Xylitol‐Containing Nasal Irrigation or Nebulization in Postoperative Sinonasal Care: A Systematic Review and Meta‐Analysis With GRADE Assessment

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ABSTRACT 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; I 2 = 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; I 2 = 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.