Innovative regenerative treatment Innovative regenerative treatment

forfor the tympanic membrane the tympanic membrane perforation perforation

New York University, May 5New York University, May 5 2011, New York, USA2011, New York, USA

Shin-ichi Kanemaru, M.D., Ph.D.1) Hiroo Umeda, M.D. 2), Yoshiharu Kitani, M.D. 2), Satoshi Ohno,

M.D. 2), Tsuyoshi Kojima, M.D. 2), Tatsuo Nakamura, M.D., Ph.D. 3), Shigeru Hirano, M.D., Ph.D.2), Juichi Ito, M.D., Ph.D. 2)

1) Department of Otolaryngology–Head and Neck Surgery, Medical Research Institute, Kitano Hospital, Osaka, Japan2) Department of Otolaryngology–Head and Neck Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan3)Department of Bioartificial Organs, Institute for Frontier Medical 　　　 Sciences, Kyoto University, Kyoto, Japan 

Medical Research InstituteKitano Hospital

Disadvantages of TM perforation?Disadvantages of TM perforation?

Background

Hearing loss, Decline of Hearing loss, Decline of speech speech articulationarticulation

Easy and recurrent infection Easy and recurrent infection

Tinnitus, aural fullness and etc. Tinnitus, aural fullness and etc.

Restrictions of daily life activities Restrictions of daily life activities

Cancellation effectCancellation effect

Collision of sounds in the cochlea

Collision of sounds in the cochlea

Rapid attenuation of energy

Greatest disadvantage of TM

perforation

Greatest disadvantage of TM

perforation

Large TMP often causes over 50dBHLLarge TMP often causes over 50dBHL

Hearing aid amplifies the "cancellation effect" Hearing aid amplifies the "cancellation effect"

conversation ： 40-60dB50dBHL Hearing Aid

What are the present treatments of TM perforation ？？

What are the present treatments of TM perforation ？？

Necessity of skin incision and harvest of auto-tissue

Necessity of hospitalization

Failure and sequelae of operation

Mental/physical burden and costs

OperationOperation

Cells

Scaffold Regulatory factors

in situ tissue engineering

Tissue engineering Approach for Regeneration

of TM

Gelatin sponge B-FGF

Good regenerative conditions

Seal by fibrin glue

Regeneration of TM

Method and Procedures

Gelatin spongeGelatin spongeb-FGFb-FGF

TM perforationTM perforationTM perforationTM perforationFibrin GlueFibrin Glue

After 3 weeks After 3 weeks Disruption of the perforation edgeDisruption of the perforation edge

　Patients who are susceptible Patients who are susceptible to this treatmentto this treatment

Dry TM and tympanic cavity without active inflammation during the previous 3 yearsProper aeration and no regions of soft tissue density in the mastoid and tympanic cavities based on Temporal bone CTs Intact ossicular chains

No cholesteatoma and no invasion of epithelia into tympanic cavity

Patients Patients  

Patients/ears: n=140/158 (M/F:59/81), Age: 10-91

Causes of b-FGF group Control group TM perforation n=148 n=10

Otitis media 90 5

Postoperatively 14 2

Old trauma 20 1

Residual perforation afteroperation/ventilation tube 24 2insertion 

　

Subtotal perforationSubtotal perforationDisruption of the perforation edgeDisruption of the perforation edgeGelatin Sponge with b-FGFGelatin Sponge with b-FGF

Case 1. Case 1. 65y.o. male OMC for 65y.o. male OMC for 30years30years

After 3 weeksAfter 3 weeks After 4 months After 4

months After 4 monthsAfter 4 months

Hearing LevelBefore: 61dB After: 33dB

0.125 　　 0.250 0.5 1 2 　 4 8 kHz

3 months after

Before treatment

dB0

10

20

30

40

50

60

70

80

90

100

Conversation range

Case 2. 39-y.o. female 　

After 1 month

Total perforation after TM tube insertion

After 3 months

Hearing Level Before: 50dB After: 10dB

3 months after

Before treatment

dB0

10

20

30

40

50

60

70

80

90

1000.125 　　 0.250 0.5 1 2 　 4 8 kHz

Overall Results of b-FGF group

Grade I ： PS<1/3, Grade II:PS 1/3 ～ 2/3, Grade III ： PS>2/3 NA: Average hearing level of 0.5, 1 and 2 kHz

LA: Average hearing level of 0.125, 0.25 and 0.5 kHz *TO: Temporary otorrhea **RTM: Retraction of tympanic membrane

***Chole: Cholesteatoma

Classification by Grade I 　 Grade II 　　　　Grade III perforation size 　　 (n=37) (n=64) (n=47) Number of times 　　 1-3 　　　　　　 1-4 　　　　　 1-4 for treatment （ Ave. ） (1.31) 　　　　 (1.31) 　　　　　 (1.95) 　　　　　 　 Closure rates 　　 　 　 94.6 ％　　 　　　 85.9 ％　　　　　 83.0% (35/37) (55/64) (39/47) Improvement NA:14.1dB 20.6dB 24.5dB of the ave. HL LA :28.7dB 31.1dB 35.3dB

Adverse *TO: n=3 n=10 n=12 　 events ** RTM: n=2 n=5 n=5 ***Chole: n=0 n=2 n=2

%* ** ***

*<0.001, **< 0.001, ***<0.001: Mann Whitney U test

Comparison between the two groups

0 40 50 60 70 80 90 100 dB

% 100 90

80

70

60

Speech articulation Speech articulation

Before treatment

After treatment

Why can we easily achieve to TM regeneration?

Why can we easily achieve to TM regeneration?

Gelatin sponge＋

bFGF

Gelatin sponge＋

bFGF

Factors for making possible to regenerate TM

Tissue stem cells/Progenitor cells

Gelatin sponge as a scaffold

b-FGF as a growth factor

Creating optimal regenerative conditions

Cells

Disruption of the perforation edge

CellsAuditory Epithelial Migration

Process of the TM regeneration

43 year old male , OMC for 28year

Before after 9days after 1m

1 2 3

Cells

There are tissue stem cells/progenitor cells that are origin of regenerative TM around the perforation edge.

Disruption of the perforation edge

Scaffold Gelatin sponge

Gelatin sponge is made of a protein extracted from collagen and has an open space structure. A sustained release substrate for b-FGF

Strong inducer for blood capillaries

Strong inducer for blood capillaries

Fibroblast growth factorFibroblast growth factor

improvement in the local regenerative conditions

Suitable for regeneration of the intermediate layer of TM

Growth factor ：　 b-FGF

B-FGF

Histology of TMEpithelial

layer

Intermediate Fibrous layer

EAM side

Spontaneous regenerated part of TM

Regenerated TM by this treatment

Before 2 ms after

Differences in growing speed

Spontaneous regeneration

Regenerated TM by this treatment

IIIIII

IIIIII

I: epithelial layer, II: intermediate fibrous layer, III: mucosal layer

Gelatin sponge with b-FGF

Seal by fibrin glueSeal by fibrin glue

Ideal cell culture

condition

Ideal cell culture

condition

Creating optimal regenerative conditions

Protection of dry and infection

Fibrin glue

　　 No skin incision and no harvest of autologous tissues Wide application for various kinds/sizes of the TM perforation including total perforations

Only 10 minutes simple/easy treatments for outpatients

Ideal hearing up and tinnitus reduction immediately after the treatment No restrictions of the patient’s daily life No severe sequelae and no disadvantages

Cost-effective and alleviation of mental and physical burdens of the patients

　　 No skin incision and no harvest of autologous tissues Wide application for various kinds/sizes of the TM perforation including total perforations

Only 10 minutes simple/easy treatments for outpatients

Ideal hearing up and tinnitus reduction immediately after the treatment No restrictions of the patient’s daily life No severe sequelae and no disadvantages

Cost-effective and alleviation of mental and physical burdens of the patients

Remarkable advantages

Summary

This study demonstrated that the combination of a gelatin sponge, b-FGF and fibrin glue was effective for regeneration of the TM perforation.

This is the innovative regenerative therapy: easy, simple, cost-effective and minimum-invasive treatment for outpatients.

Our dream coming true!

Medical Research Institute Kitano Hospital, Osaka, Japan

Hybrid Tympanoplasty

Tympanoplasty TM regeneration

safety sequelae

Hearing improvement

cost-effective

adaptation

Background

What is the Hybrid Tympanoplasty?

After mastoidectomy and posterior tympanotomy,cleaning of the tympanic cavity through mastoid cavity

No need to harvest of temporal fascia for No need to harvest of temporal fascia for reconstruction of TMreconstruction of TM

No need to exfoliate soft tissue of EAM and TM No need to exfoliate soft tissue of EAM and TM

To perform regeneration of the TM though external auditory meatus

I II

MastoidectomyPosterior tympanotpmy

III

Regeneration of MACs

IV

Regeneration of TM

Procedures of Hybrid Tympanoplasty

Merits of the Hybrid Tympanoplasty

Day or short stay surgery.

Minimum sequelae are associated with this procedure because of no

Restrictions are not placed on the patient’s daily life.

There are low risks of damage to chorda tympani nerve.

It is possible to fully regenerate normal TM morphology and to improve hearing up to maximum level.

Wide renge of applications.

Adaptation of Hybrid Tympanoplasty

Chronic otitis media

No adaptation for cholesteatoma, adhesive otitis media

No adaptation for post operative cases

Intact case of ossicular chains

4 weeks after Hybrid Tympanoplasty

Hearing level: 42.5dB/15.0dB (before/after)

Histology of TM