Supraglottic airway vs. endotracheal tube for sinonasal surgery: a systematic review and meta-analysis

This systematic review evaluates the relative safety and side-effect profiles of endotracheal tubes (ETs) and supraglottic airway devices (SGAs) for airway management in endoscopic sinus surgery (ESS).

A search of MEDLINE, Embase and the Cochrane Library was conducted in April 2025. Random-effects meta-analysis was performed for outcomes reported by three or more studies with comparable methodology; remaining outcomes were synthesised narratively. Primary outcomes were aspiration events, airway contamination and adverse post-operative symptoms (cough, sore throat, hoarseness, nausea and vomiting); secondary outcomes were operative time and estimated blood loss. Nine studies (714 patients, 1995-2024) were eligible.

Aspiration was rare (one asymptomatic ET case). Pooled analysis demonstrated a significant reduction in airway contamination with SGA use (RR 0.27, 95% CI 0.15-0.47, I²=0%). Device contamination was common in both (SGAs 0-86%, ETs 53-77%) but of limited clinical consequence. Pooled analysis also demonstrated a significant reduction in post-operative day 0 cough with SGA use (RR 0.39, 95% CI 0.23-0.68, I²=0%), whereas day 0 sore throat showed no significant difference (RR 0.65, 95% CI 0.24-1.74, I²=68.7%). Trends toward reduced hoarse voice, blood loss and operative time favoured SGAs but were not significant.

The historical concern that SGAs offer inferior airway protection during ESS is not supported by current comparative evidence. In appropriately selected, low-aspiration-risk patients, SGAs represent a safe alternative to ETs. Given the heterogeneous evidence base, findings should assist rather than replace clinical judgment, with device selection guided by individual patient and procedural factors.