Dr Hwang presents an outstanding and balanced overview of the current state of balloon dilation of the sinuses. A number of his points merit emphasis and further comment. He very accurately describes both the strengths and weaknesses of the published studies examining balloon dilation. Unfortunately, many factors contribute to the relatively weak level of evidence that currently exists. These include the heterogeneity of chronic rhinosinusitis (CRS), variations in techniques and philosophies among surgeons, and the challenge of performing wellcontrolled, double-blinded, unbiased studies of surgical instruments or techniques . When examining the level of evidence for other commonly used surgical instruments, such as powered shavers (microdebriders), endoscopes, or image-guided surgery, one finds that the level of evidence for this “mainstream” equipment is actually weaker than the current evidence for balloon dilation. For example, powered shavers have been widely used since the mid 1980s, but it has taken nearly 30 years to obtain high-level evidence supporting this practice. A recently published randomized, double-blinded trial compared powered shavers and hand instruments. It found that shavers decreased operative time but did not improve blood loss or postoperative healing. Thus, while the level of evidence supporting balloon dilation is not strong, it is better than the evidence supporting many other widely accepted techniques and instruments. While recent debate has focused on the question “to balloon or not to balloon?”, perhaps it is more relevant to step back and consider the overall surgical philosophy and goals for each individual patient. This calls into question our current understanding of the pathophysiologic characteristics of CRS, which should be the driving force behind our surgical decision making. In the preendoscopic era, surgical dogma advocated removal of condemned mucosa using Caldwell-Luc or other transnasal procedures using a headlight and noncutting instruments. When the endoscope was introduced, it represented a radically different method of performing sinus surgery and led to an increased understanding of CRS and the importance of mucociliary clearance via natural outflow tracts, especially the osteomeatal complex. Some viewed this with great skepticism, and heated debates ensued. Whether balloon dilation represents a similar major shift or reexamination of treatment philosophies and understanding of sinus disease remains to be determined. We now believe that the heterogeneous entity labeled CRS is actually a multifactorial disease process with varying contributions of inflammation and immune dysfunction, potential microbial exacerbations, and inevitable mucociliary dysfunction. Some patients with limited disease or isolated mucoceles may only require an ostial dilation that can be achieved with a balloon or a variety of other instruments. These cases are similar to “plumbing problems” and have an extremely high cure rate regardless of the instrument used for ostial enlargement. Unfortunately, most patients with CRS have an underlying immune dysfunction, such as those with nasal polyposis. Merely ventilating the sinus by dilating the ostia (with any instrument) does not appear to address the underlying pathophysiologic abnormality. Recent studies have shown that postoperative cavities that are opened widely provide access for topical steroids and other medications used to treat the underlying inflammatory process. Unfortunately balloon dilation does not appear to provide adequate ostial dimensions to maximize postoperative delivery of topical therapies throughout the sinuses. Once a surgeon has decided on his or her overall surgical goals for a given patient based on the type and localizationofCRS,postoperativecare, and treatments, the next issue should be selection of proper instruments to accomplish those goals. A number of factors come into play: patient safety, evidence for outcomes, surgeon experience, and cost. Dr Hwang has Rodney J. Schlosser, MD