Expression of inducible nitric oxide synthase (iNOS/NOS II) in the cochlea of guinea pigs after intratympanical endotoxin-treatment

Morphometric Evaluation of the Facial and Vestibulocochlear Nerves Using MR Imaging in Patients with Menière Disease

BACKGROUND AND PURPOSE

Menière disease (MD) is a condition of unknown etiology, involving genetic predisposition, autoimmune processes, viral infections, cellular apoptosis, and oxidative stress. This study aimed to investigate potential differences in cranial nerves VII and VIII in patients with MD using hydrops MRI (FLAIR) for morphometric evaluations.

MATERIALS AND METHODS

Sequences acquired were 3T MRI, CISS, and 3D FLAIR. We evaluated the morphometrics of cranial nerves VII and VIII from the cerebellopontine angle to the internal auditory canal fundus, comparing the nonaffected and affected sides. Furthermore, we examined the findings in relation to symptom duration and evaluated the feasibility of FLAIR in the morphometry of the cranial nerves.

RESULTS

A total of 53 patients with MD with unilateral symptoms were included. After statistical analysis, no significant differences were found regarding morphometric changes in the affected side compared with the nonaffected side of cranial nerves VII and VIII. There was also no significant difference between the morphometric evaluations of patients with different symptom durations. The morphometric evaluation using hydrops MRI sequences (FLAIR) showed no significant difference compared with established morphometric highly T2-weighted imaging (CISS).

CONCLUSIONS

Our data found no differences in nerve morphometry between clinically nonaffected and affected sides in patients with unilateral MD, nor any correlation with symptom duration. This finding contrasts with previous ones of correlations between clinical features and endolymphatic hydrops. A disease process starting before clinical symptom onset could be a possible explanation. Morphometric evaluation of brain nerves using hydrops MRI sequences is practical and provides similar results compared with T2-weighted imaging, improving patient comfort and reducing MRI scan times.

Cochlear implantation impairs intracochlear microcirculation and counteracts iNOS induction in guinea pigs

Introduction

Preservation of residual hearing remains a great challenge during cochlear implantation. Cochlear implant (CI) electrode array insertion induces changes in the microvasculature as well as nitric oxide (NO)-dependent vessel dysfunction which have been identified as possible mediators of residual hearing loss after cochlear implantation.

Methods

A total of 24 guinea pigs were randomized to receive either a CI (n = 12) or a sham procedure (sham) by performing a cochleostomy without electrode array insertion (n = 12). The hearing threshold was determined using frequency-specific compound action potentials. To gain visual access to the stria vascularis, a microscopic window was created in the osseous cochlear lateral wall. Cochlear blood flow (CBF) and cochlear microvascular permeability (CMP) were evaluated immediately after treatment, as well as after 1 and 2 h, respectively. Finally, cochleae were resected for subsequent immunohistochemical analysis of the iNOS expression.

Results

The sham control group showed no change in mean CBF after 1 h (104.2 ± 0.7%) and 2 h (100.8 ± 3.6%) compared to baseline. In contrast, cochlear implantation resulted in a significant continuous decrease in CBF after 1 h (78.8 ± 8.1%, p < 0.001) and 2 h (60.6 ± 11.3%, p < 0.001). Additionally, the CI group exhibited a significantly increased CMP (+44.9% compared to baseline, p < 0.0001) and a significant increase in median hearing threshold (20.4 vs. 2.5 dB SPL, p = 0.0009) compared to sham after 2 h. Intriguingly, the CI group showed significantly lower iNOS-expression levels in the organ of Corti (329.5 vs. 54.33 AU, p = 0.0003), stria vascularis (596.7 vs. 48.51 AU, p < 0.0001), interdental cells (564.0 vs. 109.1 AU, p = 0.0003) and limbus fibrocytes (119.4 vs. 18.69 AU, p = 0.0286).

Conclusion

Mechanical and NO-dependent microvascular dysfunction seem to play a pivotal role in residual hearing loss after CI electrode array insertion. This may be facilitated by the implantation associated decrease in iNOS expression. Therefore, stabilization of cochlear microcirculation could be a therapeutic strategy to preserve residual hearing.

Performance and self-perceived hearing impairment after cochlear implantation in Menière's disease

OBJECTIVE

Evaluation of the self-perceived hearing impairment and performance after cochlear implantation in patients with definite Menière's disease (MD).

PATIENTS AND METHODS

Seventeen unilaterally or bilaterally profoundly hearing-impaired patients suffering from MD who received a cochlear implantat (CI) were eligible for inclusion in this study. Their self-perceived hearing impairment using the short Speech Spatial and Qualities of Hearing Scale (SSQ12) as well as their performance in speech perception (German language Freiburger mono- and multisyllable test, Oldenburger sentence test) were compared with a best-matched control group of non-MD patients up to 24 months of follow-up.

RESULTS

MD patients improved significantly in perception of monosyllables presented at 65 dBSPL, from preoperatively best aided 18.2% [2.4, 34.0] to 51.7% [39.4, 63.9] 1 year after cochlear implantation (mean [95% confidence interval]). Their performance approached the matched controls with 63.2% [55.7, 70.8]. Monosyllables presented at a lower intensity of 55 dBSPL revealed a significant underperformance of the MD patients (21.1% [12.6, 29.6]) in contrast to the non-MD controls (39.1% [30.9, 47.4]) 12 months post-CI. Self-assessed hearing disability was significantly more pronounced in MD patients with a mean total SSQ12 score of 3.6 [2.4, 4.9] in comparison to 6.1 [5.4, 6.8] of the matched non-MD controls after 12 months of cochlear implantation.

CONCLUSION

Cochlear implantation substantially improves hearing capabilities in profoundly hearing-impaired patients with MD, but they tend to underperform in comparison to non-MD patients at least at lower sound pressure levels. This is likely one reason for the poorer self-assessed hearing function of cochlear implanted MD patients.

LEVEL OF EVIDENCE

3, retrospective, nonrandomized follow-up study.

Intratympanic infliximab is a safe and effective rescue therapy for refractory immune-mediated hearing loss

PURPOSE

To determine the efficacy and safety of the intratympanic infiltration of infliximab at the hearing threshold of patients in follow-up for refractory immune-mediated hearing loss.

METHODS

17 patients were collected with relapses, despite maintenance treatment with oral azathioprine associated or not with oral prednisone at low doses (between 5 and 7.5 ml/day) or refractory relapses to previous intratympanic corticoid treatment being 19 affected ears infiltrated. We measured the hearing threshold by Pure-Tone Average (PTA) 500-3000 Hz, 125-8000 Hz and 250-8000 Hz in pre-infiltration (baseline) and follow-up 3 weeks post-infiltration with auditory threshold at frequencies 125-8000 Hz.

RESULTS

The average age was 50.68 years (±15.23 years). After the administration of intratympanic infliximab, an improvement of the hearing threshold was showed in the Pure-Tone Average (PTA) calculated at 500-3000 Hz (p = 0.004), 125-8000 Hz (p = 0.001) and 250-8000 Hz (p = 0.006). An immediate improvement in low frequencies also was observed: 125, 250 and 500 Hz (p = 0.009, p = 0.002 and p < 0.001 respectively) also at 1000 Hz (p = 0.004) and a persistence of the effect at 3 months in the low frequencies: 125 Hz (p = 0.020), 250 Hz (p = 0.006) and 500 Hz (p = 0.002).

CONCLUSIONS

Infliximab intratympanic infiltration improves the hearing threshold in patients with immune-mediated hearing loss. The effect of improving the hearing threshold is higher in low frequencies and persists within 3 months of the infiltration. The administration of intratympanic infliximab is an effective and safe technique.

Inner ear disturbances related to middle ear inflammation

The inner and middle ear are connected mainly through round and oval windows, and inflammation in the middle ear cavity can spread into the inner ear, which might induce a disturbance. In cases with intractable otitis media, attention should also be paid to symptoms related to the inner ear. In this paper, middle ear inflammation and related inner ear disturbances are reviewed with a focus on representative middle ear diseases (such as acute otitis media, chronic otitis media, otitis media with anti-neutrophil cytoplasmic antibody-associated vasculitis, eosinophilic otitis media, cholesteatoma with labyrinthine fistula, and reflux-related otitis media). Their clinical concerns are then discussed with reference to experimental studies. In these diseases, early diagnosis and adequate treatment are required to manage not only middle ear but also inner ear conditions.

Oxidative Stress in the Blood Labyrinthine Barrier in the Macula Utricle of Meniere's Disease Patients

The blood labyrinthine barrier (BLB) is critical in the maintenance of inner ear ionic and fluid homeostasis. Recent studies using imaging and histopathology demonstrate loss of integrity of the BLB in the affected inner ear of Meniere's disease (MD) patients. We hypothesized that oxidative stress is involved in the pathogenesis of BLB degeneration, and to date there are no studies of oxidative stress proteins in the human BLB. We investigated the ultrastructural and immunohistochemical changes of the BLB in the vestibular endorgan, the macula utricle, from patients with MD (n = 10), acoustic neuroma (AN) (n = 6) and normative autopsy specimens (n = 3) with no inner ear disease. Each subject had a well-documented clinical history and audiovestibular testing. Utricular maculae were studied using light and transmission electron microscopy and double labeling immunofluorescence. Vascular endothelial cells (VECs) were identified using isolectin B4 (IB4) and glucose-transporter-1 (GLUT-1). Pericytes were identified using alpha smooth muscle actin (αSMA) and phalloidin. IB4 staining of VECS was consistently seen in both AN and normative. In contrast, IB4 was nearly undetectable in all MD specimens, consistent with the significant VEC damage confirmed on transmission electron microscopy. GLUT-1 was present in MD, AN, and normative. αSMA and phalloidin were expressed consistently in the BLB pericytes in normative, AN specimen, and Meniere's specimens. Endothelial nitric oxide synthase (eNOS), inducible nitric oxide synthase (iNOS), and nitrotyrosine were used as markers of oxidative stress. The VECs of the BLB in Meniere's had significantly higher levels of expression of iNOS and nitrotyrosine compared with normative and AN specimen. eNOS-IF staining showed similar patterns in normative and Meniere's specimens. Microarray-based gene expression profiling confirmed upregulation of iNOS mRNA from the macula utricle of Meniere's patients compared with AN. Nitrotyrosine, a marker recognized as a hallmark of inflammation, especially when seen in association with an upregulation of iNOS, was detected in the epithelial and stromal cells in addition to VECs in MD. Immunohistochemical and ultrastructural degenerative changes of the VEC suggest that these cells are the primary targets of oxidative stress, and pericyte pathology including degeneration and migration, likely also plays a role in the loss of integrity of the BLB and triggering of inflammatory pathways in MD. These studies advance our scientific understanding of oxidative stress in the human inner ear BLB and otopathology.

Genetics of guanylyl cyclase pathways in the cochlea and their influence on hearing

Although hearing loss is the most common sensory deficit in Western societies, there are no successful pharmacological treatments for this disorder. Recent experiments have demonstrated that manipulation of intracellular cyclic guanosine monophosphate (cGMP) concentrations can have both beneficial and harmful effects on hearing. In this review, we will examine the role of cGMP as a key second messenger involved in many aspects of cochlear function and discuss the known functions of downstream effectors of cGMP in sound processing. The nitric oxide-stimulated soluble guanylyl cyclase system (sGC) and the two natriuretic peptide-stimulated particulate GCs (pGCs) will be more extensively covered because they have been studied most thoroughly. The cochlear GC systems are attractive targets for medical interventions that improve hearing while simultaneously representing an under investigated source of sensorineural hearing loss.

Distribution and change of peroxynitrite in the guinea pig cochlea following noise exposure

Nitric oxide (NO)-mediated pathology depends on the formation of reactive intermediates, such as the peroxynitrite (ONOO⁻). ONOO⁻ can nitrate free tyrosine and tyrosine residues of proteins. Therefore, increases in tyrosine nitration reflect the amount of ONOO⁻ produced by oxidative stress. The distribution of 3-nitrotyrosine (3-NT), an ONOO⁻ marker, in the organ of corti and the cochlear lateral wall tissue from the guinea pig were examined using fluorescence immunohistochemistry. The immunoactivity of 3-NT in the normal guinea pig was compared with animals exposed to 122dBA broadband noise, 4 h/day, for 2 consecutive days. In the normal animals, 3-NT immunoreactivity was found in the outer hair cells (OHCs), inner hair cells (IHCs), pillar cells (PCs), spiral ganglion cells (SPCs) and the marginal cells of stria vascularis in the lateral wall. Sound exposure increased the 3-NT signal in all of the cells and resulted in extensive outer hair cell loss. A quantitative analysis of the 3-NT change in OHCs and marginal cells of lateral wall showed that immunolabeling was significant (P<0.01, n=10) in the noise exposure group compared with that of the control group. Anti-3-NT and propidium iodide double labeling showed that 3-NT was distributed mainly in the apical end of OHCs. In addition, 3-NT was distributed outside of the nucleus of the OHCs and marginal cells. In conclusion, the data indicate that noise exposure leads to a significant production of ONOO⁻ in the cochlear lateral wall and organ of corti. This is consistent with the known increase of NO production by loud sound stress and suggests that NO-derived free radicals participate in the cochlear pathophysiology of noise-induced hearing loss.

Influence of high-altitude hypoxic environments on the survival of cochlear hair cells and spiral ganglion neurons in rats

The aim of the present study was to observe the histological changes in the peripheral auditory system in rats at different time-points after relocating from low altitude to high altitude (3,600 m). The general physical condition of the rats was observed and cochlear tissue samples were obtained every month. The morphology and survival of the cochlear hair cells (HCs) were observed using cochlear surface preparation at 1, 30, 90, 120, 150 and 180 days after moving to the plateau area. Changes in spiral ganglion neurons (SGNs) were detected at different time-points using immunofluorescence technology on frozen sections. No obvious morphological changes were observed in the cochlear HCs within 1–3 months of the rats moving to the plateau area, and there was little loss of outer HCs (OHCs) at 3 months. Cell swelling, dislocation and loss of cochlear OHCs were apparent at 4 months, and the losses of cochlear OHCs and inner HCs (IHCs) were 54 and 39%, respectively at 6 months. The loss of SGNs was observed at 3 months, and there was a loss of 28–35% of SGNs during 3–6 months. Thus, a high-altitude hypoxic environment influenced the cochlear HCs in rats after moving to the plateau area in a time-dependent manner. The damage to SGNs occurred earlier than the HCs, although SGN damage was not aggravated with time. Furthermore, compared with cochlear HCs, cochlear SGNs were identified to be markedly more sensitive to hypoxia, and exerted an adaptive mechanism to protect neurons from hypoxia.

Hearing impairment, cochlear morphology, and peroxynitrite (ONOO(-)) formation in adult and aging NOS II knockout mice

CONCLUSION

Nitric oxide synthase (NOS) II induction is a protective mechanism against age-related degeneration of the cochlea.

OBJECTIVES

An induction of NOS II has been described in different inner ear pathologies. The objective was to examine the role of NOS II in age-related degeneration of the cochlea.

METHODS

The hearing ability in adult and aging NOS II knockout mice (KO) and their wildtype (WT) littermates was explored via auditory brainstem response (ABR) measurements. Inner ear morphological differences were studied with scanning electron microscopy (SEM). Immunohistochemistry was used to examine the induction of NOS II in the inner ear of aging WT mice. Expression of nitrotyrosin, a marker protein for the reactive oxygen species peroxynitrite, was compared between KO and WT mice using immunohistochemistry.

RESULTS

Adult KO mice exhibited a mild hearing impairment. WT mice showed an induction of NOS II after 6 months of age. Age-related hearing deterioration was accelerated in KO mice, which was accompanied by increased nitrotyrosin formation and outer hair cell loss.

Changes in Cochlear Blood Flow Due to Endotoxin-Induced Otitis Media

The purpose of this study was to elucidate the influence of otitis media on blood flow in the lateral wall of the cochlea by means of a model of endotoxin-induced otitis media. The cochlear blood flow (CBF) following lipopolysaccharide inoculation into the middle ear cavities of rats was measured by laser-Doppler flowmetry and compared with that of untreated ears. After this evaluation, the influence on CBF of concomitant use of a nitric oxide synthase inhibitor was also investigated. The first day after inoculation, the CBF of treated ears decreased significantly. This decrease recovered gradually between the 7th and 14th days. With concomitant use of a nitric oxide synthase inhibitor, the decrease in CBF was prevented to some extent. The results showed a functional influence upon CBF by endotoxin-induced otitis media. The significance of prophylactic use of the drug is also discussed in regard to the effect on CBF following otitis media.

Cochlear implantation in Ménière's disease patients

OBJECTIVE

A significant portion of the Ménière's disease (MD) population will ultimately have severe-to-profound hearing loss in their affected ear. When this occurs bilaterally or when a patient has poor hearing in the contralateral ear, these patients may meet criteria for cochlear implantation (CI). Here, we describe our institution's CI outcomes in MD patients.

STUDY DESIGN

Retrospective chart and literature review.

SETTING

Tertiary referral center.

PATIENTS

Twenty-one patients with either bilateral MD or unilateral MD who underwent CI in their ear affected with MD.

INTERVENTION(S)

Cochlear implantation.

MAIN OUTCOME MEASURE(S)

Postoperative speech perception.

RESULTS

Results for the MD patients were also compared with a standard sample of 178 adult recipients implanted with newest generation technology. Collapsing across status of MD activity, there was a significant difference between the MD CNC word recognition scores and that of the standard sample (43.2 versus 59.1%, p = 0.02). When separating the MD patients into groups according to the status of disease activity, those with active MD achieved scores that were not significantly different from the standard sample (55.7 versus 59.1%, p = 0.94), although those without active MD were significantly different from the standard group (38.2 versus, p = 0.002). Patients undergoing surgical or ablative procedures for their MD symptoms had statistically significant improvement in their CI hearing outcomes compared with those who did not (CNC words: p = 0.014; CNC phonemes: p = 0.035). Six patients had persistent vertiginous symptoms of MD before CI. After CI, 2 had complete resolution of vertigo, 3 had subjective improvement in their symptoms, and 1 noticed no change.

CONCLUSION

Ménière's disease patients' hearing outcomes seem to be worse than the general CI population. However, those with active MD perform similarly to the general CI population.

The protective effect of Salvia miltiorrhiza on gentamicin-induced ototoxicity

OBJECTIVE

The clinical use of aminoglycoside antibiotics is limited in most countries because of auditory toxicity side effects. However, their use is common in developing countries because they are inexpensive and convenient. Salvia miltiorrhiza extracts are used clinically in China for their antioxidant properties. We investigated the effect of a clinically approved injectable S. miltiorrhiza solution on inducible nitric oxide synthase (iNOS) generation induced by the aminoglycoside antibiotic gentamicin and an ototoxicity protective mechanism.

METHODS

Sixty adult guinea pigs were used in this study and divided into four groups. Auditory brainstem response (ABR) testing was performed before and after treatments and animals were sacrificed for morphological and immunostaining assays after determining threshold shifts in ABR. The cochleae were examined by transmission electron microscopy (TEM) and scanning electron microscopy (SEM) to observe ultrastructural changes. In addition, hair cell loss, iNOS and caspase-3 expression, and apoptosis were measured.

RESULTS

The result showed that hearing loss, iNOS overexpression accompanied with disorganization in the cochlea, and terminal deoxynucleotidyl transferase- mediated dUTP- biotin nick end labeling (TUNEL)-stained positive cells in animals treated with gentamicin. However, pretreatment with S. miltiorrhiza (3g/kg/day for 10 days) decreased gentamicin-induced hearing loss, attenuated iNOS and caspase-3 expression, and decreased the number of apoptotic cells. Furthermore, it also reduced the ultrastructural damage due to ototoxicity as observed by SEM and TEM.

CONCLUSIONS

These findings indicate that S. miltiorrhiza protects against gentamicin-induced ototoxicity and could apply to the protection of ototoxicity.

Review of the biologic agents used for immune-mediated inner ear disease

INTRODUCTION AND OBJECTIVES

Immune-mediated inner ear disease (IMIED) is one of the few reversible forms of sensorineural hearing loss. Treatment is based on high-dose corticosteroids, although long-term therapy is associated with serious adverse effects; this has led to the use of other agents or different routes of administration such as transtympanic delivery. This study analyses the role of biological agents in IMIED management.

MATERIAL AND METHODS

We searched PUBMED for studies that examined the response to treatment with different biological agents in patients with IMIED. The following data were extracted from the selected studies and entered into a standardised database: exclusion and inclusion criteria, characteristics of the patients studied, treatment, outcome measures and response rates achieved.

RESULTS

Thirteen studies were included in this review. A TNF alpha inhibitor (etanercept, infliximab, adalimumab) was used in 8 studies, an IL-1 antagonist (anakinra) was used in 3 studies and rituximab, an antibody directed against the CD20 surface antigen on B lymphocytes, was evaluated in 2 studies. Most studies achieved a hearing improvement or stabilisation in more than 70% of treated patients.

CONCLUSIONS

Biological agents can play a role in the management of patients with IMIED, at least in those patients who do not respond to conventional therapy or whose hearing is not stabilised. However, specially-designed randomised controlled clinical trials are needed to assess their effectiveness.

Nitric oxide--a versatile key player in cochlear function and hearing disorders

Nitric oxide (NO) is a signaling molecule which can generally be formed by three nitric oxide synthases (NOS). Two of them, the endothelial nitric oxide synthase (eNOS) and the neural nitric oxide synthase (nNOS), are calcium/calmodulin-dependent and constitutively expressed in many cell types. Both isoforms are found in the vertebrate cochlea. The inducible nitric oxide synthase (iNOS) is independent of calcium and normally not detectable in the un-stimulated cochlea. In the inner ear, as in other tissues, NO was identified as a multitask molecule involved in various processes such as neurotransmission and neuromodulation. In addition, increasing evidence demonstrates that the NO-dependent processes of cell protection or, alternatively, cell destruction seem to depend, among other things, on changes in the local cochlear NO-concentration. These alterations can occur at the cellular level or within a distinct cell population both leading to an NO-imbalance within the hearing organ. This dysfunction can result in hearing loss or even in deafness. In cases of cochlear malfunction, regulatory systems such as the gap junction system, the blood vessels or the synaptic region might be affected temporarily or permanently by an altered NO-level. This review discusses potential cellular mechanisms how NO might contribute to different forms of hearing disorders. Approaches of NO-reduction are evaluated and the transfer of results obtained from experimental animal models to human medication is discussed.

Hearing preservation in Guinea pigs with long-standing endolymphatic hydrops

HYPOTHESIS

Interruption of the excitotoxic and inflammatory pathways implicated in endolymphatic hydrops (ELH)-associated hearing loss (HL) should afford hearing protection at the neuronal level.

BACKGROUND

Previous work in our laboratory in the mouse model of ELH shows that dimethyl sulfoxide (DMSO), an anti-inflammatory solvent, can slow the progression of HL before neuronal degeneration occurs. Riluzole, a glutamate release inhibitor, may provide synergistic benefit. This study was designed to quantify the effects of DMSO and riluzole in a long-term model.

METHODS

Guinea pigs with surgically induced ELH were sorted into 3 groups: riluzole+DMSO (Group 1), DMSO alone (Group 2), and untreated controls (Group 3). Animals in Groups 1 and 2 received daily injections of the study drug(s). All animals underwent auditory-evoked brainstem response evaluation every 4 weeks until 24 weeks, when they were sacrificed. Cochleae were preserved; spiral ganglion density was quantified. Animals without hydrops were excluded from the study as surgical failures.

RESULTS

Animals from all groups developed unilateral HL. At the end of the experiment, HL was significantly lower in Group 1 relative to Group 3 (p = 0.049) and trended toward lower in Group 2 relative to Group 3 (p = 0.097). Groups 1 and 2 were not different (p = 0.311). At the cellular level, there is no evidence of neuronal degeneration in either treated group, whereas there is a significant neuronal degeneration in the untreated group.

CONCLUSION

These results confirm the hearing protection observed with DMSO in short-term studies. However, unlike the previous study, which showed no additive benefit to riluzole, the combined treatment group in this study showed a hearing-protective effect at 24 weeks. This indicates a potential additive benefit conferred by riluzole toward long-term hearing protection. The study also finds evidence of statistically significant neuronal protection with both treatment groups. Overall, study provides additional evidence that DMSO and riluzole may preserve or slow the long-term progression of ELH-associated HL.

Astragalosides reduce cisplatin ototoxicity in guinea pigs

Cisplatin is known to cause high-frequency neurosensory hearing loss. While reactive oxygen species have been shown to play a role, reactive nitrogen species have been implicated, but not proven to be involved, in cisplatin ototoxicity. The purpose of the present study was to investigate the role of nitric oxide (NO) in cisplatin ototoxicity by administering astragalosides, a natural antioxidant, in conjunction with cisplatin. Guinea pigs were injected with cisplatin, astragalosides or both. Auditory brainstem-evoked responses (ABRs) were measured before and 3 days after cisplatin administration. The cochlear tissue was then assayed for NO and malondialdehyde (MDA), and cochleae were also examined by scanning electron microscopy. Cisplatin alone caused significant ABR threshold shifts at all stimuli tested, whereas astragalosides alone caused no shifts. There was a significant reduction in threshold shift for clicks, 8-kHz and 16-kHz tone bursts (but not 32 kHz) when astragalosides was given with cisplatin. Both the MDA concentration and the NO concentration in the astragalosides/cisplatin group were significantly lower than those of the cisplatin group. Correspondingly, the loss of outer hair cells in the astragalosides/cisplatin group was much less than that in the cisplatin group. This suggests that astragalosides reduces cisplatin ototoxicity by its antioxidant property.

Potential role for lipopolysaccharide in congenital sensorineural hearing loss

Congenital sensorineural hearing loss (SNHL) is common. In the Western world, the incidence is 1-3 per 1000 live births. The aetiology encompasses genetic and non-genetic factors accounting for 55 % and 45 % of cases, respectively. Reports that describe the contribution of intrauterine infection to the occurrence of congenital SNHL are limited, and comparative analysis of the different pathogens is lacking. Lipopolysaccharide (LPS), a product of bacteriolysis, has been demonstrated to be associated with inner ear damage in experimental studies. To elucidate the potential role of this toxin in congenital SNHL and to identify the pathogenesis and transmission routes, we reviewed the literature. We speculate that different routes of exposure to LPS in utero may result in congenital inner ear damage.

Nitrogen and oxygen molecules in meningitis-associated labyrinthitis and hearing impairment

Pneumococcal meningitis remains a serious disease with a case fatality rate of 15%-25%. Furthermore, long-term residues affect up to 50% of survivors. One of the most frequent sequelae is sensorineural hearing loss, which occurs in 26% of survivors of pneumococcal meningitis. Unfortunately, sufficient treatment regimens are still missing. New insights into the pathology and pathophysiology of meningitis-associated hearing loss have come from animal models of bacterial meningitis. Most likely, bacteria reach the cochlea through the cochlear aquaeduct. Once arrived in the perilymphatic spaces, they induce a severe suppurative labyrinthitis. The blood-labyrinth barrier breaks, hair cells are damaged, and neurons in the spiral ganglion undergo cell death, leading to meningitis-associated hearing loss. Reactive oxygen and nitrogen species, in particular peroxynitrite, seem to be among the crucial mediators of cochlear damage and hearing loss during meningitis. In our rat model of pneumococcal meningitis, adjunctive therapy with the antioxidants and peroxynitrite scavengers Mn(III)tetrakis(4-bencoic acid)-porphyrin (MnTBAP) and N-Acetyl-L-Cystein (NAC) significantly attenuated acute and long-term hearing loss. In several other animal studies of pneumococcal meningitis, adjunctive antioxidant therapy also protected infected animals from intracranial complications. Therefore, the use of antioxidants seems to be a promising future treatment option in pneumococcal meningitis.

Nitric oxide production from cultured spiral ligament fibrocytes: effects of corticosteroids

CONCLUSION

This is the first report of nitric oxide (NO) production by cultured spiral ligament (SL) fibrocytes. The data suggest that dexamethasone (Dex) suppresses NO production by SL fibrocytes. Given that SL fibrocytes play a role in cochlear fluid and ion homeostasis, glucocorticoids may suppress cochlear malfunction caused by NO production in SL fibrocytes.

OBJECTIVE

To investigate NO production by cultured SL fibrocytes and regulation of NO production by Dex in mouse secondary cell cultures.

MATERIALS AND METHODS

Cultured SL fibrocytes were stimulated with tumor necrosis factor-alpha (TNF-alpha), and NO production was visualized with membrane-permeable 4-amino-5-methylamino-2',7'-difluorofluorescein diacetate (DAF-FM diacetate). Inducible nitric oxide synthase (NOSII) messenger RNA (mRNA) was measured by reverse transcription-polymerase chain reaction (RT-PCR).

RESULTS

After TNF-alpha stimulation, the fluorescence intensity increased in a time-dependent manner. This increase in fluorescence intensity was suppressed by a nonspecific NOS inhibitor, N(G)-nitro L-arginine methyl ester (L-NAME), and Dex. After TNF-alpha stimulation, expression of NOSII mRNA was observed. Expression of NOSII mRNA was inhibited by Dex.

Mechanisms of noise-induced hearing loss indicate multiple methods of prevention

Recent research has shown the essential role of reduced blood flow and free radical formation in the cochlea in noise-induced hearing loss (NIHL). The amount, distribution, and time course of free radical formation have been defined, including a clinically significant late formation 7-10 days following noise exposure, and one mechanism underlying noise-induced reduction in cochlear blood flow has finally been identified. These new insights have led to the formulation of new hypotheses regarding the molecular mechanisms of NIHL; and, from these, we have identified interventions that prevent NIHL, even with treatment onset delayed up to 3 days post-noise. It is essential to now assess the additive effects of agents intervening at different points in the cell death pathway to optimize treatment efficacy. Finding safe and effective interventions that attenuate NIHL will provide a compelling scientific rationale to justify human trials to eliminate this single major cause of acquired hearing loss.

Evaluation of the mouse model for acute otitis media

Various animal models have been employed for otitis media research. The mouse has been studied less, in spite of its many advantages. To better understand the suitability of the mouse for studies of otitis media, an evaluation was made of its middle ear inflammatory processes following inoculation with heat-killed Streptococcus pneumoniae (strain 6A), one of the three most common bacteria to cause otitis media in the human. A total of 94 BALB/c mice were injected transtympanically with three concentrations of heat-killed bacteria (10(4), 10(6), and 10(9) organisms per ml) and inflammation evaluated with both histologic examination and auditory brainstem response audiometry. Dose-related measures of the time course of inflammation showed it was maximal at 3 days. PBS-injected control mice also demonstrated some degree of middle ear inflammation. Therefore, inflammation measures from PBS injected mice were used as the threshold above which histologic inflammatory changes would be considered a response to bacteria. These quantitative comparisons of bacterial and PBS inoculations revealed the most significant middle ear measures of inflammation were amount of fluid in the middle ear, tympanic membrane thickness, and number of inflammatory cells. The induction of middle ear inflammation in the mouse demonstrated the applicability of this model for investigations of otitis media.

Gentamicin induced nitric oxide-related oxidative damages on vestibular afferents in the guinea pig

Gentamicin is a well-known ototoxic aminoglycoside. However, the mechanism underlying this ototoxicity remains unclear. One of the mechanisms which may be responsible for this ototoxicity is excitotoxic damage to hair cells. The overstimulation of the N-methyl-d-aspartate (NMDA) receptors increases the production of nitric oxide (NO), which induces oxidative stress on hair cells. In order to determine the mechanism underlying this excitotoxicity, we treated guinea pigs with gentamicin by placing gentamicin (0.5 mg) pellets into a round window niche. After the sacrifice of the animals, which occurred at 3, 7 and 14 days after the treatment, the numbers of hair cells in the animals were counted with a scanning electron microscope. We then performed immunostaining using neuronal nitric oxide synthase (nNOS), inducible NOS (iNOS) and nitrotyrosine antibodies. The number of hair cells in the animals was found to decrease significantly after 7 days. nNOS and iNOS expression levels were observed to have increased 3 days after treatment. Nitrotyrosine was expressed primarily at the calyceal afferents of the type I hair cells 3 days after treatment. Terminal deoxynucleotidyl transferase biotin-dUTP nick end labeling (TUNEL) staining revealed positive hair cells 3 days after treatment. Our results suggest that inner ear treatment with gentamicin may upregulate nNOS and iNOS to induce oxidative stress in the calyceal afferents of type I hair cells, via nitric oxide overproduction.

Evidence for an Akt-kinase/NO/cGMP pathway in the cochlea of guinea pigs

The protein kinase Akt (protein kinase B) can be activated by numerous growth factors via PI-3 kinase-generated phosphoinositides and is thought to have anti-apoptotic properties. Activated Akt/PKB boosts the activity of endothelial NO synthase (NOS III), which has been found in the key areas of the inner ear (e.g., hair cells and stria vascularis). In order to localize activated Akt/PKB (phospho-Akt) in the cochlea of guinea pigs, sections of ten temporal bones were observed immunohistochemically. The strongest immunoreactivity was found in and underneath inner hair cells (IHC). Within the organ of Corti, reactivity was found in supporting cells, while outer hair cells remained unstained. Spiral ganglion cells, the endothelium of the lateral wall and the vascular area of the modiolus showed moderate staining. The results give evidence that activated Akt/PKB influences the activity of the NO/cGMP pathway in the cochlea. Because of the antiapoptotic properties, activated Akt should now be examined under non-physiological conditions.

Endothelial nitric oxide synthase upregulation in the guinea pig organ of Corti after acute noise trauma

Endothelial nitric oxide synthase (eNOS) upregulation was identified 60 h after acute noise trauma in morphologically intact cells of the reticular lamina in the organ of Corti of the guinea pig in the second turn of the cochlea. Using gold-coupled anti-eNOS antibodies and electron microscopy, it was shown that eNOS expression was upregulated in all cell areas and cell types except inner hair cells. Furthermore, eNOS was found in the organelle-free cytoplasm and in mitochondria of various cell types. The density of eNOS in mitochondria was considerably higher compared with the surrounding cytoplasm. Since eNOS activity is regulated by calcium, the eNOS detection was combined with calcium precipitation, a method for visualizing intracellular Ca2+ distribution. After acute noise trauma, intracellular Ca2+ was increased in all cell types and cell areas except in outer hair cells. Comparing the distribution patterns of eNOS and calcium, significantly elevated levels (P < 0.0001) of eNOS were detected within a 100 nm radius near calcium precipitates in all cuticular structures as well as microtubule-rich regions and Deiters' cells near Hensen cells. The observed colocalization lends support to the postulated mechanism of eNOS activation by Ca2+. eNOS upregulation after acute noise trauma might therefore be part of an induced stress response. The eNOS upregulation in cell areas with numerous microtubule- and actin-rich structures is discussed with respect to possible cytoskeleton-dependent processes in eNOS regulation.

Endothelial nitric oxide synthase upregulation in the cochlea of the guinea pig after intratympanic gentamicin injection

Single-shot transtympanic gentamicin therapy has become a popular treatment modality for Meniere's disease despite the known possible ototoxic properties of this drug. It was shown recently that NO production and iNOS were upregulated after gentamicin application, which was interpreted as a possible effect of ototoxicity. In this study we analyzed the expression of eNOS after gentamicin application to determine a possible correlation of this enzyme with gentamicin-induced ototoxicity. We compared eNOS expression in gentamicin-treated and non-treated guinea pigs in the second turn of the cochlea, an area corresponding to speech perception in humans. Gentamicin (4 mg) was injected intratympanically into the middle ear of guinea pigs ( n =3) and the reduction of the hearing threshold level was determined by recording acoustic-evoked potentials (AEP) before and 5 days after gentamicin application. Morphological alterations in the organ of Corti were analyzed by light and electron microscopy. Gold-labeled anti-eNOS antibodies were counted in eight different cell areas for quantification of eNOS expression. Seven animals were analyzed as controls. After gentamicin application, a deterioration of hearing level was observed varying from 10 to 30 dB. A high degree of vacuolization was identified in the third row of outer hair cells. At the subcellular level, the subsurface cisterns in outer hair cells were dissociated from the basolateral cell membrane, and the mitochondrial membranes were frequently damaged. Statistically significant upregulation of eNOS was observed in all cell types analyzed. Depending on the various cell types the amount of gold-labeled eNOS antibodies was 2.5 to 5.7 times higher after gentamicin application. We observed significant eNOS upregulation after gentamicin application in the cochlea, in conjunction with cellular damages and decreased hearing.

Soluble guanylate cyclase and neuronal nitric oxide synthase colocalize in rat nucleus tractus solitarii

Nitric oxide has been implicated in transmission of cardiovascular signals in the nucleus tractus solitarii (NTS). Pharmacological studies suggest that activation of neurons by nitric oxide in the NTS may involve soluble guanylate cyclase (sGC). However, anatomical data supporting this suggestion have not been available. In this study, we tested the hypothesis that neurons and fibers containing neuronal nitric oxide synthase (nNOS) lie in close proximity to those containing sGC and the two enzymes colocalize in some neurons and fibers in the NTS. We perfused six rats and obtained brain stem sections for double immunofluorescent staining utilizing antibodies selective for sGC and for nNOS combined with confocal microscopy. The distribution and staining intensity of nNOS-immunoreactivity (IR) was similar to our earlier reports. IR of sGC was present in cell bodies, proximal dendrites and fibers of many brain stem regions. Strong sGC-IR was noted in the hypoglossal, dorsal motor nucleus of vagus and gracilis nuclei. The NTS exhibited moderate sGC-IR. Superimposed images showed that many NTS neurons contained both nNOS-IR and sGC-IR. The percentage of sGC-IR positive cells that were also nNOS-IR positive differed among NTS subnuclei. Similarly, the percentage of nNOS-IR positive cells that were also sGC positive differed among NTS subnuclei. Fibers stained for both nNOS-IR and sGC-IR were also present in NTS subnuclei. In addition, we identified fibers that were stained for nNOS-IR or sGC-IR alone and often found such singly labeled fibers apposed to each other. These data support our hypothesis and provide anatomical support for the suggestion that nitroxidergic activation of the NTS involves sGC.

Round window membrane and labyrinthine pathological changes: an overview

The round window membrane is considered the most likely pathway from the middle to the inner ear. Various substances placed in the middle ear have been seen to pass through the round window membrane. Once toxic substances or inflammatory mediators such as cytokines and nitric oxide enter the inner ear, various inner ear sequelae such as labyrinthitis, endolymphatic hydrops, sensorineural hearing loss or more insidious diseases can occur.

Aminoguanidine reduces cisplatin ototoxicity

Cisplatin is known to cause high-frequency neurosensory hearing loss. While reactive oxygen species have been shown to play a role, reactive nitrogen species have been implicated, but not proven to be involved, in cisplatin ototoxicity. The purpose of the present study was to investigate the role of nitric oxide (*NO) in cisplatin ototoxicity by administering aminoguanidine (AG), a relatively specific inhibitor of inducible nitric oxide synthase (iNOS), in conjunction with cisplatin. Rats were injected with cisplatin, AG, or both. Auditory brainstem evoked responses (ABR) were measured before and 3 days after cisplatin administration. The cochlear tissue was then assayed for *NO and malondialdehyde. Cisplatin alone caused significant ABR threshold shifts at all stimuli tested, whereas AG alone caused no shifts. There was a significant reduction in threshold shift for clicks and 16 kHz tone bursts (but not 32 kHz) when AG was given with cisplatin. The malondialdehyde concentration (but not the *NO concentration) in the AG/cisplatin group was significantly lower than that of the cisplatin group. This suggests that AG reduces cisplatin ototoxicity by directly scavenging hydroxyl radicals. The iNOS pathway may play a role in the generation of free radicals and hearing loss resulting from cisplatin administration, but this conclusion was not supported by our data.

A comparative study of intratympanic steroid and NO synthase inhibitor for treatment of cochlear lateral wall damage due to acute otitis media

We studied the damage to the cochlear lateral wall induced by otitis media and the therapeutic effects of intratympanic administration of steroid and nitric oxide (NO) synthase inhibitor. In Sprague-Dawley rats, right middle ear cavities were inoculated with lipopolysaccharide, followed after 30 min by intratympanic administration of dexamethasone, NOS-inhibitor or PBS. Twenty-four hours after lipopolysaccharide inoculation, cochlear blood flow was measured by laser-Doppler flowmetry. Prostaglandin E(1) was topically applied to the round window membrane of the right ear and changes in cochlear blood flow were calculated. Changes of cochlear blood flow were significantly different among the three groups. Increases in cochlear blood flow following PGE(1) application were higher in the group that received NOS-inhibitor. Electron microscopic examination revealed that changes in the stria vascularis were less severe in rats treated with dexamethasone or NOS-inhibitor. Our results show the effectiveness of intratympanic dexamethasone or NOS-inhibitor in treating cochlear lateral wall damage caused by otitis media.

Candidate???s Thesis: Platelet-Activating Factor???Induced Hearing Loss: Mediated by Nitric Oxide?

OBJECTIVES/HYPOTHESIS

Platelet-activating factor (PAF)in middle ear effusion is thought to induce hearing loss. The purpose of this study is to investigate the role of nitric oxide (NO) in the mechanism of PAF-induced hearing loss by studying the effects of PAF application on the round window membrane (RWM) with and without PAF-antagonist NO-blocker.

STUDY DESIGN

Longitudinal study on randomized guinea pigs using PAF to induce hearing loss. METHODS Guinea pigs were divided into four groups: PBS, PAF, PAF-antagonist, and L-NAME. The PBS group received phosphate buffered saline (PBS) and the PAF groups received 10, 20, and 40 microg of PAF soaked into gelfoam and placed on the RWM. PAF-antagonist (WEB 2170) and NOS inhibitor NG-nitro-l-arginine-methylester (L-NAME) were injected intraperitoneally prior to PAF 20 microg application on the RWM. The following three tests were performed on each animal group: Hearing was tested with an auditory brainstem response (ABR) test over 24 hours. At the end of 24 hours, cochlear hair cells were examined by scanning electron microscopy (SEM) and immunohistochemistry was carried out on the cochlea to test the expression of inducible nitric oxide synthase (iNOS).

RESULTS

The PAF group developed significant elevation of ABR threshold and cochlear hair cell damage in the SEM group as compared with the PBS control group. The PAF-antagonist (WEB 2170) and the L-NAME groups did not show significant elevation of ABR threshold and cochlear hair cell damage compared with the group administered PAF 20 microg, but in the PAF-antagonist group, the elevation of ABR threshold was significant compared with that of the PBS control group, whereas it was not significant compared with the PBS group in the L-NAME group. Strong expression of iNOS on cochlea was observed in the PAF group and lighter expression was seen in PBS, WEB 2170, and L-NAME groups.

CONCLUSIONS

This study demonstrated that PAF placed on the RWM induced hearing loss and cochlear hair cell damage. The PAF-antagonists and L-NAME prevented the PAF-induced hearing loss and inhibited iNOS expression in the cochlea. These findings suggest that the PAF-induced hearing loss caused by cochlear hair cell damage may have been mediated by NO. PAF-antagonists and L-NAME may have future therapeutic implications in preventing sensorineural hearing loss associated with chronic otitis media. The results of this study have significant potential clinical application.

Altered expression of inducible nitric oxide synthase (iNOS) in the cochlea

Using immunohistochemistry and Western blot, the expression of inducible nitric oxide synthase (iNOS) in the lateral wall and organ of Corti was examined in normal (unstimulated) and stimulated mice and guinea pigs. The stimuli were: (1). injection of bacterial lipopolysaccharide (LPS, 5 mg/ml) into the middle ear through the tympanic membrane and (2). exposure to a 110 dB SPL (A-weighted) broadband noise, 3 h/day, for three consecutive days. For the unstimulated condition, weak iNOS expression was found in the vascular endothelium, marginal cells, nerve fibers, stereocilia of hair cells and Hensen's cells of the organ of Corti. More intense iNOS fluorescence signals were observed in cochlear tissues (particularly in hair cells and stria vascularis marginal cells) in animals exposed to loud sound or treated with LPS. Although the precise roles of iNOS expression in normal cochlear function have yet to be determined, enhanced iNOS expression following noise exposure and LPS suggests its participation in cochlear pathophysiology, including noise- and inflammatory factor-induced hearing loss.

In vitro activation of extracellular signal-regulated kinase1/2 in the inner ear of guinea pigs

Growth factors such as vascular endothelial growth factor (VEGF) exert their proliferative properties partly through activation of mitogen-activated protein kinase/extracellular signal-regulated kinase (MAPK/ERK1/2). Although both VEGF and inactive ERK could be detected in the inner ear of guinea pigs, under normal conditions activated ERK (phospho-ERK) was found only sparely. Cochleae of adult guinea pigs were removed, incubated with VEGF in a carbogen-gased organ-bath for 5, 15, 30 and 60 min (n=6 in each group), fixed with PFA 4%, embedded in paraffin and sectioned, followed by immunohistochemical staining to inactive and active ERK. Whereas inactive ERK was found in all cochleae, in sensory and supporting cells of the apex activated ERK was strongly detected after 5-min VEGF-incubation. After 15 min all Corti-organs showed clear staining corresponding to activated ERK, which decreased again after 30 min. Faint staining in endothelial cells of the spring-coil-vessels and in the spiral ganglion cells was found after 30 min and was increased after 60 min, while the staining in the Corti-organs vanished. Addition of the MEK-inhibitor PD 98059 to the organ-bath led to diminished phospho-ERK1/2 immunostaining. These findings provide evidence for a VEGF-dependent phosphorylation of ERK1/2 in the cochlea. Activated ERK1/2 is thought to support axonal outgrowth, enhancement of cell survival and to regulate the turnover of the NO/cGMP-pathway.

The demonstration of nitric oxide in cochlear blood vessels in vivo and in vitro: the role of endothelial nitric oxide in venular permeability

The objectives of the current study were to investigate the distribution and production of NO in cochlear blood vessels, and to assess whether the inhibition of basal NO production leads to vascular protein leakage of the cochlear microvasculature. Using the fluorescent dye 4,5-diaminofluorescein diacetate, NO was detected, both in vitro and in vivo, in the endothelial cells of various cochlear blood vessels, including the spiral modiolar artery, the vessel of the basilar membrane and the vessels of the spiral osseous lamina. Vessel leakage was assessed using intravital fluorescence microscopy following systemic infusion of fluorescein isothiocyanate-labeled bovine albumin. Local perfusion of the cochlear basal turn with either Ringer's solution or Ringer's containing an inactive nitric oxide synthase inhibitor (100 microM) produced minimal protein leakage. Perfusion with the nitric oxide synthase inhibitor N(G)-nitro-L-arginine methyl ester (100 microM) produced significantly enhanced vascular protein leakage. The findings demonstrate the presence of endothelial NO in the cochlear blood vessels and suggest that NO protects cochlear venules against excessive vascular leakage.

Effects of nitric oxide synthase inhibitor on cochlear blood flow

We observed in rats the changes in cochlear blood flow (CoBF) and cutaneous blood flow of the abdominal wall (AbBF) after the administration of the NO synthase inhibitor, N-nitro-L-arginine-methyl ester (L-NAME). Ten minutes after i.v. infusion of L-NAME (0.2, 1, 5, 10 mg/kg), L-arginine, which is a substrate of NO, was infused (100 mg/kg) i.v. Employing a laser Doppler flowmeter, the changes in blood flow were recorded from the basal turn of the right cochlea or the abdominal wall and blood pressure (BP) was recorded from the left femoral artery simultaneously. Vascular conductance (VC) was calculated from CoBF/mean BP (cochlear VC) or AbBF/mean BP (abdominal VC). The findings in rats generally agreed with those in guinea pigs [Brechtelsbauer et al., Hear. Res. 77 (1994) 38-42]. Intravenous infusion of L-NAME produced a dose-dependent depression of cochlear VC at 0.2 mg/kg (-18.9), 1 mg/kg (-37.9%), 5 mg/kg (-45.8%) and 10 mg/kg (-48.3%). AbBF also decreased after infusion of L-NAME (5 mg/kg) but to a lesser degree (-41.1% in VC) with no significance compared to CoBF (5 mg/kg). Infusion of L-arginine partially reversed the CoBF decrease caused by L-NAME. The group of 0.2 mg/kg infusion of L-NAME showed the largest degree of recovery with L-arginine, while the 10 mg/kg group showed the smallest. The decrease in AbBF did not recover substantially with L-arginine, the degree being less than that of each group in the CoBF experiment. It was suggested that the NO/soluble guanylate cyclase/cGMP system is more active in the cochlear microcirculation. With the round window (RW) application of 1% L-NAME (2 microl), cochlear VC was decreased by 21.6%, which was closest to that of the 0.2 mg/kg group of L-NAME i.v. infusion. The cochlear VC depression after local application of L-NAME did not show any recovery (-0.3%) by RW application of 5% L-arginine (2 microl) 25 min after L-NAME application; a slight gradual increase was observed when a higher concentration (20%) of L-arginine was applied to the RW. We propose that i.v. infusions of L-NAME and L-arginine primarily affect the precapillary arteriole of the spiral modiolar artery which effectively regulates microcirculation as a resistance vessel, and that RW application affects the vessels of the lateral wall, not the spiral modiolar artery because of the difficulty of substance diffusion.

Nitric oxide in the inner ear

During the past year significant advances have been made in our understanding of the functional significance of nitric oxide (NO) in the inner ear. NO synthase and the NO production site have now been localized using immunohistochemistry and a new fluorescence indicator for NO. The functional significance of NO in the inner ear, in particular as a neurotransmitter, is becoming increasingly clear. Increasing evidence suggests that excessive NO production may play an essential role in inner ear disorders. The production of an inducible form of NO synthase may be closely related to this phenomenon. Based on the mechanisms of inner ear disorders, new pharmacological strategies for preventing or treating inner ear disorders have been suggested.

Brain-derived neurotrophic factor and nitric oxide synthase inhibitor protect the vestibular organ against gentamicin ototoxicity

In order to find a way to develop a new treatment for inner ear disorders, the effects of a nitric oxide synthase (NOS) inhibitor [N-nitro-L-arginine methylester (L-NAME)] and a neurotrophin [brain-derived neurotrophic factor (BDNF)] were investigated. The effect of L-NAME and BDNF on gentamicin-induced vestibular hair cell damage was investigated by using the in vitro LIVE/DEAD system. Both L-NAME and BDNF individually reduced the vestibular hair cell damage caused by gentamicin but the combination of L-NAME and BDNF was more successful in preventing damage. It is therefore suggested that treatment with a combination of an NOS inhibitor and a neurotrophin will help us to treat inner ear disorders.

Etanercept therapy for immune-mediated cochleovestibular disorders: preliminary results in a pilot study

OBJECTIVE

Immune-mediated cochleovestibular disorders (IMCVDs) continue to present a management challenge to the otolaryngologist. Antirheumatic agents, commonly used for IMCVDs, are associated with variable efficacy and sometimes with serious side effects. The authors describe the preliminary result of their experience in patients with IMCVDs who have been treated with etanercept, a tumor necrosis factor alpha receptor blocker, recently approved by the United States Food and Drug Administration for the treatment of rheumatoid arthritis.

STUDY DESIGN

Retrospective case series.

SETTING

Tertiary care hospital.

PATIENTS

Twelve patients suspected of having IMCVD who did not respond to conventional therapies or experienced side effects of the conventional therapies.

INTERVENTION

Etanercept 25 mg by subcutaneous injection twice per week.

MAIN OUTCOME MEASURES

The main outcome measurement was assessment of hearing change by air conduction pure tone audiograms and/or word discrimination. When present, vertigo, tinnitus, and aural fullness were assessed as well.

RESULTS

Follow-up of more than 5 months was available for all patients (range, 5-12 months). Eleven (92%) of 12 patients had improvement or stabilization of hearing and tinnitus, seven (88%) of eight patients who had vertigo and eight (89%) of nine patients who had aural fullness had resolution or significant improvement of their symptoms. The benefit persisted until the last visit (5-12 months after etanercept was begun). The condition of one patient improved dramatically at first but deteriorated after 5 months. The patient's hearing was rescued and stabilized with the addition of leflunomide to etanercept. Similarly, three other patients required a second antirheumatic agent to stabilize their hearing. There were no significant side effects from the etanercept therapy.

CONCLUSIONS

Our limited data suggest that etanercept therapy is safe and may be efficacious in carefully selected patients with IMCVDs, at least on a short-term basis. These preliminary efficacy and safety results appear encouraging enough to warrant further follow-up and studies for better determination of the potential clinical utility of etanercept for IMCVDs.

Reactive nitrogen species contribute to blood-labyrinth barrier disruption in suppurative labyrinthitis complicating experimental pneumococcal meningitis in the rat

Sensorineural hearing damage is a frequent complication of bacterial meningitis, affecting as many as 30% of survivors of pneumococcal meningitis. There is a substantial body of evidence that oxidants, such as reactive nitrogen species (RNS), are central mediators of brain damage in experimental bacterial meningitis. In the present study, we investigated whether RNS also contribute to the pathophysiology of suppurative labyrinthitis in our well-established rat model of pneumococcal meningitis. In all infected rats, but not in uninfected controls, we observed suppurative labyrinthitis. Cochlear inflammation was accompanied by severe blood-labyrinth barrier (BLB) disruption as evidenced by increased Evans Blue extravasation. Furthermore, increased cochlear expression of endothelial nitric oxide synthase (eNOS) and inducible nitric oxide synthase (iNOS) was detected by immunohistochemistry. Colocalization of iNOS and tyrosine nitration (a marker of RNS attack) indicated that nitric oxide (NO) produced by iNOS contributes to oxidative cochlear damage through the action of RNS. To determine the pathophysiological role of RNS in BLB disruption, rats were treated with peroxynitrite scavengers (MnTBAP and uric acid, UA). Six h after adjunctive treatment with 300 mg/kg i.p. UA or 15 mg/kg i.p. MnTBAP+100 mg/kg i.p. ceftriaxone, BLB disruption was significantly reduced compared with that in infected animals treated only with ceftriaxone. Therefore, we conclude that RNS are involved in the breaching of the BLB during meningogenic pneumococcal labyrinthitis.

Expression of Inducible Nitric Oxide Synthase in the Cochlea following Immune Response in the Endolymphatic Sac of Guinea Pigs

Immunohistochemical study for inducible nitric oxide synthase (iNOS or NOS II) in the cochlea of guinea pigs was performed after the injection of keyhole limpet hemocyanin (KLH) into the endolymphatic sac. Morphological changes were observed in the cochlea of all animals after the injection of KLH. Increased iNOS expression was detected in the lateral wall, organ of Corti and ganglion cells. It is known that high levels of nitric oxide can lead to inner ear dysfunction. Our results suggest that iNOS may mediate the inner ear disturbance as seen in endolymphatic hydrops.

Autoimmune vestibulo-cochlear disorders

Autoimmune vestibulo-cochlear disorders (AVCD) represent a group of syndromes with overlapping clinical features, manifesting as sensorineural hearing loss, often associated with vertigo, tinnitus, and aural fullness, and believed to be caused by an autoimmune mechanism. Although definitive evidence of a classic "autoimmune process" is still lacking, substantial indirect evidence has accumulated to strongly indicate such a pathogenesis. Rapidly progressing AVCD is analogous to rapidly progressive glomerulonephritis in that inner ear inflammation progresses to severe, irreversible damage within 3 months of onset (and often much more quickly). Thus patients with rapidly progressive AVCD are treated with a sense of urgency. Prompt treatment with corticosteroids and other antirheumatic/immunosuppressive agents can preserve hearing and vestibular functions. We are not aware of any randomized controlled clinical trials evaluating the efficacy of antirheumatic/immunosuppressive agents in AVCD. In this article we review reports of various therapies that have been tried in this condition and our experience of etanercept therapy in AVCD.

Immunohistochemical detection of vascular endothelial growth factor (VEGF) and VEGF receptors Flt-1 and KDR/Flk-1 in the cochlea of guinea pigs

Vascular endothelial growth factor (VEGF) is known as an endothelial cell-specific mitogen. There are no reports concerning the presence of VEGF in the inner ear. To gain information, immunohistochemical analysis using specific antibodies to VEGF and to both known VEGF receptors Flt-1 and KDR/Flk-1 was performed on paraffin-sectioned temporal bones from five guinea pigs. Immunoreactivity of VEGF, Flt-1 and KDR/Flk-1 was detectable in spiral ganglion cells. VEGF could also be found in the endothelium of blood vessels, in the spiral ligament and in the organ of Corti. Flt-1 was found in the limbus epithelium, in all supporting cells of the organ of Corti, in Claudius cells, cells of the sulcus and in the spiral ligament. Flk-1 could be detected in some supporting cells of the organ of Corti (inner pillar cells and Deiters' cells). Immunoreactivity to Flk-1 was also found in endothelium of blood vessels and in the spiral ligament. Hair cells showed VEGF immunostaining, but did not contain staining to Flt-1 nor Flk-1. In the stria vascularis any immunoreactivity to all used VEGF and VEGF receptor antibodies could not be detected. The findings were supported by Western blot analysis on inner ear tissues and ovaries from guinea pigs. We may conclude that the growth factor VEGF and both receptors participate in cochlear physiology.