Objective: The aim of this study was to compare the quality of life and complications of endoscopic sinus surgery, with and without image guidance, in patients with chronic rhinosinusitis. Design and setting: Systematic review and meta-analysis of clinical trials. PubMed, Embase, Scopus, Web of Science, SciELO, Cochrane Central Register of Controlled Trials, LILACS, and ClinicalTrials.gov were searched on April 22, 2022. Main outcome measures: A search strategy was used to retrieve clinical trials that compared the quality of life and complications of endoscopic sinus surgery with and without image guidance from the databases. The risk of bias was assessed using the Cochrane Risk of Bias tool. RevMan 5.4. was used for data synthesis. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed. The Grading of Recommendations Assessment Development and Evaluation method was used to evaluate the strength of the evidence. Results: A total of 3281 articles were retrieved from the databases. Six studies met the inclusion criteria, and five could be combined by meta-analysis (638 patients). Image guidance showed improved efficacy in opening diseased paranasal sinuses compared with conventional endoscopic sinus surgery (risk ratio: 0.19; 95% confidence interval, 0.04-0.85; p = 0.03). There was a trend toward a reduction in complications with image-guided surgery, although it did not reach statistical significance (risk ratio: 0.53; 95% confidence interval, 0.20-1.41; p = 0.20). Conclusion: Image guidance is an important tool that helps improve surgical results and possibly increases the safety and quality of life of patients with chronic rhinosinusitis.