To study the indications for and effectiveness of Nunchaku-style silicone tube intubation (NSTI) in treating primary acquired lacrimal drainage obstruction (PALDO). In this interventional cohort study, 235 consecutive patients in 1 institution who had complete lacrimal obstruction were investigated. Of those, 212 PALDO patients were enrolled, and 156 of the PALDO patients ultimately satisfied our treatment protocol and were then followed up for 12 months postsurgery. Patients without dacryocystitis underwent NSTI, while those with dacryocystitis underwent NSTI or endonasal dacryocystorhinostomy (EN-DCR) using the NST as a stent. The tubes were left in place for 8 weeks, and all patients received identical postoperative care. Resolution was deemed as patency assessed by irrigation. Logistic regression analyses were performed to compare the success of NSTI for upper (puncta and canaliculus) and lower (lacrimal sac and nasolacrimal duct) obstruction, NSTI for lower obstruction with and without dacryocystitis, and NSTI and EN-DCR for lower obstruction with dacryocystitis. Comparison of the success rates at 12 months postsurgery showed significance as follows: treatment with NSTI was more successful for upper obstruction (94.6 %) than for lower obstruction (71.4 %) [odds ratio (OR) 8.23; P < 0.01]; treatment with NSTI was more successful for lower obstruction without dacryocystitis (82.9 %) than for dacryocystitis (52.4 %) (OR 4.96; P < 0.05); and treatment with EN-DCR (95.5 %) was more successful than NSTI (52.4 %) for treating lower obstruction with dacryocystitis (OR 16.99; P < 0.001). NSTI is effective for treating PALDO; however, EN-DCR is more effective for treating PALDO cases complicated by dacryocystitis.