Image guidance is a technique used to assist the physician during endoscopic sinus surgery (ESS). This study seeks to compare ESS with and without image guidance, analyzing a number of parameters that can impact on efficacy.This study took place at Otorhinolaryngology department, Faculty of Medicine, Cairo University. The study group consisted of 10 patients who underwent ESS using an optical-based image-guided system (IGS). The control group consisted of 10 patients who underwent ESS without image guidance. The main outcomes measured were major and minor complications; estimated blood loss (EBL); operative time; and the need for revision surgery.The IGS group had more sinuses being opened; no major and one minor complication; an average EBL of 178 cc, an average procedure time of 135 minutes; and one patient who needed repeat surgery in a 3-month follow-up period. The non-IGS group had one major complication and one minor complication; an average EBL of 149 cc; and three patients who needed repeat surgery within 3 months.The use of an IGS for endoscopic sinus surgery may reduce the complications associated with the procedure and allow for a more thorough operation. However, operative time and EBL may be increased.