In addition to the selected endoscope, a good halogen or xenon light source is essential for the best possible optics while using the endoscopes. This also requires good quality fiber-optic cables to connect with light source. Handheld light sources that can connect to Hopkins endoscopes are available, but a light cable and a separate light source are preferable and easier to use.

Before starting nasal endoscopy, the patient’s nose should be prepared by applying topical local anesthetic with decongestant. Our preference is to use two sprays of cophenylcaine spray (5 % lignocaine with 0.5 % phenylephrine) into each nasal cavity (Fig. 7.2), which should be left for at least 5 min before attempting any instrumentation, to allow sufficient time for the anesthetic and vasoconstrictive effect. The patient should then be positioned appropriately, either sitting upright facing the examiner or lying down, with head elevation of about 45°, and turned toward the examiner who should be on the patient’s right side. Diagnostic nasal endoscopy in the clinic can then be performed with a 2.7-mm, 30° nasal endoscope, using a three pass technique. The endoscope should be held in the right hand and supported between the thumb and index finger of the left hand, to avoid any sudden movements. With each pass, the condition of the nasal mucosa and anatomical structures are examined, as well as carefully noting of any anatomical variations or intranasal pathology.

Endoscopic lacrimal surgery is almost always performed between two surgeons including an Ophthalmologist and rhinologist. A full complement of all nasal endoscopes, as well as sinus and ophthalmology instruments should be available [1, 2]. The endoscope needs to be connected to a light cable and high-quality light source, as well as a camera and large viewing stack (Fig. 7.3) which can be seen by both sets of surgeons and theatre scrub nurse. The operating surgeon should be positioned on to the right side of the patient with the assisting surgeon adjacent to them. Good interaction between the two surgeons is essential to facilitate the surgery, for example in guiding the light probe to demonstrate the extent of bone removal required for adequate exposure of the lacrimal sac and also in supporting the sac while the other surgeon is opening it. The scrub nurse and instrument tray should be positioned on the opposite side of the patient, and the anesthetist needs to be away from the operating head end (Fig. 7.4a, b).