Effect of topically applied basic fibroblast growth factor on injured cochlear nerve

Molecular and Clinical Significance of Fibroblast Growth Factor 2 in Development and Regeneration of the Auditory System

The fibroblast growth factor 2 (FGF2) is a member of the FGF family which is involved in key biological processes including development, cellular proliferation, wound healing, and angiogenesis. Although the utility of the FGF family as therapeutic agents has attracted attention, and FGF2 has been studied in several clinical contexts, there remains an incomplete understanding of the molecular and clinical function of FGF2 in the auditory system. In this review, we highlight the role of FGF2 in inner ear development and hearing protection and present relevant clinical studies for tympanic membrane (TM) repair. We conclude by discussing the future implications of FGF2 as a potential therapeutic agent.

FGF2 and EGF for the Regeneration of Tympanic Membrane: A Systematic Review

Objective

A systematic review was conducted to compare the effectiveness and safety of fibroblast growth factor-2 (FGF2) and epidermal growth factor (EGF) for regeneration of the tympanic membrane (TM).

Methods

The PubMed database was searched for relevant studies. Experimental and clinical studies reporting acute and chronic TM perforations in relation to two healing outcomes (success rate and closure time) and complications were selected.

Results

A total of 47 studies were included. Five experimental studies showed closure rates of 55%-100% with FGF2 compared with 10%-62.5% in controls for acute perforations. Five experimental studies showed closure rates of 30.3%-100% with EGF and 3.6%-41% in controls for chronic perforations. Two experimental studies showed closure rates of 31.6% or 85.7% with FGF2 and 15.8% or 100% with EGF. Nine clinical studies of acute large perforations showed closure rates of 91.4%-100% with FGF2 or EGF. Two clinical studies showed similar closure rates between groups treated with FGF2 and EGF. Seven clinical studies showed closure rates of 88.9%-100% within 3 months and 58%-66% within 12 months using FGF2 in repair of chronic perforations, but only one study showed a significantly higher closure rate in the saline group compared with the FGF2 group (71.4% vs. 57.5%, respectively, P = 0.547). In addition, three experimental studies showed no ototoxicity associated with FGF2 or EGF. No middle ear cholesteatoma or epithelial pearls were reported, except in one experimental study and one clinical study, respectively.

Conclusions

FGF2 and EGF showed good effects and reliable safety for the regeneration of TM. In addition, EGF was better for the regeneration of acute perforations, while FGF2 combined with biological scaffolds was superior to EGF for chronic perforations, but was associated with high rates of reperforation over time. Further studies are required to determine whether EGF or FGF2 is better for TM regeneration.

Regeneration of the tympanic membrane using fibroblast growth factor-2

OBJECTIVE

A systematic review was conducted to investigate the effectiveness of fibroblast growth factor-2 on the regeneration of tympanic membrane perforation.

METHODS

The PubMed database was searched for relevant studies. Experimental studies, human randomised controlled trials, prospective single-arm studies and retrospective studies reporting acute and chronic tympanic membrane perforations in relation to two healing outcomes (success rate and closure time), were selected.

RESULTS

All 11 clinical studies investigating the effect of fibroblast growth factor-2 on traumatic tympanic membrane perforations in humans reported a success rate of 89.3-100 per cent, with a closure time of around 2 weeks. Three studies of fibroblast growth factor-2 combined with Gelfoam showed that the success rate of chronic tympanic membrane perforation was 83-98.1 per cent in the fibroblast growth factor-2 group, but 10 per cent in the gelatine sponge groups.

CONCLUSION

Fibroblast growth factor-2 with or without biological material patching promotes regeneration in cases of acute and chronic tympanic membrane perforation, and is safe and efficient. However, the best dosage, application time and administration pathway of fibroblast growth factor-2 are still to be elucidated.

A spatial and temporal gradient of Fgf differentially regulates distinct stages of neural development in the zebrafish inner ear

Neuroblasts of the statoacoustic ganglion (SAG) initially form in the floor of the otic vesicle during a relatively brief developmental window. They soon delaminate and undergo a protracted phase of proliferation and migration (transit-amplification). Neuroblasts eventually differentiate and extend processes bi-directionally to synapse with hair cells in the inner ear and various targets in the hindbrain. Our studies in zebrafish have shown that Fgf signaling controls multiple phases of this complex developmental process. Moderate levels of Fgf in a gradient emanating from the nascent utricular macula specify SAG neuroblasts in laterally adjacent otic epithelium. At a later stage, differentiating SAG neurons express Fgf5, which serves two functions: First, as SAG neurons accumulate, increasing levels of Fgf exceed an upper threshold that terminates the initial phase of neuroblast specification. Second, elevated Fgf delays differentiation of transit-amplifying cells, balancing the rate of progenitor renewal with neuronal differentiation. Laser-ablation of mature SAG neurons abolishes feedback-inhibition and causes precocious neuronal differentiation. Similar effects are obtained by Fgf5-knockdown or global impairment of Fgf signaling, whereas Fgf misexpression has the opposite effect. Thus Fgf signaling renders SAG development self-regulating, ensuring steady production of an appropriate number of neurons as the larva grows.

Neurons of the statoacoustic ganglion (SAG), which innervate the inner ear, are derived from neuroblasts originating from the floor of the otic vesicle. Neuroblasts quickly delaminate from the otic vesicle to form dividing progenitors, which eventually differentiate into mature neurons of the SAG. Fgf has been implicated in initial neuroblast specification in multiple vertebrate species. However, the role of Fgf at later stages remains uncertain, because previous studies have not been able to evaluate the effects of changing levels of Fgf, nor have they been able to clearly distinguish the effects of Fgf at different stages of SAG development. We have combined conditional loss of function, misexpression, and laser-ablation studies in zebrafish to elucidate how graded Fgf coordinates distinct steps in SAG development. Initially moderate Fgf in a spatial gradient specifies neuroblasts within the otic vesicle. Later, mature SAG neurons express Fgf5 and, as additional neurons accumulate outside the otic vesicle, rising levels of Fgf terminate further specification. Elevated Fgf also slows maturation of progenitors, maintaining a stable progenitor pool in which growth and differentiation are evenly balanced. This feedback facilitates steady production of new neurons as the animal grows through larval and adults stages.

Platelet-rich plasma: a promising product for treatment of peripheral nerve regeneration after nerve injury

Nerve regeneration includes regrowth of injured axons as well as myelination, restoration of synaptic connections and recovery of physiological functions. Platelet-rich plasma (PRP) is prepared from the patient's own blood and contains growth factors that influence wound healing and used in various surgical fields including oral and maxillofacial surgery. When platelets are activated either ex vivo or in vivo, growth factors and proteins were released from platelets' alpha granules. Recent studies proved that PRP could promote regeneration of injured peripheral nerve. This review focuses on current trials using PRP to promote nerve regeneration and repairment, and proposes potential clinical application of PRP for nerve injury in the future.

Rebuilding lost hearing using cell transplantation

OBJECTIVE

The peripheral auditory nervous system (cochlea and auditory nerve) has a complex anatomy, and it has traditionally been thought that once the sensorineural structures are damaged, restoration of hearing is impossible. In the past decade, however, the potential to restore lost hearing has been intensively investigated using molecular and cell biological techniques, and we can now part with such a pessimistic view. In this review, we examine an important field in hearing restoration research: cell transplantation.

METHODS

Most efforts in this field have been directed to the replacement of hair cells by transplantation to the cochlea. Here, we focus on transplantation to the auditory nerve, from the side of the cerebellopontine angle rather than the cochlea.

RESULTS

Delivery of cells to the cochlea is potentially damaging, and nerve cells transplanted distally to the Schwann-glial transitional zone (cochlear side) may become inhibited when they reach the transitional zone. The auditory nerve is probably the most suitable route for cell transplantation.

CONCLUSION

The auditory nerve occupies an important position not only in neurosurgery but also in various diseases in other disciplines, and several lines of recent evidence indicate that it is a key target for hearing restoration. It is familiar to most neurosurgeons, and the recent advances in the molecular and cell biology of inner-ear development are of direct importance to neurorestorative medicine. In this article, we review the anatomy, development, and molecular biology of the auditory nerve and cochlea, with emphasis on the advances in cell transplantation.

The potential role of endogenous stem cells in regeneration of the inner ear

Stem cells in various mammalian organs retain the capacity to renew themselves and may be able to restore damaged tissue. Their existence has been proven by genetic tracer studies that demonstrate their differentiation into multiple tissue types and by their ability to self-renew through proliferation. Stem cells from the adult nervous system proliferate to form clonal floating colonies called spheres in vitro, and recent studies have demonstrated sphere formation by cells in the cochlea in addition to the vestibular system and the auditory ganglia, indicating that these tissues contain cells with stem cell properties. The presence of stem cells in the inner ear raises the hope of regeneration of mammalian inner ear cells but is difficult to correlate with the lack of spontaneous regeneration seen in the inner ear after tissue damage. Loss of stem cells postnatally in the cochlea may correlate with the loss of regenerative capacity and may limit our ability to stimulate regeneration. Retention of sphere forming ability in adult vestibular tissues suggests that the limited capacity for repair may be attributed to the continued presence of progenitor cells. Future strategies for regeneration must consider the distribution of endogenous stem cells in the inner ear and whether the tissue retains cells with the capacity for regeneration.

Engraftment and differentiation of embryonic stem cell-derived neural progenitor cells in the cochlear nerve trunk: growth of processes into the organ of Corti

Hearing loss in mammals is irreversible because cochlear neurons and hair cells do not regenerate. To determine whether we could replace neurons lost to primary neuronal degeneration, we injected EYFP-expressing embryonic stem cell-derived mouse neural progenitor cells into the cochlear nerve trunk in immunosuppressed animals 1 week after destroying the cochlear nerve (spiral ganglion) cells while leaving hair cells intact by ouabain application to the round window at the base of the cochlea in gerbils. At 3 days post transplantation, small grafts were seen that expressed endogenous EYFP and could be immunolabeled for neuron-specific markers. Twelve days after transplantation, the grafts had neurons that extended processes from the nerve core toward the denervated organ of Corti. By 64-98 days, the grafts had sent out abundant processes that occupied a significant portion of the space formerly occupied by the cochlear nerve. The neurites grew in fasciculating bundles projecting through Rosenthal's canal, the former site of spiral ganglion cells, into the osseous spiral lamina and ultimately into the organ of Corti, where they contacted hair cells. Neuronal counts showed a significant increase in neuronal processes near the sensory epithelium, compared to animals that were denervated without subsequent stem cell transplantation. The regeneration of these neurons shows that neurons differentiated from stem cells have the capacity to grow to a specific target in an animal model of neuronal degeneration.

Reinnervation of hair cells by auditory neurons after selective removal of spiral ganglion neurons

Hearing loss can be caused by primary degeneration of spiral ganglion neurons or by secondary degeneration of these neurons after hair cell loss. The replacement of auditory neurons would be an important step in any attempt to restore auditory function in patients with damaged inner ear neurons or hair cells. Application of beta-bungarotoxin, a toxin derived from snake venom, to an explant of the cochlea eradicates spiral ganglion neurons while sparing the other cochlear cell types. The toxin was found to bind to the neurons and to cause apoptotic cell death without affecting hair cells or other inner ear cell types as indicated by TUNEL staining, and, thus, the toxin provides a highly specific means of deafferentation of hair cells. We therefore used the denervated organ of Corti for the study of neuronal regeneration and synaptogenesis with hair cells and found that spiral ganglion neurons obtained from the cochlea of an untreated newborn mouse reinnervated hair cells in the toxin-treated organ of Corti and expressed synaptic vesicle markers at points of contact with hair cells. These findings suggest that it may be possible to replace degenerated neurons by grafting new cells into the organ of Corti.

Activation of protein kinase CbetaI constitutes a new neurotrophic pathway for deafferented spiral ganglion neurons

In mammals, degeneration of peripheral auditory neurons constitutes one of the main causes of sensorineural hearing loss. Unfortunately, to date, pharmacological interventions aimed at counteracting this condition have not presented complete effectiveness in protecting the integrity of cochlear neural elements. In this context, the protein kinase C (PKC) family of enzymes are important signalling molecules that play a role in preventing neurodegeneration after nervous system injury. The present study demonstrates, for the first time, that the PKC signalling pathway is directly neurotrophic to axotomised spiral ganglion neurons (SGNs). We found that PKCbetaI was strictly expressed by postnatal and adult SGNs both in situ and in vitro. In cultures of SGNs, we observed that activators of PKC, such as phorbol esters and bryostatin 1, induced neuronal survival and neurite regrowth in a manner dependent on the activation of PKCbetaI. The neuroprotective effects of PKC activators were suppressed by pre-treatment with LY294002 (a PI3K inhibitor) and with U0126 (a MEK inhibitor), indicating that PKC activators promote the survival and neurite outgrowth of SGNs by both PI3K/Akt and MEK/ERK-dependent mechanisms. In addition, whereas combining the neurotrophins brain-derived neurotrophic factor (BDNF) and neurotrophin-3 (NT3) was shown to provide only an additive effect on SGN survival, the interaction between PKC and neurotrophin signalling gave rise to a synergistic increase in SGN survival. Taken together, the data indicate that PKCbetaI activation represents a key factor for the protection of the integrity of neural elements in the cochlea.

Expression of bFGF and NGF and their receptors in chick’s auditory organ following overexposure to noise

Growth factors are known to activate signaling cascades for DNA replication; they participate in the regulation of cell differentiation and are required as positive signals for cell survival. Thus, many of them may be regarded as potential candidates stimulating regeneration processes in the inner ear. We analyzed the expression of basic fibroblast growth factor (bFGF) and nerve growth factor (NGF) and their receptor (bFGFR and NGFR)-like immunoreactivity in chick basilar papillae, along with bFGF and NGF mRNA expression. The evaluation was made 1 and 5 days after exposure to wide-band noise with two increasing levels of acoustic energy. For both factors, the immunoreactivity was shown predominantly in the middle part of basilar papilla, in noise-exposed, but not control birds. It was localized in the cytoplasm of hair cells, nuclei of supporting cells and cytoplasm of ganglion cells. Strong immunoreactivity of bFGFR and NGFR was found both in control and noise-exposed animals, with the cell localization similar to that of growth factors. The increase in mRNA expression for bFGF and NGF was found in noise-exposed animals only after lower exposure to noise, on day 5 after exposure (p<0.01). A lack of increased expression after higher exposure could be excused by larger damage of hair cells followed by the increase of mRNA for beta-actin to which the results were referred. The results suggest bFGF and NGF involvement in postinjury regeneration of the basilar papilla.

Differentiation of an auditory neuronal cell line suitable for cell transplantation

The auditory neuroblast cell line US/VOT-N33 (N33), which is conditionally immortal, was studied as an in vitro model for the differentiation of spiral ganglion neurons (SGNs) and as a candidate for cell transplantation in rodents. It expresses numerous molecular markers characteristic of auditory neuroblasts, including the transcription factors GATA3, NeuroD, Brn3a and Islet1, as well as the neuronal cytoskeletal protein beta3-tubulin. It displays active migratory behaviour in vitro and in vivo. In the presence of the fibroblast growth factors FGF1 or FGF2 it differentiates bipolar morphologies similar to those of native SGNs. In coculture with neonatal cochlear tissue it is repelled from epithelial surfaces but not from native SGNs, alongside which it extends parallel neuronal processes. When injected into the retina in vivo, EGFP-labelled N33 cells were traced for 1-2 weeks and migrated rapidly within the subretinal space. Cells that found their way into the retinal ganglion cell layer extended multiple processes but did not express beta3-tubulin. The ability of N33 to migrate, to differentiate, to localize with native SGNs in vitro and to survive in vivo suggests that they provide an effective model for SGN differentiation and for cell transplantation into the ear.

Fibroblast growth factor-2 immunoreactivity is present in the central and peripheral auditory pathways of adult rats

Recent findings have pointed out the role of neurotrophic factors in the survival and maintenance of neurons of the auditory system. Basic fibroblast growth factor (bFGF, FGF-2) is a potent neurotrophic molecule whose actions can be seen in the central and peripheral nervous systems. In the present study, FGF-2 immunoreactivity was analyzed in the auditory pathways of the adult rat, employing a well-characterized polyclonal antibody against FGF-2. In the cochlea, FGF-2 immunoreactivity was observed in the inner and outer hair cells of the organ of Corti, spiral ganglion neurons, spiral limbus, and stria vascularis. Stereological methods employing optical fractionator revealed the presence of 84.5, 15, and 0.5% of spiral ganglion neurons possessing FGF-2 immunoreactivity of strong, moderate, and weak intensity, respectively. In the central auditory pathways, FGF-2 immunoreactivity was found in the cytoplasm of the neurons of the cochlear nuclei, trapezoid body nuclei, medial geniculate nucleus, and inferior colliculus. The two-color immunoperoxidase method showed FGF-2 immunoreactivity in the nuclei of astrocytes throughout the central auditory pathway. Computer-assisted microdensitometric image analysis revealed higher levels of specific mean gray values of FGF-2 immunoreactivity in the trapezoid body and ventral cochlear nucleus and also in the spiral ganglion and inner hair cells. Sections incubated with FGF-2 antibody preabsorbed with human recombinant FGF-2 showed no immunoreaction in the majority of the studied regions, exhibiting only a slight immunoreactive product in the hair cells of the organ of Corti. Furthermore, no changes in immunoreactivity were observed in sections incubated with FGF-2 antiserum preincubated with human recombinant acidic FGF (FGF-1). The findings suggest that FGF-2 may exert paracrine and autocrine actions on neurons of the central and peripheral auditory systems and may be of importance in the mechanism of hearing diseases.