Different Materials for Plugging a Dehiscent Superior Semicircular Canal: A Comparative Histologic Study Using a Gerbil Model.

HYPOTHESIS: The choice of the material for plugging a dehiscence of the superior semicircular canal is based on the ease of use and the success of the procedure to permanently relieve symptoms without adverse side effects. BACKGROUND: Dehiscence of the superior semicircular canal can lead to autophony, conductive hearing loss, and vertigo. Surgical treatment by plugging the canal is a highly effective treatment of the symptoms in many patients, although, the procedure can be associated with some degree of hearing loss in more than or equal to 25% of the patients. The available data indicate that adverse effects may be more frequently observed with bone wax as compared with other materials. METHODS: In the present study we compare the tissue reactions induced by plugging the superior semicircular canal with autologous bone pate/bone chips, muscle, fat, artificial bone wax, and teflon in the gerbil model in an attempt to identify the material leading to successful plugging with the least adverse tissue reactions. RESULTS: Our data show that successful plugging was achieved in 100% of the ears by bone pate/bone chips, teflon, and bone wax while the success rate was significantly lower (<50%) following muscle and fat. The proportion of adverse tissue reactions was significantly more pronounced using bone wax as compared with teflon and bone pate/bone chips. CONCLUSION: The use of teflon or autologous bone as a material for plugging a dehiscent superior semicircular canal should be favored over bone wax, muscle, and fat.

Leukocyte Adhesion as an Indicator of Oxygenator Thrombosis During Extracorporeal Membrane Oxygenation Therapy?

Thrombosis is the most common technical complication with extracorporeal membrane oxygenation (ECMO). Accumulations of leukocytes on the gas exchange membranes within a membrane oxygenator (MO) may initiate thrombosis and influence outcome. MOs (n = 41) were removed routinely from adult patients on ECMO, preserved, and analyzed for their cellular deposits using nuclear (4',6-diamidino-2-phenylindole) and cell type-specific markers (CD45; von Willebrand factor, vWF). The extent of cellular colonization was correlated with patient data. Blood contact caused adhesion of leukocytes and accumulation of vWF. Six MOs contained "pseudomembranes" (PM). MOs with PM were from younger patients (median [interquartile range {IQR}]; age, 36 [30-47] vs. 61 [51-71] years; p = 0.040) and the leukocyte count before ECMO was on average higher (21 [16-24] vs. 15 [8-18] ×10 per L; p = 0.051) compared with PM-free MOs. The development of PMs did not influence pressure drop across the MO. Data indicating coagulation disorder within the MOs (d-dimers, fibrinogen, and platelets) were not significantly different between the groups. There was only one acute MO thrombosis in a PM-free MO. The support time of the analyzed MOs with PM tended to be longer when compared with PM-free MOs (11 [6-19] vs. 8 [5-11] days). Nevertheless, all patients with MOs with PMs were successfully weaned (6/6 vs. 17/35) and discharged from hospital (6/6 vs. 17/35; p = 0.027) compared with patients with PM-free MOs. In conclusion, elderly people on ECMO showed reduced PM formation that may reduce the risk of MO thrombosis. Younger patients had no negative effect.

How to Avoid a Learning Curve in Stapedotomy: A Standardized Surgical Technique.

OBJECTIVE: To evaluate, whether a learning curve for beginners in stapedotomy can be avoided by using a prosthesis with thermal memory-shape attachment in combination with a standardized laser-assisted surgical technique. STUDY DESIGN: Retrospective case review. SETTING: Tertiary referral center. PATIENTS: Fifty-eight ears were operated by three experienced surgeons and compared with a group of 12 cases operated by a beginner in stapedotomy. INTERVENTION: Stapedotomy. MAIN OUTCOME MEASURES: Difference of pure-tone audiometry thresholds measured before and after surgery. RESULTS: The average postoperative gain for air conduction in the frequencies below 2 kHz was 20 to 25 dB and decreased for the higher frequencies. Using the Mann-Whitney-U test for comparing mean gain between experienced and inexperienced surgeons showed no significant difference (p = 0.281 at 4 kHz and p > 0.7 for the other frequencies). A Spearman rank correlation of the postoperative gain for air- and bone-conduction thresholds was obtained at each test frequency for the first 12 patients consecutively treated with a thermal memory-shape attachment prosthesis by two experienced and one inexperienced surgeon. This analysis does not support the hypothesis of a "learning effect" that should be associated with an improved outcome for successively treated patients. CONCLUSION: It is possible to avoid a learning curve in stapes surgery by applying a thermal memory-shape prosthesis in a standardized laser-assisted surgical procedure.

Behavioral auditory thresholds and loss of ribbon synapses at inner hair cells in aged gerbils.

The potential contribution of auditory synaptopathy to age dependent hearing loss was studied in groups of young and old gerbils. The analysis of the number of inner hair cell ribbon synapses in aged gerbils (37.9±3.3months of age) revealed only a relatively small (11-17%) loss in the basal two thirds of the cochlea, while a more pronounced reduction was identified towards the apex (almost 40%) when compared to a group of young gerbils (9.5±3.2months of age). Mean threshold elevation in the old gerbils was around 25dB at 2 and 10kHz. Frequency-specific behavioral thresholds and ribbon synapse counts were not significantly correlated for the middle and basal regions of the cochlea, despite thresholds varying over a 45dB SPL range. This suggests that besides a small age-dependent loss of ribbon synapses, additional cochlear pathologies, most likely a decreased endocochlear potential, contribute to peripheral hearing loss in old gerbils.

Comparing the inferior colliculus of young and old gerbils (Meriones unguiculatus) with an emphasis on GABA.

Indicators of an age-dependent down-regulation of GABA (gamma amino butyric acid) have been well-documented in the inferior colliculus (IC) of several rat strains. In the present study, we performed a quantitative light microscopic analysis of GABA-immunostained IC sections to characterize the effect of age on the cross-sectional area of the IC, the number and density of GABAergic cells and the expression of GABA in gerbils. Compared to young gerbils, a significant shrinkage of the IC but no loss of GABAergic cells was found resulting in an increased density of GABAergic cells in old gerbils. The expression of GABA in neurons and the neuropil of the IC did not differ between young and old gerbils. The results in the gerbil differ considerably from age-dependent changes described for the rat IC, showing clear species-specific differences.

The effect of gabapentin on gap detection and forward masking in young and old gerbils.

OBJECTIVES: Auditory temporal processing frequently appears more affected in old subjects than would be predicted by the degree of peripheral hearing loss, pointing to an age-dependent central processing deficit. In parallel, an age-dependent decline of inhibitory function has been demonstrated in the auditory pathway, suggesting a causal relationship between temporal processing and inhibition. Gabapentin has been specifically synthesized as a potential gamma-amino-butyric-acid (GABA) mimetic with the capability to cross the blood-brain barrier. Gabapentin treatment ameliorated tinnitus in a rat model and improved tinnitus annoyance in humans with acoustic trauma. Consequently, the present study evaluated the effect of gabapentin on auditory temporal processing in the gerbil model. DESIGN: Psychometric functions were collected for different test paradigms. (A) "Gap detection": The detection of a gap in the middle of a 800 msec broadband noise pulse was determined either at 15 or at 30 dB SL. (B) "Forward masking": The detection of a 20 msec probe stimulus following 2.5 msec after a 400 msec 40 dB SPL masker was determined with masker and probe frequency at 2.85 kHz. The effect of gabapentin was evaluated by collecting gap detection and forward masking functions before, during, and after treating gerbils with gabapentin doses of 115 or 350 mg/kg/day administered via drinking water. Data under different experimental conditions were collected for groups of 3 to 5 young (<2 years) and 6 to 10 old (>2 years) gerbils. Two-way analyses of variance for the factors age groups and treatment groups with subsequent pairwise comparisons for significant effects were used for the statistical evaluation of the data. RESULTS: For gap detection, mean thresholds were significantly increased in the group of old as compared with the young gerbils at 30 dB SL (young 2.0 msec; old 3.2 msec) and at 15 dB SL (young 2.9 msec; old 9.1 msec). Gabapentin had no significant effect on gap detection, and there was no significant interaction between age group and gabapentin treatment. Mean thresholds in the forward masking paradigm were significantly elevated in old (45.5 dB SPL) as compared with young (35.0 dB SPL) gerbils. Overall, gabapentin had no significant effect on masked thresholds; however, there was a significant interaction between treatment and age. Subsequent pairwise comparisons revealed no significant effect on masked thresholds in old gerbils but showed significantly elevated thresholds of young gerbils during 350 mg/kg gabapentin (38.3 dB SPL) compared with thresholds obtained in young gerbils before (32.3 dB SPL) and after (33.5 dB SPL) treatment. CONCLUSIONS: Gabapentin did not exert a therapeutic effect on impaired gap detection and forward masking in old gerbils. The lack of an effect of gabapentin on impaired auditory temporal processing in old gerbils and the finding of elevated masked thresholds in young gerbils can be reconciled with reports of only moderate GABAergic effects compared with other drugs (e.g., comparing elevation of GABA levels in the brain by gabapentin and vigabatrin) and effects due to binding of gabapentin to alpha-2-delta units of voltage-gated calcium channels.

Localization of gentamicin uptake in the acutely isolated inner ear of the rat.

The quantitative analysis of fluorescence in frozen sections of rat inner ears exposed to Texas Red conjugated gentamicin revealed distinct gradients of gentamicin fluorescence. At 500 µg/ml gentamicin fluorescence occurred in inner and outer hair cells, the interdental cell region, the spiral limbus below the interdental cells, the nerve fiber bundle in the spiral lamina, the inner sulcus cells and the dorsal region of the spiral ligament. No gentamicin fluorescence was observed in the Hensen / Claudius cells, the ventral region of the spiral ligament, the stria vascularis and the spiral ganglion. In the vestibule only the hair cell epithelium and the transitional cells of the saccule showed gentamicin fluorescence while no gentamicin fluorescence was found in hair cell epithelia and transitional cells of utricle and ampule, nerve fibers below hair cell epithelia of saccule, utricle and ampule and in dark cells. The gentamicin flurescence increased at higher concentrations. Gentamicin exposure led to more pronounced gentamicin fluorescence in the cochlea compared to the vestibule. Based on the predominant gentamicin fluorescence in the hair cell - limbus region of the cochlea at a low dose we propose that gentamicin may interact with the K(+)-flow from the inner hair cells back to the scala media.

A micro-computed tomographic study: determination of the angle between the tympanic membrane and stapes footplate in a total ossicular reconstruction prosthesis reconstruction.

OBJECTIVES: To examine the anatomical relationship of the angles between tympanic membrane and stapes footplate and the variation of these angles among different temporal bones in order to characterize the optimal shape of total ossicular reconstruction prostheses (TORPs). METHODS: Ten specimens of human temporal bones were prepared for examination with micro-computed tomography. Five of the 10 temporal bones were implanted with 3 types of TORPs before subjecting them to micro-computed tomography. The angles between tympanic membrane and stapes footplate were determined. The contact of the TORPs to these structures was assessed. RESULTS: The angle between the stapes footplate and the tympanic membrane was, on average, 25.9 degrees in a plane along the transverse axis of the stapes footplate and 24.6 degrees in a plane along the longitudinal axis of the stapes footplate. Consideration of these angles in TORPs resulted in an optimal contact with the tympanic membrane and stapes footplate, especially for prostheses with a large foot. CONCLUSION: TORPs should be adjusted in shape before insertion into the middle ear. Further developments should consider prostheses with preadjusted angles or appliances for the exact modification of the prostheses during surgery.

Influence of Surface Processing on the Biocompatibility of Titanium.

Surface conditioning of titanium middle ear implants results in an improved biocompatibility, which can be characterized by the properties of fibroblasts cultured on conditioned surfaces. Titanium has been established as a favorable biomaterial in ossicular chain reconstruction. The epithelization of the surface of the implants is important for their integration and stable positioning in the middle ear. Mouse fibroblast cells were cultured on platelets made from pure Grade 2 titanium. Platelets that had been etched along their production process were compared to unetched platelets. The DNA in the cell nuclei was stained with DAPI and the actin filaments of the cytoskeleton were stained with FITC-conjugated phalloidin in order to analyze the cells grown on etched and unetched platelets by fluorescence microscopy. SEM (scanning electron microscopic) images were used to compare the surface structure of etched and unetched titanium platelets. There was a statistically significant increase of the area covered by the cytoplasm and increased actin expression by fibroblasts grown on the etched titanium platelets. In addition, the area of the platelets covered by nuclei on the etched platelets exceeded on average the one on unetched platelets, although this difference was not significant. The SEM pictures comparing unetched and etched titanium platelets showed a clear difference in surface structure. Surface conditioning of titanium implants improved the epithelization by fibroblasts and consequently etched titanium should be the preferred biomaterial for reconstructive middle ear surgery.

Electrophysiological and morphological development of the inner ear in Belgian Waterslager canaries.

Belgian Waterslager (BW) canaries have an inherited hearing loss due to missing and abnormal hair cells, but it is unclear whether the loss is congenital or developmental. We used auditory brainstem responses and scanning electron microscopy to describe the development of auditory sensitivity and hair cell abnormalities in BW and non-BW canaries. In both strains, adult ABR thresholds were higher than behavioral thresholds, but BW canaries exhibited higher thresholds than non-BW canaries across all frequencies. Immediately post-hatch, ABR thresholds and hair cell numbers were similar in both strains. Two weeks later, thresholds were significantly higher in BW canaries, and hair cell number progressively decreased as the birds aged. These data show that in BW canaries: the peripheral auditory system is functionally similar to non-BW canary from hatch to 2 weeks, ABR thresholds improve during this developmental period, actually becoming better than those of adults, but then worsen as the bird continues to age. Hair cell number and appearance is similar to non-BW canaries at hatch but progressively declines after 30 days of age. These data show that the hearing loss characteristic of BW canaries is, at least in part, developmental and is established by the time song learning begins.

Prognostic importance of "clear versus revised margins" in oral and pharyngeal cancer.

BACKGROUND: Opinions differ regarding the usefulness of accurate, but costly, frozen sections. Most physicians believe that negative margins are essential for the prognosis of patients with oral and pharyngeal cancer. We examined whether immediate repeated resections in patients with positive margins, based on findings from frozen sections, resulted in improved patient survival. METHODS: Data from 417 patients identified with cancer of the pharynx and floor of the mouth were analyzed retrospectively. RESULTS: The 5-year survival rate for R0 and R1-R0 groups was 72% to 76% and was significantly better (p ≤ .034) than that for R1 and R2 groups (58%, 40%). Despite clear margins, large tumors had a poorer prognosis than that of small tumors. CONCLUSIONS: Patients receiving repeated resection had the same survival rate as patients who had the tumor resected immediately with negative margins. The use of frozen sections yields a benefit for 15.6% of the operated patients and increases the overall 5-year survival rate by 2% to 3%.

Impact of normothermic perfusion and protein supplementation on human endothelial cell function during organ preservation.

BACKGROUND: Hypothermia-induced changes in endothelial cell (EC) morphology and function after organ storage may influence the initial outcome and development of transplant-associated coronary artery disease. METHODS: Human saphenous vein ECs were incubated with saline (NaCl), University of Wisconsin (UW), and histidine-tryptophan-ketoglutarate (HTK) solution, with and without protein additives, at 4 degrees C and 37 degrees C. After 6 hours, ECs were recultivated for 24 and 48 hours with culture medium (reperfusion). Mitochondrial activity, adenosine triphosphate concentration, cell count, and inflammatory responses were analyzed. RESULTS: Cold preservation did not affect the mitochondrial activity of ECs and allowed a complete regeneration of the metabolic turnover after reperfusion. However, under normothermic conditions the metabolism of the cells was influenced by time and type of preservation solution. While both the mitochondrial activity and cell count did not change after treatment with NaCl and culture medium, the metabolic turnover of cells treated with HTK and UW solution significantly increased (twofold) and decreased (twofold, p < 0.05), respectively, after reperfusion. The endothelial reactivity remained unchanged after treatment with NaCl and HTK. The addition of serum proteins significantly improved mitochondrial activity of cells treated with warm NaCl and HTK (p < 0.05). The UW-treated cells burned out through a significant up-regulation of the ATP concentration resulting in a complete metabolic regression after reperfusion and induction of apoptosis. CONCLUSIONS: Normothermic preservation in UW prevented regeneration of ECs, while treatment with HKT solution did not irreversibly affect mitochondrial activity of ECs and allowed complete regeneration of metabolism and function. Serum proteins improved the preservation effect of HTK and NaCl.

Efficiency in extracorporeal membrane oxygenation-cellular deposits on polymethylpentene membranes increase resistance to blood flow and reduce gas exchange capacity.

Bioline-coated polymethylpentene (PMP) membrane oxygenators (MO) are used for extracorporeal membrane oxygenation (ECMO) to improve gas exchange in patients with severe acute respiratory distress syndrome (ARDS). However, in some patients, long-term durability is limited due to fibrous and cellular accumulations on the gas exchange surface which can increase resistance to blood flow and diffusion path. These surface deposits of PMP MO after removal were studied with scanning electron and fluorescence microscopy techniques. Three of 31 patients supported by a PMP MO in an ECMO setting required a replacement of the oxygenator after a mean support interval of 11 +/- 7 days due to an increase in flow resistance and an impairment of the gas exchange capacity. The membrane surface of the MO was covered with a fibrous network with imbedded platelets and red blood cells. A membranous structure composed of single cells and clusters of cells covered large areas of the PMP fibers. We assume that these cellular deposits lower the efficacy of ECMO. The identification of these cells could be a key for future therapeutic interventions and improvements in the development of MO.

Protein expression of pigment-epithelium-derived factor in rat cochlea.

Pigment-epithelium-derived factor (PEDF) is a 50-kDa glycoprotein with well-recognised expression in various mammalian organs showing diverse (e.g. anti-angiogenic and neuroprotective) activities. However, at present, no information is available regarding the potential function of this cytokine in the inner ear. As a first approach to investigating whether PEDF is involved in cochlear function, we have explored its protein expression in the rat cochlea by immunocytochemistry. Our results show that PEDF expression in the cochlea is most prominent in the basilar membrane below the organ of Corti, in the lateral wall (especially in the stria vascularis), in ganglion neurons, and in the endothelia of blood vessels. Our findings on its distribution in the cochlea suggest that PEDF in the basilar membrane prevents blood vessel formation that would disturb cochlear micromechanics and would interfere with the mechano-electrical transduction in the organ of Corti. In cochlear ganglion neurons, PEDF might serve a neuroprotective function possibly protecting these neurons from excessive glutamate released by the inner hair cells. Our data constitute the first report on the morphological protein distribution of this multifunctional molecule in the rat cochlea and suggest its role in important functions of the internal ear.

Evoked cochlear potentials in the barn owl.

Gross electrical responses to tone bursts were measured in adult barn owls, using a single-ended wire electrode placed onto the round window. Cochlear microphonic (CM) and compound action potential (CAP) responses were evaluated separately. Both potentials were physiologically vulnerable. Selective abolishment of neural responses at high frequencies confirmed that the CAP was of neural origin, while the CM remained unaffected. CAP latencies decreased with increasing stimulus frequency and CAP amplitudes were correlated with known variations in afferent fibre numbers from the different papillar regions. This suggests a local origin of the CAP along the tonotopic gradient within the basilar papilla. The audiograms derived from CAP and CM threshold responses both showed a broad frequency region of optimal sensitivity, very similar to behavioural and single-unit data, but shifted upward in absolute sensitivity. CAP thresholds rose above 8 kHz, while CM responses showed unchanged sensitivity up to 10 kHz.

Temporal integration in the gerbil: the effects of age, hearing loss and temporally unmodulated and modulated speech-like masker noises.

We characterized temporal integration for 2k Hz pure tones with durations between 10 and 1000 ms in young, normal hearing old and old gerbils with a small hearing loss. Thresholds determined in silence increased for durations below 300 ms and were on average more than 10 dB higher for the 10 ms signal than asymptotic thresholds for the long signals. The amount of temporal integration tended to be less in gerbils with hearing loss. Threshold determination was repeated in the same individuals in the presence of speech-like unmodulated and modulated masking noises. Threshold shift due to the maskers was inversely related to the threshold in silence resulting in a reduced inter-individual variability of thresholds in both masking conditions. Thresholds differed systematically between both masker types in a duration dependent fashion. For long signal durations (300 and 1000 ms) thresholds were on average 2dB lower and for the 10 ms signal 1.9 dB higher in the presence of the modulated masker. These differences in threshold obtained with the two maskers were significant. One hypothesis is that long signals can be detected in the troughs of the modulated masker, while peaks interfere with the detection of short signals.

Forward masking in gerbils: the effect of age.

We investigated forward masking in 21 gerbils as a function of age (5-47 months) using 400ms maskers at 40dB SPL and a 20ms, 2.85kHz probe presented 2.5ms after the masker. Elevated thresholds for the unmasked probe were only observed in animals older than 3 years. Unmasked thresholds showed no significant age-dependent hearing loss in animals below 3 years of age. In these animals without peripheral hearing loss, we found a significant age-dependent increase of masker-induced threshold shift. A regression analysis revealed that threshold shift increased from 23dB in 1 year old gerbils to 37dB in 3 year old animals. Increased forward masking in these animals with no sign of peripheral hearing loss points to a central processing deficit.

A quantitative analysis of psychometric functions for different auditory tasks in gerbils.

The psychometric function relates the probability of a correct response to the variation of a physical stimulus parameter. In many perceptual tasks one point on this function is defined by a more or less arbitrary threshold criterion and threshold is used to study the effects of various treatments or age. Besides threshold, the shape of the psychometric function provides additional information. The variability of internal (neural) noise and the sensorineural transduction function will affect the shape of the psychometric function and may, therefore, reveal important features in the processing of stimulus characteristics. Here we analyze the effect of age on psychometric functions from gerbils: (A) for the detection of a tone or noise pulse in silence which is generally regarded as a measure of cochlear function and (B) for a gap detection task, investigating aspects of temporal processing that involve the ascending auditory pathway. Our data show that the slope of the psychometric function for the detection of tone and noise pulses in silence is independent of age and threshold. In contrast, the steepness of the psychometric function is decreased in gerbils with impaired temporal resolution. We discuss these observations in the context of physiological data from young and old animals.

Evaluation of vascular endothelial growth factor addition in vitro on mouse inner ear progenitor cell cultures.

We analyzed progenitor cell cultures of inner ear tissue from newborn mice, and found proliferating cells, morphologically differentiating cells and subpopulations of cells expressing either neuronal or glial markers. In addition, we observed the expression of fetal liver kinase-1, a receptor for the vascular endothelial growth factor in a subpopulation of the cultured cells. Consistent with the expression of fetal liver kinase-1, addition of vascular endothelial growth factor at a dose of 10 ng/ml increased the expansion rate of inner ear-derived progenitor cells. Together with other published data, these results suggest that the vascular endothelial growth factor might be involved in inducing or supporting cochlear repair processes.

Stapes surgery: the diameter of the long process of the incus.

HYPOTHESIS: The aim of this study was to examine the long process of the incus in respect of its shape and its dimensions at the site of the attachment of a stapes prosthesis. BACKGROUND: One of the complications in stapes surgery is the erosion of the long process of the incus at the site of the attachment of the prosthesis, resulting in a fluctuating conductive hearing loss. Knowing the dimensions of the attachment site of the prosthesis at the long process of the incus will make it possible to optimize the size of the prosthesis loop. METHODS: The incus was obtained from 11 patients who had undergone middle ear surgery for hearing improvement or cholesteatoma removal. The ossicles were kept in 4% paraformaldehyde and were processed for histological examination after decalcification in ethylenediamine tetra-acetic acid. The 5-microm slices were stained with toluidine blue and examined in the light microscope. Using digitized video images of the histological slices, the diameters, circumference, and surface of the specimens were determined. RESULTS: The diameter of the long process of the incus at 1.4+/-0.28 mm from the tip, which is the average site of prosthesis attachment, showed an oval shape with a minimum diameter of 0.66+/-0.05 mm, a maximum diameter of 0.81+/-0.1 mm, and a circumference of 2.46+/-0.23 mm. CONCLUSION: The loop of a stapes prosthesis should have the following dimensions: diameter 0.9 mm, loop length of 2.2 mm, and opening of loop 0.7 mm. However, the material of the prosthesis and its malleability are also important factors.