Anatomy of the Round Window Region With Relation to Selection of Entry Site Into the Scala Tympani.

OBJECTIVES/HYPOTHESIS: The aim of cochlear implantation is to safely insert an electrode array into the scala tympani (ST) while avoiding damage to surrounding structures. There is disagreement on the optimal way of entering the ST-the round window (RW) approach versus cochleostomy. Regardless of the chosen approach, it is vital to understand the regional anatomy, which is complex, difficult to conceptualize, and rarely dissected in temporal bone courses. The goal of this study was to examine the anatomy of the RW to gain more in-depth knowledge on the local relationships of the anatomical structures and propose an approach for entering the ST in cochlear implant surgery tailored to the encountered anatomy. STUDY DESIGN: Cadaveric prevalence study and expert opinion with literature review. METHODS: Cadaveric temporal bone dissection (n = 13) by the first author assessing the RW anatomy. RESULTS: The round window membrane (RWM) and the osseous spiral lamina (OSL) are curved structures, each with a horizontal and a vertical part. The two horizontal portions are very closely apposed. The relationship between the OSL and the RWM determines the best site for a cochleostomy, which if required is best placed anteroinferiorly to the RWM. The distance between the oval window inferior margin and the RW membrane is less than 2 to 3 mm. The ST initially extends inferiorly and medially to the RW. CONCLUSIONS: The findings of our dissection have implications for cochlear implant surgery in aiming to avoid trauma to the OSL and basilar membrane and aid decision making in choosing the safest surgical approach. LEVEL OF EVIDENCE: 5. Laryngoscope, 131:E598-E604, 2021.

Minimally invasive drug delivery to the cochlea through application of nanoparticles to the round window membrane.

Direct drug delivery to the cochlea is associated with the risk of irreversible damage to the ear. In this study, liposome and polymersome nanoparticles (NPs), both formed from amphiphilic molecules (lipids in liposomes and block copolymers in polymersomes), were tested as potential tools for drug delivery to the cochlea via application onto the round window membrane in adult mice (strain C3H). One day after round window membrane application, both types of NPs labeled with fluorescent markers were identified in the spiral ganglion in all cochlear turns without producing any distinct morphological or functional damage to the inner ear. NPs were detected, although to a lesser extent, in the organ of Corti and the lateral wall. The potential of liposome and polymersome NPs as therapeutic delivery systems into the cochlea via the round window membrane was evaluated using disulfiram, a neurotoxic agent, as a model payload. Disulfiram-loaded NP delivery resulted in a significant decrease in the number of spiral ganglion cells starting 2 days postapplication, with associated pronounced hearing loss reaching 20-35 dB 2 weeks postapplication as assessed through auditory brainstem responses. No changes in hair cell morphology and function (as assessed by recording otoacoustic emissions) were detected after disulfiram-loaded NP application. No effects were observed in controls where solution of free disulfiram was similarly administered. The results demonstrate that liposome and polymersome NPs are capable of carrying a payload into the inner ear that elicits a biological effect, with consequences measurable by a functional readout.

Immunodefense of the round window.

A systematic analysis using serial sectioning of the round window membrane (RWM) in the cynomolgus monkey was performed. Light and transmission electron microscopy (LM and TEM) revealed that the RWM rim may be endowed with gland-like structures with glyco-protein material secernated into the window niche. This was detected in one third of the specimens. The secreted material displayed waste material and scavenger cells. There was also a rich network of capillaries, lymph channels, and sinusoidal veins containing leukocytes. Their abluminal surfaces displayed mature plasma cells and monocytes. These findings suggest that in certain primates the middle ear may have developed specific immunoprotective means for disposal of foreign and noxious substances before they reach the inner ear.

Distribution of PLGA nanoparticles in chinchilla cochleae.

OBJECTIVES: To study the distribution of polylactic/glycolic acid-encapsulated iron oxide nanoparticles (PLGA-NPs) in chinchilla cochleae after application on the round window membrane (RWM). STUDY DESIGN AND SETTING: Six chinchillas (12 ears) were equally divided into controls (no treatments) and experimentals (PLGA-NP with or without magnetic exposure). After 40 minutes of PLGA-NP placement on the RWM, perilymph was withdrawn from the scala tympani. The RWM and cochleae were fixed with 2.5% glutaraldehyde and processed for transmission electron microscopy. RESULTS: Nanoparticles were found in cochleae with or without exposure to magnet forces appearing in the RWM, perilymph, endolymph, and multiple locations in the organ of Corti. Electron energy loss spectroscopy confirmed iron elements in nanoparticles. CONCLUSION: The nanoparticles were distributed throughout the inner ear after application on the chinchilla RWM, with and without magnetic forces. SIGNIFICANCE: PLGA-NP applied to the RWM may have potential for sustained therapy to the inner ear.

Influence of pH on the ototoxicity of cisplatin: a round window application study.

Cisplatin is an antineoplastic agent that produces a number of dose-limiting side effects, including ototoxicity. We investigated the effect of pH on cisplatin ototoxicity. Auditory brainstem responses (ABR) were recorded in chinchillas. Then the auditory bullae were opened and acidic (pH=6.5), neutral (pH=7.4) or alkaline (pH=10.2) phosphate-buffered saline (PBS) was applied to the round window membrane. After 30 min, any remaining solution was removed and cisplatin solution was applied to the round window membrane. After 3 days, follow-up ABRs were performed and the cochleae were processed for morphological analysis. Neutral PBS+cisplatin administration resulted in profound threshold changes at all frequencies. Acidic PBS+cisplatin administration showed had a trend of increased threshold changes, but the change did not reach statistical significance. However, the degree of hair cell loss was significantly higher than that of the neutral PBS-cisplatin group. Alkaline PBS significantly reduced cisplatin-induced threshold changes (P<0.05) compared to the neutral PBS group. Because the pH of cisplatin solution was 6.0, pH 6.0 PBS was applied to round window membrane. This acidic PBS solution did not cause any hearing impairment. These results demonstrate that pH can modulate the ototoxic effects of cisplatin.

Morphologic changes in round window membrane after topical hydrocortisone and dexamethasone treatment.

HYPOTHESIS: Are all glucocorticoids supposed to have the same effect on the round window membrane? BACKGROUND: Interest in glucocorticoids for topical treatment of inner ear diseases is increasing. The safety of such treatment should therefore be an important consideration before clinical use. METHODS: In this study the authors investigated the morphology of the round window membrane after topical instillation of dexamethasone or hydrocortisone into the middle ear. Twenty Sprague-Dawley rats were used. Five rats received 5 doses, and five rats 10 doses, of 1 microg (20 microl) dexamethasone in the right ear, and five others were given 5 doses, and five rats 10 doses, of 2% (20 microl) hydrocortisone solution, also in the right ear. Membrane morphology was studied in both light microscopy and transmission electron microscopy. The thickness of exposed membranes was measured and compared with that of control membranes. RESULTS: Thickening and microscopically signs of inflammation were observed in hydrocortisone-exposed membranes but not in dexamethasone-exposed membranes, which did not differ morphologically from those in control ears. CONCLUSION: Although hydrocortisone has anti-inflammatory properties, it seems to provoke inflammation in the round window membrane after topical instillation. Dexamethasone had no such effects, however.

Clinical aspects of round window membrane permeability under normal and pathological conditions.

Current research and an overall review of 25 years of round window membrane studies are presented. The approach, rationale and concepts that have evolved from these studies are described. Ultrastructural studies of the round window membrane of humans, monkeys, felines and rodents have disclosed three basic layers: an outer epithelium, a middle core of connective tissue and an inner epithelium. Interspecies variations are mainly in terms of thickness, being thinnest in rodents and thickest in humans. Morphologic evidence suggests that the layers of the round window participate in resorption and secretion of substances to and from the inner ear, and that the membrane could play a role in the defense system of the ear. Different substances, including antibiotics and tracers, when placed in the middle ear side traverse the membrane. Tracers placed in perilymph become incorporated into the membrane by the inner epithelial cells. Permeability is selective and factors affecting permeability include size, concentration, electrical charge, thickness of the membrane and tacilitating agents. Passage of substances through the membrane is by different pathways, the nature of which is seemingly decided at the outer epithelium of the membrane. Round window membrane studies have provided increased knowledge of the anatomy and function of this structure, as well as new insights into pathology and pathogenesis. The concepts that have evolved from these studies are potentially useful for understanding middle and inner ear interactions, and for eventual drug delivery (based on permeability) to the inner ear.

Ototoxicity of sodium nitroprusside is not due to nitric oxide.

Sodium nitroprusside (SNP) has been used as a donor for nitric oxide (NO) to study the effects of NO on the mammalian cochlea. In the present study, we set out to determine whether NO was the chemical responsible for the ototoxic effects seen after the application of SNP at the round window membrane of the adult guinea pig cochlea. In the first instance, NO released from S-nitrosocysteine, a compound not related to cyanide, has no toxic effect on the hair cells of the cochlea. Light-exposed SNP that could no longer produce NO, light-exposed SNP to which acetylcysteine (ATC) or hydroxycobalamin (HCL) was added to eliminate cyanide, and freshly prepared SNP to which ATC or HCL was added were also tested. Six groups of animals consisting of three animals in each group were used. The single chemical or combination of chemicals stated above was soaked in a piece of gelfoam that was then applied to the round window membrane of the animal under ketamine-xylasine anesthesia. The animals were reanesthetized 3 days later and perfused for scanning electron microscopy and hair cell quantitative analysis. The results showed that, in animals given S-nitrosocysteine, no hair cell loss was noted, while light-exposed SNP led to severe hair cell damage similar to that seen after the administration of fresh SNP. In animals treated with the mixture of light-exposed SNP and ATC or HCL, or fresh SNP with ATC or HCL, ototoxicity was significantly attenuated. These results have convincingly demonstrated that NO at a certain level is not destructive to auditory hair cells and the hair cell loss observed after SNP application is most likely due to the cyanide released from the SNP instead of NO.

Hair cell regeneration after local application of gentamicin at the round window of the cochlea in the pigeon.

Hair cells in the basilar papilla of birds have the capacity to regenerate after injury. Methods commonly used to induce cochlear damage are systemic application of ototoxic substances such as aminoglycoside antibiotics or loud sound. Both methods have disadvantages. The systemic application of antibiotics results in damage restricted to the basal 50% of the papilla and has severe side effects on the kidneys. Loud sound damages only small parts of the papilla and is restricted to the short hair cells. The present study was undertaken to determine the effect of local aminoglycoside application on the physiology and morphology of the avian basilar papilla. Collagen sponges loaded with gentamicin were placed at the round window of the cochlea in adult pigeons. The time course of hearing thresholds was determined from auditory brain stem responses elicited with pure tone bursts within a frequency range of 0.35-5.565 kHz. The condition of the basilar papilla was determined from scanning electron micrographs. Five days after application of the collagen sponges loaded with gentamicin severe hearing loss, except for the lowest frequency tested, was observed. Only at the apical 20% of the basilar papilla hair cells were left intact, all other hair cells were missing or damaged. At all frequencies there was little functional recovery until day 13 after implantation. At frequencies above 1 kHz functional recovery occurred at a rate of up to 4 dB/day until day 21, beyond that day recovery continued at a rate below 1 dB/day until day 48 at the 5.6 kHz. Below 1 kHz recovery occurred up to day 22, the recovery rate was below 2 dB/day. A residual hearing loss of about 15-25 dB remained at all frequencies, except for the lowest frequency tested. At day 20 new hair cells were seen on the basilar papilla. At day 48 the hair cells appeared to have recovered fully, except for the orientation of the hair cell bundles. The advantage of the local application of the aminoglycoside drug over systemic application is that it damages almost all hair cells in the basilar papilla and it has no toxic side effects. The damage is more extensive than with systemic application.

Round window membrane. Structure function and permeability: a review.

The ultrastructure of the round window membrane of humans, monkeys, felines, and rodents discloses three basic layers: an outer epithelium, a middle core of connective tissue, and an inner epithelium. Interspecies variations are mainly in terms of thickness, being thinnest in rodents and thicker in humans. Morphologic evidence suggests that the layers of the round window participate in absorption and secretion of substances to and from the inner ear, and that the entire membrane could play a role in the defense system of the ear. Different substances, including antibiotics, local anesthetics, and tracers such as cationic ferritin, horseradish peroxidase, and 1 mu latex microspheres, are placed in the middle ear side traverse the membrane. Cationic ferritin and 1 micron microspheres placed in perilymph become incorporated by the inner epithelial cells of the membrane. Permeability is selective; factors include size, concentration, liposolubility, electrical charge, and thickness of the membrane. Passage of substances through the round window membrane is by different pathways, the nature of which is seemingly decided at the outer epithelium of the round window membrane.

Induction of free radicals in the cochlea by an aminoglycoside antibiotic.

Free radicals are known to cause damage to biological tissues. We used histochemical methods to examine the emergence of free radicals in kanamycin (KM)-treated guinea pig cochlea. As a preliminary in vitro study, the emergence of free radicals was observed in guinea pig cochlea incubated with KM. In an in vivo study, KM was placed on the guinea pig round window membrane and the emergence of free radicals was observed over time. The emergence of free radicals was observed along the luminal membrane and hair bundles of outer hair cells. The appearance and disappearance of free radicals in the cochlea coincided with the transport of KM into the inner ear. These findings suggest that the emergence of free radicals could be attributed to the administration of KM.

Ototoxicity of sodium nitroprusside.

Nitric oxide (NO) not only has normal physiological roles like vasodilation and neurotransmission in the living organism, it could also have possible neurodestructive effects under certain pathological conditions. The present study aimed to determine whether direct exposure of guinea pig cochlea to a NO donor like sodium nitroprusside (SNP), or a nitric oxide synthase (NOS) inhibitor like N(G)-nitro-L-arginine methyl ester (L-NAME), would cause damage to the auditory hair cells. A piece of gelfoam was placed on the round window of the right ear of adult albino guinea pigs. It was then soaked with 0.1 ml of SNP (3.4 microM), 0.1 ml of L-NAME (9.3 microM or 18.5 microM) or 0.1 ml of injection water, the vehicle used to dissolve the above chemicals. Twelve animals receiving SNP were perfused 1 day, 2, 3 and 7 days later, with three animals being used for each survival period. Six animals receiving L-NAME were allowed to survive up to 7 days before perfusion. Eight animals receiving injection water or 0.45% saline were used as controls. With the scanning electron microscope, the inner and outer hair cells were counted over a 1 mm length of the basilar membrane in each turn of every cochlea. The results showed that, in animals treated with L-NAME at both concentrations stated, no significant loss of either inner or outer hair cells was noted in any part of the cochlea studied. However, as early as 1 day after SNP treatment, a striking loss of inner and outer hair cells was observed in the three lower turns of the cochlea. Damage to the outer hair cells was extended to the apical turn with increasing survival period, but no significant loss of inner hair cells was evident in the apical turn at any of the survival periods studied. To rule out the possibility that the effects were due to the presence of cyanide, a metabolite of SNP, hydroxycobalamin was introduced into the scala tympani of three animals through a cannula-osmotic pump device during SNP treatment. There was no significant difference in the results between the groups with and without hydroxycobalamin infusion 7 days after SNP treatment. The present study suggests that an excessive production of NO in the inner ear could lead to extensive loss of hair cells.

Subepithelial fiber components of the round window membrane of the guinea pig: an ultrastructural and immunohistochemical study.

Subepithelial fiber components of the round window membrane (RWM) of the guinea pig were studied by the following methods: transmission electron microscopy (TEM), scanning electron microscopy (SEM) with NaOH treatment, high-voltage electron microscopy (HVEM) and immunohistochemical staining. SEM observation revealed intersecting collagen fibers and a vascular network in the middle layer. TEM observation showed that at the attachment region to the bone fibroblasts, collagen fibers and elastic fibers were intermingled with each other, and mesenchymal cells (bone-lining cells) were scattered on the surface of the bone. The cytoplasmic processes of fibroblasts and bone-lining cells were connected by interdigitations. HVEM demonstrated that collagen fibers of the RWM were directly linked to the fibers of the bone matrix. Immunohistochemically, the middle layer was positive for antibody to type I collagen. Immunoreaction for fibronectin was also positive at the middle layer and most intense in the region attached to the bone. Thus, the RWM is securely attached to the bone by type I collagen fibers together with the bone-lining cells and fibroblasts.

Oval and round window membrane changes in otitis media in the human. An ultrastructural study.

An ultrastructural study of oval and round window changes in otitis media in humans was done. Ten cases were evaluated. In this first ultrastructural study of oval and round windows in otitis media, done at different stages of the disease, the round window membrane changes were similar to those of the mucoperiostium. Morphologic evidence suggests that the round window membrane layers participate in absorption and secretion of substances to and from the inner ear, such that the entire membrane could play a role in a middle and inner ear "defense system." Although the middle ear side of the footplate of the stapes had histopathological changes, the vestibular side remained essentially unchanged.

Mechanical properties of human round window, basilar and Reissner's membranes.

In order to measure the mechanical strength of small and delicate biological specimens, a microtesting system was developed. We measured the mechanical properties of the round window, basilar and Reissner's membranes taken from the autopsied cases. The testing method was a displacement of the specimen by a force sensor needle until rupture. A load-displacement curve was then drawn and the mechanical value of each specimen was calculated. Reissner's membrane was the weakest, though it showed a measurable strength. From the load-displacement curve of the basilar membrane, it could be displaced by a smaller force than the rupture strength of Reissner's membrane. Speculation about the concept of a negative summating potential in Meniere's disease is therefore theoretically possible from a mechanical point of view.

Round window membrane in serous and purulent otitis media. Structural study in the rat.

The rat was used as an animal model to reveal structural alterations in the round window membrane (RWM) during serous otitis media (SOM) and purulent otitis media (POM) over a 6-week period. Comparison of POM animals and control animals showed that the RWM in the former became almost six times as thick as that in controls, whereas that of SOM animals was twice as thick. The structural changes in the RWM in POM animals were confined mainly to the epithelium facing the middle ear cavity and the subepithelial space, which was invaded by inflammatory cells and exhibited dilated vessels. The normal flat epithelium was transformed via cuboidal cells to a cylindric epithelium containing both ciliated and goblet cells. In SOM animals, light microscopy revealed only minor changes in the RWM structure. Ultrastructurally, however, the connective tissue layer exhibited dense aggregations of collagen, increased numbers of fibroblasts, and, in one case, elastic fibers. This last phenomenon was not observed in either POM ears or normal ears. The study showed that various inflammatory conditions of the middle ear, both noninfectious (SOM) and infectious (POM), can cause different structural alterations of the RWM. These structural changes may influence passage through the RWM differently.

The round window membrane under normal and pathological conditions.

Current research and an overall review of round window membrane studies is presented and the concepts that have evolved from these studies are described. Ultrastructural studies of the round window membrane of rodents, felines, and primates disclosed three basic layers: an outer epithelium lining the middle ear, a middle core of connective tissue, and an inner epithelium bordering the inner ear. Morphological evidence suggests that the membrane participates in: (a) the release of mechanical energy supplied by the ossicular chain to the labyrinthine fluids; (b) an alternative route for sound energy to enter the cochlea; (c) secretion into and absorption from perilymph; and (d) the defense system of the middle and inner ears. Permeability of the round window is considered an accident and not a function of the membrane. The complications of permeability (potential ototoxicity) and its potential usefulness (drug delivery) are discussed.

Hyaluronan applied to lesioned round window membrane is free from cochlear ototoxicity.

Hyaluronan (HYA) in 1% solution was instilled into the round window (RW) niche of rats (n = 6) prior to perforating the round window membrane (RWM). Cochlear functioning and structure were then monitored by recording auditory brainstem responses (ABRs) at 2-31.5 kHz and by scanning electron microscopy. Perforation of the RWM alone (n = 6) resulted in immediate loss of ABR thresholds between 6 and 31.5 kHz in 2 of 6 animals. Similar results were obtained after instilling HYA into the RW niche and subsequent RWM perforation (n = 6). After 2 months, ABR thresholds were recorded at all frequencies in the HYA-treated animals, whereas in 2 of the controls no ABR thresholds could be elicited at 20 and 31.5 kHz. However, in both treatment groups the mean ABR thresholds and mean latencies for wave II at the ABR threshold returned to the pre-surgical (normal) range after 2 months. With respect to the cochlear morphology the results in both treatment groups were also alike including minor structural changes in hair cell stereociliae but no loss of hair cells. It is concluded that HYA, when instilled into the middle ear with the inner ear opened, is free from cochlear otoxicity.

Permeability of the round window membrane to horseradish peroxidase in experimental otitis media.

The permeability of the round window membrane (RWM) was studied by using horseradish peroxidase (HRP) in the different stages of otitis media developed in guinea pigs, and it was compared with normal RWM under transmission electron microscopic examination. The experimental model of otitis media was developed by inoculation of a Pseudomonas aeruginosa suspension. When HRP could penetrate into the inner layer of a normal RWM, the duration of HRP instillation into the round window niche was 10 minutes. The permeability of the RWM in otitis media was as follows: 3-day animals showed penetration of HRP into the middle layer. In 1-week animals, HRP had penetrated into the inner layer in all 10 ears. In 2-week animals, HRP had penetrated into the inner layer in 6 of 11 ears. In 4-week animals, however, HRP was not seen in 6 of 7 ears. HRP had penetrated through the damaged focus of the epithelial cells by inflammation. These results suggest that any derangement of the epithelial linings could increase the penetration of HRP and also ototoxic materials into the inner ear through the RWM.

Structural changes in the round window membrane following exposure to Escherichia coli lipopolysaccharide and hydrocortisone.

The present study focused on structural changes of the round window membrane (RWM) from agents that evoke transient or permanent impairment of the auditory brainstem response when applied into the RW niche. Escherichia coli (E. coli) lipopolysaccharide (LPS) in sterile water (SW) and a 2% suspension of hydrocortisone (CORT), micronized in SW, were instilled into the round window (RW) niche of Sprague-Dawley rats. The morphology of the RWM was analyzed 3 to 21 days after instillation of either substance. Both substances caused minor structural alterations at the light microscopic level. The RWM showed a slight thickening and an invasion of inflammatory cells. At the ultrastructural level, the CORT-treated specimens showed an increased epithelial height and numerous microvilli, whereas the epithelium of the LPS-treated specimens was extended and contained few microvilli resembling those in the normal RWM. We postulate that the RWM may undergo dynamic structural changes when exposed to various agents. The structural alterations per se can influence the passage of substances from the middle ear to the inner ear.