Background <p>Chronic dacryocystitis (CD) is mainly treated by surgery. Nasal dacryocystorhinostomy is divided into internal and external approaches. The efficacy and safety are controversial, and clinical studies are susceptible to bias due to the baseline characteristics of patients. Therefore, this retrospective, non-randomized study based on propensity score matching (PSM) to compare the therapeutic effects of endoscopic and external dacryocystorhinostomy.</p> Methods <p>A total of 98 patients (98 eyes) with CD admitted to our hospital from January 2019 to December 2024 were retrospectively included in the study. According to different surgical plans, they were divided into the endoscopic dacryocystorhinostomy (EN-DCR) group (<i>n</i> = 54) and the external dacryocystorhinostomy (EDCR) group (<i>n</i> = 44). The PSM method was used to match the two groups of patients according to the nearest neighbor matching method 1: 1 (caliper value = 0.05). The therapeutic effect and perioperative indexes of the two groups were recorded. The lacrimal gland secretion function [tear film rupture time (BUT), Schirmer I test (SIT)], epiphora degree score, inflammatory indexes [serum interleukin-1β (IL-1β), matrix metalloproteinase-3 (MMP-3), prostaglandin E2 (PGE2)] and complications before and after operation were compared.</p> Results <p>After matching, 34 patients in each group were included in the study. The total effective rate, operation time, hospitalization time and intraoperative blood loss in the EN-DCR group were better than those in the EDCR group (<i>P</i> &lt; 0.05). After operation, the BUT of the EN-DCR group was higher than that of the EDCR group, and the SIT, epiphora score, IL-1β, MMP-3 and PGE2 levels of the EN-DCR group were lower than those of the EDCR group (<i>P</i> &lt; 0.05). Compared with the EDCR group, the patency rate of lacrimal duct in the EN-DCR group was significantly increased at 2 and 6 months after operation, and the recurrence rate was significantly decreased (<i>P</i> &lt; 0.05). The total incidence of complications in the EN-DCR group (2.94%) was significantly lower than that in the EDCR group (23.53%) (<i>P</i> &lt; 0.05).</p> Conclusions <p>The therapeutic effect of endoscopic dacryocystorhinostomy in CD patients is better than that of external dacryocystorhinostomy.</p> Trial registration <p>Retrospectively registered.</p>