Nasolacrimal obstruction after inferior meatus nasal antrostomy

Transient epiphora following rhinoplasty or intranasal procedures is a common occurrence. Permanent nasolacrimal duct obstruction, however, is rare. This article documents four cases of nasolacrimal duct obstruction following intranasal antrostomy. Three patients were cured by dacryocystorhinostomy and a fourth refused surgery. The anatomy of the nasolacrimal duct in the inferior meatus has considerable variation. Although the duct typically opens in the inferior meatus immediately under the insertion of the inferior turbinate, the orifice can be a single hole, a slit, multiple holes, or a trough, and can be located anywhere from 30 to 40 mm dorsal to the anterior nares. We review the embryology and anatomy of the nasolacrimal orifice in the nose and make recommendations for safe surgery in the inferior meatus.     

Nasal endoscopy in the treatment of congenital lacrimal sac mucoceles

PURPOSE: To determine the incidence of intranasal cysts associated with lacrimal sac mucoceles and the cure rate with nasal endoscopic cyst marsupialization. DESIGN: Interventional case series. METHODS: SETTING: University-affiliated teaching hospital. PATIENT POPULATION: Twenty-five infants with non infected or infected lacrimal sac mucoceles or dacrocystitis without obvious mucocele were consecutively enrolled. INTERVENTION PROCEDURES: Management included local lacrimal massage, parenteral antibiotics, and when still symptomatic, nasolacrimal duct probing with concomitant nasal endoscopy. Intranasal cysts identified were marsupialized until the distal end of the nasolacrimal duct probe was visualized. MAIN OUTCOME MEASURES: Presence of intranasal cyst identification and cure rate. RESULTS: Infants were 4 days to 10 weeks old (mean 19 days). Forty-eight percent had a bluish cutaneous mass inferior and lateral to the lacrimal sac. Twenty percent were bilateral. At presentation, 76 percent had dacrocystitis. Fourteen percent had respiratory distress. Only one child responded to medical management. At endoscopy, 23 of 24 infants had ipsilateral intranasal cysts. The one child without nasal cyst had recurrent dacrocystitis and no mucocele. All children with mucocele were cured except one child with residual nasolacrimal duct obstruction. CONCLUSIONS: Lacrimal sac mucoceles were almost always associated with intranasal cysts. Nasal endoscopy is a valuable addition to the treatment plan for lacrimal sac mucoceles not responding to a brief trial of massage or infantile dacrocystitis. To avoid potential complications, we recommend against waiting until infection occurs before proceeding with surgery.     

Endoscopic laser dacryocystorhinostomy. An unusual post-operative finding: re-opening of the nasolacrimal duct.

Endoscopic laser dacryocystorhinostomy (DCR) is a recognized technique for the surgical treatment of epiphora. Nasolacrimal duct obstruction is surgically bypassed by creating a passage from the lacrimal sac to the nasal cavity (rhinostomy). Some patients have undergone endonasal laser-assisted DCR, and were found to have an obstructed rhinostomy at follow-up. However, they reported a subjective improvement in their symptoms. Five such patients, at six months follow-up, were found to have a non-functioning rhinostomy with fluorescein dye emerging from under the inferior turbinate. These five patients along with four controls had post-operative macrodacryocystograms (MDCG) to delineate the anatomical passage by which tears were entering the nasal cavity. In the control group, clear passage of contrast into the middle meatus was demonstrated in three of the four subjects. In the study group, passage of dye to the inferior meatus, via the nasolacrimal duct was demonstrated in four of the five subjects. It is well recognized that a proportion of patients suffering from epiphora will have a natural resolution of their symptoms. Our results demonstrate that the resolution of epiphora in some operated patients was due to a re-opening of the nasolacrimal duct, and not because of a patent rhinostomy.     

鼻内镜下鼻泪管前径路和后径路切除上颌窦良性病变

目的 探讨鼻内镜下上颌窦内侧壁入路切除上颌窦良性病变的手术径路及手术方法的可行性及疗效.方法 2003年6月至2010年8月,采用鼻内镜下经鼻腔鼻泪管前径路和鼻泪管后径路的多种方式切除上颌窦良性病变139例,其中内翻性乳头状瘤43例、真菌性上颌窦炎63例、上颌窦囊肿28例、出血坏死性息肉3例、骨瘤2例.所有病例术前行CT检查,可疑内翻性乳头状瘤患者同步行MRI检查.鼻泪管前方径路采取3种方式:梨状孔入路、泪前隐窝入路(包括解剖鼻泪管和不解剖鼻泪管2种方式)、梨状孔鼻泪管人路,共治疗97例;鼻泪管后方径路也采取3种方式:下鼻甲翻转、双蒂下鼻甲、单蒂下鼻甲,共治疗42例.观察患者术后疗效.结果全部病例在鼻内镜下经鼻彻底清除病变,保护了鼻泪管,保留了下鼻甲,无一例发生鼻泪管损伤和下鼻甲坏死.术后鼻塞、头痛、闷胀不适、异味、牙疼和麻木感等症状逐步消失.9例感觉鼻腔干燥,经鼻腔冲洗等处理后1个月左右逐渐消失.随访6 ～79个月,骨瘤和出血坏死性息肉未见复发.所有真菌性上颌窦炎患者术中均可见窦腔黏膜明显水肿、增厚,术后3个月左右逐渐消失,无一例复发.2例上颌窦囊肿患者术后10个月和18个月在上颌窦其他部位再发,但囊肿小且无临床症状未作处理.内翻性乳头状瘤患者有3例复发,1例术后17个月上颌窦口上方局限性肿物突出,病理示乳头状瘤复发,门诊予以清理后随访1年未见复发;1例于术后15个月前筛处复发,行筛窦广泛切除后随访3年未见复发;1例术后26个月上颌窦后外侧壁局部复发,二次行蒂在前方单蒂下鼻甲方式手术,术后1年再次复发,行鼻内镜下Denker手术,随访18个月未见复发征象.所有病例术后3个月上颌窦创面上皮、瘢痕覆盖,下鼻甲形态良好,下鼻道开窗者较术中明显瘢痕变小,且引流通畅无闭锁.结论鼻内镜下鼻泪管前、后径路上颌窦手术可以减小创伤,充分暴露窦腔视野,并为术后内镜复查和复发后的处理提供了视窗;保留下鼻甲避免了鼻腔外侧壁去除过多而导致的术后干燥、结痂、头痛等并发症.     

Endoscopic marsupialization of bilateral lacrimal sac mucoceles with nasolacrimal duct cysts

A lacrimal sac mucocele is an uncommon disease usually treated by ophthalmologists. In rare cases, it is sometimes associated with a nasolacrimal duct cyst presenting as an intranasal cystic mass, which needs the involvement of an otolaryngologist in diagnosis and management. Two cases of lacrimal sac mucoceles with nasolacrimal duct cysts are presented with a brief literature review. Both cases presented with intranasal cystic masses that caused nasal obstruction and were cured with endoscopic marsupialization of the cysts.     

Manometric measurement of lacrimal sac pressure after endoscopic and external dacryocystorhinostomy

OBJECTIVE: To evaluate endoscopic and external dacryocystorhinostomy (DCR) using a quantitative, objective functional tool. MATERIAL AND METHODS: This study comprised 58 cases divided into 4 groups: healthy controls; patients suffering from epiphora due to nasolacrimal duct (NLD) obstruction; patients who had undergone endoscopic DCR; and patients who had undergone external DCR. The lacrimal sac pressure was measured during blinking, forced blinking and the Valsalva maneuver using a polygraph. RESULTS: Negative pressure was detected during blinking and forced blinking in all normal subjects and in most patients who had successfully undergone DCR. In contrast, positive pressure was detected in cases with epiphora and patients in whom DCR had failed. Negative pressure was higher after endoscopic than external DCR. During the Valsalva maneuver there were no pressure changes in normal cases and patients with epiphora. In contrast, positive pressure was detected after all of the successful procedures (being higher after external than endoscopic DCR) and in most of the patients in whom external DCR failed. CONCLUSIONS: In normal subjects, negative pressure is created during blinking. In cases with epiphora due to NLD obstruction, the lacrimal pump is affected but its function is restored after successful DCR. The suction power of the pump mechanism is more effective after endoscopic than external DCR.     

Endoscopic marsupialization of congenital nasolacrimal duct cyst with dacryocoele

A congenital nasolacrimal duct cyst is an uncommon condition in the newborn usually treated by ophthalmologists. Prolapse or expansion of the cyst into the nose may lead to respiratory distress and difficulty in feeding as newborns are obligate nose breathers, which needs the involvement of the Otolaryngologist in diagnosis and management. The authors report a series of 8 children presenting with a congenital nasolacrimal duct cyst and dacryocoele and highlight the importance of endoscopic nasal examination of newborns presenting with respiratory problems. Diagnostic studies included intranasal endoscopy and CT scanning of the nasolacrimal system and nose. All the patients were treated by endoscopic marsupialization of the cyst. Nasolacrimal duct abnormality should be considered in the differential diagnosis of neonatal respiratory distress and nasal obstruction. Nasal endoscopy is essential in the work-up of all children with nasal obstruction and respiratory distress. CT scanning is the investigative method of choice. Endoscopic marsupialization followed by lacrimal duct irrigation is effective in the treatment of congenital nasolacrimal duct cyst and results in complete resolution of symptoms.     

Use of endocanalicular dacryocystorhinostomy with multidiode laser in children

Objective

To evaluate the clinical outcome and efficacy of endocanalicular laser dacryocystorhinostomy using a multidiode laser in cases unresponsive to medical therapy, probing or intubation of pediatric nasolacrimal duct obstruction.

Methods

Eight children with nasolacrimal duct obstruction were treated with a multidiode laser. The study was prospective, non-randomized, and noncomparative. The patients, 2 (25%) males and 6 (75%) females, ranged in age from 8 to 13 years (mean 11.25 ± 2.43). Surgery was performed under general anesthesia. All procedures were performed using a multidiode laser. The nasal passage was visualized with a 30° nasal video endoscope. In all cases, silicone stents were inserted. The main outcome measure was resolution or improvement of the epiphora and no major laser damage intranasally. Patients were followed for at least 6 months.

Results

The endocanalicular laser dacryocystorhinostomy failed in one of the 8 (12.5%) cases, which had been secondary to trauma. The others were due to primary nasolacrimal duct obstruction. External dacryocystorhinostomy was performed on the failed case. None of the cases with primary nasolacrimal duct obstruction had obstruction after the endocanalicular laser dacryocystorhinostomy operation.

Conclusions

Endocanalicular laser dacryocystorhinostomy using a multidiode laser appears to be an effective technique in cases unresponsive to medical therapy, probing or intubation of primary nasolacrimal duct obstruction.     

Neonatal respiratory distress secondary to bilateral intranasal dacryocystocoeles

Obstruction of the nasolacrimal duct is a common congenital abnormality reported in up to 84% of neonatal patients [J. Yohendran, A.C. Wignall, E.J. Beckenham, Bilateral congenital dacryocystocoeles with concurrent intranasal mucocoeles causing respiratory distress in a neonate, Asian J. Surg. 29 (2) (2006) 109-111; M.J. Cunningham, J.J. Woog, Endonasal endoscopic dacryocystorhinostomy in children, Arch. Otolaryngol. Head Neck Surg. 124 (1998) 328-333; D. Guery, E.L. Kendig, Congenital impotency of the nasolacrimal duct, Arch. Ophthalmol. 97 (1979) 1656-1658]. Rarely, obstruction results in the development of an intranasal lacrimal duct cyst, or dacryocystocoele, which arises inferolateral to the inferior turbinate [H.R. Jin, S.O. Shin, Endoscopic marsupialisation of bilateral lacrimal sac mucoceles with nasolacrimal duct cysts, Auris Nasus Larynx 26 (1999) 441-445]. These lesions can cause nasal obstruction and, when bilateral, significant respiratory compromise. We present the case of a 3-day-old infant with bilateral intranasal lacrimal duct cysts causing nasal obstruction and intermittent respiratory compromise. The diagnosis was suspected on clinical examination and confirmed on MRI. The patient was successfully managed by bilateral endoscopic marsupialisation and probing of the nasolacrimal ducts. We also present a review of the literature surrounding investigation and management of intranasal lacrimal duct cysts.     

Endoscopic management of pediatric nasolacrimal anomalies

Developmental anomalies of the nasolacrimal drainage system typically manifest early in childhood with epiphora and occasionally infection. Although the majority of cases of congenital nasolacrimal obstruction resolve spontaneously with conservative medical management, certain anomalies require operative intervention. Included in this latter group are dacryocystoceles or nasolacrimal duct cysts. The application of endoscopic sinus surgical techniques to children with persistent symptomatic nasolacrimal obstruction provides an alternative to external dacryocystorhinostomy that appears to be equally efficacious and concurrently allows for the potential correction of any predisposing intranasal pathology. Endonasal endoscopic dacryocystorhinostomy is best performed as a joint otolaryngologic-ophthalmologic procedure.     

鼻内镜下鼻腔外侧壁切开上颌窦手术

目的报告经鼻完成鼻腔外侧壁切开并保留鼻泪管和下鼻甲，进入上颌窦的新方法及临床初步应用结果，并就手术方法和适应证进行探讨。方法12例住院手术患者，男9例，女3例；年龄42-68岁。术前或术中组织病理学确诊为上颌窦内翻性乳头状瘤8例，鼻息肉2例，复发性上颌骨囊肿1例，上颌窦根治术后囊肿1例。2例肿瘤患者因随访少于12个月不计入疗效评定。所有患者术前接受鼻内镜及鼻窦CT扫描检查。6例肿瘤患者同期行鼻窦MRI检查。手术在全麻下进行。方法为在下鼻甲头端鼻腔外侧壁切开，解剖出鼻泪管后形成鼻泪管-下鼻甲瓣，内移后形成上颌窦入路，在鼻内镜直视下完成窦内病灶清除。术终复位下鼻甲和鼻泪管并完成下鼻道开窗。结果10例患者均为单侧发病，6例上颌窦内翻性乳头肿瘤Krouse分期均为13。术中见肿瘤起源于上颌窦，各壁均受累，前、内壁明显。2例鼻息肉累及上颌窦各壁。术后随访7～60个月，平均22个月，术腔上皮化，下鼻甲形态良好。1例术后6个月下鼻道上颌窦开窗口局部复发，局部清创后无复发。10例术后无溢泪等并发症。结论经鼻腔外侧壁切开并保留鼻泪管和下鼻甲进入上颌窦，为彻底切除上颌窦病灶及经上颌窦进入眶底和翼腭窝等提供一新的微创入路和方法。     

Manometric Measurement of Lacrimal Sac Pressure after Endoscopic and External Dacryocystorhinostomy

Objective—To evaluate endoscopic and external dacryocystorhinostomy (DCR) using a quantitative, objective functional tool. Material and methods—This study comprised 58 cases divided into 4 groups: healthy controls; patients suffering from epiphora due to nasolacrimal duct (NLD) obstruction; patients who had undergone endoscopic DCR; and patients who had undergone external DCR. The lacrimal sac pressure was measured during blinking, forced blinking and the Valsalva maneuver using a polygraph. Results—Negative pressure was detected during blinking and forced blinking in all normal subjects and in most patients who had successfully undergone DCR. In contrast, positive pressure was detected in cases with epiphora and patients in whom DCR had failed. Negative pressure was higher after endoscopic than external DCR. During the Valsalva maneuver there were no pressure changes in normal cases and patients with epiphora. In contrast, positive pressure was detected after all of the successful procedures (being higher after external than endoscopic DCR) and in most of the patients in whom external DCR failed. Conclusions—In normal subjects, negative pressure is created during blinking. In cases with epiphora due to NLD obstruction, the lacrimal pump is affected but its function is restored after successful DCR. The suction power of the pump mechanism is more effective after endoscopic than external DCR.     

鼻内镜下手术治疗慢性泪囊炎的经验体会

目的 探讨鼻内镜下手术治疗慢性泪囊炎的经验。方法 选择2006年5月至2010年3月收治的213例(225眼)慢性泪囊炎、鼻泪管堵塞患者,其中慢性泪囊炎行颜面部切口手术复发25眼,均行鼻内镜下手术治疗。造瘘口均采用EC耳脑胶黏合固定成形。结果 213例(225眼)中,同期行鼻中隔高位偏曲矫正33眼,钩突肥大切除20眼,中鼻甲前端息肉样变切除19眼,鼻息肉切除16眼。术后完全无溢泪199眼,好转19眼,无效7眼。有效率96.8% 。结论 泪囊内壁黏膜完全切开且无张力外翻是手术成功的关键,造瘘口行EC耳脑胶吻合牢固可靠。术后定期鼻内镜下换药是手术治疗不可缺少的环节。     

Is it necessary to accompany probing with endoscopy in cases of congenital nasolacrimal canal obstruction?

Objective

To compare the results of probing with and without endoscopy in cases of congenital nasolacrimal duct obstruction who had previously not undergone probing.

Methods

Fifty-one children with congenital nasolacrimal duct obstruction who underwent surgical intervention between June 2007 and April 2009 in our hospital were included in the study. Patients who had had previous probings were excluded from the study. Conventional probing was performed in 37 eyes of 25 patients, and probing with intranasal endoscopic visualization in 36 eyes of 26 patients. Diagnosis was based on history of epiphora since birth or shortly after, and fluorescein dye disappearance test.

Results

Thirty-two of 37 eyes (86.48%) were cured by probing. Of the 5 cases with complaints, 1 had lacrimal sac fistula. Thirty-four of 36 eyes (94.44%) were cured by probing guided by endoscope observation. Thirty-two cases had stenosis at the lower end of the nasolacrimal duct which required probing. In two cases the probe passed submucosally to the floor of the nose. In two cases a false passage was made at the upper end of the inferior meatus. In these cases, the operation was continued by repeating the process until the distal end of the nasolacrimal canal was seen to have been passed.

Conclusion

Probing with endoscopy may be excessive in primary cases but in cases which have undergone unsuccessful probing, it is useful for visualization of anomalies in the lower nasolacrimal canal and to obtain the correct anatomic position for the probe.     

The Surgical Outcome of Endoscopic Dacryocystorhinostomy According to the Obstruction Levels of Lacrimal Drainage System

Objectives

Many factors influence the outcome of endoscopic dacryocystorhinostomy (DCR). One of the most important prognostic factors is the level of obstruction in the lacrimal drainage system. The main objective of this report is to evaluate both the frequency of obstruction by anatomical region of the lacrimal drainage system on dacryocystography (DCG) and the surgical outcome of endoscopic DCR according to the obstruction level.

Methods

A retrospective series of 48 patients (60 eyes) who had undergone endoscopic DCR from January 2005 to November 2007 were enrolled. Preoperative evaluation consisted of a standard examination which included lacrimal irrigation, probing, DCG and osteomeatal unit (OMU) computed tomography. Patients were classified into four groups according to the obstruction level on DCG. Surgical outcome was evaluated postoperatively by subjective improvement of epiphora and patent rhinostomy opening on nasal endoscopic exam.

Results

Of 60 eyes, the levels of obstruction were the common canaliculus in 14 eyes (23.3%), the lacrimal sac in 13 eyes (21.7%), the duct-sac junction in 13 eyes (21.7%) and the nasolacrimal duct (NLD) in 20 eyes (33.3%). The ductsac junction obstruction was treated most successfully (100%), followed by NLD obstruction (90%), common canaliculus obstruction (78.6%) and saccal obstruction (69.2%).

Conclusion

In patients with lacrimal drainage system obstruction, preoperative evaluation of obstruction level using DCG may be helpful for predicting the surgical outcome of endoscopic DCR. The saccal obstruction may have a worse prognosis than the other obstruction levels.     

Endonasal laser dacryocystorhinostomy: its role in anticoagulated patients

OBJECTIVE: To report the results of endoscopic laser-assisted dacryocystorhinostomy in anticoagulated patients. STUDY DESIGN: A retrospective study of 16 consecutive anticoagulated patients with distal nasolacrimal duct obstruction treated by endoscopic laser-assisted dacryocystorhinostomy. METHODS: A case note review was made of all patients treated with endoscopic laser-assisted dacryocystorhinostomy who were taking coumadin in two centers between 1993 and 2000. The parameters of age, gender, indications for surgery, surgical findings, complications, and outcome were analyzed. The mean follow-up time was 14 months (range, 9-26 mo). RESULTS: Fifteen of the 16 patients who were treated had an eventual successful outcome, but 6 patients required revision surgery. The patient whose symptoms were not improved was shown to have functional epiphora. No patient had a problem with primary or secondary epistaxis, and no patient required admission. A major benefit was the lack of disruption of anticoagulant therapy. CONCLUSIONS: Endoscopic laser-assisted dacryocystorhinostomy is a safe, efficient technique for the relief of distal nasolacrimal duct obstruction in anticoagulated patients. Not only does it avoid any disruption to their anticoagulant therapy, but it also can be performed as an outpatient procedure.     

Endoscopic dacryocystorhinostomy vs KTP 532 laser-assisted endoscopic dacryocystorhinostomy

Objectives  Advances in endoscopy and lasers have improved surgical management of chronic nasolacrimal duct obstruction. This is a preliminary comparison between standard and laser assisted endoscopic dacryocystorhinostomy (DCR). Study Design  Combined retrospective and prospective study. Setting  Tertiary referral hospital. Patients and Methods  Thirty-eight cases of chronic nasolacrimal duct obstruction underwent endoscopic DCR (26 standard and 12, laser-assisted) and were assessed at 3 and at 6 months postoperatively by nasal endoscopy. Results  Three months postoperatively (n=38), total relief of epiphora among the nonlaser group was 80.76 vs 75% in the laser group (P=0.982). At 6 months (n=19), the laser group had recorded 100% symptomatic relief compared to 85.71% in the nonlaser group (P=0.964). The laser group suffered fewer complications (33.33 vs 46.15% for nonlaser group). Conclusion  Lasers show promise in long-term management of duct obstruction and are associated with fewer complications. A larger study is required before and generalization is made.     

Anastomosis of nasal mucosal and lacrimal sac flaps in endoscopic dacryocystorhinostomy

Endoscopic dacryocystorhinostomy (DCR) is a well-established alternative to external approaches in the treatment of nasolacrimal canal obstruction. From July 2004 to December 2008, 92 endoscopic DCRs were performed on 88 patients at the Department of Otorhinolaryngology, San Raffaele Hospital, Milan. All patients were affected by chronic dacryocystitis with epiphora. Preoperative work-up included Jones tests, lacrimal pathways irrigation, nasal endoscopy, and imaging evaluation by computed tomography. The technique involved anastomosis of nasal mucosal, lacrimal sac flaps and a large bony ostium. A silicone tube was inserted in all patients that remained for a period of 3 months. The first endoscopic intervention was successful in 91.30% of patients. After a second revision endoscopic DCR, the overall success rate raised to 95.65%. Anastomosis of nasal mucosal between lacrimal sac flaps plays a key role in endoscopic DCR with a high success rate both in primary nasolacrimal obstructions and in revision cases.     

鼻内镜下泪囊鼻腔造孔术

目的总结鼻内镜下泪囊鼻腔造孔术并探讨术后鼻泪管再通现象及其原因。方法36例(39眼)慢性泪囊炎患者,男7例(7眼),女29例(32眼),年龄23￣71岁,平均39.6岁,病程半年￣12年,均在局麻、鼻内镜下行泪囊鼻腔造孔术,随访亦在鼻内镜下进行,以黏膜表面麻醉为主。结果术后8￣10周术腔逐渐上皮化,35眼泪道冲洗通畅,溢泪及溢脓症状均消失;2眼冲洗通而不畅,需加压,有冲洗液溢出;2眼泪道冲洗不通,仍有溢泪及溢脓症状。总有效率94.5%(37/39)。鼻内镜下观察,冲洗通畅者造瘘口有液体流出。随访6个月部分病人(4眼)下鼻道原鼻泪管开口处冲洗时亦有液体流出。结论慢性泪囊炎病人在行鼻内镜下泪囊鼻腔造孔术后效果好,且部分病人鼻泪管可再通。     

Results of endoscopic assisted probing for congenital nasolacrimal duct obstruction in older children

PURPOSE: To evaluate the results of lacrimal probing with the use of nasal endoscopy and identify the anatomical anomalies responsible for the symptoms in older children. METHODS: Fifty-two eyes of 40 children with congenital nasolacrimal duct obstruction underwent primary probing of the lacrimal duct under general anaesthetic in conjunction with nasal endoscopy. Patients followed up for at least 6 months. Cure was defined as complete resolution of symptoms or minimal symptoms brought on by cold or wind. RESULTS: The age range was 12-126 months. In 30/52 (57.7%) eyes the symptoms were attributed to a single mechanical obstruction. Seven eyes had canalicular stenosis. Three eyes had upper nasolacrimal duct obstruction. Nine eyes had narrow duct and nine eyes had atresia of the distal end of the duct. Two eyes had only intranasal abnormalities. In 16/52 (30.76%) eyes a combination of anomalies was responsible for the symptoms. Nine eyes had canalicular stenosis in association with: either a membrane at the valve of Hasner in four, or a narrow duct in three, or intranasal anomalies in two. Two eyes had punctual stenosis and narrow duct. Two eyes had narrow duct and tight inferior turbinate. Three eyes had abnormal openings in association with stenotic ducts. Six (11.54%) eyes had functional blockage. With the use of endonasal endoscopy, intranasal anomalies identified in 12 eyes and treated in nine. One eye had large inferior conchae. One eye had inferior concha adherent to lateral nasal wall. One eye had redundant nasal mucosa. Three eyes had tight inferior turbinate. Three had abnormal openings. In three eyes the probe went submucosally. The overall success rate was 84.6% (44/52 eyes). Eight eyes remained unchanged. Endoscopically treated cases contributed to the overall success by 17.31%. CONCLUSION: Multiple anatomical anomalies within the lacrimal system and abnormalities of the nose are quite common in older children. Lacrimal probing remains the primary treatment and nasal endoscopy is a useful adjunct to probing increasing the success rate of the procedure.