Cochlear implantation trauma and noise ... - Wiley Online Library

THE ANATOMICAL RECORD PART A 288A:473– 481 (2006)

Cochlear Implantation Trauma and Noise-Induced Hearing Loss: Apoptosis and Therapeutic Strategies ADRIEN A. ESHRAGHI AND THOMAS R. VAN DE WATER* University of Miami Ear Institute, Department of Otolaryngology, University of Miami, Miller School of Medicine, Miami, Florida

ABSTRACT Cochlear implantation trauma and noise-induced hearing loss both involve a physical disruption of the organ of Corti and may involve several mechanisms of cell death at the molecular level, i.e., necrosis, necrosis-like programmed cell death (PCD; type 2 PCD), and apoptosis (type 1 PCD). This article reviews several promising therapeutic strategies that are currently being developed. One of these promising new strategies involves the use of a highly effective peptide inhibitor of the c-Jun N-terminal kinase cell death signal cascade (i.e., D-JNKI-1) to prevent apoptosis of injured auditory hair cells. Our recent studies showed prevention of cochlear implantation-induced hearing loss by infusing this peptide into the cochlea of guinea pigs. Another otoprotective therapy under investigation is the application of mild hypothermia to protect the cochlea from the development of a hearing loss that follows exposure to a physical trauma, e.g., electrode array insertional trauma. These forward-looking strategies have the potential of improving hearing outcomes after cochlear implantation and providing novel means of otoprotection from noise-induced trauma. Anat Rec Part 288A:473– 481, 2006. © 2006 Wiley-Liss, Inc.

Key words: cochlear implant; electrode insertion trauma; sound trauma; hearing loss; cell death signal cascades; otoprotection; apoptosis; necrosis

Trauma to the inner ear can result in death of sensory cells within the cochlea if a damage threshold is exceeded. Outer hair cells (OHCs) are usually the first to be damaged during physical trauma, followed by the inner hair cells (IHCs) and lastly the supporting cells of the organ of Corti. Several mechanisms of cell death are thought to be involved: necrosis, necrosis-like programmed cell death (PCD; type 2 PCD), and apoptosis (type 1 PCD). In this article, we present the role of cell death signal cascades in two common types of physical trauma to the cochlea, i.e., electrode insertion trauma- and noise trauma-induced hearing losses. We also discuss some innovative therapeutic strategies applicable to the protection of hearing from trauma-initiated forms of hearing loss.

Apoptosis Apoptosis appears to play a critical role in the pathogenesis of hearing loss that develops following physical trauma to the cochlea, i.e., sound trauma or electrode insertion trauma. Apoptosis is associated with an active cell death process and can be identified by distinct mor©

2006 WILEY-LISS, INC.

phologic features such as nuclear condensation and fragmentation of nuclear DNA within the affected cell, whereas necrosis is a passive consequence of an overwhelming injury to a cell and is marked by nuclear swelling and lyses of the affected cell. Necrosis-like PCD has some of the features of apoptosis, but usually does not involve the activation of procaspase molecules (Hertz et al., 2005). While acute hearing loss posttrauma can in-

Grant sponsor: MED-EL, Medical Electronics GmbH, Innsbruck, Austria. *Correspondence to: Thomas R. Van De Water, Cochlear Implant Research Program, University of Miami Ear Institute, 1600 N.W. 10th Avenue, RMSB 3160, Miami, FL 33136. Fax: 305-2435552. E-mail: [email protected] Received 29 December 2005; Accepted 29 December 2005 DOI 10.1002/ar.a.20305 Published online 20 March 2006 in Wiley InterScience (www.interscience.wiley.com).

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Fig. 1. A cartoon depicting the potential role that the different activated caspases can play in the apoptosis of a hair cell that has been traumatized by a physical injury such as sound trauma or electrode insertion trauma.

volve necrosis, necrosis-like PCD, and apoptosis, the progressive hearing loss that develops following an initial insult to the cochlea appears to be due predominantly to apoptosis of damaged hair cells. Apoptosis is an active biochemical process that is controlled by the damaged cell once a threshold of damage has been exceeded and it is meant to protect the overall health and survival capability of the whole organism by the elimination of pathological and potentially dangerous cells. Not all the cell death signaling pathways that direct damaged sensory cells to undergo apoptosis within a traumatized cochlea are precisely known, and they are currently under active investigation (Hu et al., 2000, 2002a, 2002b, 2006; Nicotera et al., 2003; Van De Water et al., 2004; Wang et al., 2004; Yang et al., 2004). Apoptosis is controlled by the expression of several genes and proteins, which include members of the Bcl-2 family of pro- and antiapoptotic proteins, some of the members of the family of caspase proteases, and cytochrome c (Herz et al., 2005; Kim et al., 2005). Caspases are a family of aspartate-specific cysteine proteases, which exist as latent intracellular zymogens (Van De Water et

al., 2004). More than 14 caspases have been identified and are divided into two groups: upstream initiator caspases (caspases 2, 8, 9, and 10) and downstream effector caspases (caspases 3, 5, 6, and 7). Effector caspases, once activated, selectively cleave distinct intracellular substrates that lead to the dismantling of a cell’s architecture, DNA, signaling apparatus, and restorative repair mechanisms. The sequence of caspase activation shows that distinct cascades are activated depending on the specific pathology, conditions employed, and the cell type. At present, caspases 8, 9, and 3 are known to be involved in the apoptosis of physically damaged hair cells (Nicotera et al., 2003) and caspases 5 and 6 by the results of an inhibitor study are suggested to participate (Do et al., 2004), while caspases 7 and 10 are thought to be involved but not yet proven to participate in the process of apoptosis of physical trauma-damaged hair cells (Fig. 1) (Van De Water et al., 2004). The underlying events include loss of mitochondrial transmembrane potential, release of cytochrome c from the damaged mitochondria into the cytoplasm, formation of an apotosome, sequential activation of activator and then effector pro-

APOPTOSIS AND THERAPEUTIC STRATEGIES

Fig. 2. The MAPK/JNK signaling pathway and the site of action of pharmacological inhibitors. A typical MAPK pathway highlights the similarity in organization shared by these pathways, where a stimulus interacts with a receptor and leads to the activation of small G-proteins (e.g., H-Ras) and GTPases (e.g., Cdc-42). G-proteins can be inhibited with Ftases (e.g., B-581) and G-proteins with GTPase inhibitors such as the ␤-toxin derived from Clostridium difficile. The protein kinase cascade that is subsequently activated is composed of up to four tiers of kinase molecules, culminating in activation of a specific MAPK (JNK molecule). In the specific example of the mammalian MAPK/JNK pathway, diversity in signaling is seen with multiple different kinases at the various levels of the pathway. JNKs are the products of three different genes, yielding the protein products JNK-1, JNK-2, and JNK-3. These protein kinases phosphorylate a variety of target proteins, including nuclear substrates and mitochondrial substrates, and substrates at other locations within the damaged cell. Two small molecule pharmacological inhibitors of this pathway are as follows: CEP-1347 inhibits the signal cascade at the level of MLK3 (i.e., MAPKK), and D-JNKI-1 and SP 600125 directly inhibit the signal cascade at the level of the JNKs. The action of the c-Jun, a downstream target of activated JNKs, can be partially blocked by using an antisense oligonucleotide (i.e., c-jun AS) to block the amplification and therefore the downstream effects of this transcription factor.

caspases, and a subsequent increase in lipid peroxidation of cellular membranes. The apoptosis-suppressor gene products of Bcl-2 and Bcl-xL play important protective functions in preventing the release of cytochrome c into the cytosol of an injured cell, thereby preventing the activation of procaspase 9, which would in turn activate procaspase 3, or other effector caspases (e.g., procaspase 6). The precise molecular mechanism leading to the induction of the cell death in the cochlea is not yet entirely clear; one signal cascade includes activation of c-jun N-terminal kinase (JNK), also known as stress-activated protein kinase (SAPK) of the mitogen-activated protein kinase (MAPK) pathway (Pirvola et al., 2000). Figure 2 shows the MAPK/ JNK cell death signal cascade and the site of action of many pharmacologic inhibitors that have been demonstrated either to block or partially to block different points within this signaling pathway and Figure 3 shows the mechanism of action by which D-JNKI-1 blocks the actions of JNK, with c-Jun being used as the example of a major downstream target (Zine and Van De Water, 2004). An example of the ability of the D-JNKI-1 peptide molecule to prevent the apoptosis of auditory hair cells is seen in Figure 4, where organ of Corti explants were exposed to an ototoxic level of neomycin and if these explants were

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not treated with D-JNKI-1, there was extensive loss of hair cells via apoptosis (Wang et al., 2003). The mode of action of the D-JNKI-1 inhibitor peptide in preventing hair cell loss is partially understood because phosphorylation of c-Jun by JNK within hair cell nuclei was prevented in the inhibitor-treated cultures but occurred in the neomycin-exposed untreated explants (Fig. 5). In addition, the treatment of the neomycin-exposed explants with D-JNKI-1 suppressed the expression of c-fos transcripts (Fig. 4), which is due to the blocking of the action of JNK on activation of a downstream target, i.e., Elk-1 (Fig. 2). Another signal cascade may involve the focal adhesion kinase pathway, which is known to disrupt the extracellular matrix below the outer hair cells by modulating the binding of actin to integrins following acoustic trauma. Information regarding the activation of downstream caspase 3 and its relationships to JNK activation is not yet fully understood. An understanding of these events is essential for understanding the mechanisms that govern cell death and cell survival during and following traumatic injury to the cochlea.

COCHLEAR IMPLANT INSERTION TRAUMA Histological evaluation of the cochlea after insertion of a cochlear implant electrode into the scala tympani of temporal bones obtained from cadavers has demonstrated in multiple studies that there can be immediate damage to different structures of the cochlea such as the basilar membrane, spiral ligament, and osseous spiral lamina (Fayad et al., 1991; Welling et al., 1993; Nadol et al., 2001; Eshraghi et al., 2003). In a previous cryohistological study of human temporal bones, we analyzed both electrode position and overt structural damage to the cochlea and based on these observations have formulated a numerical scale of values ranging from 0 to 4 to rate the extent and severity of initial macroscopic trauma to the cochlea by the insertion of full-size electrode arrays that in an implanted patient would act to stimulate directly the auditory neurons present in Rosenthal’s canal (Fayad et al., 1991). We used this trauma scale (Table 1) to demonstrate that the severity of direct trauma to cochlear structures can be lessened by the design and use of less traumatic electrodes and by modification of the surgical technique used for the insertion of the electrode array (Balkany et al., 2002; Eshraghi et al., 2004). However, using objective electrophysiological testing of the hearing threshold (auditory brainstem response (ABR) and distortion products of otoacoustic emissions (DPOAE)) in a rat model of cochlear implant electrode trauma, we have demonstrated that despite a very soft technique of electrode insertion and a grade 0 of macroscopic trauma to the cochlear duct, we still observed the development of a progressive loss of hearing for up to 1 week after the initial physical trauma caused by electrode insertion. These observations lead us to postulate that the insertion of a cochlear implant electrode array causes tissue trauma on a molecular level that cannot be rated on our scale of direct physical trauma, which can kill auditory hair cells via either necrosis, necrosis-like PCD, apoptosis, or any combination of these mechanisms of cell death. Do et al. (2004) discussed in their mouse model of implantation trauma that a hydraulic trauma induced by the insertion of an electrode and postoperative inflammation represent alternative pathways of damage to the cochlea that can result in the development of a hearing loss. The results in their study

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Fig. 3. A cartoon depicting the composition of the D-JNKI-1 peptide (a 10 aa section of the TAT molecule combined with a 20 aa sequence of the binding domain for the JNK molecules from the c-Jun interactive protein one, JIP-1, cytoplasm scaffold protein) (Bonny et al., 2001) and the action of JNK on the activation of c-Jun and the mechanism by which D-JNKI-1 peptide blocks the action of JNK on this downstream target.

demonstrate that discrete changes in the volume of cochlear perilymph result in repeatable hearing losses and that the use of cell death inhibitors (e.g., pancaspase inhibitor-zVAD-FMK and specific inhibitors to caspase 3, 5, and 6) significantly protected the hearing from a loss of threshold in response to hydraulic trauma from injection of a bolus of artificial perilymph that was equal to 30% of the original perilymph volume (Do et al., 2004). In a recent study, we have characterized the pattern of hearing loss that occurs in the guinea pig following electrode insertion trauma with the same objective measurements of hearing that was used in our rat model (i.e., DPOAEs and ABRs) of electrode insertion trauma-induced hearing loss (Eshraghi et al., 2005a). In this model, we performed a cochleostomy to insert the electrode into the cochlea, while in the rat model, we used a round window membrane route for electrode insertion. We have confirmed with this new electrode insertion trauma model in the guinea pig that immediately following insertion trauma, there is an acute loss of hearing (approximately 20 dB SPL), followed by a progressive loss of hearing of the same amount that developed over 7 days after electrode insertion trauma in our rat model of cochlear implantation trauma. In the operated cochlea, we observed an initial increase of ABR thresholds following electrode insertion trauma (P ⬎ 0.05) across all frequencies tested (which included the apical part of the cochlea that is far from the site of electrode insertion trauma). There was also a progressive and significant decrease in the amplitudes of the DPOAEs (P ⬎ 0.05) after electrode insertion trauma. Cochleae from control and electrode insertion trauma guinea pigs were fixed and organ of Corti surface prepa-

rations were microdissected from the lower middle turns. The tectorial membrane was carefully removed prior to FITC-phalloidin/propidium iodide staining. The doublestained organ of Corti specimens were observed using confocal microscopy that allows for identification of OHC and IHC cuticular plates with their stereocilliary bundles and on a deeper level of focus the nuclei of the IHCs and OHCs. We observed changes in nuclear staining in these auditory hair cells that are consistent with apoptosis, i.e., nuclear DNA condensation and formation of apoptotic bodies. TUNEL labeling of the middle turn organ of Corti surface preparations from contralateral control and electrode insertion traumatized cochlea at 12, 24, and 36 hr posttrauma showed a progressive increase in TUNELlabeled hair cell nuclei in the traumatized cochleae over time posttrauma while compared to the contralateral control cochleae. These observations lead us to propose a modification to our previous classification of cochlear implant trauma because the specimens were categorized as grade 0 trauma. Grade 0 is now considered as no observable macroscopic damage, but with the possibility of damage on a molecular level (Table 1).

D-JNKI-1 Inhibitor Therapy The apoptosis of auditory neurons as a consequence of oxidative stress damage has been shown to involve the downstream target of the JNK signal cascade, i.e., c-Jun (Scarpidis et al., 2003). A previous study using D-JNKI-1, which competitively binds to JNK molecules, which prevents interaction with their downstream targets and signaling capacity (Fig. 3), has demonstrated that this inhib-


itory peptide can prevent loss of both hearing capacity and hair cells in animals challenged with exposure to either a damaging level of sound trauma or to an ototoxic level of an aminoglycoside antibiotic (Wang et al., 2003).

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Using our guinea pig model of cochlear implant trauma and the same objective measurements (i.e., DPOAE and ABR tests) used to define hearing function after inner ear trauma, we studied the otoprotective effect of direct delivery of the synthetic inhibitory peptide of JNKs [i.e., perfusion of 10 ␮M solution of D-JNKI-1 in artificial perilymph (AP) into the scala tympani]. We have demonstrated that there was no posttrauma increase in the ABR thresholds or decrease in DPOAE amplitudes in electrode insertion-traumatized cochleae while traumatized cochleae that were either not treated or treated with perfusion with only AP all experienced an ongoing loss of hearing function for the duration of this experiment, i.e., 7 days (Van De Water et al., 2005). D-JNKI-1 peptide acts by interrupting the MAPK/JNK signal cascade at the level of JNK molecules preventing the phosphorylation of c-Jun, which disrupts the formation of an AP-1 transcription factor; by preventing the JNKs from disrupting the activity of the antiapoptotic members of the Bcl-2 family; and by JNK activation of other downstream targets (e.g., ATF-2). Thus, D-JNKI-1 is a promising molecule in the arsenal of otoprotective molecules for the development of therapeutic strategies for the prevention of hearing loss during electrode insertion in partial hearing patients. In sum, the delayed progressive component of electrode insertion trauma-initiated hearing loss can be prevented by treating the cochlea immediately after electrode insertion with a peptide inhibitor of the c-Jun N-terminal kinase cell death pathway.

Mild Hypothermia Therapy Hypothermia has been shown to have a protective effect in the brain following a traumatic injury (Busto et al., 1987; Dietrich et al., 1994, 1996; Kil et al., 1996). The beneficial effect of hypothermia on neuronal injury has been attributed to a variety of mechanisms. These include a reduction in metabolic rate, reduced tissue oxygen consumption, decreased metabolic acidosis, a suppression of calcium influx into neurons, diminished nitric oxide production, and a reduction in the level of glutamate excitotoxicity (Hyodo et al., 2001; Eshraghi et al., 2005b). Hypothermia has also been demonstrated to reduce brain damage following ischemia by inhibiting the forma-

Fig. 4. D-JNKI-1 treatment prevents apoptosis and loss of neomycin-exposed hair cells. A–C: Confocal images of antimyosin VIIa (red) and TUNEL (green) double-labeled P3 organ of Corti explants. A: Untreated control explant. B: Explant exposed to 1 mM neomycin for 48 hr. C: Explant exposed to 1 mM neomycin in the presence of 2 ␮M DJNKI-1 for 48 hr. Neomycin exposure resulted in a severe loss of hair cells and the presence of many TUNEL-labeled nuclei within the region of the damaged auditory sensory epithelium (B). Most hair cells were already missing, but a few remaining damaged hair cells that were in the process of apoptosis are indicated by TUNEL labeling of their nuclei (arrows). D-JNKI-1 completely prevented neomycin-induced apoptotic cell death of both IHCs and OHCs; no TUNEL-positive cells were present (C). Arrowhead, IHC; rows 1–3, OHCs. Scale bars ⫽ 20 ␮m. D: Results of quantitative analysis of hair cell counts to determine the protective effect of D-JNKI-1 on IHCs, OHCs, and total hair cells (total HCs) against neomycin-induced loss in organ of Corti explants obtained from the middle turns of P3 mouse cochleae. Hair cell counts are presented as mean ⫾ SD (bars) from five separate experiments (n ⫽ 3–5 explants/ condition). D-JNKI-1 treatment of explants provided protection against neomycin-induced hair cell loss that was highly significant (P ⬍ 0.001). Reprinted with permission from Wang et al. (2003).

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TABLE 1. Grinding system: cochlear trauma postelectrode array implantation Grade 1: No observable macroscopic trauma* Grade 2: Elevation of basilar membrane Grade 3: Dislocatioon of electrode to scala vestibule Grade 4: Fracture of osseous spiral lamina or modiolus, or tear in tissues of stria vascularis/spiral ligament complex *Possible damage at the molecular level that can lead to apoptosis. (Modified from: Eshraghi et al., Comparative study of cochlear damage with three perimodialar electrode design. Laryngoscope 2003;113:415– 419)

In a recent study, we evaluated the otoprotective effect of mild hypothermia in our rat model of cochlear implantation trauma (Balkany et al., 2005). One ear was randomly chosen to undergo electrode insertion while the contralateral ears served as nonoperative controls. In group 1, subjects were kept at 37°C throughout the procedure using a heating blanket and heat lamp. The core temperature of the animals was monitored continuously using a rectal probe with digital readout. In group 2, subjects were cooled from 37°C to 34°C using a cooling blanket for 30 min before surgery and kept at this state of mild hypothermia during surgery and electrode insertion trauma and for a period of 30 min after trauma.

Electrophysiology Tests

Fig. 5. Neomycin exposure caused both hair cell loss and c-Jun phosphorylation in sensory cell nuclei in organ of Corti explants. Transverse plane tissue sections of P3 mouse organ of Corti explants. A and D: Untreated control explants. B and E: Explants exposed to 1 mM neomycin for 24 hr. C and F: Explants exposed to 1 mM neomycin in the presence of D-JNKI-1 (2 ␮M) for 24 hr. A–C: Sections stained with hematoxylin and eosin. Nuclear condensations were present in some of the remaining hair cells in the neomycin-exposed explant (B) but were not present in either control explant hair cells (A) or in the hair cells of neomycin-exposed cultures that were protected by D-JNKI-1 (C). D–F: Sections immunostained with an antiphospho-c-Jun antibody. Phospho-c-Jun antibody-immunolabeled hair cells were present in the neomycin-exposed explant (E) but were not detected in either the control explants (D) or the explants that had been coincubated with neomycin and D-JNKI-1 peptide for 24 hr. F: Large arrowheads indicate the area of the IHCs, and small arrowheads indicate the area of the OHCs. Scale bars ⫽ 5 ␮m. G: Results from real-time RT-PCR analysis of c-fos expression in cochlear explants. Bar graphs show relative levels of c-fos expression normalized to tubulin mRNA (n ⫽ 3). RNAs were extracted from untreated control, neomycin-exposed (24 hr), and neomycin-exposed, D-JNKI-1-treated (24 hr) P3 cochlear explants. Note that c-fos expression was significantly upregulated in cochlear explants after neomycin exposure and was at a near untreated control explant level of expression in the neomycin-exposed, D-JNKI-1-treated explants. Reprinted with permission from Wang et al. (2003).

tion of reactive oxygen species (ROS), thereby limiting the extent of oxidative stress (Zhao et al., 1996). More recently, it was reported that hypothermia could protect against noise-induced threshold elevation of hearing thresholds (i.e., ABR measures) in laboratory mice (Henry, 2003).

Recordings were performed immediately prior to surgery and on days 0 (immediately after surgery), 3, 5, and 7 using the same objective test of hearing previously reported (ABRs and DPOAEs). The result of this study demonstrates that mild hypothermia can reduce the immediate component of trauma-induced hearing loss and prevent the progressive component of loss of auditory function following cochlear electrode insertion in the rat model of cochlear implantation trauma-induced hearing loss.

NOISE-INDUCED HEARING LOSS It has been known for some time that noise-induced hair cell death in the cochlea and loss of hearing function continue well after the termination of a noise exposure. However, the underlying mechanisms leading to the expansion of a noise-induced cochlear lesion are not yet fully understood. Hu et al. (2002a) have reported involvement of the apoptotic pathway in the progression of OHC death in the chinchilla cochlea following exposure to a 4 kHz narrow band noise at 110 dB SPL for 1 hr. Morphological examination of OHC nuclei with propidium iodide-stained DNA revealed nuclear condensation and fragmentation, typical morphological features of apoptosis. Apoptosis of the OHCs developed asymmetrically toward the apical and basal parts of the cochleae following sound exposure. Two days after the noise exposure, there was still active OHC pathology with condensed and fragmented nuclei in the basal part of the cochlea. Detection of caspase 3 activation in this study, an intracellular marker for a late stage of apoptosis, showed in their study a spatial agreement between the apoptotic nuclei and activated caspase 3. This observation was confirmed and extended in a more recent study by this group (Nicotera et al., 2003), where the participation of caspase 3 activation in hair cell (HC) apoptosis was confirmed and the participation of activated


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Fig. 6. Local delivery of D-JNKI-1 into the scala tympani protected against acoustic trauma-induced hair cell loss. A and B: Scanning electron micrographs of areas of acoustic trauma damage in cochleae from the same noise-exposed animal. In the damaged area of the contralateral unperfused cochleae, the most severe damage was observed in the row of IHCs (I) and the first row of OHCs (O), with a gradation of damage in the second and the third rows of OHCs (A). Note that direct delivery of 10 ␮M D-JNKI-1 into the scala tympani of the cochlea effectively prevented acoustic trauma-induced hair cell loss (B). Scale bar ⫽ 15 ␮m. C and D: Quantitative analysis of hair cell damage consisted of counting all hair cells along the entire length of the cochlear ducts. Cochleograms represent the mean survival of hair cells as the function of the distance

from the apex (in mm) in contralateral unperfused cochleae (C; n ⫽ 3) and in the 10 ␮M D-JNKI-1-perfused cochleae (D; n ⫽ 3) of the same animals. Noise exposure caused a narrow band of hair cell trauma in the cochlea located 14 –16 mm from the apex of the cochlea. Ninety-one percent of the IHCs (white circles) and 43% of the OHCs were lost from this area by 30 days after the initial acoustic trauma in the unprotected cochleae (C). Note the typical gradient of loss from the first row (black circles) to the second (dark gray circles) and third (light gray circles) rows of OHCs. In contrast, only 6% OHCs and 11.9% IHCs were lost as a consequence of acoustic trauma in cochleae that were treated with local application of a 10 ␮M solution of D-JNKI-1 (D). Reprinted with permission from Wang et al. (2003).

caspases 8 and 9 was added to the process on sound trauma-induced apoptosis of damaged HCs. Another study has shown that activation of apoptotic changes in the nucleus of a damaged HC correlates with a decrease in F-actin staining of the affected HC linking nuclear changes with alterations in the distribution of cellular proteins that are necessary for function (Hu et al., 2002b). A very recent finding has been that in the early time after sound trauma, apoptosis is a prominent feature within the sound-damaged cochlea and only later is there an equal distribution of both necrosis and apoptosis among the sound-damaged cells of the traumatized cochleae (Yang et al., 2004). Apoptosis therefore appears to play a critical role in the pathogenesis of noise-induced hearing loss. In contrast, Yoshida and Liberman (2000) have demonstrated that sound conditioning (pretreatment with a lowlevel of nondamaging sound) protects the cochlea against hair cell death and thereby preserves hearing after a subsequent acoustic trauma that exposes the cochlea to a damaging level of sound. Using a combination of immunolabel and Western blotting techniques, these investigators have shown that acoustic trauma causes the release of cytochrome c from the mitochondria into the cytoplasm and a decrease in bcl-2 immunostaining of the outer hair

cells. Sound conditioning was shown to trigger a protective effect against these detrimental changes. These results demonstrate that bcl-2 plays an important role in the regulation of hair cell death and provides evidence that the neuroprotective bcl-2 gene acts as an inducible gene that can be unregulated by a sound conditioning paradigm and thereby protect the cochlea from noise-induced hearing loss.

D-JNKI-1 Inhibitor Therapy Hearing loss can be caused by acoustic trauma, which principally affects the viability of sensory hair cells via the MAPK/JNK cell death signaling pathway that incorporates JNK molecules (i.e., JNKs 1, 2, and 3). Wang et al. (2003) evaluated the otoprotective efficacy of D-JNKI-1, a cell-permeable peptide (Bonny et al., 2001) that blocks JNK signaling (Figs. 2 and 3). The experimental studies included organ cultures of neonatal mouse cochlea exposed to an ototoxic drug (Figs. 4 and 5) and cochleae of adult guinea pigs that were exposed to acoustic trauma. Local delivery of D-JNKI-1 prevented acoustic traumainduced permanent hearing loss in a dose-dependent manner. Figure 6 shows the results of D-JNKI-1 protection against hair cell loss depicting the surface ultrastructure

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Fig. 7. Perfusion of D-JNKI-1 into the scala tympani protected against acoustic trauma-induced permanent hearing loss. A and B: Hearing thresholds from contralateral noise-exposed unperfused left cochleae (A; n ⫽ 6) and the noise-exposed right cochleae perfused with a 10 ␮M solution of D-JNKI-1 (B; n ⫽ 6) from the same animals. Hearing loss was calculated as the difference in decibels between auditory thresholds before acoustic trauma, 20 min (black circles) and 30 days (white circles) after noise exposure. Acoustic trauma (6 kHz, 120 dB SPL, 30 min) induced a maximum hearing loss of 60 dB when measured 20 min after exposure. Note the spontaneous but incomplete recovery of thresholds in the contralateral unperfused cochleae (A). Protection against a permanent hearing loss was clearly observed for the 10 ␮M D-JNKI-1-treated cochleae, with an initial hearing loss (TTS) that was

similar to the contralateral unperfused cochleae at 20 min but with a near complete recovery of hearing function by 30 days after exposure (B). C and D: Protective effect of 10 ␮M D-JNKI-1 against acoustic trauma on amplitude-intensity function of the CAP evoked by stimulation with 8 kHz tone bursts. Shown are the results obtained before (white circles) and 6 days after exposure to the acoustic trauma paradigm (black circles). Acoustic trauma induced a drastic decrease in the CAP amplitude for all intensity levels of sound stimulation (8 kHz) in the contralateral noiseexposed unperfused left cochleae by day 6 (C). Note a near complete recovery of the amplitude-intensity function by 6 days after exposure in cochleae perfused with 10 ␮M D-JNKI-1 (D). A–D: All points represent mean ⫾ SEM values calculated from six animals. Reprinted with permission from Wang et al. (2003).

of a protected and an unprotected organ of Corti as well as quantitative data on hair cell loss as determined by counts of intact hair cells of SEM-prepared cochlear ducts. Treatment of sound trauma-exposed cochlea with D-JNKI-1 also prevented the conversion of a temporary threshold shift (TTS) into a permanent threshold shift (PTS) as depicted in Figure 7. These results indicate that the MAPK-JNK signal pathway is involved in acoustic trauma-induced hair cell loss and also in the development of a permanent hearing loss after exposure to a damaging level of sound or noise. Blocking this signal pathway with D-JNKI-1 is of potential therapeutic value for long-term protection of both the morphological integrity and the physiological function of the organ of Corti during times of

physical trauma-initiated oxidative stress, which can lead to the apoptosis of damaged hair cells.

Hypothermia Therapy Henry and Chole (1984) have studied the thresholds of the cochlear action potential from rodents at euthermic (38°C) and hypothermic (30°C and 25°C) conditions as determined by rectal temperatures. When subjects susceptible to PTS at low and middle frequencies (anesthetized immature mice) were exposed to 115 dB noise, hypothermia reduced the level of the PTS at these most susceptible frequencies (2–16 kHz). When alert adult mice were exposed to this level of damaging noise, hypothermia


protected them from the development of a PTS at their most vulnerable frequency (i.e., 32 kHz). More recently, Henry (2003) has studied the scalp-recorded cochlear nerve envelope response (CNER). The CNER measure reflects the ability of high-frequency cochlear nerve axons to fire in a phase-locked fashion to lowfrequency modulations of the acoustic envelope of high-frequency stimuli. This property is useful in evaluating the adverse effects of noise exposure on the ability of the ear to detect acoustic changes characteristic of vocalizations and speech. Hypothermia (30°C) elevated CNER thresholds elicited by high-frequency stimuli. Mice exposed to noise when hypothermic had smaller threshold elevations than those exposed when euthermic (36°C) (Henry, 2003).

CONCLUSIONS Cochlear implant insertion trauma and noise-induced hearing loss both involve physical disruption of the organ of Corti and involve both necrosis and apoptosis pathways at the molecular level. Promising new therapeutic strategies are currently under investigation. One of these promising new strategies involves the use of a highly effective peptide inhibitor of the c-Jun N-terminal kinase cell death pathway (i.e., D-JNKI-1) and the other protective therapy is the use of mild hypothermia to protect the cochlea from the deleterious effect of physical trauma-initiated apoptosis.

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