The nasal cavity of every patient must be inspected in the preoperative evaluation (Fig. 27.6). If a septoplasty for deviated nasal septum or a middle turbinectomy is required, they can be completed along with the CDCR procedure (Figs. 27.7 and 27.8).

The caruncle, medial canthal soft tissues may be anesthetized by deep infiltration with equal parts of 2 % lignocaine and adrenaline 1:200,000, and 0.5 % bupivacaine (Fig. 27.9). The nasal cavity is anesthetized by packing with a mixture of 4 % lignocaine and adrenaline, and submucosal injection of 2 % lignocaine with adrenaline (Fig. 27.10). Adrenaline is to be avoided in hypertensive patients.

Once the preparation is complete, the technique may vary. For external or endoscopic CDCR, regular DCR osteotomy is performed respectively, followed by creation of the lacrimal sac flaps. A portion of the caruncle is then excised followed by enlargement of the track from the conjunctival cul-de-sac to the middle meatus of the nose with the help of Wheeler of Von-Graefe’s knife [4–6]. A Bowman’s probe is introduced into the track and it is further enlarged with blunt dissection. The Bowman’s probe is allowed to touch the septum and the length from the medial canthus to the tip is measured. Subtracting 2 mm from this measurement would give the length of Jones tube to be placed [5]. Jones tubes or bypass tubes of the surgeon’s preference are then placed in the track under visualization to avoid touching the septum and secured at the medial canthus with 6-0 prolene. Tubes with a flange hole are preferred for ease of suturing.

For the minimally invasive placement of bypass tubes without a DCR (the author’s preferred technique) [14], a 4-mm incision is given just below the caruncle and the tissues gently separated with a Wescott scissors (Fig. 27.11). A 14 gauge needle is then used through this track and directed inferomedially through the thin lacrimal bone into the middle meatus under endoscopic guidance (Fig. 27.12). A partial anterior middle turbinectomy is done where needed (Fig. 27.8). The ideal position of the needle in the nasal cavity is midway between the nasal septum and the lateral wall of the nose (Fig. 27.13). Once this position is achieved, the caruncular end of the needle is grasped and the length of the needle measured (Fig. 27.14), which is correlated with the length of the Jones or Gladstone–Putterman tube (Gunther–Weiss company, Portland, Oregon) to be used. The track is dilated with gold dilators (Gunther–Weiss Company, Portland, Oregon) and the tube mounted on lacrimal probe steadily placed into the nasal cavity through the newly created track (Fig. 27.15). The nasal end of the ostium is not enlarged and this leads to a snugly fitted tube (Fig. 27.16). The tube is then secured with a 4-0 prolene at the caruncular end (Fig. 27.17).