Bone quality and biomechanical function: a lesson from human ossicles

Bone mineral density of the incus body and long process in patients with chronic otitis media and its relationship with functional outcome in type II tympanoplasty

BACKGROUND

Inflammatory conditions such as chronic otitis media (COM) can cause irreversible impairments in the microarchitecture and functions of the incus, which subsequently leads to conductive hearing loss.

OBJECTIVES

To investigate bone mineral density (BMD) of the incus body (IB) and long process (ILP) on preoperative temporal CT in COM patients with and without incudo-stapedial joint discontinuity (ISJD), and also to determine the association between BMD values and the postoperative air-bone gap (ABG) in the ISJD group.

MATERIAL AND METHODS

The mean IB density (IBD)/occipital bone density (OBD) and ILP density (ILPD)/OBD values were compared between the patients with and without ISJD. The correlation between ABG gain and preoperative incus density values was assessed in the ISJD group.

RESULTS

The mean IBD/OBD and ILPD/OBD values were significantly higher in patients with intact ISJ. There was a moderate positive correlation between postoperative ABG gain and ILPD/OBD values in the ISJD group.

CONCLUSION AND SIGNIFICANCE

The decrease in BMD of the incus may involve ILP as well as IB in patients with ISJD caused by ILP lysis in COM. A higher preoperative ILPD/OBD was correlated with a higher postoperative ABG gain in COM patients with ISJD.

Cholesteatoma Severely Impacts the Integrity and Bone Material Quality of the Incus

Cholesteatoma can lead to progressive destruction of the auditory ossicles along with conductive hearing loss but precise data on the microstructural, cellular, and compositional aspects of affected ossicles are not available. Here, we obtained incus specimens from patients who had cholesteatoma with conductive hearing loss. Incudes were evaluated by micro-computed tomography, histomorphometry on undecalcified sections, quantitative backscattered electron imaging, and nanoindentation. Results were compared with two control groups taken from patients with chronic otitis media as well as from skeletally intact donors at autopsy. The porosity of incus specimens was higher in cholesteatoma than in chronic otitis media, along with a higher osteoclast surface per bone surface. Histomorphometric assessment revealed higher osteoid levels and osteocyte numbers in cholesteatoma incudes. Incudes affected by cholesteatoma also showed lower matrix mineralization compared with specimens from healthy controls and chronic otitis media. Furthermore, the modulus-to-hardness ratio was higher in cholesteatoma specimens compared with controls. Taken together, we demonstrated increased porosity along with increased osteoclast indices, impaired matrix mineralization, and altered biomechanical properties as distinct features of the incus in cholesteatoma. Based on our findings, a possible impact of impaired bone quality on conductive hearing loss should be further explored.

Biomechanical Characteristics and Analysis Approaches of Bone and Bone Substitute Materials

Bone has a special structure that is both stiff and elastic, and the composition of bone confers it with an exceptional mechanical property. However, bone substitute materials that are made of the same hydroxyapatite (HA) and collagen do not offer the same mechanical properties. It is important for bionic bone preparation to understand the structure of bone and the mineralization process and factors. In this paper, the research on the mineralization of collagen is reviewed in terms of the mechanical properties in recent years. Firstly, the structure and mechanical properties of bone are analyzed, and the differences of bone in different parts are described. Then, different scaffolds for bone repair are suggested considering bone repair sites. Mineralized collagen seems to be a better option for new composite scaffolds. Last, the paper introduces the most common method to prepare mineralized collagen and summarizes the factors influencing collagen mineralization and methods to analyze its mechanical properties. In conclusion, mineralized collagen is thought to be an ideal bone substitute material because it promotes faster development. Among the factors that promote collagen mineralization, more attention should be given to the mechanical loading factors of bone.

Mammalian middle ear mechanics: A review

The middle ear is part of the ear in all terrestrial vertebrates. It provides an interface between two media, air and fluid. How does it work? In mammals, the middle ear is traditionally described as increasing gain due to Helmholtz’s hydraulic analogy and the lever action of the malleus-incus complex: in effect, an impedance transformer. The conical shape of the eardrum and a frequency-dependent synovial joint function for the ossicles suggest a greater complexity of function than the traditional view. Here we review acoustico-mechanical measurements of middle ear function and the development of middle ear models based on these measurements. We observe that an impedance-matching mechanism (reducing reflection) rather than an impedance transformer (providing gain) best explains experimental findings. We conclude by considering some outstanding questions about middle ear function, recognizing that we are still learning how the middle ear works.

High Heterogeneity of Temporal Bone CT Aspects in Osteogenesis Imperfecta Is Not Linked to Hearing Loss

OBJECTIVES

To determine whether temporal bone computed tomography (CT) features are linked to the presence and type of hearing loss in osteogenesis imperfecta (OI) when considering hearing-impaired OI patients and normally hearing (NH) OI ones. A secondary objective was to assess whether other factors influence CT features in a large sample: age, type of mutation, or bone mineral density (BMD).

METHODS

A total of 41 adults with OI underwent CTs and pure-tone audiometry in 82 ears. Hearing thresholds were normal in 64 out of 82 ears, and most had not been operated on for stapedectomy or stapedotomy. Ossicle density, footplates, oval and round windows, retrofenestral peri- and endolabyrinths, and temporal pneumatization were analyzed twice by an experienced radiologist. CT features were compared to hearing, age, collagen mutations, and bone mineral density.

RESULTS

Unexpectedly a high prevalence of footplate, ossicle, and otic capsule anomalies was observed, even in NH ears. Footplate hypodensity or thickening was mostly found in ears without conductive hearing loss. There were significantly more retrofenestral anomalies or window obstruction in ears with a sensorineural hearing loss component than in ears without. Age was significantly higher in ears with middle layer hypodensity than in ears without. Patients with mutations were expected to have reduced collagen quantity and had significantly more footplate or retrofenestral anomalies than those with qualitative mutations. BMD was significantly higher in ears without temporal hyperpneumatization.

CONCLUSION

Temporal bone CT features in OI are present in a large proportion of patients, had they hearing loss or not, and might be determined more by collagen mutation type than by age or BMD.

Internal vascular channel architecture in human auditory ossicles

The vascular supply of the human auditory ossicles has long been of anatomical and clinical interest. While the external blood supply has been well‐described, there is only limited information available regarding the internal vascular architecture of the ossicles, and there has been little comparison of this between individuals. Based on high‐resolution micro‐CT scans, we made reconstructions of the internal vascular channels and cavities in 12 sets of ossicles from elderly donors. Despite considerable individual variation, a common basic pattern was identified. The presence of channels within the stapes footplate was confirmed. The long process of the incus and neck of the stapes showed signs of bony erosion in all specimens examined. More severe erosion was associated with interruption of some or all of the main internal vascular channels which normally pass down the incudal long process; internal excavation of the proximal process could interrupt vascular channels in ossicles which did not appear to be badly damaged from exterior inspection. An awareness of this possibility may be helpful for surgical procedures that compromise the mucosal blood supply. We also calculated ossicular densities, finding that the malleus tends to be denser than the incus. This is mainly due to a lower proportion of vascular channels and cavities within the malleus.

Numerical Analysis of Stapes Prosthesis Constraining in the Case of Otosclerosis

In the case of otosclerosis, it has been noticed that even though there are a variety of different prostheses on the market, due to the anatomical characteristics, it is not always possible to restore excellent mobility to the ossicles and the prosthesis. On the one hand, this happens because the incus long process and the prosthesis create difficult angles. On the other hand, incus necrosis is among the most common causes of the loss of stability to the prosthesis and stapedectomy failure. The aim of this research is to suggest an improvement for stapes prosthesis stability and numerically evaluate the impact of the prosthesis constraining to its dynamical behavior. Numerical 3D models of a standard as well as a modified (adjustable angled) stapes prosthesis were created in order to achieve this aim. Consequently, the modal analysis has been performed to evaluate the mechanical behavior of the prosthesis, assuming that the piston (thick part) would be made of Teflon, and the thin part, fixated on the incus long process, would be made from titanium alloy. Finally, the numerical analysis has been conducted by changing the boundary conditions in respect of the prosthesis constraining, where the attached stapes prosthesis connects to the ossicular chain. Subsequently, there were two hypotheses raised for the prosthesis loop constraining. The first is that during the surgery, the prosthesis is perfectly crimped with certain looseness. The second is that the prosthesis is outgrown by the tissues over time and thus becomes over-constrained. Then, the analyzed standard stapes prosthesis does not fulfil its functions because of the over-constraining that develops over time. An improvement for the standard stapes prosthesis, i.e., a modified stapes prosthesis (adjustable angled), that has been proposed in this research allows avoidance of the negative effects of the over-constrained standard stapes prosthesis that appear over time. Moreover, the proposed modified prosthesis helps to regain hearing when the angle between the incus long process and prosthesis is unfavorable.

Morphometry of auditory ossicles in medieval human remains from Central Europe

Human auditory ossicles, the malleus, the incus, and the stapes, are located in the tympanic cavity in the temporal bone and through forming a chain for the sound transmission from the tympanic membrane to the cochlea, they play an important role in the hearing process. Despite their clinical, phylogenetic, and evolutionary significance, the morphometry of the human ear bones has not been examined systematically. The ear ossicles are the smallest bones of the human skeleton, attaining their final size and morphology already at birth. Initially, they have been found to exhibit minimal morphometric variation, but further studies brought the opposite results. The aim of this study was to examine the morphometric variation of human auditory ossicles recovered from medieval and postmedieval subadult skeletons from Poland, Central Europe. The analysis involved in a total of 166 ear bones. Their measurements were performed on microscopic images using CorelDraw x4, according to a protocol of Quam and Rak with modification of Flohr et al. and Wadhwa et al. Our study showed a significant metric variation in the measurements taken at areas of the greatest morphological variability of the ossicles. We found that greater linear dimensions were associated with lower values of angular measurements. These results reveal the inherent variation found in these supposed functionally constrained structures. Representation of even greater number of populations, time periods, and developmental stages are needed. Further study will expand our understanding of the global scope of variation found in ear ossicular morphology and its functional implications for paleoanthropology.

On the hearing effects of a cholesteatoma growing: A biomechanical study

Chronic otitis media enables the appearance of a benign middle ear tumor, known as a cholesteatoma, that may compromise hearing. To evaluate the influence of a cholesteatoma growth on the hearing function, a computational middle ear model based on the finite element method was used and three different size of cholesteatoma were modeled. The cholesteatoma solidification and the consequent degradation of the ossicles were also simulated as two condition that commonly occurs during cholesteatoma evolution. A sound pressure level of 80 dB SPL was applied in the tympanic membrane and a steady state analysis was performed for frequencies from 100 Hz to 10 kHz. The displacements of both the tympanic membrane and the stapes footplate were measured. The results were compared with a healthy case and it was shown that the cholesteatoma development leads to a decrease in the umbo and stapes displacements. The ossicles degradation simulation showed the higher difference comparing with the cholesteatoma in an initial stage, with lower displacements in the stapes footplate mainly for high frequencies. The observed displacement differences are directly connected to hearing loss, being possible to conclude that cholesteatoma evolution in the middle ear will lead to hearing problems, mainly in an advanced stage.

Characterization of mechanical behaviour of healthy and injured human incus by eigenfrequency evaluation

The usage of finite element method techniques gives a possibility to replace time-consuming experiments or imitate physical process in the ear by numerical simulation. Especially, the research of spatial motion of ossicular chain in the middle ear is of high interest for the oto-surgeons and engineers. It is known that the most affected bone from the ossicular chain is the incus. After the cholesteatoma operation and tympanoplasty, the affected incus is removed or sacrificed; thus, the possibility of transducing noise lays on the stapes, new titanium or other material prosthesis. In this case, the affected incus was removed because of the cholesteatoma that was lying in front of it in the tympanic cavity. The removed incus with the affected long process passed micro-computed tomography. The computer-aided design systems allowed redesigning a 'healthy' incus with an intact long process. In this way, it was possible to evaluate the influence of damaged long process of incus in the vibrational analysis. This article analyses the problems of mechanical behaviour of injured and healthy human incus. The numerical simulation has demonstrated that the features of healthy incus and analysed injured incus do not differ significantly, especially at low (about 500 Hz) frequencies. It explains why there is no impact of cholesteatoma on hearing for a long time in the audiogram.

Human auditory ossicles as an alternative optimal source of ancient DNA

DNA recovery from ancient human remains has revolutionized our ability to reconstruct the genetic landscape of the past. Ancient DNA research has benefited from the identification of skeletal elements, such as the cochlear part of the osseous inner ear, that provides optimal contexts for DNA preservation; however, the rich genetic information obtained from the cochlea must be counterbalanced against the loss of morphological information caused by its sampling. Motivated by similarities in developmental processes and histological properties between the cochlea and auditory ossicles, we evaluate the ossicles as an alternative source of ancient DNA. We show that ossicles perform comparably to the cochlea in terms of DNA recovery, finding no substantial reduction in data quantity and minimal differences in data quality across preservation conditions. Ossicles can be sampled from intact skulls or disarticulated petrous bones without damage to surrounding bone, and we argue that they should be used when available to reduce damage to human remains. Our results identify another optimal skeletal element for ancient DNA analysis and add to a growing toolkit of sampling methods that help to better preserve skeletal remains for future research while maximizing the likelihood that ancient DNA analysis will produce useable results.

Human auditory ossicles as an alternative optimal source of ancient DNA

DNA recovery from ancient human remains has revolutionized our ability to reconstruct the genetic landscape of the past. Ancient DNA research has benefited from the identification of skeletal elements, such as the cochlear part of the osseous inner ear, that provides optimal contexts for DNA preservation; however, the rich genetic information obtained from the cochlea must be counterbalanced against the loss of morphological information caused by its sampling. Motivated by similarities in developmental processes and histological properties between the cochlea and auditory ossicles, we evaluate the ossicles as an alternative source of ancient DNA. We show that ossicles perform comparably to the cochlea in terms of DNA recovery, finding no substantial reduction in data quantity and minimal differences in data quality across preservation conditions. Ossicles can be sampled from intact skulls or disarticulated petrous bones without damage to surrounding bone, and we argue that they should be used when available to reduce damage to human remains. Our results identify another optimal skeletal element for ancient DNA analysis and add to a growing toolkit of sampling methods that help to better preserve skeletal remains for future research while maximizing the likelihood that ancient DNA analysis will produce useable results.

Clinical measurements of bone tissue mechanical behavior using reference point indentation

Over the last thirty years, it has become increasingly clear the amount of bone (e.g. 'bone quantity') and the quality of the bone matrix (e.g. 'bone quality') both critically contribute to bone's tissue-level mechanical behavior and the subsequent ability of bone to resist fracture. Although determining the tissue-level mechanical behavior of bone through mechanical testing is relatively straightforward in the laboratory, the destructive nature of such testing is unfeasible in humans and in animal models requiring longitudinal observation. Therefore, surrogate measurements are necessary for quantifying tissue-level mechanical behavior for the pre-clinical and clinical evaluation of bone strength and fracture risk in vivo. A specific implementation of indentation known as reference point indentation (RPI) enables the mechanical testing of bone tissue without the need to excise and prepare the bone surface. However, this compromises the ability to carefully control the specimen geometry that is required to define the bone tissue material properties. Yet the versatility of such measurements in clinical populations is provocative, and to date there are a number of promising studies that have utilized this tool to discern bone pathologies and to monitor the effects of therapeutics on bone quality. Concurrently, on-going efforts continue to investigate the aspects of bone material behavior measured by RPI, and the compositional factors that contribute to these measurements. There are currently two variants, cyclic- and impact- RPI, that have been utilized in pre-clinical and clinical studies. This review surveys clinical studies that utilize RPI, with particular emphasis on the clinical instrument, as well as the endeavors to understand the fundamental mechanisms of such measurements. Ultimately, an improved awareness in the tradeoffs and limitations of in vivo RPI is critical towards the effective and successful utilization of this tool for the overall improvement of fragility determination in the clinic.

A universal curve of apatite crystallinity for the assessment of bone integrity and preservation

The reliable determination of bioapatite crystallinity is of great practical interest, as a proxy to the physico-chemical and microstructural properties, and ultimately, to the integrity of bone materials. Bioapatite crystallinity is used to diagnose pathologies in modern calcified tissues as well as to assess the preservation state of fossil bones. To date, infrared spectroscopy is one of the most applied techniques for bone characterisation and the derived infrared splitting factor (IRSF) has been widely used to practically assess bioapatite crystallinity. Here we thoroughly discuss and revise the use of the IRSF parameter and its meaning as a crystallinity indicator, based on extensive measurements of fresh and fossil bones, virtually covering the known range of crystallinity degree of bioapatite. A novel way to calculate and use the infrared peak width as a suitable measurement of true apatite crystallinity is proposed, and validated by combined measurement of the same samples through X-ray diffraction. The non-linear correlation between the infrared peak width and the derived ISRF is explained. As shown, the infrared peak width at 604 cm⁻¹ can be effectively used to assess both the average crystallite size and structural carbonate content of bioapatite, thus establishing a universal calibration curve of practical use.

Side-Effects of Convulsive Seizures and Anti-Seizure Therapy on Bone in a Rat Model of Epilepsy

The severe sole effects of seizures on the cortical part of bone were reported in our previous study. However, the side effects of anti-epileptic drug therapy on bones has not been differentiated from the effects of the convulsive seizures, yet. This study provides the first report on differentiation of the effects of seizures and carbamazepine (a widely used antiepileptic drug) therapy on bones; 50 mg/kg/day drug was given to genetically induced absence epileptic rats for five weeks. Distinct bone regions including cortical, trabecular, and growth plate in each of tibia, femur, and spine tissues were studied using Fourier transform infrared (FT-IR) imaging and Vickers microhardness test. Blood levels of vitamin D and bone turnover biomarkers were also measured. According to the FT-IR imaging results, both seizure and carbamazepine-treated groups, more dominantly the drug-treated group, had lower mineral content with altered collagen crosslinks and higher crystallinity, implying reduced bone strength. Lower microhardness values also supported lower mechanical strength in bones. The most affected bone tissue and region from seizures and treatment was found as the spine and cortical, respectively. While there was a reduction in vitamin D and calcium levels in both seizure and carbamazepin-treated groups, significantly elevated PTH and bone turnover biomarkers were only seen in the drug-treated group.

Early bone tissue aging in human auditory ossicles is accompanied by excessive hypermineralization, osteocyte death and micropetrosis

Within the mineralized bone, osteocytes form a multifunctional mechanosensitive network orchestrating bone remodelling. A preserved osteocyte population is a crucial determinant of bone quality. In human auditory ossicles, the early decrease in osteocyte numbers but maintained integrity remains an unexplained phenomenon that might serve for sound transmission from air to the labyrinth. Here we analysed the frequency, size and composition of osteocyte lacunae in the auditory ossicles of 22 individuals from early postnatal period to old age. Mineralization of the bone matrix was determined using backscattered electron imaging. No signs of bone remodelling were observed above the age of 1 year. We detected characteristics of early bone tissue aging, such as decrease in osteocytes, lower total lacunar density and lacunar area, as well as high matrix mineralization accompanied by distinct accumulation of micropetrotic lacunae and decreased indentation depths. The majority of these changes took place in the first months and years of life, while afterwards only minor reorganization was present. With osteocyte apoptosis potentially being a consequence of low mechanical stimuli, the early loss of osteocytes without initiation of bone remodelling indicates an adaptive response conserving the architecture of the auditory ossicles and ensuring stable sound transmission throughout life.

Vibrational spectroscopic techniques to assess bone quality

Although musculoskeletal diseases such as osteoporosis are diagnosed and treatment outcome is evaluated based mainly on routine clinical outcomes of bone mineral density (BMD) by DXA and biochemical markers, it is recognized that these two indicators, as valuable as they have proven to be in the everyday clinical practice, do not fully account for manifested bone strength. Thus, the term bone quality was introduced, to complement considerations based on bone turnover rates and BMD. Bone quality is an "umbrella" term that incorporates the structural and material/compositional characteristics of bone tissue. Vibrational spectroscopic techniques such as Fourier transform infrared microspectroscopy (FTIRM) and imaging (FTIRI), and Raman spectroscopy, are suitable analytical tools for the determination of bone quality as they provide simultaneous, quantitative, and qualitative information on all main bone tissue components (mineral, organic matrix, tissue water), in a spatially resolved manner. Moreover, the results of such analyses may be readily combined with the outcomes of other techniques such as histology/histomorphometry, small angle X-ray scattering, quantitative backscattered electron imaging, and nanoindentation.

Panel 2: Anatomy (Eustachian Tube, Middle Ear, and Mastoid-Anatomy, Physiology, Pathophysiology, and Pathogenesis)

Objective In this report, we review the recent literature (ie, past 4 years) to identify advances in our understanding of the middle ear-mastoid-eustachian tube system. We use this review to determine whether the short-term goals elaborated in the last report were achieved, and we propose updated goals to guide future otitis media research. Data Sources PubMed, Web of Science, Medline. Review Methods The panel topic was subdivided, and each contributor performed a literature search within the given time frame. The keywords searched included middle ear, eustachian tube, and mastoid for their intersection with anatomy, physiology, pathophysiology, and pathology. Preliminary reports from each panel member were consolidated and discussed when the panel met on June 11, 2015. At that meeting, the progress was evaluated and new short-term goals proposed. Conclusions Progress was made on 13 of the 20 short-term goals proposed in 2011. Significant advances were made in the characterization of middle ear gas exchange pathways, modeling eustachian tube function, and preliminary testing of treatments for eustachian tube dysfunction. Implications for Practice In the future, imaging technologies should be developed to noninvasively assess middle ear/eustachian tube structure and physiology with respect to their role in otitis media pathogenesis. The new data derived from these structure/function experiments should be integrated into computational models that can then be used to develop specific hypotheses concerning otitis media pathogenesis and persistence. Finally, rigorous studies on medical or surgical treatments for eustachian tube dysfunction should be undertaken.

Differential effects of pannexins on noise-induced hearing loss

Hearing loss, including noise-induced hearing loss, is highly prevalent and severely hinders an individual's quality of life, yet many of the mechanisms that cause hearing loss are unknown. The pannexin (Panx) channel proteins, Panx1 and Panx3, are regionally expressed in many cell types along the auditory pathway, and mice lacking Panx1 in specific cells of the inner ear exhibit hearing loss, suggesting a vital role for Panxs in hearing. We proposed that Panx1 and/or Panx3 null mice would exhibit severe hearing loss and increased susceptibility to noise-induced hearing loss. Using the auditory brainstem response, we surprisingly found that Panx1^-/- and Panx3^-/- mice did not harbor hearing or cochlear nerve deficits. Furthermore, while Panx1^-/- mice displayed no protection against loud noise-induced hearing loss, Panx3^-/- mice exhibited enhanced 16- and 24-kHz hearing recovery 7 days after a loud noise exposure (NE; 12 kHz tone, 115 dB sound pressure level, 1 h). Interestingly, Cx26, Cx30, Cx43, and Panx2 were up-regulated in Panx3^-/- mice compared with wild-type and/or Panx1^-/- mice, and assessment of the auditory tract revealed morphological changes in the middle ear bones of Panx3^-/- mice. It is unclear if these changes alone are sufficient to provide protection against loud noise-induced hearing loss. Contrary to what we expected, these data suggest that Panx1 and Panx3 are not essential for baseline hearing in mice tested, but the therapeutic targeting of Panx3 may prove protective against mid-high-frequency hearing loss caused by loud NE.

Anisotropy in bone demineralization revealed by polarized far-IR spectroscopy

Bone material is composed of an organic matrix of collagen fibers and apatite nanoparticles. Previously, vibrational spectroscopy techniques such as infrared (IR) and Raman spectroscopy have proved to be particularly useful for characterizing the two constituent organic and inorganic phases of bone. In this work, we tested the potential use of high intensity synchrotron-based far-IR radiation (50–500 cm⁻¹) to gain new insights into structure and chemical composition of bovine fibrolamellar bone. The results from our study can be summarized in the following four points: (I) compared to far-IR spectra obtained from synthetic hydroxyapatite powder, those from fibrolamellar bone showed similar peak positions, but very different peak widths; (II) during stepwise demineralization of the bone samples, there was no significant change neither to far-IR peak width nor position, demonstrating that mineral dissolution occurred in a uniform manner; (III) application of external loading on fully demineralized bone had no significant effect on the obtained spectra, while dehydration of samples resulted in clear differences. (IV) using linear dichroism, we showed that the anisotropic structure of fibrolamellar bone is also reflected in anisotropic far-IR absorbance properties of both the organic and inorganic phases. Far-IR spectroscopy thus provides a novel way to functionally characterize bone structure and chemistry, and with further technological improvements, has the potential to become a useful clinical diagnostic tool to better assess quality of collagen-based tissues.