II. The majority of the participants were male. Table 1 summarizes the key characteristics of the included studies. Risk of Bias Assessment Risk of bias was assessed across five domains for seven key outcomes, with the overall risk of bias also being judged. The outcomes assessed were intraoperative blood loss, emergence time, time to first rescue analgesia, time to modified Aldrete score > 9, incidence of hypotension, incidence of bradycardia, and incidence of postoperative nausea and vomiting. Across most outcomes, the overall risk of bias was judged as some concerns, mainly arising from issues in domain 5. For emergence time, one study was judged to be at high risk of bias, largely due to concerns in domains 4 (measurement of outcomes) and 5. Other studies reporting emergence time were judged as having some concerns overall. The risk of bias assessment per outcome is given in supplementary (Supplementary Figures SA1-SA14) . Statistical Analyses Outcomes Efficacy Intraoperative Blood Loss (mL) Five out of the eighteen included trials reported intraoperative blood loss (N = 306). A statistically non-significant difference was seen for volume of intraoperative blood loss between the two groups (MD -1.18 mL, 95% CI [-2.99 to 0.63], P = 0.200, I 2 = 0%) (Fig. 2A) . Duration of Surgery (minutes) Twelve out of the eighteen included trials reported duration of surgery (N = 746). A statistically non-significant difference was seen for the surgical duration between dexmedetomidine and esmolol usage (MD -3.04 minutes, 95% CI [-6.16 to 0.08], P = 0.056, I 2 = 70.5%) (Fig. 2B) . Omitting Shivakumara et al., 2018 in the LOO analysis reduced I 2 heterogeneity to 16% (Supplementary Table S2) . Univariate meta-regression using the year of publication as covariate did not significantly explain variation in effect sizes. Likewise, neither raw total sample size nor log total sample size was able to explain the heterogeneity (Supplementary Figures S2A-C) . Emergence Time (minutes) Ten trials reported emergence time. Esmolol use showed a statistically significant shorter time to emergence (MD 3.13 minutes, 95% CI [2.64 to 3.63], P < 0.001, I 2 = 87.7%) (Fig. 2C) . Omitting Ravikumar et al., 2017 in the LOO analysis reduced I 2 to 68.3%, with considerable heterogeneity persisting (Supplementary Table S3) . Subgroup analyses by dexmedetomidine maintenance dose or esmolol maintenance dose did not meaningfully resolve heterogeneity (Supplementary Figures S2D, S2E) . Univariate meta-regression with year of publication as covariate showed that it was not a significant predictor of the difference in emergence time between dexmedetomidine and esmolol, with residual heterogeneity remaining very high. Likewise, no evidence of association was seen between total study sample size and effect estimates, or log total study sample size and effect estimates (Supplementary Figures S2F-H) . Time to First Rescue Analgesia (minutes) Nine studies reported time to first rescue analgesia. Dexmedetomidine use showed a significantly higher time to first rescue analgesic administration (MD 27.83 minutes, 95% CI [26.41 to 29.26], P = 0, I 2 = 54.3%) (Fig. 2D) . LOO analysis omitting Vasavi et al., 2024 reduced I 2 heterogeneity to 1.2% (Supplementary Table S4) . Time to Aldrete Score > 9 (minutes) Two trials reported time to Aldrete score > 9. In one study (n = 60), the dexmedetomidine group reached this threshold later than those receiving esmolol (10.4 ± 2.5 minutes versus 8.5 ± 2.3 minutes). In the other study (n = 60), reported time was much longer with dexmedetomidine (180 minutes versus 150 minutes). Due to the substantial differences in reported absolute times between the two trials, likely due to different starting and ending points, meta-analysis was not performed. Both studies, however, showed a longer time to recovery in the dexmedetomidine group compared with the esmolol group. Time to Modified Aldrete Score > 9 (minutes) Six studies reported time to modified Aldrete score > 9. Dexmedetomidine use showed a significantly higher time to modified Aldrete score > 9 (MD 2.68 minutes, 95% CI [2.26 to 3.11], P < 0.001, I 2 = 34.1%) (Fig. 2E) . Ramsay Sedation Score (RSS) at 15 Minutes Postoperation Seven studies reported RSS 15 minutes postoperatively. Dexmedetomidine use showed a significantly higher RSS (MD 0.94, 95% CI [0.38 to 1.50], P = 0.001, I 2 = 98.7%) (Fig. 2F) . Subgroup by maintenance dose of esmolol resolved heterogeneity (Supplementary Figure S2I) but not of dexmedetomidine (Supplementary Figure S2J) . Heterogeneity remained high across all LOO iterations (Supplementary Table S5) . Ramsay Sedation Score at 30 Minutes Postoperation Nine studies reported RSS 30 minutes postoperatively. Dexmedetomidine use showed a significantly higher RSS (MD 0.84, 95% CI [0.51 to 1.18], P < 0.001, I 2 = 97.4%) (Fig. 2G) . Subgroups by maintenance dose of esmolol or dexmedetomidine did not resolve heterogeneity (Supplementary Figure S2K, S2L) . Heterogeneity remained high across all LOO iterations (Supplementary Table S6) . Ramsay Sedation Score at 60 Minutes Postoperation Eight studies reported RSS 60 minutes postoperatively. Non-significant difference was seen for RSS (MD 0.17, 95% CI [-0.01 to 0.35], P = 0.069, I 2 = 86.1%) (Fig. 2H) . Subgroups by maintenance dose of esmolol or dexmedetomidine did not resolve heterogeneity (Supplementary Figure S2M, S2N) . Heterogeneity remained high across all LOO iterations (Supplementary Table S7) . Safety Incidence of Hypertension Two trials reported hypertension incidence, which was significantly higher with dexmedetomidine use (RR 6.94, 95% CI [2.03 to 23.69], P = 0.002, I 2 = 0%) (Fig. 3A) . Incidence of Hypotension Two trials reported hypotension incidence. Nonsignificant difference was seen between the two groups (RR 0.20, 95% CI [0.02 to 1.65], P = 0.135, I 2 = 0%) (Fig. 3B) . Incidence of Bradycardia Two trials reported on bradycardia incidence, which was significantly higher with dexmedetomidine use (RR 3.96, 95% CI [1.62 to 9.65], P = 0.002, I 2 = 0%) (Fig. 3C) . Incidence of Postoperative Nausea and Vomiting (PONV) Three trials reported PONV incidence, which was significantly lower with dexmedetomidine use (RR 0.26, 95% CI [0.10 to 0.73], P = 0.010, I 2 = 0%) (Fig. 3D) . Incidence of Dry Mouth Three trials reported dry mouth incidence, which was significantly higher with dexmedetomidine use (RR 4.26, 95% CI [2.10 to 8.64], P < 0.001, I 2 = 0%) (Fig. 3E) . Incidence of Shivering Two trials reported shivering incidence. Nonsignificant difference was seen between the two groups (RR 0.39, 95% CI [0.10 to 1.42], P = 0.153, I 2 = 0%) (Fig. 3F) . Publication Bias Publication bias was assessed for all outcomes which were reported by ten or more studies (duration of surgery and emergence time). Visual inspection of funnel plots did not indicate signs of major asymmetry. For duration of surgery (Supplementary Figure S3A) , there was some asymmetry seen, but not enough to conclude major publication bias. For emergence time (Supplementary Figure S3B) the funnel plot appeared largely symmetrical, showing no strong signs of publication bias. Overall, although there was some concern regarding asymmetry for duration of surgery, the evidence for publication bias across outcomes was limited and not conclusive. GRADE Certainty of Evidence Certainty of evidence was appraised for seven key outcomes most relevant to patient health or care (intraoperative blood loss, emergence time, time to first rescue analgesia, time to modified Aldrete score > 9, incidence of hypotension, incidence of bradycardia, and incidence of postoperative nausea and vomiting). Findings are presented in the form of a Summary of Findings (SoF) table (Table 2) . Discussion The findings of this systematic review and meta-analysis provide a comprehensive comparison between dexmedetomidine and esmolol for perioperative management during functional endoscopic sinus surgery (FESS). Both medications are commonly used to manage hemodynamic responses and postoperative recovery, but their effects on various outcomes remain a subject of ongoing debate. The included studies, comprising 1,056 participants across 18 randomized controlled trials (RCTs), highlight key differences and similarities in efficacy and safety profiles between these two agents. Summary of Key Findings Efficacy Outcomes Our analysis reveals several noteworthy points regarding the comparative effects of dexmedetomidine and esmolol. In terms of intraoperative blood loss, no significant differences were observed between the two groups, which suggests that neither drug has a clear advantage in minimizing bleeding during surgery. Similarly, duration of surgery showed a trend toward reduced time with dexmedetomidine, but this difference was not statistically significant. A more striking difference was observed in emergence time, with esmolol providing a significantly shorter recovery time compared to dexmedetomidine. This aligns with past studies which show that dexmedetomidine may delay recovery when administered with propofol ( 31 ). Dexmedetomidine provides smooth recovery by decreasing agitation associated with emergence ( 32 , 33 ), and by adjusting the dose of propofol administered, the delay in recovery time can be reduced to non-significant levels ( 32 ). Conversely, time to first rescue analgesia was significantly longer in the dexmedetomidine group, indicating its role in prolonging postoperative analgesia. Ramsay Sedation Scale is an established 6-point tool which provides a simple monitoring method to gauge the awareness level of the patient ( 34 ). Dexmedetomidine was associated with a significantly higher Ramsay Sedation Score (RSS) at 15 and 30 minutes postoperation, reinforcing its sedative properties. A nonsignificant increase in the RSS with dexmedetomidine was observed at 60 minutes postoperation as well. While sedation can be beneficial for patient comfort, it may also delay the postoperative recovery process, as evidenced by the prolonged time to modified Aldrete score > 9 with dexmedetomidine. The modified Aldrete scoring system is a post-anesthesia recovery tool used to evaluate the readiness for post-anesthesia discharge of the patient ( 35 ). It consists of five criteria including activity, respiration, circulation, consciousness, and oxygen saturation which are rated from 0 to 1 depending on the patient condition, with a score of 9–10 indicating a readiness for discharge ( 35 ). Dexmedetomidine causing prolonged time to reach modified Aldrete score of greater than 9 means that the patient has to be kept in post-anesthesia care unit (PACU) for a longer period. In contrast, esmolol’s lack of a sedative effect allows for a faster return to baseline alertness and function ( 36 ), potentially facilitating a quicker discharge from the PACU. Safety Outcomes In terms of safety, dexmedetomidine was associated with significantly higher incidences of hypertension and bradycardia, which are well-documented side effects of the drug. Dexmedetomidine is known to cause dose-dependent decrease in systolic and diastolic blood pressures along with bradycardia ( 37 ). A higher loading dose presents with hypertension followed by hypotension, but with a low loading dose, the response is mainly hypotensive, without the preceding hypertension ( 37 ). However, incidence of hypotension did not differ significantly between the two drugs. Interestingly, dexmedetomidine was associated with a significantly lower incidence of postoperative nausea and vomiting, which may be considered a clinical advantage, especially in patients at risk for nausea and vomiting following surgery. Postoperative nausea and vomiting is considered one of the most significant factors contributing towards patient dissatisfaction after anesthesia ( 38 , 39 ). However, dexmedetomidine also led to a higher incidence of dry mouth, which could impact patient comfort in the postoperative period. These findings contribute to the evolving understanding of the pharmacological management of perioperative care in FESS. Esmolol’s advantage in reducing emergence time and its lack of significant adverse effects make it a favorable option when quick recovery from anesthesia is prioritized. Alternatively, dexmedetomidine’s sedative properties, combined with prolonged analgesia and decreased postoperative nausea and vomiting, may be more beneficial in cases where post-surgical comfort is desired. However, the observed hypertension and bradycardia in the dexmedetomidine group necessitate careful monitoring, particularly in patients with pre-existing cardiovascular conditions. Strengths This review has several notable strengths that contribute to the robustness of its findings. First, it is the first to systematically evaluate the head to head efficacy and safety of dexmedetomidine and esmolol in the context of FESS, and includes only RCTs, which enhances the internal validity of the conclusions. Secondly, the search strategy was comprehensive, incorporated additional sources and citation searching, and resulted in the inclusion of 18 trials published between 2013 and 2025. This thorough approach ensured an up-to-date evidence base. The use of GRADE assessment to evaluate the certainty of evidence, along with adherence to the PRISMA guidelines in the study selection process, strengthens the transparency and methodological rigor of the review. These methodological choices collectively enhance the trustworthiness of the pooled estimates. Limitations This study has several limitations. Many safety endpoints were reported in only two to three trials with relatively small event counts, which may have produced imprecise estimates. This limits confidence in safety conclusions. Most studies (15/18) were conducted in India; all trials were conducted in a single-center setting and enrolled ASA I-II adult patients with mean ages in the 30 to 40-year range. Thus, the results may not generalize to older patients, those with significant cardiac comorbidity, or different healthcare systems. Several statistically significant differences were small in absolute terms such as the ~ 3 minutes for time to modified Aldrete Score > 9, which brings into question the clinical significance of the finding, even when statistical significance has been shown. The heterogeneity observed across several outcomes, particularly in emergence time and Ramsay Sedation Scores, needs to be noted as well. This variability may reflect differences in dosing regimens, patient populations, or study methodologies, and underscores the need for more consistent study designs in future trials. Future Directions Several areas warrant further investigation. First, while both dexmedetomidine and esmolol have been studied individually in various contexts, comparisons in larger, multicenter RCTs are needed to clarify the observed discrepancies in outcome measures. Moreover, patient-specific factors, such as comorbidities (e.g., hypertension, heart disease) and age, should be considered in designing future trials to determine the most appropriate drug choice for individual patients. Long-term outcomes, such as patient satisfaction, quality of life, and cost-effectiveness, should also be considered in order to provide a complete view of the impact of these interventions on patient care. Future reviews may also benefit from obtaining individual-participant data (IPD) from trial investigators to better assess the effectiveness of each drug for important subpopulations. Conclusion This systematic review and meta-analysis found that both dexmedetomidine and esmolol may be effective agents for hemodynamic control during FESS, with comparable efficacy in minimizing intraoperative blood loss. Esmolol may offer faster emergence and recovery, while dexmedetomidine may lead to reduced nausea and vomiting risk. However, dexmedetomidine may carry a higher risk of bradycardia and dry mouth. Clinicians should individualize agent selection based on surgical priorities and patient needs. Further large, multicentric trials are needed to strengthen the evidence base and refine clinical guidance. Declarations Competing interests The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. Ethics approval and consent to participate Not needed, as this review utilized already published, publicly available data. Consent for publication Consent for publication is not applicable as this study involves publicly available data. Author Contribution **S.A.W.:** Conceptualization, Methodology, Software, Validation, Formal Analysis, Investigation, Resources, Data Curation, Writing – Original Draft, Writing – Reviewing & Editing, Visualization, Supervision, Project Administration. **A.W.:** Conceptualization, Methodology, Software, Validation, Investigation, Writing – Original Draft, Writing – Reviewing & Editing, Visualization, Supervision. **M.A.A.:** Software, Formal Analysis, Writing – Original Draft, Validation. **H.J.:** Writing – Original Draft, Validation, Supervision. **M.A.B.:** Software, Validation, Methodology, Data Curation, Writing – Original Draft, Writing – Reviewing & Editing. **S.I.:** Software, Investigation, Data Curation, Validation, Writing – Reviewing & Editing. **E.H.:** Software, Methodology, Data Curation, Validation, Writing – Reviewing & Editing **. M.U.I.:** Writing – Reviewing & Editing, Validation, Supervision. **M.W.B.W:** Validation, Writing – Reviewing & Editing. **M.N.S:** Validation, Writing – Reviewing & Editing. Data Availability The data availability statement is not applicable as this study involves publicly available data. No new datasets were generated or analysed during this study. References Kennedy DW. Functional Endoscopic Sinus Surgery: Technique. Arch Otolaryngol - Head Neck Surg. 1985;111(10):643–9. Smith TL, Kern R, Palmer JN, Schlosser R, Chandra RK, Chiu AG, et al. Medical therapy vs surgery for chronic rhinosinusitis: a prospective, multi-institutional study with 1‐year follow‐up. Int Forum Allergy Rhinol. 2013;3(1):4–9. Krings JG, Kallogjeri D, Wineland A, Nepple KG, Piccirillo JF, Getz AE. Complications of primary and revision functional endoscopic sinus surgery for chronic rhinosinusitis. The Laryngoscope. 2014;124(4):838–45. Kelly EA, Gollapudy S, Riess ML, Woehlck HJ, Loehrl TA, Poetker DM. Quality of surgical field during endoscopic sinus surgery: a systematic literature review of the effect of total intravenous compared to inhalational anesthesia. Int Forum Allergy Rhinol. 2013 June;3(6):474–81. Fedok FG, Ferraro RE, Kingsley CP, Fornadley JA. Operative times, postanesthesia recovery times, and complications during sinonasal surgery using general anesthesia and local anesthesia with sedation. Otolaryngol Neck Surg. 2000;122(4):560–6. Fromme GA, MacKenzie RA, Gould AB, Lund BA, Offord KP. Controlled hypotension for orthognathic surgery. Anesth Analg. 1986 June;65(6):683–6. Ko M, Chuang K, Su C. Multiple Analyses of Factors Related to Intraoperative Blood Loss and the Role of Reverse Trendelenburg Position in Endoscopic Sinus Surgery. The Laryngoscope. 2008 Sept;118(9):1687–91. Reel B, Maani CV. Dexmedetomidine. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 [cited 2025 Nov 20]. Available from: http://www.ncbi.nlm.nih.gov/books/NBK513303/ Higgins JP, Green S, editors. Cochrane Handbook for Systematic Reviews of Interventions: Cochrane Book Series [Internet]. 1st ed. Wiley; 2008 [cited 2025 Apr 10]. Available from: https://onlinelibrary.wiley.com/doi/book/ 10.1002/9780470712184 Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021;n71. Wasti SA. Comparative Efficacy and Safety of Dexmedetomidine Versus Esmolol in Patients Undergoing Functional Endoscopic Sinus Surgery: A Systematic Review and Meta-Analysis [Internet]. OSF Registries; 2025 [cited 2025 Nov 20]. Available from: https://osf.io/uzef6/ Ouzzani M, Hammady H, Fedorowicz Z, Elmagarmid A. Rayyan—a web and mobile app for systematic reviews. Syst Rev. 2016;5(1):210. Ahmad DT, Khan DAS, Hussain DA. COMPARATIVE EVALUATION OF THE EFFICACY OF DEXMEDETOMIDINE VERSUS ESMOLOL FOR CONTROLLED HYPOTENSION IN FUNCTIONAL ENDOSCOPIC SINUS SURGERY. Bajwa SS, Kaur J, Kulshrestha A, Haldar R, Sethi R, Singh A. Nitroglycerine, esmolol and dexmedetomidine for induced hypotension during functional endoscopic sinus surgery: A comparative evaluation. J Anaesthesiol Clin Pharmacol. 2016;32(2):192. Damarla R, Mamidi M. Dexmedetomidine and esmolol for induced hypotension for functional endoscopic sinus surgery-a comparative study. Natl J Physiol Pharm Pharmacol. 2021;(0):1. M G, N A, B RKP, B CV, Somashekhar AH. Dexmedetomidine versus Esmolol for Induced Hypotension during Functional Endoscopic Sinus Surgery - A Prospective Randomised Comparative Study. Eur J Cardiovasc Med. 2024;14:214–23. Komal Joshi, Sharad Kumar Mishra. Comparison of Dexmedetomidine and Esmolol Induced Hypotension in Functional Endoscopic Sinus Surgery. 2023 Dec 30 [cited 2025 Nov 20]; Available from: https://zenodo.org/doi/10.5281/zenodo.11389182 Kakati R, Borah P, Bhattacharyya R, Deori A. Controlled Hypotension in Functional Endoscopic Sinus Surgery: A Comparison between Esmolol and Dexmedetomidine - A Randomized Prospective Study. Int J Contemp Med Res [Internet]. 5(2). Available from: https://ijcmr.com/uploads/7/7/4/6/77464738/ijcmr_1881_v1.pdf Meghasree M, S. V. Lakshmi K, Naik B. A STUDY ON THE EFFECTIVENESS OF DEXMEDETOMIDINE AND ESMOLOL FOR INDUCED HYPOTENSION IN FUNCTIONAL ENDOSCOPIC SINUS SURGERIES DONE UNDER GENERAL ANAESTHESIA. INDIAN J Appl Res. 14(10). Omara AF, Mohammed Abo Hagar A, Fawzy Amer A. The Effect of Esmolol Versus Dexmedetomidine on Postoperative Pain Control in Endoscopic Sinus Surgery: A Randomized Trial. Anesthesiol Pain Med. 2025 June 30;15(3):e158065. M PK, H AS, Tn C, Sv S. A Comparative study of intraoperative infusion of dexmedetomidine vs esmolol for controlled hypotension in functional endoscopic sinus surgeries. Eur J Cardiovasc Med. 2024 June 20;14:1149–54. Rather MA, Bashir F, Ahad S. Comparison of Dexmedetomidine, Esmolol and Sodium Nitroprusside for Hypotensive Anaesthesia in Functional Endoscopic Sinus Surgery. M R, P S. COMPREHENSIVE STUDY ON EFFECTIVENESS AND ADVANTAGES OF DEXMEDETOMIDINE AND ESMOLOL IN CONTROLLED HYPOTENSION FOR FUNCTIONAL ENDOSCOPIC SINUS SURGERY. J Evol Med Dent Sci. 2017;6(34):2789–93. Sahu BP, Nayak LK, Mohapatra PS, Mishra K. Induced Hypotension in Functional Endoscopic Sinus Surgery: A Comparative Study of Dexmedetomidine and Esmolol. Cureus [Internet]. 2021 May 17 [cited 2025 Nov 21]; Available from: https://www.cureus.com/articles/58879-induced-hypotension-in-functional-endoscopic-sinus-surgery-a-comparative-study-of-dexmedetomidine-and-esmolol Shaheen MSA, Sardar K, Chowdhury AN, Mondal SK, Ahmed R, Alam SS. Controlled Hypotension for Functional Endoscopic Sinus Surgery: A Comparative study between Dexmedetomidine versus Esmolol. J Bangladesh Soc Anaesthesiol. 2018;31(2):67–74. Shams T, El Bahnasawe N, Abu-Samra M, El-Masry R. Induced hypotension for functional endoscopic sinus surgery: A comparative study of dexmedetomidine versus esmolol. Saudi J Anaesth. 2013;7(2):175. Sharma CK, Singh M, Yadav RL. COMPARATIVE EFFICACY OF ESMOLOL AND DEXMEDETOMIDINE IN ACHIEVING CONTROLLED HYPOTENSION DURING FUNCTIONAL ENDOSCOPIC SINUS SURGERY: A RANDOMIZED DOUBLE-BLIND STUDY. Int J Curr Pharm Res. 2025;70–4. Shivakumara KC. A Comparative Study of the Effects of Dexmedetomidine and Esmolol Infusion on Haemodynamic Parameters and Surgical Condition during Functional Endoscopic Sinus Surgery. 2016;7(11). Penta SP, Sowjanya K, Yenikepalli L, Prameela B. A COMPARATIVE EVALUATION OF INDUCED HYPOTENSION USING NITROGLYCERINE, ESMOLOL, AND DEXMEDETOMIDINE DURING FUNCTIONAL ENDOSCOPIC SINUS SURGERY. INDIAN J Appl Res. 15(8). Vasavi T, Parveen S, Krishna MM. “COMPARISON BETWEEN INTRAVENOUS DEXMEDETOMIDINE VERSUS ESMOLOL FOR INDUCED HYPOTENSION IN FUNCTIONAL ENDOSCOPIC SINUS SURGERY: A PROSPECTIVE, CONTROLLED, RANDOMIZED DOUBLE BLINDED STUDY”. INDIAN J Appl Res. 14(8). Ohtani N, Kida K, Shoji K, Yasui Y, Masaki E. Recovery Profiles from Dexmedetomidine as a General Anesthetic Adjuvant in Patients Undergoing Lower Abdominal Surgery. Anesth Analg. 2008;107(6):1871–4. Kim DJ, Kim SH, So KY, Jung KT. Effects of dexmedetomidine on smooth emergence from anaesthesia in elderly patients undergoing orthopaedic surgery. BMC Anesthesiol. 2015;15(1):139. Aouad MT, Zeeni C, Al Nawwar R, Siddik-Sayyid SM, Barakat HB, Elias S, et al. Dexmedetomidine for Improved Quality of Emergence From General Anesthesia: A Dose-Finding Study. Anesth Analg. 2019;129(6):1504–11. Sachdeva A, Jaswal S, Walia HS, Batra YK. Correlating the Depth of Sedation Between the Ramsay Sedation Scale and Bispectral Index Using Either Intravenous Midazolam or Intravenous Propofol in Elderly Patients Under Spinal Anaesthesia. Cureus [Internet]. 2023 Dec 19 [cited 2025 Nov 21]; Available from: https://www.cureus.com/articles/171787-correlating-the-depth-of-sedation-between-the-ramsay-sedation-scale-and-bispectral-index-using-either-intravenous-midazolam-or-intravenous-propofol-in-elderly-patients-under-spinal-anaesthesia Deshmukh PP, Chakole V. Post-Anesthesia Recovery: A Comprehensive Review of Sampe, Modified Aldrete, and White Scoring Systems. Cureus [Internet]. 2024 Oct 6 [cited 2025 Nov 21]; Available from: https://www.cureus.com/articles/306889-post-anesthesia-recovery-a-comprehensive-review-of-sampe-modified-aldrete-and-white-scoring-systems Asouhidou I, Trikoupi A. Esmolol reduces anesthetic requirements thereby facilitating early extubation; a prospective controlled study in patients undergoing intracranial surgery. BMC Anesthesiol. 2015;15(1):172. Ko KH, Jun IJ, Lee S, Lim Y, Yoo B, Kim KM. Effective dose of dexmedetomidine to induce adequate sedation in elderly patients under spinal anesthesia. Korean J Anesthesiol. 2015;68(6):575. Timerga S, Befkadu A. Prevalence and associated factors of postoperative nausea and vomiting among adult patients undergoing elective surgery. Ann Med Surg. 2024;86(3):1304–8. Okuda C, Inoue S, Kawaguchi M. Anesthesia-related care dissatisfaction: a cohort historical study to reveal related risks. Braz J Anesthesiol Engl Ed. 2021;71(2):103–9. Tables Table 1 and 2 are available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files Table2.docx Table1.docx SupplementaryFileSuppl1.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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1","display":"","copyAsset":false,"role":"figure","size":5713,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ePRISMA Flowchart\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"placeholderimage.png","url":"https://assets-eu.researchsquare.com/files/rs-8501577/v1/1b424c96e421a78877379d2d.png"},{"id":100342651,"identity":"26d19927-4322-4448-9808-45826bdb167e","added_by":"auto","created_at":"2026-01-16 00:07:10","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":1527600,"visible":true,"origin":"","legend":"\u003cp\u003eSee image above for figure legend.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-8501577/v1/ea0ad8105ed86c5a490759e6.png"},{"id":100373628,"identity":"15ceb0f8-23fb-47f7-9f39-05213f07cdf2","added_by":"auto","created_at":"2026-01-16 08:15:34","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":740046,"visible":true,"origin":"","legend":"\u003cp\u003eSee image above for figure legend.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-8501577/v1/e01c21d7532351ccfa6743f7.png"},{"id":101635817,"identity":"d096b4d8-5890-484d-804c-b19e2ad36a8b","added_by":"auto","created_at":"2026-02-02 06:27:08","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":3272819,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8501577/v1/96ebdb28-176f-4d17-931f-cf051a14444e.pdf"},{"id":100373561,"identity":"7054b5c4-1db2-4f01-8f12-f69430468966","added_by":"auto","created_at":"2026-01-16 08:14:55","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":15981,"visible":true,"origin":"","legend":"","description":"","filename":"Table2.docx","url":"https://assets-eu.researchsquare.com/files/rs-8501577/v1/b403f4fca43119bbb98a9610.docx"},{"id":100373522,"identity":"8a7869a0-12e4-41b8-b68d-42b522e9237e","added_by":"auto","created_at":"2026-01-16 08:14:46","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":33821,"visible":true,"origin":"","legend":"","description":"","filename":"Table1.docx","url":"https://assets-eu.researchsquare.com/files/rs-8501577/v1/d40d84810efe3367b4a8ed12.docx"},{"id":100342659,"identity":"2fb71b4d-ce0b-442c-8966-015a7d50eb60","added_by":"auto","created_at":"2026-01-16 00:07:10","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":2505195,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryFileSuppl1.docx","url":"https://assets-eu.researchsquare.com/files/rs-8501577/v1/6568a0095877ed077f3d9042.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Comparative Efficacy and Safety of Dexmedetomidine and Esmolol in Functional Endoscopic Sinus Surgery (FESS): A Systematic Review and Meta-analysis","fulltext":[{"header":"Introduction","content":"\u003cp\u003eFunctional Endoscopic Sinus Surgery (FESS) is a surgical technique designed to improve sinus drainage and ventilation by removing obstructed tissue in diseased sinuses (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e), with chronic rhinosinusitis being its most frequent indication (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Despite its advantages, FESS carries potential risks, including bleeding, injury to surrounding structures such as CSF rhinorrhea, dural tear, optic nerve injuries, and anesthesia-related complications to name a few, all of which can impact patient outcomes (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eSurgical field visualization is an important factor that can prevent complications. Intraoperative blood loss can obstruct the surgical field, prolong the operative time, and increase the risk of surgical complications due to a poor surgical field (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Thus, effective perioperative management is essential to minimize these risks and enhance both surgical outcomes and patient safety.\u003c/p\u003e \u003cp\u003eStrategies to minimize perioperative stress and prevent complications during FESS include anesthetic agents (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e), achieving controlled hypotension and heart rate (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e), and perioperative positioning of the patient in the reverse Trendelenburg position (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Anesthetic agents like opioids, benzodiazepines, propofol, and inhalational anesthetics, though helpful in ensuring sedation and pain control, are associated with risks, including respiratory depression, hemodynamic instability, and postoperative nausea and vomiting. The idea behind controlled hypotension is that it could reduce intraoperative blood loss, improve surgical field quality, and reduce operative time. Various agents used for this purpose include β-blockers, α-2 agonists, vasodilators such as nitroglycerin and sodium nitroprusside, and some anesthetics like propofol and sevoflurane, which have the added benefit of blood pressure reduction despite sedation.\u003c/p\u003e \u003cp\u003eOur systematic review and meta-analysis aim to compare the efficacy and safety of two such agents: Dexmedetomidine and Esmolol. Dexmedetomidine, an α2-agonist, provides sedation, analgesia, and controlled hypotension by reducing norepinephrine release via brainstem α2-receptor activation (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Esmolol, an ultra-short-acting beta-blocker, is frequently used to manage intraoperative hemodynamic fluctuations. Though individual studies compare the safety and efficacy of these drugs in FESS, pooled evidence in the form of a systematic review and meta-analysis is lacking. This review aims to address that gap.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eWe conducted this systematic review and meta-analysis in line with the Cochrane Handbook for Systematic Reviews of Interventions (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e), and reported it according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist of 2020 (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). This review is registered on the Open Science Framework (OSF) (Registration DOI: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.17605/OSF.IO/UZEF6\u003c/span\u003e\u003cspan address=\"10.17605/OSF.IO/UZEF6\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e) (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Ethical approval was not needed for this review, as already published, publicly available data were utilized.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eData Sources and Search Strategy:\u003c/h2\u003e \u003cp\u003eWe searched the PubMed, Embase, Scopus, Web of Science, Cochrane and ClinicalTrials.gov from inception to August 28, 2025. Additional studies were identified through citation chaining and searching websites. The detailed search strategies for each source are provided in \u003cb\u003eSupplementary Table \u003cspan refid=\"MOESM1\" class=\"InternalRef\"\u003eS1\u003c/span\u003e\u003c/b\u003e. The search string consisted of three search terms: i) Functional Endoscopic Sinus Surgery; ii) Dexmedetomidine; and iii) Esmolol.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eStudy Selection Process:\u003c/h3\u003e\n\u003cp\u003eAll retrieved records were imported into Rayyan (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e) for screening. After removing duplicates, two reviewers independently screened titles, abstracts, and full texts according to pre-specified inclusion and exclusion criteria. Disagreements were resolved by a third reviewer.\u003c/p\u003e\n\u003ch3\u003eEligibility Criteria:\u003c/h3\u003e\n\u003cp\u003eInclusion criteria were: 1. Adult patients undergoing functional endoscopic sinus surgery (FESS); 2. Usage of dexmedetomidine as intervention; 3. Comparison with esmolol as control; 4. Reporting relevant efficacy and/or safety outcomes; 5. Randomized controlled trials (RCTs) by design.\u003c/p\u003e \u003cp\u003eExclusion criteria were: 1. Studies enrolling animals or patients undergoing procedure other than FESS; 2. Not using dexmedetomidine as intervention; 3. Not comparing to esmolol; 4. Not reporting relevant efficacy and/or safety outcomes; 5. Other study designs such as case reports, reviews, and case series.\u003c/p\u003e\n\u003ch3\u003eData Extraction:\u003c/h3\u003e\n\u003cp\u003eFour reviewers independently extracted data using pre-piloted sheets, such that data from each study were extracted by two reviewers. Discrepancies were resolved by discussion or, if needed, by a third reviewer. Extracted data included study characteristics, intervention details, and patient demographics, and outcome data.\u003c/p\u003e\n\u003ch3\u003eRisk of Bias Assessment:\u003c/h3\u003e\n\u003cp\u003eTwo reviewers independently assessed risk of bias using the Cochrane Risk of Bias 2 (RoB 2) tool. Risk of bias was judged per outcome for seven key endpoints: intraoperative blood loss, emergence time, time to first rescue analgesia, time to modified Aldrete score\u0026thinsp;\u0026gt;\u0026thinsp;9, and incidences of hypotension, bradycardia, and postoperative nausea and vomiting. Disagreements were resolved by consensus or, if needed, by a third reviewer.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eCertainty of Evidence:\u003c/h2\u003e \u003cp\u003eCertainty of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. Certainty was rated as high, moderate, low, or very low. The primary domains for downgrading the quality of evidence are risk of bias, inconsistency, indirectness, imprecision, and publication bias. Findings were organized and summarised using the GRADEpro software.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis:\u003c/h2\u003e \u003cp\u003eStatistical analyses were conducted in R (version 4.5.1) using a random-effects model. For continuous outcomes, mean differences (MD) with 95% confidence intervals (CIs) were calculated, and for dichotomous outcomes, risk ratios (RR) with 95% CIs were calculated. Heterogeneity was assessed using the χ\u003csup\u003e2\u003c/sup\u003e and I\u003csup\u003e2\u003c/sup\u003e statistics. Sensitivity analyses were performed using a leave-one-out approach, and subgroup and meta-regression analyses were conducted to explore heterogeneity. Publication bias was assessed for outcomes with \u0026ge;\u0026thinsp;10 studies by funnel plots. For outcomes with fewer studies, publication bias was not formally evaluated due to limited statistical power.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eStudy Selection Process\u003c/h2\u003e \u003cp\u003eThe literature search yielded a total of 102 records through databases and registers. 39 duplicates were removed and the remaining articles were screened on the basis of title-abstracts and then full-texts. 11 studies met the eligibility criteria and were included. From other sources (website and citation searching), 109 records were screened and 7 studies met the inclusion criteria. In total, 18 studies were included in this systematic review and meta-analysis (\u003cspan additionalcitationids=\"CR14 CR15 CR16 CR17 CR18 CR19 CR20 CR21 CR22 CR23 CR24 CR25 CR26 CR27 CR28 CR29\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). The detailed study selection process is outlined in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flowchart \u003cb\u003e(Fig.\u0026nbsp;1)\u003c/b\u003e.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eCharacteristics of Included Studies\u003c/h2\u003e \u003cp\u003eThis systematic review and meta-analysis included a total of 18 randomized controlled trials, comprising 1,056 participants. The studies were published between the years 2013 and 2025. All studies were parallel-group, single-center trials; most were conducted in India (k\u0026thinsp;=\u0026thinsp;15), followed by Egypt (k\u0026thinsp;=\u0026thinsp;2) and Bangladesh (k\u0026thinsp;=\u0026thinsp;1). All trials compared dexmedetomidine, administered intravenously, to esmolol, also administered intravenously, in functional endoscopic sinus surgery (FESS). The most common dosing regimen for dexmedetomidine was a loading dose of 1 \u0026micro;g/kg given over 10 minutes, followed by a maintenance dose of 0.4\u0026ndash;0.8 \u0026micro;g/kg/hr. For esmolol, the most common regimen was a loading dose of 1 mg/kg given over 1 minute, followed by a maintenance dose of 0.4\u0026ndash;0.8 mg/kg/hr. Mean participant ages varied from 29.24\u0026thinsp;\u0026plusmn;\u0026thinsp;1.38 years to 40.12\u0026thinsp;\u0026plusmn;\u0026thinsp;11.9 years. The American Society of Anesthesiologists (ASA) physical statuses of the included participants were ASA I-II. The majority of the participants were male. \u003cb\u003eTable\u0026nbsp;1\u003c/b\u003e summarizes the key characteristics of the included studies.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eRisk of Bias Assessment\u003c/h2\u003e \u003cp\u003eRisk of bias was assessed across five domains for seven key outcomes, with the overall risk of bias also being judged. The outcomes assessed were intraoperative blood loss, emergence time, time to first rescue analgesia, time to modified Aldrete score\u0026thinsp;\u0026gt;\u0026thinsp;9, incidence of hypotension, incidence of bradycardia, and incidence of postoperative nausea and vomiting.\u003c/p\u003e \u003cp\u003eAcross most outcomes, the overall risk of bias was judged as some concerns, mainly arising from issues in domain 5. For emergence time, one study was judged to be at high risk of bias, largely due to concerns in domains 4 (measurement of outcomes) and 5. Other studies reporting emergence time were judged as having some concerns overall. The risk of bias assessment per outcome is given in supplementary \u003cb\u003e(Supplementary Figures SA1-SA14)\u003c/b\u003e.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analyses\u003c/h2\u003e \u003cdiv id=\"Sec15\" class=\"Section3\"\u003e \u003ch2\u003eOutcomes\u003c/h2\u003e \u003cdiv id=\"Sec16\" class=\"Section4\"\u003e \u003ch2\u003eEfficacy\u003c/h2\u003e \u003cp\u003e \u003cb\u003eIntraoperative Blood Loss (mL)\u003c/b\u003e \u003c/p\u003e \u003cp\u003eFive out of the eighteen included trials reported intraoperative blood loss (N\u0026thinsp;=\u0026thinsp;306). A statistically non-significant difference was seen for volume of intraoperative blood loss between the two groups (MD -1.18 mL, 95% CI [-2.99 to 0.63], P\u0026thinsp;=\u0026thinsp;0.200, I\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;0%) \u003cb\u003e(Fig.\u0026nbsp;2A)\u003c/b\u003e.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eDuration of Surgery (minutes)\u003c/h2\u003e \u003cp\u003eTwelve out of the eighteen included trials reported duration of surgery (N\u0026thinsp;=\u0026thinsp;746). A statistically non-significant difference was seen for the surgical duration between dexmedetomidine and esmolol usage (MD -3.04 minutes, 95% CI [-6.16 to 0.08], P\u0026thinsp;=\u0026thinsp;0.056, I\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;70.5%) \u003cb\u003e(Fig.\u0026nbsp;2B)\u003c/b\u003e. Omitting \u003cem\u003eShivakumara et al., 2018\u003c/em\u003e in the LOO analysis reduced I\u003csup\u003e2\u003c/sup\u003e heterogeneity to 16% \u003cb\u003e(Supplementary Table S2)\u003c/b\u003e. Univariate meta-regression using the year of publication as covariate did not significantly explain variation in effect sizes. Likewise, neither raw total sample size nor log total sample size was able to explain the heterogeneity \u003cb\u003e(Supplementary Figures S2A-C)\u003c/b\u003e.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eEmergence Time (minutes)\u003c/h2\u003e \u003cp\u003eTen trials reported emergence time. Esmolol use showed a statistically significant shorter time to emergence (MD 3.13 minutes, 95% CI [2.64 to 3.63], P\u0026thinsp;\u0026lt;\u0026thinsp;0.001, I\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;87.7%) \u003cb\u003e(Fig.\u0026nbsp;2C)\u003c/b\u003e. Omitting \u003cem\u003eRavikumar et al., 2017\u003c/em\u003e in the LOO analysis reduced I\u003csup\u003e2\u003c/sup\u003e to 68.3%, with considerable heterogeneity persisting \u003cb\u003e(Supplementary Table S3)\u003c/b\u003e. Subgroup analyses by dexmedetomidine maintenance dose or esmolol maintenance dose did not meaningfully resolve heterogeneity \u003cb\u003e(Supplementary Figures S2D, S2E)\u003c/b\u003e.\u003c/p\u003e \u003cp\u003eUnivariate meta-regression with year of publication as covariate showed that it was not a significant predictor of the difference in emergence time between dexmedetomidine and esmolol, with residual heterogeneity remaining very high. Likewise, no evidence of association was seen between total study sample size and effect estimates, or log total study sample size and effect estimates \u003cb\u003e(Supplementary Figures S2F-H)\u003c/b\u003e.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eTime to First Rescue Analgesia (minutes)\u003c/h2\u003e \u003cp\u003eNine studies reported time to first rescue analgesia. Dexmedetomidine use showed a significantly higher time to first rescue analgesic administration (MD 27.83 minutes, 95% CI [26.41 to 29.26], P\u0026thinsp;=\u0026thinsp;0, I\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;54.3%) \u003cb\u003e(Fig.\u0026nbsp;2D)\u003c/b\u003e. LOO analysis omitting \u003cem\u003eVasavi et al., 2024\u003c/em\u003e reduced I\u003csup\u003e2\u003c/sup\u003e heterogeneity to 1.2% \u003cb\u003e(Supplementary Table S4)\u003c/b\u003e.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eTime to Aldrete Score\u0026thinsp;\u0026gt;\u0026thinsp;9 (minutes)\u003c/h2\u003e \u003cp\u003eTwo trials reported time to Aldrete score\u0026thinsp;\u0026gt;\u0026thinsp;9. In one study (n\u0026thinsp;=\u0026thinsp;60), the dexmedetomidine group reached this threshold later than those receiving esmolol (10.4\u0026thinsp;\u0026plusmn;\u0026thinsp;2.5 minutes versus 8.5\u0026thinsp;\u0026plusmn;\u0026thinsp;2.3 minutes). In the other study (n\u0026thinsp;=\u0026thinsp;60), reported time was much longer with dexmedetomidine (180 minutes versus 150 minutes). Due to the substantial differences in reported absolute times between the two trials, likely due to different starting and ending points, meta-analysis was not performed. Both studies, however, showed a longer time to recovery in the dexmedetomidine group compared with the esmolol group.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003eTime to Modified Aldrete Score\u0026thinsp;\u0026gt;\u0026thinsp;9 (minutes)\u003c/h2\u003e \u003cp\u003eSix studies reported time to modified Aldrete score\u0026thinsp;\u0026gt;\u0026thinsp;9. Dexmedetomidine use showed a significantly higher time to modified Aldrete score\u0026thinsp;\u0026gt;\u0026thinsp;9 (MD 2.68 minutes, 95% CI [2.26 to 3.11], P\u0026thinsp;\u0026lt;\u0026thinsp;0.001, I\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;34.1%) \u003cb\u003e(Fig.\u0026nbsp;2E)\u003c/b\u003e.\u003c/p\u003e \u003cdiv id=\"Sec22\" class=\"Section3\"\u003e \u003ch2\u003eRamsay Sedation Score (RSS) at 15 Minutes Postoperation\u003c/h2\u003e \u003cp\u003eSeven studies reported RSS 15 minutes postoperatively. Dexmedetomidine use showed a significantly higher RSS (MD 0.94, 95% CI [0.38 to 1.50], P\u0026thinsp;=\u0026thinsp;0.001, I\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;98.7%) \u003cb\u003e(Fig.\u0026nbsp;2F)\u003c/b\u003e. Subgroup by maintenance dose of esmolol resolved heterogeneity \u003cb\u003e(Supplementary Figure S2I)\u003c/b\u003e but not of dexmedetomidine \u003cb\u003e(Supplementary Figure S2J)\u003c/b\u003e. Heterogeneity remained high across all LOO iterations \u003cb\u003e(Supplementary Table S5)\u003c/b\u003e.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec23\" class=\"Section2\"\u003e \u003ch2\u003eRamsay Sedation Score at 30 Minutes Postoperation\u003c/h2\u003e \u003cp\u003eNine studies reported RSS 30 minutes postoperatively. Dexmedetomidine use showed a significantly higher RSS (MD 0.84, 95% CI [0.51 to 1.18], P\u0026thinsp;\u0026lt;\u0026thinsp;0.001, I\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;97.4%) \u003cb\u003e(Fig.\u0026nbsp;2G)\u003c/b\u003e. Subgroups by maintenance dose of esmolol or dexmedetomidine did not resolve heterogeneity \u003cb\u003e(Supplementary Figure S2K, S2L)\u003c/b\u003e. Heterogeneity remained high across all LOO iterations \u003cb\u003e(Supplementary Table S6)\u003c/b\u003e.\u003c/p\u003e \u003cdiv id=\"Sec24\" class=\"Section3\"\u003e \u003ch2\u003eRamsay Sedation Score at 60 Minutes Postoperation\u003c/h2\u003e \u003cp\u003eEight studies reported RSS 60 minutes postoperatively. Non-significant difference was seen for RSS (MD 0.17, 95% CI [-0.01 to 0.35], P\u0026thinsp;=\u0026thinsp;0.069, I\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;86.1%) \u003cb\u003e(Fig.\u0026nbsp;2H)\u003c/b\u003e. Subgroups by maintenance dose of esmolol or dexmedetomidine did not resolve heterogeneity \u003cb\u003e(Supplementary Figure S2M, S2N)\u003c/b\u003e. Heterogeneity remained high across all LOO iterations \u003cb\u003e(Supplementary Table S7)\u003c/b\u003e.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec25\" class=\"Section3\"\u003e \u003ch2\u003eSafety\u003c/h2\u003e \u003cdiv id=\"Sec26\" class=\"Section4\"\u003e \u003ch2\u003eIncidence of Hypertension\u003c/h2\u003e \u003cp\u003eTwo trials reported hypertension incidence, which was significantly higher with dexmedetomidine use (RR 6.94, 95% CI [2.03 to 23.69], P\u0026thinsp;=\u0026thinsp;0.002, I\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;0%) \u003cb\u003e(Fig.\u0026nbsp;3A)\u003c/b\u003e.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec27\" class=\"Section2\"\u003e \u003ch2\u003eIncidence of Hypotension\u003c/h2\u003e \u003cp\u003eTwo trials reported hypotension incidence. Nonsignificant difference was seen between the two groups (RR 0.20, 95% CI [0.02 to 1.65], P\u0026thinsp;=\u0026thinsp;0.135, I\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;0%) \u003cb\u003e(Fig.\u0026nbsp;3B)\u003c/b\u003e.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec28\" class=\"Section2\"\u003e \u003ch2\u003eIncidence of Bradycardia\u003c/h2\u003e \u003cp\u003eTwo trials reported on bradycardia incidence, which was significantly higher with dexmedetomidine use (RR 3.96, 95% CI [1.62 to 9.65], P\u0026thinsp;=\u0026thinsp;0.002, I\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;0%) \u003cb\u003e(Fig.\u0026nbsp;3C)\u003c/b\u003e.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eIncidence of Postoperative Nausea and Vomiting (PONV)\u003c/h3\u003e\n\u003cp\u003eThree trials reported PONV incidence, which was significantly lower with dexmedetomidine use (RR 0.26, 95% CI [0.10 to 0.73], P\u0026thinsp;=\u0026thinsp;0.010, I\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;0%) \u003cb\u003e(Fig.\u0026nbsp;3D)\u003c/b\u003e.\u003c/p\u003e \u003cdiv id=\"Sec30\" class=\"Section2\"\u003e \u003ch2\u003eIncidence of Dry Mouth\u003c/h2\u003e \u003cp\u003eThree trials reported dry mouth incidence, which was significantly higher with dexmedetomidine use (RR 4.26, 95% CI [2.10 to 8.64], P\u0026thinsp;\u0026lt;\u0026thinsp;0.001, I\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;0%) \u003cb\u003e(Fig.\u0026nbsp;3E)\u003c/b\u003e.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec31\" class=\"Section2\"\u003e \u003ch2\u003eIncidence of Shivering\u003c/h2\u003e \u003cp\u003eTwo trials reported shivering incidence. Nonsignificant difference was seen between the two groups (RR 0.39, 95% CI [0.10 to 1.42], P\u0026thinsp;=\u0026thinsp;0.153, I\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;0%) \u003cb\u003e(Fig.\u0026nbsp;3F)\u003c/b\u003e.\u003c/p\u003e \u003cdiv id=\"Sec32\" class=\"Section3\"\u003e \u003ch2\u003ePublication Bias\u003c/h2\u003e \u003cp\u003ePublication bias was assessed for all outcomes which were reported by ten or more studies (duration of surgery and emergence time). Visual inspection of funnel plots did not indicate signs of major asymmetry. For duration of surgery \u003cb\u003e(Supplementary Figure S3A)\u003c/b\u003e, there was some asymmetry seen, but not enough to conclude major publication bias. For emergence time \u003cb\u003e(Supplementary Figure S3B)\u003c/b\u003e the funnel plot appeared largely symmetrical, showing no strong signs of publication bias. Overall, although there was some concern regarding asymmetry for duration of surgery, the evidence for publication bias across outcomes was limited and not conclusive.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec33\" class=\"Section3\"\u003e \u003ch2\u003eGRADE Certainty of Evidence\u003c/h2\u003e \u003cp\u003eCertainty of evidence was appraised for seven key outcomes most relevant to patient health or care (intraoperative blood loss, emergence time, time to first rescue analgesia, time to modified Aldrete score\u0026thinsp;\u0026gt;\u0026thinsp;9, incidence of hypotension, incidence of bradycardia, and incidence of postoperative nausea and vomiting). Findings are presented in the form of a Summary of Findings (SoF) table \u003cb\u003e(Table\u0026nbsp;2)\u003c/b\u003e.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe findings of this systematic review and meta-analysis provide a comprehensive comparison between dexmedetomidine and esmolol for perioperative management during functional endoscopic sinus surgery (FESS). Both medications are commonly used to manage hemodynamic responses and postoperative recovery, but their effects on various outcomes remain a subject of ongoing debate. The included studies, comprising 1,056 participants across 18 randomized controlled trials (RCTs), highlight key differences and similarities in efficacy and safety profiles between these two agents.\u003c/p\u003e\n\u003ch3\u003eSummary of Key Findings\u003c/h3\u003e\n\u003cdiv id=\"Sec36\" class=\"Section2\"\u003e \u003ch2\u003eEfficacy Outcomes\u003c/h2\u003e \u003cp\u003eOur analysis reveals several noteworthy points regarding the comparative effects of dexmedetomidine and esmolol. In terms of intraoperative blood loss, no significant differences were observed between the two groups, which suggests that neither drug has a clear advantage in minimizing bleeding during surgery. Similarly, duration of surgery showed a trend toward reduced time with dexmedetomidine, but this difference was not statistically significant. A more striking difference was observed in emergence time, with esmolol providing a significantly shorter recovery time compared to dexmedetomidine. This aligns with past studies which show that dexmedetomidine may delay recovery when administered with propofol (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). Dexmedetomidine provides smooth recovery by decreasing agitation associated with emergence (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e), and by adjusting the dose of propofol administered, the delay in recovery time can be reduced to non-significant levels (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). Conversely, time to first rescue analgesia was significantly longer in the dexmedetomidine group, indicating its role in prolonging postoperative analgesia.\u003c/p\u003e \u003cp\u003eRamsay Sedation Scale is an established 6-point tool which provides a simple monitoring method to gauge the awareness level of the patient (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e). Dexmedetomidine was associated with a significantly higher Ramsay Sedation Score (RSS) at 15 and 30 minutes postoperation, reinforcing its sedative properties. A nonsignificant increase in the RSS with dexmedetomidine was observed at 60 minutes postoperation as well. While sedation can be beneficial for patient comfort, it may also delay the postoperative recovery process, as evidenced by the prolonged time to modified Aldrete score\u0026thinsp;\u0026gt;\u0026thinsp;9 with dexmedetomidine. The modified Aldrete scoring system is a post-anesthesia recovery tool used to evaluate the readiness for post-anesthesia discharge of the patient (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e). It consists of five criteria including activity, respiration, circulation, consciousness, and oxygen saturation which are rated from 0 to 1 depending on the patient condition, with a score of 9\u0026ndash;10 indicating a readiness for discharge (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e). Dexmedetomidine causing prolonged time to reach modified Aldrete score of greater than 9 means that the patient has to be kept in post-anesthesia care unit (PACU) for a longer period. In contrast, esmolol\u0026rsquo;s lack of a sedative effect allows for a faster return to baseline alertness and function (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e), potentially facilitating a quicker discharge from the PACU.\u003c/p\u003e \u003cdiv id=\"Sec37\" class=\"Section3\"\u003e \u003ch2\u003eSafety Outcomes\u003c/h2\u003e \u003cp\u003eIn terms of safety, dexmedetomidine was associated with significantly higher incidences of hypertension and bradycardia, which are well-documented side effects of the drug. Dexmedetomidine is known to cause dose-dependent decrease in systolic and diastolic blood pressures along with bradycardia (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e). A higher loading dose presents with hypertension followed by hypotension, but with a low loading dose, the response is mainly hypotensive, without the preceding hypertension (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e). However, incidence of hypotension did not differ significantly between the two drugs. Interestingly, dexmedetomidine was associated with a significantly lower incidence of postoperative nausea and vomiting, which may be considered a clinical advantage, especially in patients at risk for nausea and vomiting following surgery. Postoperative nausea and vomiting is considered one of the most significant factors contributing towards patient dissatisfaction after anesthesia (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e). However, dexmedetomidine also led to a higher incidence of dry mouth, which could impact patient comfort in the postoperative period.\u003c/p\u003e \u003cp\u003eThese findings contribute to the evolving understanding of the pharmacological management of perioperative care in FESS. Esmolol\u0026rsquo;s advantage in reducing emergence time and its lack of significant adverse effects make it a favorable option when quick recovery from anesthesia is prioritized. Alternatively, dexmedetomidine\u0026rsquo;s sedative properties, combined with prolonged analgesia and decreased postoperative nausea and vomiting, may be more beneficial in cases where post-surgical comfort is desired. However, the observed hypertension and bradycardia in the dexmedetomidine group necessitate careful monitoring, particularly in patients with pre-existing cardiovascular conditions.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec38\" class=\"Section2\"\u003e \u003ch2\u003eStrengths\u003c/h2\u003e \u003cp\u003eThis review has several notable strengths that contribute to the robustness of its findings. First, it is the first to systematically evaluate the head to head efficacy and safety of dexmedetomidine and esmolol in the context of FESS, and includes only RCTs, which enhances the internal validity of the conclusions. Secondly, the search strategy was comprehensive, incorporated additional sources and citation searching, and resulted in the inclusion of 18 trials published between 2013 and 2025. This thorough approach ensured an up-to-date evidence base. The use of GRADE assessment to evaluate the certainty of evidence, along with adherence to the PRISMA guidelines in the study selection process, strengthens the transparency and methodological rigor of the review. These methodological choices collectively enhance the trustworthiness of the pooled estimates.\u003c/p\u003e \u003cdiv id=\"Sec39\" class=\"Section3\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eThis study has several limitations. Many safety endpoints were reported in only two to three trials with relatively small event counts, which may have produced imprecise estimates. This limits confidence in safety conclusions. Most studies (15/18) were conducted in India; all trials were conducted in a single-center setting and enrolled ASA I-II adult patients with mean ages in the 30 to 40-year range. Thus, the results may not generalize to older patients, those with significant cardiac comorbidity, or different healthcare systems. Several statistically significant differences were small in absolute terms such as the ~\u0026thinsp;3 minutes for time to modified Aldrete Score\u0026thinsp;\u0026gt;\u0026thinsp;9, which brings into question the clinical significance of the finding, even when statistical significance has been shown. The heterogeneity observed across several outcomes, particularly in emergence time and Ramsay Sedation Scores, needs to be noted as well. This variability may reflect differences in dosing regimens, patient populations, or study methodologies, and underscores the need for more consistent study designs in future trials.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e\n\u003ch3\u003eFuture Directions\u003c/h3\u003e\n\u003cp\u003eSeveral areas warrant further investigation. First, while both dexmedetomidine and esmolol have been studied individually in various contexts, comparisons in larger, multicenter RCTs are needed to clarify the observed discrepancies in outcome measures. Moreover, patient-specific factors, such as comorbidities (e.g., hypertension, heart disease) and age, should be considered in designing future trials to determine the most appropriate drug choice for individual patients. Long-term outcomes, such as patient satisfaction, quality of life, and cost-effectiveness, should also be considered in order to provide a complete view of the impact of these interventions on patient care. Future reviews may also benefit from obtaining individual-participant data (IPD) from trial investigators to better assess the effectiveness of each drug for important subpopulations.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis systematic review and meta-analysis found that both dexmedetomidine and esmolol may be effective agents for hemodynamic control during FESS, with comparable efficacy in minimizing intraoperative blood loss. Esmolol may offer faster emergence and recovery, while dexmedetomidine may lead to reduced nausea and vomiting risk. However, dexmedetomidine may carry a higher risk of bradycardia and dry mouth. Clinicians should individualize agent selection based on surgical priorities and patient needs. Further large, multicentric trials are needed to strengthen the evidence base and refine clinical guidance.\u003c/p\u003e "},{"header":"Declarations","content":"\u003cp\u003e \u003ch2\u003eCompeting interests\u003c/h2\u003e \u003cp\u003eThe authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eEthics approval and consent to participate\u003c/h2\u003e \u003cp\u003eNot needed, as this review utilized already published, publicly available data.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent for publication\u003c/strong\u003e \u003cp\u003e Consent for publication is not applicable as this study involves publicly available data.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003e**S.A.W.:** Conceptualization, Methodology, Software, Validation, Formal Analysis, Investigation, Resources, Data Curation, Writing \u0026ndash; Original Draft, Writing \u0026ndash; Reviewing \u0026amp; Editing, Visualization, Supervision, Project Administration. **A.W.:** Conceptualization, Methodology, Software, Validation, Investigation, Writing \u0026ndash; Original Draft, Writing \u0026ndash; Reviewing \u0026amp; Editing, Visualization, Supervision. **M.A.A.:** Software, Formal Analysis, Writing \u0026ndash; Original Draft, Validation. **H.J.:** Writing \u0026ndash; Original Draft, Validation, Supervision. **M.A.B.:** Software, Validation, Methodology, Data Curation, Writing \u0026ndash; Original Draft, Writing \u0026ndash; Reviewing \u0026amp; Editing. **S.I.:** Software, Investigation, Data Curation, Validation, Writing \u0026ndash; Reviewing \u0026amp; Editing. **E.H.:** Software, Methodology, Data Curation, Validation, Writing \u0026ndash; Reviewing \u0026amp; Editing **. M.U.I.:** Writing \u0026ndash; Reviewing \u0026amp; Editing, Validation, Supervision. **M.W.B.W:** Validation, Writing \u0026ndash; Reviewing \u0026amp; Editing. **M.N.S:** Validation, Writing \u0026ndash; Reviewing \u0026amp; Editing.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe data availability statement is not applicable as this study involves publicly available data. No new datasets were generated or analysed during this study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eKennedy DW. Functional Endoscopic Sinus Surgery: Technique. Arch Otolaryngol - Head Neck Surg. 1985;111(10):643\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSmith TL, Kern R, Palmer JN, Schlosser R, Chandra RK, Chiu AG, et al. Medical therapy vs surgery for chronic rhinosinusitis: a prospective, multi-institutional study with 1‐year follow‐up. Int Forum Allergy Rhinol. 2013;3(1):4\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKrings JG, Kallogjeri D, Wineland A, Nepple KG, Piccirillo JF, Getz AE. Complications of primary and revision functional endoscopic sinus surgery for chronic rhinosinusitis. The Laryngoscope. 2014;124(4):838\u0026ndash;45.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKelly EA, Gollapudy S, Riess ML, Woehlck HJ, Loehrl TA, Poetker DM. Quality of surgical field during endoscopic sinus surgery: a systematic literature review of the effect of total intravenous compared to inhalational anesthesia. Int Forum Allergy Rhinol. 2013 June;3(6):474\u0026ndash;81.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFedok FG, Ferraro RE, Kingsley CP, Fornadley JA. Operative times, postanesthesia recovery times, and complications during sinonasal surgery using general anesthesia and local anesthesia with sedation. Otolaryngol Neck Surg. 2000;122(4):560\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFromme GA, MacKenzie RA, Gould AB, Lund BA, Offord KP. Controlled hypotension for orthognathic surgery. Anesth Analg. 1986 June;65(6):683\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKo M, Chuang K, Su C. Multiple Analyses of Factors Related to Intraoperative Blood Loss and the Role of Reverse Trendelenburg Position in Endoscopic Sinus Surgery. The Laryngoscope. 2008 Sept;118(9):1687\u0026ndash;91.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eReel B, Maani CV. Dexmedetomidine. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 [cited 2025 Nov 20]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://www.ncbi.nlm.nih.gov/books/NBK513303/\u003c/span\u003e\u003cspan address=\"http://www.ncbi.nlm.nih.gov/books/NBK513303/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHiggins JP, Green S, editors. Cochrane Handbook for Systematic Reviews of Interventions: Cochrane Book Series [Internet]. 1st ed. Wiley; 2008 [cited 2025 Apr 10]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://onlinelibrary.wiley.com/doi/book/\u003c/span\u003e\u003cspan address=\"https://onlinelibrary.wiley.com/doi/book/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1002/9780470712184\u003c/span\u003e\u003cspan address=\"10.1002/9780470712184\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePage MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021;n71.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWasti SA. Comparative Efficacy and Safety of Dexmedetomidine Versus Esmolol in Patients Undergoing Functional Endoscopic Sinus Surgery: A Systematic Review and Meta-Analysis [Internet]. OSF Registries; 2025 [cited 2025 Nov 20]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://osf.io/uzef6/\u003c/span\u003e\u003cspan address=\"https://osf.io/uzef6/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOuzzani M, Hammady H, Fedorowicz Z, Elmagarmid A. Rayyan\u0026mdash;a web and mobile app for systematic reviews. Syst Rev. 2016;5(1):210.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAhmad DT, Khan DAS, Hussain DA. COMPARATIVE EVALUATION OF THE EFFICACY OF DEXMEDETOMIDINE VERSUS ESMOLOL FOR CONTROLLED HYPOTENSION IN FUNCTIONAL ENDOSCOPIC SINUS SURGERY.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBajwa SS, Kaur J, Kulshrestha A, Haldar R, Sethi R, Singh A. Nitroglycerine, esmolol and dexmedetomidine for induced hypotension during functional endoscopic sinus surgery: A comparative evaluation. J Anaesthesiol Clin Pharmacol. 2016;32(2):192.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDamarla R, Mamidi M. Dexmedetomidine and esmolol for induced hypotension for functional endoscopic sinus surgery-a comparative study. Natl J Physiol Pharm Pharmacol. 2021;(0):1.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eM G, N A, B RKP, B CV, Somashekhar AH. Dexmedetomidine versus Esmolol for Induced Hypotension during Functional Endoscopic Sinus Surgery - A Prospective Randomised Comparative Study. Eur J Cardiovasc Med. 2024;14:214\u0026ndash;23.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKomal Joshi, Sharad Kumar Mishra. Comparison of Dexmedetomidine and Esmolol Induced Hypotension in Functional Endoscopic Sinus Surgery. 2023 Dec 30 [cited 2025 Nov 20]; Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://zenodo.org/doi/10.5281/zenodo.11389182\u003c/span\u003e\u003cspan address=\"https://zenodo.doi/10.5281/zenodo.11389182\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKakati R, Borah P, Bhattacharyya R, Deori A. Controlled Hypotension in Functional Endoscopic Sinus Surgery: A Comparison between Esmolol and Dexmedetomidine - A Randomized Prospective Study. Int J Contemp Med Res [Internet]. 5(2). Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://ijcmr.com/uploads/7/7/4/6/77464738/ijcmr_1881_v1.pdf\u003c/span\u003e\u003cspan address=\"https://ijcmr.com/uploads/7/7/4/6/77464738/ijcmr_1881_v1.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMeghasree M, S. V. Lakshmi K, Naik B. A STUDY ON THE EFFECTIVENESS OF DEXMEDETOMIDINE AND ESMOLOL FOR INDUCED HYPOTENSION IN FUNCTIONAL ENDOSCOPIC SINUS SURGERIES DONE UNDER GENERAL ANAESTHESIA. INDIAN J Appl Res. 14(10).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOmara AF, Mohammed Abo Hagar A, Fawzy Amer A. The Effect of Esmolol Versus Dexmedetomidine on Postoperative Pain Control in Endoscopic Sinus Surgery: A Randomized Trial. Anesthesiol Pain Med. 2025 June 30;15(3):e158065.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eM PK, H AS, Tn C, Sv S. A Comparative study of intraoperative infusion of dexmedetomidine vs esmolol for controlled hypotension in functional endoscopic sinus surgeries. Eur J Cardiovasc Med. 2024 June 20;14:1149\u0026ndash;54.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRather MA, Bashir F, Ahad S. Comparison of Dexmedetomidine, Esmolol and Sodium Nitroprusside for Hypotensive Anaesthesia in Functional Endoscopic Sinus Surgery.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eM R, P S. COMPREHENSIVE STUDY ON EFFECTIVENESS AND ADVANTAGES OF DEXMEDETOMIDINE AND ESMOLOL IN CONTROLLED HYPOTENSION FOR FUNCTIONAL ENDOSCOPIC SINUS SURGERY. J Evol Med Dent Sci. 2017;6(34):2789\u0026ndash;93.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSahu BP, Nayak LK, Mohapatra PS, Mishra K. Induced Hypotension in Functional Endoscopic Sinus Surgery: A Comparative Study of Dexmedetomidine and Esmolol. Cureus [Internet]. 2021 May 17 [cited 2025 Nov 21]; Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.cureus.com/articles/58879-induced-hypotension-in-functional-endoscopic-sinus-surgery-a-comparative-study-of-dexmedetomidine-and-esmolol\u003c/span\u003e\u003cspan address=\"https://www.cureus.com/articles/58879-induced-hypotension-in-functional-endoscopic-sinus-surgery-a-comparative-study-of-dexmedetomidine-and-esmolol\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShaheen MSA, Sardar K, Chowdhury AN, Mondal SK, Ahmed R, Alam SS. Controlled Hypotension for Functional Endoscopic Sinus Surgery: A Comparative study between Dexmedetomidine versus Esmolol. J Bangladesh Soc Anaesthesiol. 2018;31(2):67\u0026ndash;74.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShams T, El Bahnasawe N, Abu-Samra M, El-Masry R. Induced hypotension for functional endoscopic sinus surgery: A comparative study of dexmedetomidine versus esmolol. Saudi J Anaesth. 2013;7(2):175.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSharma CK, Singh M, Yadav RL. COMPARATIVE EFFICACY OF ESMOLOL AND DEXMEDETOMIDINE IN ACHIEVING CONTROLLED HYPOTENSION DURING FUNCTIONAL ENDOSCOPIC SINUS SURGERY: A RANDOMIZED DOUBLE-BLIND STUDY. Int J Curr Pharm Res. 2025;70\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShivakumara KC. A Comparative Study of the Effects of Dexmedetomidine and Esmolol Infusion on Haemodynamic Parameters and Surgical Condition during Functional Endoscopic Sinus Surgery. 2016;7(11).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePenta SP, Sowjanya K, Yenikepalli L, Prameela B. A COMPARATIVE EVALUATION OF INDUCED HYPOTENSION USING NITROGLYCERINE, ESMOLOL, AND DEXMEDETOMIDINE DURING FUNCTIONAL ENDOSCOPIC SINUS SURGERY. INDIAN J Appl Res. 15(8).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVasavi T, Parveen S, Krishna MM. \u0026ldquo;COMPARISON BETWEEN INTRAVENOUS DEXMEDETOMIDINE VERSUS ESMOLOL FOR INDUCED HYPOTENSION IN FUNCTIONAL ENDOSCOPIC SINUS SURGERY: A PROSPECTIVE, CONTROLLED, RANDOMIZED DOUBLE BLINDED STUDY\u0026rdquo;. INDIAN J Appl Res. 14(8).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOhtani N, Kida K, Shoji K, Yasui Y, Masaki E. Recovery Profiles from Dexmedetomidine as a General Anesthetic Adjuvant in Patients Undergoing Lower Abdominal Surgery. Anesth Analg. 2008;107(6):1871\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKim DJ, Kim SH, So KY, Jung KT. Effects of dexmedetomidine on smooth emergence from anaesthesia in elderly patients undergoing orthopaedic surgery. BMC Anesthesiol. 2015;15(1):139.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAouad MT, Zeeni C, Al Nawwar R, Siddik-Sayyid SM, Barakat HB, Elias S, et al. Dexmedetomidine for Improved Quality of Emergence From General Anesthesia: A Dose-Finding Study. Anesth Analg. 2019;129(6):1504\u0026ndash;11.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSachdeva A, Jaswal S, Walia HS, Batra YK. Correlating the Depth of Sedation Between the Ramsay Sedation Scale and Bispectral Index Using Either Intravenous Midazolam or Intravenous Propofol in Elderly Patients Under Spinal Anaesthesia. Cureus [Internet]. 2023 Dec 19 [cited 2025 Nov 21]; Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.cureus.com/articles/171787-correlating-the-depth-of-sedation-between-the-ramsay-sedation-scale-and-bispectral-index-using-either-intravenous-midazolam-or-intravenous-propofol-in-elderly-patients-under-spinal-anaesthesia\u003c/span\u003e\u003cspan address=\"https://www.cureus.com/articles/171787-correlating-the-depth-of-sedation-between-the-ramsay-sedation-scale-and-bispectral-index-using-either-intravenous-midazolam-or-intravenous-propofol-in-elderly-patients-under-spinal-anaesthesia\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDeshmukh PP, Chakole V. Post-Anesthesia Recovery: A Comprehensive Review of Sampe, Modified Aldrete, and White Scoring Systems. Cureus [Internet]. 2024 Oct 6 [cited 2025 Nov 21]; Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.cureus.com/articles/306889-post-anesthesia-recovery-a-comprehensive-review-of-sampe-modified-aldrete-and-white-scoring-systems\u003c/span\u003e\u003cspan address=\"https://www.cureus.com/articles/306889-post-anesthesia-recovery-a-comprehensive-review-of-sampe-modified-aldrete-and-white-scoring-systems\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAsouhidou I, Trikoupi A. Esmolol reduces anesthetic requirements thereby facilitating early extubation; a prospective controlled study in patients undergoing intracranial surgery. BMC Anesthesiol. 2015;15(1):172.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKo KH, Jun IJ, Lee S, Lim Y, Yoo B, Kim KM. Effective dose of dexmedetomidine to induce adequate sedation in elderly patients under spinal anesthesia. Korean J Anesthesiol. 2015;68(6):575.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTimerga S, Befkadu A. Prevalence and associated factors of postoperative nausea and vomiting among adult patients undergoing elective surgery. Ann Med Surg. 2024;86(3):1304\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOkuda C, Inoue S, Kawaguchi M. Anesthesia-related care dissatisfaction: a cohort historical study to reveal related risks. Braz J Anesthesiol Engl Ed. 2021;71(2):103\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 1 and 2 are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Dexmedetomidine, Esmolol, Meta-analysis, Functional Endoscopic Sinus Surgery, FESS","lastPublishedDoi":"10.21203/rs.3.rs-8501577/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8501577/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eFunctional 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.\u003c/p\u003e\u003ch2\u003eObjective\u003c/h2\u003e \u003cp\u003eTo assess the relative efficacy and safety of dexmedetomidine and esmolol in patients undergoing FESS.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA 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.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eEighteen 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\u0026thinsp;\u0026gt;\u0026thinsp;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).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eModerate-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.\u003c/p\u003e","manuscriptTitle":"Comparative Efficacy and Safety of Dexmedetomidine and Esmolol in Functional Endoscopic Sinus Surgery (FESS): A Systematic Review and Meta-analysis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-16 00:07:00","doi":"10.21203/rs.3.rs-8501577/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"ab430356-9030-4c7b-921d-ef4222e05c62","owner":[],"postedDate":"January 16th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-02-02T06:26:29+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-16 00:07:00","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8501577","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8501577","identity":"rs-8501577","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}