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 well-controlled, 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.1 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.