To the Editor: We are pleased to note the appreciative comments on our recent article Functional Evaluation of a Cell Replacement Therapy in the Inner Ear (1). A cell-based replacement strategy has been proposed and investigated in recent years to substitute degenerated hair cells and spiral ganglion neurons for hearing loss, one of the major health problems in the world (2-6). However, this strategy is still in its infancy, and a number of questions need to be addressed. The selection of donor cells for transplantation is one of the critical issues. Embryonic stem (ES) cells or derived neural progenitors (7) and neural stem cells (NSCs) (8) have been found to survive and differentiate into neurons after transplantation into the inner ear of adult mammals. In an in vitro model, NSCs derived from the mice brain showed the ability to differentiate into cells expressing hair cell and neuron-specific proteins (9). In contrast to many of the candidate cells that have been explored, stem cells or progenitor cells derived from the inner ear should be more appropriate to adapt to the inner ear (10-12). The survival of implanted cells is a key issue for a cell-based strategy because it 1) determines transplantation efficacy; 2) provides the necessary time for stem cell to differentiate into hair cells or neurons; and 3) provides the time for stem cell to migrate and become integrated into the host auditory system. However, the survival rate of implanted cells is still extremely low. Approximately 0.05% of embryonic mouse NSCs survived when they were allografted transplanting into adult mouse inner ear (13). Using a stereologic method, we collected all the sections from the cochlea and counted the surviving NSCs. We found that approximately 0.04 to 0.07% implanted adult mouse NSCs survived after xenografted implantation into the inner ear of adult guinea pigs (14). Embryonic stem cells survived better in the inner ear but were still less than 1% (14). This is clearly a major limitation to the efforts using a cell therapy for restoring inner ear function (15). The low survival rate may attribute to the microenvironment in the inner ear that lacks growth factors and neurotrophins required for the survival of exogenous cells. To increase the survival of implanted cells, neurotrophins have been infused into the inner ear simultaneously with the implantation of neuronal tissue (15) or ES cells (7). To further stimulate the survival and integration of exogenous cells, we implanted embryonic mouse dorsal root ganglion neurons, a better survival model for inner ear regeneration strategy, into the inner ear. Although no significance was observed based on electrically evoked auditory brainstem responses measurement, this approach provides a good model to test the integration and the function of the implanted cells. To test what growth factors are optimal for promoting the survival of stem cells, the coculture model may be applied to culture the stem cells and sensory hair cell epithelium in the modified medium. However, to demonstrate whether stem cell-derived cells have the potential to replace the function of degenerated hair cells and neurons, an in vivo model must be used to implant the stem cells into the animals, supply with the appropriate small molecules, and test the hearing function. With the combination of stem cell-based replacement strategy and cochlear implant, we proposed and designed a Biological-EAR model, which may provide a new treatment option for hearing loss in the future (Fig. 1) (14).FIG. 1: Schematic diagram showing the Biological-EAR model. With the combination of stem cell-based replacement approach and cochlear implant, the sound will be converted into electric signals that will be perceived by the implanted cells and, in turn, be sent directly to the central auditory neurons in the brainstem, thus bypassing the degenerated hair cells and neurons.Zhengqing Hu, M.D., Ph.D.* Mats Ulfendahl, Ph.D.† *Department of Otolaryngology-HNS Wayne State University School of Medicine Detroit, Michigan, U.S.A. and †Center for Hearing and Communication Research and Department of Clinical Neuroscience Karolinska Institute Stockholm, Sweden
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