Ultrasonic- or piezoelectric-assisted DCR may be performed under either general anesthesia or local anesthesia. The author prefers general anesthesia. The middle turbinate, axilla, and adjacent lateral wall are infiltrated with 2 % xylocaine with 1:60,000 adrenaline (Fig. 22.9) and followed by nasal packing with ribbon gauze or preferably neurosurgical patties (Fig. 22.10). The patties are medicated with 0.05 % (adults) or 0.025 % (pediatric) xylometazoline. It is best to leave the patties for at least 8–10 min for good decongestion. With the patient in supine position, the patient’s head should be slightly elevated and neck slightly extended so as to facilitate superior osteotomy.

A no 15 blade or sickle knife or a radio-frequency device (Fig. 22.11) is used to make the incision over the lateral nasal mucosa down to the periosteum in front of the maxillary line (Fig. 22.12). The first horizontal incision of 12–15 mm length is made 10 mm above the axilla of the middle turbinate (Fig. 22.13). The vertical incision begins from the anterior end of the horizontal incision and ends at about two-thirds of the vertical height of the middle turbinate (Fig. 22.14). A horizontal incision is then made at right angle at the inferior end of the vertical incision until the maxillary line is reached, short of uncinate process. A Freer periosteal elevator is then used to elevate the mucoperiosteal flap, baring the underlying bone (Fig. 22.15) and is then tucked around the axilla of middle turbinate to keep it out of the operating field.