Mohamed Saad Rakab, Yasir Majhud S Alzahrani, Abdulaziz Muhayya Alotaibi, Nourah Almarri, Lamyaa Hamdan Almutairi, Rakan Y Alsuwayyid, Aasheq Mamdouh W Alanazi, Abdullah O Almutairi, Turki Nashi Alharbi, Abdullah Mohammed Alghaith, Talal Dhifallah A Alanazi, Saad Hamdi Alenzi
Xylitol-containing postoperative irrigations may provide modest symptomatic benefit in selected postoperative populations, but the evidence remains low to very low certainty and does not establish a reliable clinically important SNOT-22 benefit. Larger, multicentre RCTs with standardized dosing/delivery and head-to-head comparators are needed to define candidates, optimal regimens, and durability of benefit.
BACKGROUND: Xylitol, a five-carbon polyol with antibiofilm effects, is increasingly added to postoperative sinonasal irrigations, yet its advantage over saline remains uncertain.
METHODS: We systematically reviewed comparative studies evaluating xylitol-containing nasal solutions after ESS, septoplasty, or turbinate surgery. Searches spanned PubMed, Scopus, Web of Science, and CENTRAL from inception to 18 June 2026. Outcomes included patient-reported symptoms (SNOT-20/22, NOSE, VAS), endoscopic healing, and safety. Random-effects meta-analysis pooled effects as mean differences (MD) or standardized mean differences (SMD); certainty was appraised with GRADE.
RESULTS: Eight studies met eligibility. Xylitol showed no clear overall advantage on SNOT-20/22 (SMD -0.49, 95% CI -1.12 to 0.14; p = 0.107; I2 = 72.9%). The effect was larger yet heterogeneous post-ESS (SMD -0.79, 95% CI -1.99 to 0.41), while non-ESS effects centred on no difference (SMD -0.09, 95% CI -0.45 to 0.26). Excluding Lin 2017 resolved most heterogeneity and significantly favoured xylitol (SMD -0.27, 95% CI -0.47 to -0.06; p = 0.0098; I2 = 24.2%). VAS score showed modest yet statistically significant improvement with xylitol (MD -1.16 points, 95% CI -2.30 to -0.03; p = 0.045). NOSE showed no overall benefit (MD -4.18, 95% CI -13.04 to 4.68; p = 0.2299); non-ESS improved slightly (MD -1.17, 95% CI -2.08 to -0.26; p = 0.0387), while ESS was heterogeneous and uncertain. Endoscopic scores were not significantly different (SMD -0.21, 95% CI -0.51 to 0.08; p = 0.1157).
CONCLUSIONS: Xylitol-containing postoperative irrigations may provide modest symptomatic benefit in selected postoperative populations, but the evidence remains low to very low certainty and does not establish a reliable clinically important SNOT-22 benefit. Larger, multicentre RCTs with standardized dosing/delivery and head-to-head comparators are needed to define candidates, optimal regimens, and durability of benefit.