Image-guided surgery has been established as an important adjunctive tool for rhinologic surgery. The technology has evolved since the middle of the last century and continues to do so at a rapidly increasing rate. A number of systems exist, each with its relative benefits and drawbacks. Image guidance can assist the endoscopic sinus surgeon by confirming position within challenging anatomic fields. Many issues remain, however, before the widespread application of this technology can be justified. Many advantages exist, but significant limitations are also evident. Nonetheless, the role of image guidance in routine and advanced paranasal sinus surgery is certain to grow. Discussion and debate of the issues regarding the use of image guidance are likely to grow with it.