Patient perspectives on the need for improved hearing rehabilitation: A qualitative survey study of German cochlear implant users.

Background: The electrical cochlear implant (eCI) partially restores hearing in individuals affected by profound hearing impairment (HI) or deafness. However, the limited resolution of sound frequency coding with eCIs limits hearing in daily situations such as group conversations. Current research promises future improvements in hearing restoration which may involve gene therapy and optical stimulation of the auditory nerve, using optogenetics. Prior to the potential clinical translation of these technologies, it is critical that patients are engaged in order to align future research agendas and technological advancements with their needs. Methods: Here, we performed a survey study with hearing impaired, using an eCI as a means of hearing rehabilitation. We distributed a questionnaire to 180 adult patients from the University Medical Center Göttingen's Department of Otolaryngology who were actively using an eCI for 6 months or more during the time of the survey period. Questions revolved around patients needs, and willingness to accept hypothetical risks or drawbacks associated with an optical CI (oCI). Results: Eighty-one participants responded to the questionnaire; 68% were greater than 60 years of age and 26% had bilateral eCIs. Participants expressed a need for improving the performance beyond that experienced with their current eCI. Primarily, they desired improved speech comprehension in background noise, greater ability to appreciate music, and more natural sound impression. They expressed a willingness for engaging with new technologies for improved hearing restoration. Notably, participants were least concerned about hypothetically receiving a gene therapy necessary for the oCI implant; but expressed greater reluctance to hypothetically receiving an implant that had yet to be evaluated in a human clinical trial. Conclusion: This work provides a preliminary step in engaging patients in the development of a new technology that has the potential to address the limitations of electrical hearing rehabilitation.

Model-based prediction of optogenetic sound encoding in the human cochlea by future optical cochlear implants.

When hearing fails, electrical cochlear implants (eCIs) partially restore hearing by direct stimulation of spiral ganglion neurons (SGNs). As light can be better confined in space than electrical current, optical CIs (oCIs) provide more spectral information promising a fundamental improvement of hearing restoration by cochlear implants. Here, we turned to computer modelling for predicting the outcome of optogenetic hearing restoration by future oCIs in humans. We combined three-dimensional reconstruction of the human cochlea with ray-tracing simulation of emission from LED or laser-coupled waveguide emitters of the oCI. Irradiance was read out at the somata of SGNs. The irradiance values reached with waveguides were about 14 times higher than with LEDs, at the same radiant flux of the emitter. Moreover, waveguides outperformed LEDs regarding spectral selectivity. oCIs with either emitter type showed greater spectral selectivity when compared to eCI. In addition, modeling the effects of the source-to-SGN distance, orientation of the sources and impact of scar tissue further informs the development of optogenetic hearing restoration.

Is there an unmet medical need for improved hearing restoration?

Hearing impairment, the most prevalent sensory deficit, affects more than 466 million people worldwide (WHO). We presently lack causative treatment for the most common form, sensorineural hearing impairment; hearing aids and cochlear implants (CI) remain the only means of hearing restoration. We engaged with CI users to learn about their expectations and their willingness to collaborate with health care professionals on establishing novel therapies. We summarize upcoming CI innovations, gene therapies, and regenerative approaches and evaluate the chances for clinical translation of these novel strategies. We conclude that there remains an unmet medical need for improving hearing restoration and that we are likely to witness the clinical translation of gene therapy and major CI innovations within this decade.

[Optimized fitting of a midface implant to anchor a magnetic nasal prosthesis using 3D printing]. / 3-D-Druck-optimierte Anpassung eines Mittelgesichtsimplantats zur magnetgetragenen nasalen Epithesenversorgung.

BACKGROUND: Plate-based anchorage systems for craniofacial prostheses offer advantages over extraoral solitary titanium implants in terms of the flexible choice of mounting points and higher stability. Disadvantages become apparent in the complex individual intraoperative adaptation of the plate-based systems to the usually poorly accessible bone. The current article presents a method to overcome these disadvantages and make greater use of the advantages of plate-based systems. MATERIALS AND METHODS: The bony midface of a patient who had undergone rhinectomy for cancer of the nasal entrance was reconstructed as a virtual 3D model based on preoperative CT. The open-source software (3D-Slicer) allowed easy and fast reconstruction as well as adaptation for 3D printing using transparent plastic (MED610; stratasys Ltd., MN, USA). RESULTS: A titanium mini-plate (MEDICON) for anchoring the nasal prosthesis could be fitted extremely precisely on the midface 3D print. Important anatomical structures were spared, and screw placement was selected according to the individual bone thickness. Implantation of the in-advance fitted titanium plate was performed without complications and without further adjustments. CONCLUSION: In-advance fitting of plate-based systems for anchorage of craniofacial prostheses using 3D printing of the midface overcomes their disadvantages of time-consuming and possibly imprecise individual adaptation. This method further exploits the advantages of higher stability through more possible mounting points, even in thinner bone, to prevent loosening. In addition, in-advance fitting of titanium plates on the 3D model enables better identification and protection of important anatomical structures and shortens operative time.

On the Fabrication and Characterization of Polymer-Based Waveguide Probes for Use in Future Optical Cochlear Implants.

Improved hearing restoration by cochlear implants (CI) is expected by optical cochlear implants (oCI) exciting optogenetically modified spiral ganglion neurons (SGNs) via an optical pulse generated outside the cochlea. The pulse is guided to the SGNs inside the cochlea via flexible polymer-based waveguide probes. The fabrication of these waveguide probes is realized by using 6" wafer-level micromachining processes, including lithography processes such as spin-coating cladding layers and a waveguide layer in between and etch processes for structuring the waveguide layer. Further adhesion layers and metal layers for laser diode (LD) bonding and light-outcoupling structures are also integrated in this waveguide process flow. Optical microscope and SEM images revealed that the majority of the waveguides are sufficiently smooth to guide light with low intensity loss. By coupling light into the waveguides and detecting the outcoupled light from the waveguide, we distinguished intensity losses caused by bending the waveguide and outcoupling. The probes were used in first modules called single-beam guides (SBGs) based on a waveguide probe, a ball lens and an LD. Finally, these SBGs were tested in animal models for proof-of-concept implantation experiments.

Multiscale photonic imaging of the native and implanted cochlea.

The cochlea of our auditory system is an intricate structure deeply embedded in the temporal bone. Compared with other sensory organs such as the eye, the cochlea has remained poorly accessible for investigation, for example, by imaging. This limitation also concerns the further development of technology for restoring hearing in the case of cochlear dysfunction, which requires quantitative information on spatial dimensions and the sensorineural status of the cochlea. Here, we employed X-ray phase-contrast tomography and light-sheet fluorescence microscopy and their combination for multiscale and multimodal imaging of cochlear morphology in species that serve as established animal models for auditory research. We provide a systematic reference for morphological parameters relevant for cochlear implant development for rodent and nonhuman primate models. We simulate the spread of light from the emitters of the optical implants within the reconstructed nonhuman primate cochlea, which indicates a spatially narrow optogenetic excitation of spiral ganglion neurons.

Multichannel optogenetic stimulation of the auditory pathway using microfabricated LED cochlear implants in rodents.

When hearing fails, electrical cochlear implants (eCIs) provide the brain with auditory information. One important bottleneck of CIs is the poor spectral selectivity that results from the wide current spread from each of the electrode contacts. Optical CIs (oCIs) promise to make better use of the tonotopic order of spiral ganglion neurons (SGNs) inside the cochlea by spatially confined stimulation. Here, we established multichannel oCIs based on light-emitting diode (LED) arrays and used them for optical stimulation of channelrhodopsin (ChR)-expressing SGNs in rodents. Power-efficient blue LED chips were integrated onto microfabricated 15-µm-thin polyimide-based carriers comprising interconnecting lines to address individual LEDs by a stationary or mobile driver circuitry. We extensively characterized the optoelectronic, thermal, and mechanical properties of the oCIs and demonstrated stability over weeks in vitro. We then implanted the oCIs into ChR-expressing rats and gerbils, and characterized multichannel optogenetic SGN stimulation by electrophysiological and behavioral experiments. Improved spectral selectivity was directly demonstrated by recordings from the auditory midbrain. Long-term experiments in deafened ChR-expressing rats and in nontreated control animals demonstrated specificity of optogenetic stimulation. Behavioral studies on animals carrying a wireless oCI sound processor revealed auditory percepts. This study demonstrates hearing restoration with improved spectral selectivity by an LED-based multichannel oCI system.

µLED-based optical cochlear implants for spectrally selective activation of the auditory nerve.

Electrical cochlear implants (eCIs) partially restore hearing and enable speech comprehension to more than half a million users, thereby re-connecting deaf patients to the auditory scene surrounding them. Yet, eCIs suffer from limited spectral selectivity, resulting from current spread around each electrode contact and causing poor speech recognition in the presence of background noise. Optogenetic stimulation of the auditory nerve might overcome this limitation as light can be conveniently confined in space. Here, we combined virus-mediated optogenetic manipulation of cochlear spiral ganglion neurons (SGNs) and microsystems engineering to establish acute multi-channel optical cochlear implant (oCI) stimulation in adult Mongolian gerbils. oCIs based on 16 microscale thin-film light-emitting diodes (µLEDs) evoked tonotopic activation of the auditory pathway with high spectral selectivity and modest power requirements in hearing and deaf gerbils. These results prove the feasibility of µLED-based oCIs for spectrally selective activation of the auditory nerve.

Towards the optical cochlear implant: optogenetic approaches for hearing restoration.

Cochlear implants (CIs) are considered the most successful neuroprosthesis as they enable speech comprehension in the majority of half a million CI users suffering from sensorineural hearing loss. By electrically stimulating the auditory nerve, CIs constitute an interface re-connecting the brain and the auditory scene, providing the patient with information regarding the latter. However, since electric current is hard to focus in conductive environments such as the cochlea, the precision of electrical sound encoding-and thus quality of artificial hearing-is limited. Recently, optogenetic stimulation of the cochlea has been suggested as an alternative approach for hearing restoration. Cochlear optogenetics promises increased spectral selectivity of artificial sound encoding, hence improved hearing, as light can conveniently be confined in space to activate the auditory nerve within smaller tonotopic ranges. In this review, we discuss the latest experimental and technological developments of cochlear optogenetics and outline the remaining challenges on the way to clinical translation.

Ultrafast optogenetic stimulation of the auditory pathway by targeting-optimized Chronos.

Optogenetic tools, providing non-invasive control over selected cells, have the potential to revolutionize sensory prostheses for humans. Optogenetic stimulation of spiral ganglion neurons (SGNs) in the ear provides a future alternative to electrical stimulation used in cochlear implants. However, most channelrhodopsins do not support the high temporal fidelity pertinent to auditory coding because they require milliseconds to close after light-off. Here, we biophysically characterized the fast channelrhodopsin Chronos and revealed a deactivation time constant of less than a millisecond at body temperature. In order to enhance neural expression, we improved its trafficking to the plasma membrane (Chronos-ES/TS). Following efficient transduction of SGNs using early postnatal injection of the adeno-associated virus AAV-PHPB into the mouse cochlea, fiber-based optical stimulation elicited optical auditory brainstem responses (oABR) with minimal latencies of 1 ms, thresholds of 5 µJ and 100 µs per pulse, and sizable amplitudes even at 1,000 Hz of stimulation. Recordings from single SGNs demonstrated good temporal precision of light-evoked spiking. In conclusion, efficient virus-mediated expression of targeting-optimized Chronos-ES/TS achieves ultrafast optogenetic control of neurons.

Optogenetic stimulation of cochlear neurons activates the auditory pathway and restores auditory-driven behavior in deaf adult gerbils.

Cochlear implants partially restore hearing via direct electrical stimulation of spiral ganglion neurons (SGNs). However, spread of excitation from each electrode limits spectral coding. We explored the use of optogenetics to deliver spatially restricted and cell-specific excitation in the cochlea of adult Mongolian gerbils. Adeno-associated virus carrying the gene encoding the light-sensitive calcium translocating channelrhodopsin (CatCh) was injected into the cochlea of adult gerbils. SGNs in all cochlea turns showed stable and long-lasting CatCh expression, and electrophysiological recording from single SGNs showed that light stimulation up to few hundred Hertz induced neuronal firing. We characterized the light-induced activity in the auditory pathway by electrophysiological and behavioral analysis. Light- and sound-induced auditory brainstem responses showed similar kinetics and amplitude. In normal hearing adult gerbils, optical cochlear implants elicited stable optical auditory brainstem responses over a period of weeks. In normal hearing animals, light stimulation cued avoidance behavior that could be reproduced by subsequent acoustic stimulation, suggesting similar perception of light and acoustic stimuli. Neurons of the primary auditory cortex of normal hearing adult gerbils responded with changes in firing rates with increasing light intensity. In deaf adult gerbils, light stimulation generated auditory responses and cued avoidance behavior indicating partial restoration of auditory function. Our data show that optogenetic cochlear stimulation achieved good temporal fidelity with low light intensities in an adult rodent model, suggesting that optogenetics might be used to develop cochlear implants with improved restorative capabilities.

Propagation-based phase-contrast x-ray tomography of cochlea using a compact synchrotron source.

We demonstrate that phase retrieval and tomographic imaging at the organ level of small animals can be advantageously carried out using the monochromatic radiation emitted by a compact x-ray light source, without further optical elements apart from source and detector. This approach allows to carry out microtomography experiments which - due to the large performance gap with respect to conventional laboratory instruments - so far were usually limited to synchrotron sources. We demonstrate the potential by mapping the functional soft tissue within the guinea pig and marmoset cochlea, including in the latter case an electrical cochlear implant. We show how 3d microanatomical studies without dissection or microscopic imaging can enhance future research on cochlear implants.