The management of lacrimal fistulas is largely based on surgical treatment of the congenital type via an external approach. It is now clear that because almost all congenital lacrimal fistulas arise from the common canaliculus, simple probing, cauterizing,6 or closed excision may result in damage to the lacrimal drainage system. While some advocated that symptomatic congenital lacrimal sac fistulas are successfully treated with excision alone7,8 (closed technique) or excision with nasolacrimal intubation,9 others proposed that a DCR is necessary (open technique) owing to the coexistence of nasolacrimal duct obstruction in a significant proportion of congenital lacrimal fistulas.2 Opening the lacrimal sac also facilitates surgical dissection with exposure of the internal fistula ostium and accurate ligation and removal of the fistula from its origin, minimizing the risk of damage to the common canaliculus.10 In addition, the incidence of recurrence of the fistula should be reduced following a DCR because of the decreased resistance to outflow of tears. Intubation of the common canaliculus is recommended in all cases in which the common canaliculus has been manipulated. Subbaiah11 reported 7 cases of acquired lacrimal fistulas, all of which were successfully treated with endoscopic DCR with excision of the fistulous tract. Ross et al12 described a modified endonasal DCR approach to the excision of a congenital fistula to minimize skin incisions and also to address outflow obstruction; complete marsupialization of the lacrimal sac medial wall facilitated direct visualization of the internal fistula origin on the lateral sac wall and excision with a 3-mm punch biopsy trephine over a cannula guide. This case illustrates the advantages to direct intranasal visualization of the internal fistula ostium, helping to ensure complete excision of the fistula especially in cases of acquired or traumatic lacrimal fistulas where there may be great anatomical variation and distortion by the presence of scar tissue. Simultaneous probing of the common canaliculus and the fistula tract can help to identify canalicular involvement, prompting the use of a lacrimal stent and also avoiding canalicular injury when excising the fistula tract. The endonasal endoscopic approach was also advantageous in this case for the following: (1) treatment of coexisting nasolacrimal duct obstruction; (2) treatment of concha bullosa, which would have prevented adequate access to the nasal mucosa via an external approach; (3) exploration for possible foreign bodies following trauma; and (4) examination and removal of the ethmoid cells involved in the fistulous tract.