Aquaporins and Meniere's disease

Pathogenesis and Etiology of Ménière Disease: A Scoping Review of a Century of Evidence

Importance

Ménière disease is a rare chronic benign disorder of the inner ear with a natural history of multiple clinical phenotypes of variable severity and a tendency to burnout with time. Although multiple treatment modalities have been shown to improve the disease process-some adversely affecting cochleovestibular function-it remains uncertain whether one, several separate, or a combination of pathophysiologic mechanisms affect the disease process. A scoping review of the evidence underlying proposed pathophysiologic mechanisms of Ménière disease is needed to determine which processes are most likely to be etiopathogenic factors.

Observations

Of the 4602 relevant articles found through Embase, Ovid, and PubMed, 444 met inclusion criteria. The most common reported causes of Ménière disease were autoimmune or immune-mediated, genetic, or structural dysfunction of the inner ear. During the study period from inception to March 2021, etiologic theories shifted from structural dysfunction to autoimmune and genetic causes of Ménière disease.

Conclusions and Relevance

This scoping review found that Ménière disease is a multifactorial disease with lifelong comorbidities and loss of quality-associated life-years whose most commonly reported causes were structural dysfunction, immunologic damage, and genetic susceptibility. Recent studies have examined how autoinflammatory processes and vestibular migraine may be associated with Ménière disease. Large heterogeneity among studies may be explained by historical differences in the clinical understanding of the disease, as well as evolving intervention methodologies and practitioner expertise. Ménière disease is a multifactorial disease with lifelong comorbidities and loss of quality-associated life-years; therefore, future studies of reliable biomarkers of endolymphatic hydrops and real-time imaging are warranted to improve understanding and treatment.

Intratympanic steroid versus gentamicin for treatment of refractory Meniere's disease: A meta-analysis

PURPOSE

Intratympanic steroid injections (ITSI) have become a promising treatment for refractory Meniere's disease due to less cochleovestibular damage. However, whether ITSI would be a good alternative to intratympanic gentamicin injections (ITGI) for refractory Meniere's disease still remains controversial. Here we intended to compare the therapeutic effect of ITSI and ITGI in patients with Meniere's disease refractory to conservative treatments, in terms of vertigo control and hearing outcomes, via a meta-analysis.

METHODS

Using MEDLINE, PubMed, and EMBASE databases, we calculated pooled odds ratio (OR) estimates of vertigo control rate (i.e., class A according to AAO-HNS guideline) and standardized mean differences (SMD) of spell count, pure tone audiometry (PTA) threshold and speech discrimination score (SDS) with a 95% confidence interval (CI). The trim-and-fill method and sensitivity analysis were used as post-hoc analyses to verify the integrity of the quantitative analysis results. Furthermore, subgroup analyses were performed according to steroid type (methylprednisolone versus dexamethasone) and follow-up period (>1-year versus <1-year).

RESULTS

Five studies involving 332 patients with refractory unilateral Meniere's disease were included. In the pooled analysis, those treated with ITGI showed higher ORs than those treated with ITSI in terms of vertigo control rate (OR: 2.39, 95% CI: 0.84-6.79, P = 0.102) and spell counts (SMD: 0.24, 95% CI: -0.12-0.59, P = 0.195), but it did not reach statistical significance. However, a substantial amount of heterogeneity (I² = 71.0%, Q = 13.79, P = 0.008) and publication bias was found, suggesting a significant small-study effect. Additionally, ITSI elicited better hearing outcomes of the mean PTA threshold (SMD: 3.08, 95% CI: -1.18-7.35) and mean SDS (SMD: 11.15, 95% CI: -23.21-0.90) compared with ITGI, although no statistical significance. In subgroup analysis, the difference in vertigo control rate between ITGI and ITSI was not significant, regardless of the follow-up period and steroid type. Further, methylprednisolone appeared to be superior to dexamethasone for vertigo control. No significant complications from either treatment were reported in the literature.

CONCLUSION

The results of this study further refine the recently proposed efficacy of ITSI for the treatment of refractory Meniere's disease, demonstrating the comparable value of ITGI on vertigo control as well as better hearing preservation. Collectively, ITSI could be a safe and the effective treatment for refractory Meniere's disease. However, the current evidence on efficacy of ITSI for refractory Meniere's disease needs to be further clarified, given the substantial heterogeneity and potential biases.

Endolymphatic Sac Drainage Surgery and Plasma Stress Hormone Vasopressin Levels in Meniere's Disease

Meniere's disease is a common inner ear disorder accompanied by vertigo attacks and fluctuating hearing loss that some believe is due to a stressful lifestyle. To elucidate the scientific relationship in neuro-endocrinology between Meniere's disease and stress, we examined the surgical results of endolymphatic sac drainage surgery and changes in stress-induced plasma arginine-vasopressin levels. We enrolled 100 intractable Meniere's patients and examined surgical results and plasma vasopressin levels. Fifty-four chronic otitis media patients who underwent tympano-mastoidectomy formed a control group. We assessed surgical results during a 2-year follow-up period, including vertigo and hearing loss. We examined plasma vasopressin levels just before surgery and 1 week, 1 year, and 2 years after surgery. In patients with intractable Meniere's disease, plasma vasopressin levels were significantly reduced 1 week after surgery compared to the decrease observed in chronic otitis media patients after tympano-mastoidectomy. In intractable Meniere's disease, long-lasting low plasma vasopressin levels after surgery were associated with significantly good surgical results. In recurrent Meniere's disease, a gradual plasma vasopressin level elevation was observed after surgery, followed by recurrent vertigo attacks and sensorineural hearing loss. It is suggested that long-lasting high levels of plasma vasopressin could have adverse effects on inner ear water metabolism and the subsequent Meniere's disease symptoms. Effective treatments for Meniere's disease might be best based on the maintenance of low plasma vasopressin levels.

Identification of Potential Meniere's Disease Targets in the Adult Stria Vascularis

The stria vascularis generates the endocochlear potential and is involved in processes that underlie ionic homeostasis in the cochlear endolymph, both which play essential roles in hearing. The histological hallmark of Meniere's disease (MD) is endolymphatic hydrops, which refers to the bulging or expansion of the scala media, which is the endolymph-containing compartment of the cochlea. This histologic hallmark suggests that processes that disrupt ion homeostasis or potentially endocochlear potential may underlie MD. While treatments exist for vestibular symptoms related to MD, effective therapies for hearing fluctuation and hearing loss seen in MD remain elusive. Understanding the potential cell types involved in MD may inform the creation of disease mouse models and provide insight into underlying mechanisms and potential therapeutic targets. For these reasons, we compare published datasets related to MD in humans with our previously published adult mouse stria vascularis single-cell and single-nucleus RNA-Seq datasets to implicate potentially involved stria vascularis (SV) cell types in MD. Finally, we provide support for these implicated cell types by demonstrating co-expression of select candidate genes for MD within SV cell types.

MicroRNA Profiling as a Methodology to Diagnose Ménière's Disease: Potential Application of Machine Learning

OBJECTIVE

Diagnosis and treatment of Ménière's disease remains a significant challenge because of our inability to understand what is occurring on a molecular level. MicroRNA (miRNA) perilymph profiling is a safe methodology and may serve as a "liquid biopsy" equivalent. We used machine learning (ML) to evaluate miRNA expression profiles of various inner ear pathologies to predict diagnosis of Ménière's disease.

STUDY DESIGN

Prospective cohort study.

SETTING

Tertiary academic hospital.

SUBJECTS AND METHODS

Perilymph was collected during labyrinthectomy (Ménière's disease, n = 5), stapedotomy (otosclerosis, n = 5), and cochlear implantation (sensorineural hearing loss [SNHL], n = 9). miRNA was isolated and analyzed with the Affymetrix miRNA 4.0 array. Various ML classification models were evaluated with an 80/20 train/test split and cross-validation. Permutation feature importance was performed to understand miRNAs that were critical to the classification models.

RESULTS

In terms of miRNA profiles for conductive hearing loss versus Ménière's, 4 models were able to differentiate and identify the 2 disease classes with 100% accuracy. The top-performing models used the same miRNAs in their decision classification model but with different weighted values. All candidate models for SNHL versus Ménière's performed significantly worse, with the best models achieving 66% accuracy. Ménière's models showed unique features distinct from SNHL.

CONCLUSIONS

We can use ML to build Ménière's-specific prediction models using miRNA profile alone. However, ML models were less accurate in predicting SNHL from Ménière's, likely from overlap of miRNA biomarkers. The power of this technique is that it identifies biomarkers without knowledge of the pathophysiology, potentially leading to identification of novel biomarkers and diagnostic tests.

Characterization of rare spindle and root cell transcriptional profiles in the stria vascularis of the adult mouse cochlea

The stria vascularis (SV) in the cochlea generates and maintains the endocochlear potential, thereby playing a pivotal role in normal hearing. Knowing transcriptional profiles and gene regulatory networks of SV cell types establishes a basis for studying the mechanism underlying SV-related hearing loss. While we have previously characterized the expression profiles of major SV cell types in the adult mouse, transcriptional profiles of rare SV cell types remained elusive due to the limitation of cell capture in single-cell RNA-Seq. The role of these rare cell types in the homeostatic function of the adult SV remain largely undefined. In this study, we performed single-nucleus RNA-Seq on the adult mouse SV in conjunction with sample preservation treatments during the isolation steps. We distinguish rare SV cell types, including spindle cells and root cells, from other cell types, and characterize their transcriptional profiles. Furthermore, we also identify and validate novel specific markers for these rare SV cell types. Finally, we identify homeostatic gene regulatory networks within spindle and root cells, establishing a basis for understanding the functional roles of these cells in hearing. These novel findings will provide new insights for future work in SV-related hearing loss and hearing fluctuation.

Simultaneous Presentation of Definite Vestibular Migraine and Definite Ménière's Disease: Overlapping Syndrome of Two Diseases

Objectives: To review the clinical records of patients that exhibited the clinical features of both vestibular migraine (VM) and Ménière's disease (MD) during each episodic vertigo attack and to discuss the possible pathophysiology of such combination of symptoms.

Subjects: Ten patients that were selected according to criteria based on a combination of the diagnostic criteria for definite MD and VM (9 females and one male, age: 22–54 years) were enrolled. They were required to show features of both diseases in each vertigo attack.

Methods: The patients' medical histories and pure-tone audiometry, cervical vestibular evoked myogenic potential (cVEMP), video head-impulse test (vHIT), and caloric test results were examined. cVEMP was recorded using 500 and 1,000 Hz short tone bursts (125dBSPL, air-conducted), 500 Hz-1,000 Hz cVEMP slope, an index of endolymphatic hydrops in the saccule was calculated using normalized amplitudes of p13-n23. For performing vHIT, each subject was seated 1.5 m in front of a target and asked to keep watching it as their head was passively rotated by the examiner. Their eye movements were evaluated using video-oculography while their head movements were recorded using inertial sensors.

Results: The patients were predominantly female. On average, the onset of migrainous headaches occurred 9 years earlier than the onset of vertigo attacks. All of the patients but one had migraines with auras. Five of the 10 patients had a family history of vertigo attacks accompanied by both migrainous and auditory symptoms. The patients mainly displayed hearing loss at low frequencies. Nine patients exhibited 500–1,000 Hz cVEMP slope < −19.9, which was suggestive of endolymphatic hydrops. None of the patients who underwent vHIT showed abnormal canal function. One patient showed unilaterally decreased caloric responses.

Conclusions: These patients presented with simultaneous MD and VM signs/symptoms might be referred to “VM/MD overlapping syndrome (VM/MD-OS)” as a new clinical syndrome.

Ménière's Disease: Molecular Analysis of Aquaporins 2, 3 and Potassium Channel KCNE1 Genes in Brazilian Patients

OBJECTIVES

Ménière's disease (MD) is a complex disease of unknown etiology characterized by a symptomatic tetrad of vertigo, hearing loss, tinnitus, and aural fullness. In addition to factors related to homeostasis of the inner ear, genetic factors have been implicated in its pathophysiology, including genes related to the transport of water and ionic composition maintenance of the endolymph, such as the aquaporin genes AQP2 and AQP3, and the potassium channel gene KCNE1. The aim of this study was to identify polymorphisms of these genes and determine their association with clinical characteristics of patients with MD.

DESIGN

A case-control genetic association study was carried out, including 30 patients with definite Ménière's disease and 30 healthy controls. The coding regions of the target genes were amplified from blood samples by polymerase chain reaction (PCR), followed by direct sequencing. The associations of polymorphisms with clinical characteristics were analyzed with logistic regression.

RESULTS

Five polymorphisms were identified: rs426496 in AQP2; rs591810 in AQP3; and rs1805127, rs1805128, and rs17173510 in KCNE1. After adjustment, rs426496 was significantly associated with tinnitus during the initial crisis and with altered electronystagmography, and rs1805127 was significantly associated with nephropathy.

CONCLUSIONS

The genetic variant rs426496 in AQP2; rs591810 in AQP3 and rs1805127, rs1805128, and rs17173510, in KCNE1 were found in patients with Ménière's disease. The polymorphism rs426496, in AQP2, is associated with tinnitus at the onset of Ménière's disease and altered electronystagmography. In addition, rs1805127, in KCNE1, is associated with the presence of nephropathy.

A Two-Year Randomized Trial of Interventions to Decrease Stress Hormone Vasopressin Production in Patients with Meniere's Disease-A Pilot Study

Meniere's disease, a common inner ear condition, has an incidence of 15-50 per 100,000. Because mental/physical stress and subsequent increase in the stress hormone vasopressin supposedly trigger Meniere's disease, we set a pilot study to seek new therapeutic interventions, namely management of vasopressin secretion, to treat this disease. We enrolled 297 definite Meniere's patients from 2010 to 2012 in a randomized-controlled and open-label trial, assigning Group-I (control) traditional oral medication, Group-II abundant water intake, Group-III tympanic ventilation tubes and Group-IV sleeping in darkness. Two hundred sixty-three patients completed the planned 2-year-follow-up, which included assessment of vertigo, hearing, plasma vasopressin concentrations and changes in stress/psychological factors. At 2 years, vertigo was completely controlled in 54.3% of patients in Group-I, 81.4% in Group-II, 84.1% in Group-III, and 80.0% in Group-IV (statistically I < II = III = IV). Hearing was improved in 7.1% of patients in Group-I, 35.7% in Group-II, 34.9% in Group-III, and 31.7% in Group-IV (statistically I < II = III = IV). Plasma vasopressin concentrations decreased more in Groups-II, -III, and -IV than in Groups-I (statistically I < II = III = IV), although patients' stress/psychological factors had not changed. Physicians have focused on stress management for Meniere's disease. However, avoidance of stress is unrealistic for patients who live in demanding social environments. Our findings in this pilot study suggest that interventions to decrease vasopressin secretion by abundant water intake, tympanic ventilation tubes and sleeping in darkness is feasible in treating Meniere's disease, even though these therapies did not alter reported mental/physical stress levels.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01099046.

Aquaporins: Multiple Roles in the Central Nervous System

Aquaporins (AQPs) represent a diverse family of membrane proteins found in prokaryotes and eukaryotes. The primary aquaporins expressed in the mammalian brain are AQP1, which is densely packed in choroid plexus cells lining the ventricles, and AQP4, which is abundant in astrocytes and concentrated especially in the end-feet structures that surround capillaries throughout the brain and are present in glia limitans structures, notably in osmosensory areas such the supraoptic nucleus. Water movement in brain tissues is carefully regulated from the micro- to macroscopic levels, with aquaporins serving key roles as multifunctional elements of complex signaling assemblies. Intriguing possibilities suggest links for AQP1 in Alzheimer's disease, AQP4 as a target for therapy in brain edema, and a possible contribution of AQP9 in Parkinson's disease. For all the aquaporins, new contributions to physiological functions are likely to continue to be discovered with ongoing work in this rapidly expanding field of research. NEUROSCIENTIST 13(5):470—485, 2007.

Altered chromogranin A circulating levels in Meniere's disease

OBJECTIVES

Meniere's disease (MD) is an inner ear disorder characterized by episodic vertigo, ear fullness, and hearing loss; usually vertigo attacks cluster in specific period. We studied in MD patients the circulating levels of chromogranin A (CgA) and vasostatin-1 (VS-1), secreted by the neuroendocrine system and involved in the regulation of the endothelial barrier function.

METHODS

Serum levels were assessed in 37 MD patients and 36 controls. The ratio between VS-1 and CgA was calculated.

RESULTS

CgA was increased in patients compared to controls (1.46 versus 0.67 nM, p = 0.01) while no difference was detected for VS-1 (0.41 versus 0.39, resp.). CgA levels in patients positively correlated with the frequency of vertigo spells in the previous four weeks (p = 0.008) and negatively with the time in days from the last vertigo attack (p = 0.018). Furthermore, the VS-1/CgA ratio negatively correlated with the frequency of vertigo spells (p = 0.029) and positively correlated with the time from the last attack (p = 0.003).

CONCLUSION

The results indicate that variations of CgA levels, but not of VS-1, occur in the blood of patients with active MD, depending on the frequency of vertigo spells and the time from the last crisis.

Incidence of tympanic membrane perforation after intratympanic steroid treatment through myringotomy tubes

Intratympanic (IT) steroids are often used to treat inner ear disorders such as sudden idiopathic sensorineural hearing loss, autoimmune inner ear disease, and Ménière disease. Administration of corticosteroids via IT injection, via application with a pledget to the round window, or via catheter has been used for this purpose. The frequency of adverse events related to the IT injection of steroids is low, with pain, short-lasting vertigo, otitis media, and tympanic perforations being the most common complications. However, the safety of IT steroid therapy has not yet been established in a randomized clinical trial. In this article, we discuss a group of 11 patients with sensorineural hearing loss who underwent myringotomy and tube placement for home-based dexamethasone instillation and subsequently developed the complication of tympanic membrane perforation. It appears that there is a significantly increased incidence of tympanic membrane perforations in this population.

Expression and translocation of aquaporin-2 in the endolymphatic sac in patients with Meniere's disease

Meniere's disease, characterised by episodic vertigo, fluctuating hearing loss and tinnitus, can occur under conditions of stress. Its pathology was first revealed to be inner ear hydrops through temporal bone studies in 1938. Although its pathogenesis has been proposed to be a disorder of water transport in the inner ear, subsequently, it remains unsolved, until now. A recent study revealed that both plasma stress hormone, vasopressin (pAVP) and its receptor, V2 (V2R) expression in the inner ear endolymphatic sac were significantly higher in Meniere's patients. In the present study, to link V2R-related molecules and inner ear hydrops, we examined V2R-linked water channel molecule, aquaporin-2 (AQP2) expression and translocation in human endolymphatic sac. AQP2 mRNA expression in the endolymphatic sac was significantly higher in Meniere's patients by using real-time polymerase chain reaction, as further confirmed by western blotting. AQP2-like immunoreactivity (-LIR) was translocated from luminal to basolateral side with endosomal trapping in the endolymphatic sac at the time of AVP exposure in human endolymphatic sac tissue culture. The similar AQP2-LIR translocation was also demonstrated by forskolin and blocked by vasopressin/V2R specific antagonist, OPC31260 and protein kinase A (PKA) specific antagonists, H-89 and KT-5720. We concluded that in the pathogenesis of inner ear hydrops resulting in Meniere's attacks, pAVP elevation as a result of stress and subsequent V2R-cAMP-PKA-AQP2 activation and endosomal trapping of AQP2 in the endolymphatic sac, might be important as a basis of this disease. Further experimental and clinical studies are needed to better clarify the neuroscientific relationship between stress and Meniere's disease.

Immunohistochemical localization and mRNA expression of aquaporins in the macula utriculi of patients with Meniere's disease and acoustic neuroma

Meniere's disease is nearly invariably associated with endolymphatic hydrops (the net accumulation of water in the inner ear endolymphatic space). Vestibular maculae utriculi were acquired from patients undergoing surgery for Meniere's disease and acoustic neuroma and from autopsy (subjects with normal hearing and balance). Quantitative immunostaining was conducted with antibodies against aquaporins (AQPs) 1, 4, and 6, Na(+)K(+)ATPase, Na(+)K(+)2Cl co-transporter (NKCC1), and alpha-syntrophin. mRNA was extracted from the surgically acquired utricles from subjects with Meniere's disease and acoustic neuroma to conduct quantitative real-time reverse transcription with polymerase chain reaction for AQP1, AQP4, and AQP6. AQP1 immunoreactivity (-IR) was located in blood vessels and fibrocytes in the underlying stroma, without any apparent alteration in Meniere's specimens when compared with acoustic neuroma and autopsy specimens. AQP4-IR localized to the epithelial basolateral supporting cells in Meniere's disease, acoustic neuroma, and autopsy. In specimens from subjects with Meniere's disease, AQP4-IR was significantly decreased compared with autopsy and acoustic neuroma specimens. AQP6-IR occurred in the sub-apical vestibular supporting cells in acoustic neuroma and autopsy samples. However, in Meniere's disease specimens, AQP6-IR was significantly increased and diffusely redistributed throughout the supporting cell cytoplasm. Na(+)K(+)ATPase, NKCC1, and alpha-syntrophin were expressed within sensory epithelia and were unaltered in Meniere's disease specimens. Expression of AQP1, AQP4, or AQP6 mRNA did not differ in vestibular endorgans from patients with Meniere's disease. Changes in AQP4 (decreased) and AQP6 (increased) expression in Meniere's disease specimens suggest that the supporting cell might be a cellular target.

Metalloid transport by aquaglyceroporins: consequences in the treatment of human diseases

Metalloids can severely harm human physiology in a toxicological sense if taken up from the environment in acute high doses or chronically. However, arsenic or antimony containing drugs are still being used as treatment and are often the sole regime for certain forms of cancer, mainly types of leukemia and diseases caused by parasites, such as sleeping sickness or leishmaniasis. In this chapter, we give an outline of the positive effects of arsenicals and antimonials against such diseases, we summarize data on uptake pathways through human and parasite aquaglyceroporins and we discuss the progress and options in the development of therapeutic aquaporin and aquaglyceroporin inhibitor compounds.

Plasma vasopressin and V2 receptor in the endolymphatic sac in patients with delayed endolymphatic hydrops

OBJECTIVE

There are some kinds of sicknesses provoked by inadequate adaptation to physical and/or psychogenic stress in daily life. Delayed endolymphatic hydrops (DEH) is an inner ear disease like Ménière's disease (MD) characterized by episodic vertigo in the setting of preexisting unilateral deafness that especially occurs in civilized people with a stressful lifestyle. Its otopathologic finding was demonstrated to be inner ear endolymphatic hydrops through a temporal bone study in 1976, as in the case with MD in 1938. To elucidate the relationship between stress and the inner ear, we examined the plasma antidiuretic stress hormone vasopressin (pAVP) and its type 2 receptor (V2R) expression in the endolymphatic sac in patients with DEH.

STUDY DESIGN

A prospective molecular biological study.

METHODS

Between 1998 and 2007, we enrolled 20 patients with ipsilateral DEH to examine their pAVP during remission from vertigo attacks. Plasma vasopressin was also examined in 87 patients with unilateral MD and 30 control patients with chronic otitis media. Using the real-time polymerase chain reaction method with tissue samples obtained during surgery, we examined V2R mRNA expression in the endolymphatic sac in 6 patients with ipsilateral DEH, 9 patients with unilateral MD, and 6 control patients with acoustic neuroma.

RESULTS

Plasma vasopressin (1.5 times versus controls; unpaired t test, p = 0.140) and V2R mRNA expression in the endolymphatic sac (35.8 times versus controls; unpaired t test, p = 0.002) were higher in patients with DEH compared with those with acoustic neuroma. There were no significant differences in pAVP or V2R expression in the endolymphatic sac between DEH and MD. Patients with DEH showed a significantly negative correlation between pAVP and V2R (Pearson test, r = -0.92, p = 0.009) as in those with MD (Pearson test, r = -0.68, p = 0.043).

CONCLUSION

Civilized people are frequently exposed to stress in their daily life, and pAVP can easily become elevated at any time. Therefore, a negative feedback system between pAVP and V2R in the endolymphatic sac may function for inner ear fluid homeostasis against stress-induced increases in pAVP. For the pathogenesis of endolymphatic hydrops resulting in vertigo attacks in patients with DEH as well as MD, pAVP may represent a matter of consequence, but V2R overexpression in the endolymphatic sac could be much more essential as a basis for these diseases.

Slc4a11 gene disruption in mice: cellular targets of sensorineuronal abnormalities

NaBC1 (the SLC4A11 gene) belongs to the SLC4 family of sodium-coupled bicarbonate (carbonate) transporter proteins and functions as an electrogenic sodium borate cotransporter. Mutations in SLC4A11 cause either corneal abnormalities (corneal hereditary dystrophy type 2) or a combined auditory and visual impairment (Harboyan syndrome). The role of NaBC1 in sensory systems is poorly understood, given the difficulty of studying patients with NaBC1 mutations. We report our findings in Slc4a11(-/-) mice generated to investigate the role of NaBC1 in sensorineural systems. In wild-type mice, specific NaBC1 immunoreactivity was detected in fibrocytes of the spiral ligament, from the basal to the apical portion of the cochlea. NaBC1 immunoreactivity was present in the vestibular labyrinth, in stromal cells underneath the non-immunoreactive sensory epithelia of the macula utricle, sacule, and crista ampullaris, and the membranous vestibular labyrinth was collapsed. Both auditory brain response and vestibular evoked potential waveforms were significantly abnormal in Slc4a11(-/-) mice. In the cornea, NaBC1 was highly expressed in the endothelial cell layer with less staining in epithelial cells. However, unlike humans, the corneal phenotype was mild with a normal slit lamp evaluation. Corneal endothelial cells were morphologically normal; however, both the absolute height of the corneal basal epithelial cells and the relative basal epithelial cell/total corneal thickness were significantly increased in Slc4a11(-/-) mice. Our results demonstrate for the first time the importance of NaBC1 in the audio-vestibular system and provide support for the hypothesis that SLC4A11 should be considered a potential candidate gene in patients with isolated sensorineural vestibular hearing abnormalities.

Histopathological and ultrastructural analysis of vestibular endorgans in Meniere's disease reveals basement membrane pathology

BACKGROUND

We report the systematic analysis of the ultrastructural and cytological histopathology of vestibular endorgans acquired from labyrinthectomy in Meniere's disease.

METHODS

17 subjects with intractable Meniere's disease and ipsilateral non-serviceable hearing presenting to the Neurotology Clinic from 1997 to 2006 who chose ablative labyrinthectomy (average age = 62 years; range 29-83 years) participated. The average duration of symptoms prior to surgery was 7 years (range 1-20 years).

RESULTS

Nearly all vestibular endorgans demonstrated varying degrees of degeneration. A monolayer of epithelial cells occurred significantly more frequently in the horizontal cristae (12/13 = 92%) (p < 0.001), the superior cristae (5/5 = 100%) (p < 0.005), the posterior cristae (2/2) compared with the utricular maculae (4/17 = 24%). Basement membrane (BM) thickening was more common in all of the cristae ampullares (18 out of 20) than the utricular maculae. Although only four saccular maculae were obtained, 3 out of 4 exhibited BM thickening and monolayer degeneration. Monolayer degeneration was highly significantly correlated with the presence of BM thickening (p < 0.001). Other degenerative changes noted equally among the five vestibular endorgans which were not significantly correlated with BM thickening or monolayer degeneration included hair cell vacuolization and stereocilia loss, microvesicles in the supporting cells, and increased stromal intercellular spaces. Transmission electron microscopy demonstrated disorganization of the BM collagen-like fibrils, and normal ultrastructural morphology of the nerve terminals and myelinated fibers. Stromal fibroblasts and endothelial cells of stromal blood vessels demonstrated vacuolization, and stromal perivascular BMs were also thickened.

CONCLUSION

Systematic histopathological analysis of the vestibular endorgans from Meniere's disease demonstrated neuroepithelial degeneration which was highly correlated with an associated BM thickening. Other findings included hair cell and supporting cell microvessicles, increased intercellular clear spaces in the stroma, and endothelial cell vacuolization and stromal perivascular BM thickening.

Immunohistochemical distribution of basement membrane proteins in the human inner ear from older subjects

The immunolocalization of several basement membrane (BM) proteins was investigated in vestibular endorgans microdissected from temporal bones obtained from subjects with a documented normal auditory and vestibular function (n=5, average age=88 years old). Fluorescent immunostaining using antibodies directed at collagen IV alpha 2, nidogen-1, laminin-beta2, alpha-dystroglycan, and tenascin-C was applied to cryosections from human cochlea, cristae ampullares, utricular and saccular maculae. Collagen IV alpha 2, nidogen-1, and laminin-beta2 localized to all subepithelial cochlear BMs, Reissner's membrane, strial and spiral ligamental perineural and perivascular BMs, and the spiral limbus. Tenascin-C localized to the basilar membrane and the osseous spiral lamina. alpha-Dystroglycan localized to most cochlear BMs except those in the spiral ligament, basilar membrane and spiral limbus. Collagen IV, nidogen-1, and laminin-beta2 localized to the subepithelial BMs of the maculae and cristae ampullares, and the perineural and perivascular BMs within the underlying stroma. The BM underlying the transitional and dark cell region of the cristae ampullares also expressed collagen IV, nidogen-1, and laminin-beta2. Tenascin-C localized to the subepithelial BMs of the utricular maculae and cristae ampullares, and to calyx-like profiles throughout the vestibular epithelium, but not to the perineural and perivascular BMs. alpha-Dystroglycan colocalized with aquaporin-4 in the basal vestibular supporting cell, and was also expressed in the subepithelial BMs, as well as perivascular and perineural BMs. This study provides the first comprehensive immunolocalization of these ECM proteins in the human inner ear. The validity of the rodent models for inner ear disorders secondary to BM pathologies was confirmed as there is a high degree of conservation of expression of these proteins in the human inner ear. This information is critical to begin to unravel the role that BMs may play in human inner ear physiology and audiovestibular pathologies.

Issues, indications, and controversies regarding intratympanic steroid perfusion

PURPOSE OF REVIEW

Office-based intratympanic inner ear steroid perfusion (ITPs) treatment for Ménière's disease, autoimmune inner ear disease, and sudden sensorineural hearing loss has been expanding over the past 10-15 years, yet remains controversial. The purpose of this review is to examine the current literature of basic science and human studies of ITPs treatment.

RECENT FINDINGS

Animal studies exist regarding the delivery, distribution, biochemical, and microbiological changes in the inner ear post ITPs. However, few clinical studies exist on ITPs treatment in sudden sensorineural hearing loss and even less in treating Ménière's disease. There are no consistent studies regarding drug delivery methods, type, and concentration of steroids. Moreover, there are no studies comparing ITPs results to the natural history of Ménière's disease.

SUMMARY

ITPs has impacted otology and neurotology practice due to increased utilization. A sound understanding of the basic science and clinical studies is needed to establish long-term efficacy of ITPs in controlling hearing loss in Ménière's disease by comparison to its natural history, as well as, potential application to other disorders.

Meniere's attacks occur in the inner ear with excessive vasopressin type-2 receptors

Meniere's disease is peculiar to humans and is characterised by episodic vertigo, fluctuating hearing loss and tinnitus, and attacks of the affliction occurring under conditions of stress. Its pathology was first revealed to be inner ear hydrops through temporal bone studies in 1938. Although subsequently proposed as a disorder of water metabolism in the inner ear, its pathogenesis remains unsolved. The present study aimed to assess the link between the inner ear pathology in Meniere's disease and vasopressin, an anti-diuretic stress hormone with a potential role in inner ear fluid homeostasis. Blood samples were obtained from Meniere's disease patients in the morning, before any surgical treatment, to examine plasma vasopressin (pAVP) levels, and then from inner ear tissue during surgical treatment, to examine vasopressin type-2 receptor (V2R) in the endolymphatic sac. pAVP and the relative V2R mRNA expression in the endolymphatic sac were examined using a real-time polymerase chain reaction. Relative cAMP activity in the endolymphatic sac was also examined using tissue culture and cAMP assay. Both pAVP (1.6-fold versus controls; P = 0.048) and inner ear V2R mRNA expression (41.5-fold versus controls; P = 0.022) were significantly higher in Meniere's patients. cAMP activity was basally up-regulated (2.1-fold versus controls) and cAMP sensitivity to vasopressin application was largely elevated (4.9-fold versus controls) in Meniere's patients. We conclude that, in the pathogenesis of inner ear hydrops, resulting in Meniere's attacks, elevation of pAVP levels (probably as a result of stress) may present as a matter of consequence, but susceptibility of the V2R-overexpressed and cAMP-hypersensitized inner ear to pAVP elevation might be essential as the basis of this disease. Further experimental and clinical studies are needed to better clarify the relationship between Meniere's disease and stress.

Immunohistochemical localization of aquaporins in the human inner ear

We report the immunolocalization of aquaporins (AQPs) 1, 4, and 6 in the human auditory and vestibular endorgans. A rapid protocol was applied to audiovestibular endorgans microdissected from postmortem human temporal bones from six subjects (ages ranging from 75 to 97 years) with no history of audiovestibular disease. Temporal bones were fixed in formalin, and the endorgans were immediately microdissected. Cryostat sections were obtained from audiovestibular endorgans and were subjected to double-immunohistochemical staining with antibodies against AQPs and several cellular markers. In the human cochlea, AQP1 immunoreactivity was localized to the fibrocytes of the spiral ligament and the sub-basilar tympanic cells; AQP4 immunoreactivity was localized to the outer sulcus cells, Hensen's cells, and Claudius' cells; AQP6 immunoreactivity was localized to the apical portion of interdental cells in the spiral limbus. In the vestibular endorgans (macula utriculi and cristae), AQP1 was localized to fibrocytes and blood vessels of the underlying stroma and trabecular perilymphatic tissue; AQP4 immunoreactivity was localized to the basal pole of vestibular supporting cells; AQP6 was localized to the apical portion of vestibular supporting cells. Cochlear and vestibular hair cells and nerve fibers were not immunoreactive for any AQP. Supporting cells were identified with antibodies against glial fibrilar acidic protein. Nerve fibers and terminals were identified with antibodies against neurofilaments and Na(+)K(+)ATPase. The high degree of conservation of AQP expression in the human inner ear suggests that AQPs play a critical role in inner ear water homeostasis.