Dacryocystorhinostomy (DCR) allows an obstructed lachrymal drainage system to be drained into the nasal fossa. Since the development of endonasal microsurgical techniques, the endonasal approach presents itself as an alternative choice to the conventional external approach. It is far less traumatic, yet as efficacious as the conventional approach, and avoids the need for a skin incision and the disruption of the medial canthal structures. Twenty-six patients suffering from lachrymal system obstruction underwent 28 endonasal dacryocystorhinostomies under microscopical (n = 25) or endoscopic control (n = 3). Pre-operative assessment included clinical symptoms (sac swelling, purulent secretions, epiphora) and outflow obstruction on X-rays (conventional dacryocystography and/or subtraction macrodacryocystography). Post-operatively, 23 DCR were free of symptoms. Two presented occasional epiphora and three were unsuccessful. The presence of pre-operative purulent secretions was significantly correlated with post-operative success and with lachrymal sac patency, which is also confirmed by X-ray examination (p<0.001). Thus in cases of purulent secretion with epiphora, X-ray examination is redundant and may be avoided. On the contrary, when epiphora is an isolated symptom, X-rays must be performed in order to determine where the obstruction is located and to provide information on lachrymal sac morphology.