Image guidance surgery (IGS) has grown in popularity. This review article discusses its application in endoscopic sinus surgery (ESS). IGS technology has vastly improved with smaller, more mobile platforms that are easy to set up and use. IGS allows validation of anatomy prior to operating, especially in revision ESS. Additionally, it improves spatial orientation, is useful in teaching and training and may reduce the stress of the operating surgeon. In 2010 it was reported that whilst IGS was accessible to 95% respondents in the USA it was only used in 18% of ambulatory cases. In complex or revision ESS, usage is more variable. Interestingly, one study reported that trainees trusted the navigation system 90% of the time and were more likely to take risks if using IGS whilst operating. It is imperative to remember that image guidance has a target error of up to 2mm. It should therefore be used as a guide and not relied upon exclusively when making intraoperative decisions. As ESS complications are rare, it is difficult to assess if IGS reduces these complications. Studies to date have not seen any significant benefits from IGS use. In conclusion current research does not support IGS routinely and states that it does not provide medicolegal accountability. It does however improve the knowledge of patients’ surgical anatomy and may lead to more complete and time-efficient operation. It should be used on a case-by-case basis, in the best interests of the patient and not be solely relied upon by the user.