Endoscopic Transnasal Eustachian Tube Closure using the V-LOC Wound Closure Device

Background: Closure of the Eustachian tube (ET) is a valuable procedure for addressing cerebrospinal fluid (CSF) rhinorrhea from lateral skull base defects (otorhinorrhea). Open approaches to these CSF leaks are more invasive and may require addressing multiple sources, relative to endoscopic endonasal ET obliteration (EEETO) targeting the final common pathway of otorhinorrhea in the nasopharynx. However, anecdotally, EEETO using previously described methods can be technically challenging and prone to failure.

Methods: The V-Loc wound closure device (Covidien, New Haven, Connecticut, United States) was used endoscopically and endonasally to close the torus tubarius, obliterating the medial ET orifice, and resolving CSF otorhinorrhea in three cases. The surgical methodology of V-Loc EEETO and representative case examples are described, along with illustrative images and supplemental video.

Results: V-Loc EEETO involved four key procedural steps ([Fig. 1A-D], illustrated steps): (1) endoscopic obliteration of the medial ET mucosa with cautery ([Fig. 1A]), (2) straightening of the distal half of the V-Loc needle to a “J” and passing anterior to posterior through the superior torus tubarius ([Fig. 1B]), (3) passing the needle back through the anchor loop on the distal end of the suture ([Fig. 1C]), and (4) additional anterior to posterior passes through the torus tubarius to close the ET orifice ([Fig. 2], V-Loc suture passes; [Fig. 3], complete ET closure). The device remainder is cut and removed, and V-Loc suture barbs hold tissue closure with no need for knot tying ([Fig. 1D]). This method of V-Loc EEETO increased subjective procedural ease and speed, which was attributed primarily to avoiding endoscopic knot tying in the confined location of the nasopharynx or passing multiple knots to this site. V-Loc EEETO was utilized successfully (cessation of CSF otorhinorrhea) in three cases; all cases remained successful, without recurrence of CSF otorhinorrhea, at their most recent respective follow-up evaluations 4, 6, and 12 months postoperatively ([Fig. 4], postoperative endoscopy at 3 weeks).

Conclusion: This study describes a novel method of EEETO utilizing the V-Loc closure device to successfully resolve CSF otorhinorrhea in three cases. EEETO with V-Loc has greater simplicity and ease compared with previously reported methods involving knot tying and/or various packing; this may reduce time and frustration associated with EEETO which can be deceivingly challenging.

Fig. 1 Illustrated key steps (A–D) of the V-Loc EEETO procedure, as described in results.

Fig. 2 Intraoperative endoscopic images of right sided V-Loc EEETO demonstrating the anterior to posterior passes of the V-Loc needle through the torus tubarius.

Fig. 3 Intraoperative endoscopic image of right sided V-Loc EEETO at completion of ET closure.

Fig. 4 Endoscopic image of 3 week postoperative result after successful right sided V-Loc EEETO with cessation of otorhinorrhea. Left side is normal unoperated ET.