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Rincon Sabatino S, Rivero A, Sangaletti R, Dietrich WD, Hoffer ME, King CS, Rajguru SM. Targeted therapeutic hypothermia protects against noise induced hearing loss. Front Neurosci 2024; 17:1296458. [PMID: 38292902 PMCID: PMC10826421 DOI: 10.3389/fnins.2023.1296458] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 12/14/2023] [Indexed: 02/01/2024] Open
Abstract
Introduction Exposure to occupational or recreational loud noise activates multiple biological regulatory circuits and damages the cochlea, causing permanent changes in hearing sensitivity. Currently, no effective clinical therapy is available for the treatment or mitigation of noise-induced hearing loss (NIHL). Here, we describe an application of localized and non-invasive therapeutic hypothermia and targeted temperature management of the inner ear to prevent NIHL. Methods We developed a custom-designed cooling neck collar to reduce the temperature of the inner ear by 3-4°C post-injury to deliver mild therapeutic hypothermia. Results This localized and non-invasive therapeutic hypothermia successfully mitigated NIHL in rats. Our results show that mild hypothermia can be applied quickly and safely to the inner ear following noise exposure. We show that localized hypothermia after NIHL preserves residual hearing and rescues noise-induced synaptopathy over a period of months. Discussion This study establishes a minimally-invasive therapeutic paradigm with a high potential for rapid translation to the clinic for long-term preservation of hearing health.
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Affiliation(s)
| | - Andrea Rivero
- Department of Biomedical Engineering, University of Miami, Coral Gables, FL, United States
| | - Rachele Sangaletti
- The Miami Project to Cure Paralysis, University of Miami, Coral Gables, FL, United States
| | - W. Dalton Dietrich
- Department of Otolaryngology, University of Miami, Coral Gables, FL, United States
| | - Michael E. Hoffer
- The Miami Project to Cure Paralysis, University of Miami, Coral Gables, FL, United States
| | | | - Suhrud M. Rajguru
- Department of Biomedical Engineering, University of Miami, Coral Gables, FL, United States
- The Miami Project to Cure Paralysis, University of Miami, Coral Gables, FL, United States
- RestorEar Devices LLC, Bozeman, MT, United States
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Abstract
OBJECTIVE To determine temperature and duration of cooling necessary for achieving cochlear mild therapeutic hypothermia (MTH) via ear canal cooling using cool water and earmold attached to a Peltier device. STUDY DESIGN AND SETTING Human temporal bone lab study performed at the University of Mississippi Medical Center. INTERVENTIONS Cochlear cooling via the ear canal using water irrigation and an earmold attached to a Peltier device. Temperature analysis through implanted thermal probes within the cochlea. MAIN OUTCOME MEASURES Temperature changes in the cochlea. RESULTS Irrigation of the ear canal with water resulted in achieving MTH in approximately 4 minutes using cool water (30°C) and in approximately 2 minutes using ice-chilled water. After 20 minutes, irrigation of the ear canal using cool water plateaued at a ∆2°C while cooling with ice-chilled water results in an average ∆4.5°C. We observed MTH using a medium-length earmold attached to a Peltier device after approximately 22 minutes of cooling and achieved a maximal average ∆ of 2.3°C after 60 minutes of cooling. Finally, we observed that a longer earmold (C2L) with greater proximity to the eardrum resulted in more efficient intracochlear temperature change, achieving MTH in approximately 16 minutes. CONCLUSIONS MTH of the cochlea can be achieved with water-based ear canal irrigation and via a Peltier device connected to an aluminum earmold.
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Rau TS, Ehmann T, Zuniga MG, Plaskonka K, Keck A, Majdani O, Lenarz T. Toward a cochlear implant electrode array with shape memory effect for post-insertion perimodiolar positioning. J Biomed Mater Res B Appl Biomater 2022; 110:2494-2505. [PMID: 35678249 DOI: 10.1002/jbm.b.35107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Revised: 05/16/2022] [Accepted: 05/20/2022] [Indexed: 11/08/2022]
Abstract
For cochlear implants (CI) a final position of the electrode array (EA) along the inner wall of the spirally shaped cochlea is considered to be beneficial because it results in a closer proximity to the auditory nerve fibers. A shape memory effect (SME) could facilitate such shift of the EA toward the cochlear inner wall, but its implementation remains to be solved. The current study presents an EA prototype featuring the SME with minute adjustments of the material properties of Nitinol, a shape memory alloy, in combination with a suitable cooling strategy to prevent premature curling. Ten samples were successfully inserted by a CI surgeon into an artificial cochlear model submerged into a temperature-controllable water bath to simulate temporary hypothermia of the inner ear (31°C). Gentle insertions were possible, with an average insertion speed of 0.81 ± 0.14 mm/s. After recovery of body temperature, the desired position shift toward the modiolus was observed in all trials. Angular insertion depth increased by approximately 81.8° ± 23.4°. We demonstrate for the first time that using the body temperature responsive SME for perimodiolar EA positioning is feasible and does not impede a gentle surgical insertion.
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Affiliation(s)
- Thomas S Rau
- Department of Otolaryngology, Hannover Medical School, Hannover, Germany.,Cluster of Excellence EXC 2177/1 "Hearing4all", Hannover Medical School, Hannover, Germany
| | - Tim Ehmann
- Department of Otolaryngology, Hannover Medical School, Hannover, Germany
| | - M Geraldine Zuniga
- Department of Otolaryngology, Hannover Medical School, Hannover, Germany.,Cluster of Excellence EXC 2177/1 "Hearing4all", Hannover Medical School, Hannover, Germany
| | | | | | - Omid Majdani
- Department of Otolaryngology, Hannover Medical School, Hannover, Germany.,Cluster of Excellence EXC 2177/1 "Hearing4all", Hannover Medical School, Hannover, Germany
| | - Thomas Lenarz
- Department of Otolaryngology, Hannover Medical School, Hannover, Germany.,Cluster of Excellence EXC 2177/1 "Hearing4all", Hannover Medical School, Hannover, Germany
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Current Concepts and Future Trends in Increasing the Benefits of Cochlear Implantation: A Narrative Review. Medicina (B Aires) 2022; 58:medicina58060747. [PMID: 35744010 PMCID: PMC9229893 DOI: 10.3390/medicina58060747] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Revised: 05/25/2022] [Accepted: 05/29/2022] [Indexed: 01/29/2023] Open
Abstract
Hearing loss is the most common neurosensory disorder, and with the constant increase in etiological factors, combined with early detection protocols, numbers will continue to rise. Cochlear implantation has become the gold standard for patients with severe hearing loss, and interest has shifted from implantation principles to the preservation of residual hearing following the procedure itself. As the audiological criteria for cochlear implant eligibility have expanded to include patients with good residual hearing, more attention is focused on complementary development of otoprotective agents, electrode design, and surgical approaches. The focus of this review is current aspects of preserving residual hearing through a summary of recent trends regarding surgical and pharmacological fundamentals. Subsequently, the assessment of new pharmacological options, novel bioactive molecules (neurotrophins, growth factors, etc.), nanoparticles, stem cells, and gene therapy are discussed.
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Spankovich C, Walters BJ. Mild Therapeutic Hypothermia and Putative Mechanisms of Hair Cell Survival in the Cochlea. Antioxid Redox Signal 2021; 36:1203-1214. [PMID: 34619988 PMCID: PMC9221161 DOI: 10.1089/ars.2021.0184] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 09/29/2021] [Indexed: 12/20/2022]
Abstract
Significance: Sensorineural hearing loss has significant implications for quality of life and risk for comorbidities such as cognitive decline. Noise and ototoxic drugs represent two common risk factors for acquired hearing loss that are potentially preventable. Recent Advances: Numerous otoprotection strategies have been postulated over the past four decades with primary targets of upstream redox pathways. More recently, the application of mild therapeutic hypothermia (TH) has shown promise for otoprotection for multiple forms of acquired hearing loss. Critical Issues: Systemic antioxidant therapy may have limited application for certain ototoxic drugs with a therapeutic effect on redox pathways and diminished efficacy of the primary drug's therapeutic function (e.g., cisplatin for tumors). Future Directions: Mild TH likely targets multiple mechanisms, contributing to otoprotection, including slowed metabolics, reduced oxidative stress, and involvement of cold shock proteins. Further work is needed to identify the mechanisms of mild TH at play for various forms of acquired hearing loss.
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Affiliation(s)
- Christopher Spankovich
- Department of Otolaryngology-Head and Neck Surgery and University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Bradley J. Walters
- Department of Otolaryngology-Head and Neck Surgery and University of Mississippi Medical Center, Jackson, Mississippi, USA
- Department of Neurobiology and Anatomical Sciences, University of Mississippi Medical Center, Jackson, Mississippi, USA
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Esmailie F, Francoeur M, Ameel T. Experimental Validation of a Three-Dimensional Heat Transfer Model Within the Scala Tympani With Application to Magnetic Cochlear Implant Surgery. IEEE Trans Biomed Eng 2021; 68:2821-2832. [PMID: 33523803 PMCID: PMC8415572 DOI: 10.1109/tbme.2021.3055976] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Magnetic guidance of cochlear implants is a promising technique to reduce the risk of physical trauma during surgery. In this approach, a magnet attached to the tip of the implant electrode array is guided within the scala tympani using a magnetic field. After surgery, the magnet must be detached from the implant electrode array via localized heating, which may cause thermal trauma, and removed from the scala tympani. OBJECTIVES The objective of this work is to experimentally validate a three-dimensional (3D) heat transfer model of the scala tympani which will enable accurate predictions of the maximum safe input power to avoid localized hyperthermia when detaching the magnet from the implant electrode array. METHODS Experiments are designed using a rigorous scale analysis and performed by measuring transient temperatures in a 3D-printed scala tympani phantom subjected to a sudden change in its isothermal environment and localized heating via a small heat source. RESULTS The measured and predicted temperatures are in good agreement with an error less than 6 % ( p= 0.84). For the most conservative case where all boundaries of the model except the insertion opening are adiabatic, the power required to release the magnet attached to the implant electrode array by 1 mm 3 of paraffin is approximately half of the predicted maximum safe input power. CONCLUSIONS A 3D heat transfer model of the scala tympani is successfully validated and enables predicting the maximum safe input power required to detach the magnet from the implant electrode array. SIGNIFICANCE This work will enable the design of a thermally safe magnetic cochlear implant surgery procedure.
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Bader W, Gottfried T, Degenhart G, Johnson Chacko L, Sieber D, Riechelmann H, Fischer N, Hoermann R, Glueckert R, Schrott-Fischer A, Schmutzhard J. Measurement of the Intracochlear Hypothermia Distribution Utilizing Tympanic Cavity Hypothermic Rinsing Technique in a Cochlea Hypothermia Model. Front Neurol 2021; 11:620691. [PMID: 33505351 PMCID: PMC7830138 DOI: 10.3389/fneur.2020.620691] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 12/07/2020] [Indexed: 11/13/2022] Open
Abstract
Introduction: Cochlea implants can cause severe trauma leading to intracochlear apoptosis, fibrosis, and eventually to loss of residual hearing. Mild hypothermia has been shown to reduce toxic or mechanical noxious effects, which can result in inflammation and subsequent hearing loss. This paper evaluates the usability of standard surgical otologic rinsing as cooling medium during cochlea implantation as a potential hearing preservation technique. Material and Methods: Three human temporal bones were prepared following standard mastoidectomy and posterior tympanotomy. Applying a retrocochlear approach leaving the mastoidectomy side intact, temperature probes were placed into the basal turn (n = 4), the middle turn (n = 2), the helicotrema, and the modiolus. Temperature probe positions were visualized by microcomputed tomography (μCT) imaging and manually segmented using Amira® 7.6. Through the posterior tympanotomy, the tympanic cavity was rinsed at 37°C in the control group, at room temperature (in the range between 22 and 24°C), and at iced water conditions. Temperature changes were measured in the preheated temporal bone. In each temperature model, rinsing was done for 20 min at the pre-specified temperatures measured in 0.5-s intervals. At least five repetitions were performed. Data were statistically analyzed using pairwise t-tests with Bonferroni correction. Results: Steady-state conditions achieved in all three different temperature ranges were compared in periods between 150 and 300 s. Temperature in the inner ear started dropping within the initial 150 s. Temperature probes placed at basal turn, the helicotrema, and middle turn detected statistically significant fall in temperature levels following body temperature rinses. Irrigation at iced conditions lead to the most significant temperature drops. The curves during all measurements remained stable with 37°C rinses. Conclusion: Therapeutic hypothermia is achieved with standard surgical irrigation fluid, and temperature gradients are seen along the cochlea. Rinsing of 120 s duration results in a therapeutic local hypothermia throughout the cochlea. This otoprotective procedure can be easily realized in clinical practice.
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Affiliation(s)
- Werner Bader
- Department of Otorhinolaryngology, Medical University Innsbruck, Innsbruck, Austria
| | - Timo Gottfried
- Department of Otorhinolaryngology, Medical University Innsbruck, Innsbruck, Austria
| | - Gerald Degenhart
- Department of Radiology, University Clinics Innsbruck, Innsbruck, Austria
| | - Lejo Johnson Chacko
- Department of Otorhinolaryngology, Medical University Innsbruck, Innsbruck, Austria
| | - Daniel Sieber
- MED-EL Medical Electronics GesmbH, Research and Development, Innsbruck, Austria
| | - Herbert Riechelmann
- Department of Otorhinolaryngology, Medical University Innsbruck, Innsbruck, Austria
| | - Natalie Fischer
- Department of Otorhinolaryngology, Medical University Innsbruck, Innsbruck, Austria
| | - Romed Hoermann
- Department of Anatomy, Histology, and Embryology, Medical University Innsbruck, Innsbruck, Austria
| | - Rudolf Glueckert
- Department of Otorhinolaryngology, Medical University Innsbruck, Innsbruck, Austria
| | | | - Joachim Schmutzhard
- Department of Otorhinolaryngology, Medical University Innsbruck, Innsbruck, Austria
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Perez E, Viziano A, Al-Zaghal Z, Telischi FF, Sangaletti R, Jiang W, Dietrich WD, King C, Hoffer ME, Rajguru SM. Anatomical Correlates and Surgical Considerations for Localized Therapeutic Hypothermia Application in Cochlear Implantation Surgery. Otol Neurotol 2020; 40:1167-1177. [PMID: 31318786 PMCID: PMC6750193 DOI: 10.1097/mao.0000000000002373] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Application of localized, mild therapeutic hypothermia during cochlear implantation (CI) surgery is feasible for residual hearing preservation.
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Affiliation(s)
| | - Andrea Viziano
- Department of Otolaryngology.,Department of Clinical Sciences and Translational Medicine, University of Rome Tor Vergata, Rome, Italy
| | | | | | | | - Weitao Jiang
- Department of Biomedical Engineering, University of Miami, Miami, Florida
| | - William Dalton Dietrich
- Department of Neurological Surgery, The Miami Project to Cure Paralysis, University of Miami, Miami, Florida
| | | | | | - Suhrud M Rajguru
- Department of Otolaryngology.,Department of Biomedical Engineering, University of Miami, Miami, Florida
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Esmailie F, Francoeur M, Ameel T. Heat transfer analysis in an uncoiled model of the cochlea during magnetic cochlear implant surgery. INTERNATIONAL JOURNAL OF HEAT AND MASS TRANSFER 2020; 154:119683. [PMID: 32773843 PMCID: PMC7405954 DOI: 10.1016/j.ijheatmasstransfer.2020.119683] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Magnetic cochlear implant surgery requires removal of a magnet via a heating process after implant insertion, which may cause thermal trauma within the ear. Intra-cochlear heat transfer analysis is required to ensure that the magnet removal phase is thermally safe. The objective of this work is to determine the safe range of input power density to detach the magnet without causing thermal trauma in the ear, and to analyze the effectiveness of natural convection with respect to conduction for removing the excess heat. A finite element model of an uncoiled cochlea, which is verified and validated, is applied to determine the range of maximum safe input power density to detach a 1-mm-long, 0.5-mm-diameter cylindrical magnet from the cochlear implant electrode array tip. It is shown that heat dissipation in the cochlea is primarily mediated by conduction through the electrode array. The electrode array simultaneously reduces natural convection due to the no-slip boundary condition on its surface and increases axial conduction in the cochlea. It is concluded that natural convection heat transfer in a cochlea during robotic cochlear implant surgery can be neglected. It is found that thermal trauma is avoided by applying a power density from 2.265 × 107 W/m3 for 114 s to 6.6×107 W/m3 for 9 s resulting in a maximum temperature increase of 6°C on the magnet boundary.
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Dugan EA, Bennett C, Tamames I, Dietrich WD, King CS, Prasad A, Rajguru SM. Therapeutic hypothermia reduces cortical inflammation associated with utah array implants. J Neural Eng 2020; 17:026035. [PMID: 32240985 DOI: 10.1088/1741-2552/ab85d2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE Neuroprosthetics hold tremendous promise to restore function through brain-computer interfaced devices. However, clinical applications of implantable microelectrodes remain limited given the challenges of maintaining neuronal signals for extended periods of time and with multiple biological mechanisms negatively affecting electrode performance. Acute and chronic inflammation, oxidative stress, and blood brain barrier disruption contribute to inconsistent electrode performance. We hypothesized that therapeutic hypothermia (TH) applied at the microelectrode insertion site will positively modulate both inflammatory and apoptotic pathways, promoting neuroprotection and improved performance in the long-term. APPROACH A custom device and thermoelectric system were designed to deliver controlled TH locally to the cortical implant site at the time of microelectrode array insertion and immediately following surgery. The TH paradigm was derived from in vivo cortical temperature measurements and finite element modeling of temperature distribution profiles in the cortex. Male Sprague-Dawley rats were implanted with non-functional Utah microelectrodes arrays (UMEA) consisting of 4 × 4 grid of 1.5 mm long parylene-coated silicon shanks. In one group, TH was applied to the implant site for two hours following the UMEA implantation, while the other group was implanted under normothermic conditions without treatment. At 48 h, 72 h, 7 d and 14 d post-implantation, mRNA expression levels for genes associated with inflammation and apoptosis were compared between normothermic and hypothermia-treated groups. MAIN RESULTS The custom system delivered controlled TH to the cortical implant site and the numerical models confirmed that the temperature decrease was confined locally. Furthermore, a one-time application of TH post UMEA insertion significantly reduced the acute inflammatory response with a reduction in the expression of inflammatory regulating cytokines and chemokines. SIGNIFICANCE This work provides evidence that acutely applied hypothermia is effective in significantly reducing acute inflammation post intracortical electrode implantation.
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Affiliation(s)
- Elizabeth A Dugan
- Department of Biomedical Engineering, University of Miami, FL, United States of America
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Wang H, Stahl F, Scheper T, Steffens M, Warnecke A, Zeilinger C. Microarray-based screening system identifies temperature-controlled activity of Connexin 26 that is distorted by mutations. Sci Rep 2019; 9:13543. [PMID: 31537823 PMCID: PMC6753059 DOI: 10.1038/s41598-019-49423-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Accepted: 08/24/2019] [Indexed: 11/09/2022] Open
Abstract
Here, we show that human Connexin 26 (hCx26 or Cx26WT) hemichannel opening rapidly enables the transport of small molecules when triggered by temperature and by compensation of the Ca2+ blockade with EDTA. Point mutations within Cx26 were analysed by a novel optical microarray-based Lucifer Yellow uptake assay or by two electrode voltage clamp (TEVC) on frog oocytes to monitor simultaneous activities of channel proteins. Point mutations L90P, F161S, R184P or K188N influenced the temperature-dependent activity drastically. Since several mutations blocked trafficking, the temperature-dependent activity of the recombinant synthesized and purified wild-type Cx26WT and Cx26K188N hemichannel was tested by liposome flux assay (LFA) and on a microarray-based Lucifer Yellow uptake assay under warm conditions (>30 °C). The data from TEVC measurements and dye flux experiments showed that the mutations gave no or only a weak activity at increased temperature (>30 °C). We conclude that the position K188 in the Cx26WT forms a temperature-sensitive salt bridge with E47 whereas the exchange to K188N destabilizes the network loop- gating filter, which was recently identified as a part of the flexible Ca2+ binding site. We assume that the temperature sensitivity of Cx26 is required to protect cells from uncontrolled release or uptake activities through Cx26 hemichannels.
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Affiliation(s)
- Hongling Wang
- Hannover Medical School, Department of Otorhinolaryngology, Head- and Neck-Surgery, Carl-Neuberg-Str. 1, 30625, Hannover, Germany.,Gottfried-Wilhelm-Leibniz University of Hannover, BMWZ (Zentrum für Biomolekulare Wirkstoffe), Schneiderberg 38, 30167, Hannover, Germany
| | - Frank Stahl
- Gottfried-Wilhelm-Leibniz University of Hannover, Institut für Technische Chemie/BMWZ (Zentrum für Biomolekulare Wirkstoffe), Callinstr. 5, 30167, Hannover, Germany.,Gottfried-Wilhelm-Leibniz University of Hannover, BMWZ (Zentrum für Biomolekulare Wirkstoffe), Schneiderberg 38, 30167, Hannover, Germany
| | - Thomas Scheper
- Gottfried-Wilhelm-Leibniz University of Hannover, Institut für Technische Chemie/BMWZ (Zentrum für Biomolekulare Wirkstoffe), Callinstr. 5, 30167, Hannover, Germany.,Gottfried-Wilhelm-Leibniz University of Hannover, BMWZ (Zentrum für Biomolekulare Wirkstoffe), Schneiderberg 38, 30167, Hannover, Germany
| | - Melanie Steffens
- Hannover Medical School, Department of Otorhinolaryngology, Head- and Neck-Surgery, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Athanasia Warnecke
- Hannover Medical School, Department of Otorhinolaryngology, Head- and Neck-Surgery, Carl-Neuberg-Str. 1, 30625, Hannover, Germany.,Cluster of Excellence EXC1077 "Hearing4all", German Research Foundation (DFG; "Deutsche Forschungsgemeinschaft"), Hannover, Germany
| | - Carsten Zeilinger
- Gottfried-Wilhelm-Leibniz University of Hannover, BMWZ (Zentrum für Biomolekulare Wirkstoffe), Schneiderberg 38, 30167, Hannover, Germany.
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