Patologie vestibolari su base - Altervistacenavest.altervista.org/pdfrelazioni/Martini.pdf · Patologie vestibolari su base ... Cattedra di Audiologia e UOC di ORL‐Otochirurgia,

Cenacolo Italiano di AudiovestibologiaChieti 14 maggio 2011

Patologie vestibolari su basePatologie vestibolari su basePatologie vestibolari su base Patologie vestibolari su base genetica/genetica/dismorfologicadismorfologica::

ccome diagnosticarleome diagnosticarle

Prof. Alessandro MartiniProf. Alessandro MartiniCattedra di Audiologia & UOC di ORL‐Otochirurgia

i d O d li i i i di dAzienda Ospedaliera Universitaria di Padova

Genetica delle malattie vestibolari????Genetica delle malattie vestibolari????

MenièreMenière ………e poi??????………e poi??????e è ee è e e poe poPendredEVACHARGECHARGEUsherSuscettibilità al danno vestibolare da gentamicinaV i i i ll’ i iVertigine associata all’emicraniaFabryKabukiLAMMNistagmo alternante periodico giovanileAtassia spinocerebellare tipo 6…………………………………………….Neurofibromatosi

HereditaryHereditary MenièreMenière diseasediseaseHereditaryHereditary MenièreMenière diseasedisease

Am J Otolaryngol. 1982 Am J Otol. 1992 Sep;13(5):477‐81.

Menière's disease in congenitalnephrogenic diabetes insipidus: reporty g

May‐Jun;3(3):163‐7.Hereditary Menière's

nephrogenic diabetes insipidus: report of two twins.

Comacchio F, Boggian O, Poletto E, Beghi A Martini A Rampazzo Ay

disease: report of two families.

Beghi A, Martini A, Rampazzo A.

Laryngorhinootologie 1995

Martini A.Laryngorhinootologie. 1995 Aug;74(8):512‐5.

[Meniere disease as an autosomedominant hereditary disease]dominant hereditary disease].

Arweiler DJ, Jahnke K, Grosse‐Wilde H.


Otolaryngol Clin North Am. 2010 Oct;43(5):1121‐32.

Genetic investigations of Meniere's

J Hum Genet. 2010 Dec;55(12):834‐7.

Familiar Meniere's disease restricted

Genetic investigations of Meniere s disease.

Vrabec JT.

to 1.48 Mb on chromosome 12p12.3 by allelic and haplotype association.

Gabriková D, Frykholm C, Friberg U, Lahsaee S, Entesarian M, Dahl N, Klar J. J Laryngol Otol. 2009 Jan;123(1):29‐37.

Familial Ménière's disease: clinical and genetic aspects.

Morrison AW, Bailey ME, Morrison GA.


Otol Neurotol. 2001 Nov;22(6):874‐81.

Br J Audiol. 1999 Oct;33(5):297‐302.

The COCH gene: a frequent cause of hearing impairment and vestibular

Hereditary otovestibular dysfunctionand Ménière's disease in a large Belgian family is caused by a missense

hearing impairment and vestibular dysfunction?

Fransen E, Van Camp G.

mutation in the COCH gene.

Verstreken M, Declau F, Wuyts FL, D'Haese P, Van Camp G, Fransen E, Van

Clin Otolaryngol Allied Sci. 2001 Dec;26(6):477‐83.

den Hauwe L, Buyle S, Smets RE, Feenstra L, Van der Stappen A, Van de Heyning PH.

; ( )Hereditary cochleovestibulardysfunction due to a COCH gene mutation (DFNA9): a follow‐up study of a family.a family.Verhagen WI, Bom SJ, Fransen E, Van Camp G, Huygen PL, Theunissen EJ, Cremers CW.


Acta Otolaryngol Suppl. 2002;(548):26‐9.

Human leukocyte antigen‐A, ‐B, ‐C and

Ear Nose Throat J. 2010;89(3):122‐7.

HLA‐B27‐associated bilateral Ménièrediseasey g , ,

‐DR alleles and soluble human leukocyte antigen class I serum level in Ménière's disease.

disease.

Rawal SG, Thakkar KH, Ziai K, Santi PA, Djalilian HR.

Melchiorri L, Martini A, Rizzo R, Berto A, Adinolfi E, Baricord OR.

The results showed a significantlyThe results showed a significantly increased frequency of the Cw*07 specificities in MD patients when compared to OID patients (63.4% vs

J Laryngol Otol. 1986 Jan;100(1):21‐4.

HLA antigens in the pathogenesis of Menière's disease.p p (

32.3%; p = 6.9 x 10(‐3); relative risk [RR] = 3.6) and healthy subjects (63.4% vs 35.6%; p = 2.28 x 10(‐3); RR = 3.1).

Xenellis J, Morrison AW, McClowskey D, Festenstein H.


J Neuroendocrinol. 2010 ;22:1157‐64.J Neuroendocrinol. 2010 ;22:1157 64.

Expression and translocation of aquaporin‐2 in the endolymphatic sacin patients with Meniere's disease

Cell Physiol Biochem. 2010;26:787‐92.

Molecular analysis of ii i

in patients with Meniere s disease.

Maekawa C, Kitahara T, Kizawa K, Okazaki S, Kamakura T, Horii A, Imai T, Doi K Inohara H Kiyama Haquaporinaquaporin genesgenes 1 to 4 in

patients with Menière'sdisease

Doi K, Inohara H, Kiyama H

Cell Tissue Res. 2010 Jun;340(3):407‐19.Immunohistochemical localization anddisease.

Candreia C, Schmuziger N, Gürtler N.

Immunohistochemical localization and mRNA expression of aquaporins in the macula utriculi of patients with Meniere's disease and acousticneuroma.Ishiyama G, Lopez IA, Beltran‐Parrazal L, Ishiyama A.

ImmunohistochemicalImmunohistochemical localizationlocalization and and mRNAmRNA expressionexpression of of aquaporinsaquaporins in the in the maculamacula utriculiutriculi ofof patientspatients withwith Meniere'sMeniere's diseasedisease andand acousticacoustic neuromaneuromamacula macula utriculiutriculi of of patientspatients with with Meniere sMeniere s diseasedisease and and acousticacoustic neuroma.neuroma.

Ishiyama G Lopez IA Beltran‐Parrazal L Ishiyama A



Meniere's disease is nearly invariably associated with endolymphatic hydrops (the net accumulation of water in the inner ear endolymphatic space).

Vestibular maculae utriculi were acquired from patients undergoing surgery for Meniere's disease and acoustic neuroma and from autopsy (subjects with normalhearing and balance). Quantitative immunostaining was conducted with antibodiesagainst aquaporins (AQPs) 1, 4, and 6, Na(+)K(+)ATPase, Na(+)K(+)2Cl co‐transporter(NKCC1), and alpha‐syntrophin. mRNA was extracted from the surgically acquiredutricles from subjects with Meniere's disease and acoustic neuroma to conduct

i i l i i i i h l h i i fquantitative real‐time reverse transcription with polymerase chain reaction for AQP1, AQP4, and AQP6.

AQP1 immunoreactivity (‐IR) was located in blood vessels and fibrocytes in the underlying stroma, without any apparent alteration in Meniere's specimens whencompared with acoustic neuroma and autopsy specimens. AQP4‐IR localized to the epithelial basolateral supporting cells in Meniere's disease, acoustic neuroma, and tautopsy.



In specimens from subjects with Meniere's disease, AQP4‐IR wassignificantly decreased compared with autopsy and acoustic neuroma

i AQP6 IR d i th b i l tib l ti ll ispecimens. AQP6‐IR occurred in the sub‐apical vestibular supporting cells in acoustic neuroma and autopsy samples.

However, in Meniere's disease specimens, AQP6‐IR was significantlyincreased and diffusely redistributed throughout the supporting cellcytoplasm. Na(+)K(+)ATPase, NKCC1, and alpha‐syntrophin were expressedwithin sensory epithelia and were unaltered in Meniere's diseaset se so y ep t e a a d e e u a te ed e e e s d seasespecimens.

Expression of AQP1, AQP4, or AQP6 mRNA did not differ in vestibularendorgans from patients with Meniere's diseaseendorgans from patients with Meniere's disease.

Changes in AQP4 (decreased) and AQP6 (increased) expression in Meniere'sdisease specimens suggest that the supporting cell might be a cellulartarget.

HereditaryHereditary MenièreMenière diseasedisease && AquaporinsAquaporinsHereditaryHereditary MenièreMenière diseasedisease & & AquaporinsAquaporins

AQP1 an osmotic water channel in the kidneyAquaporins (AQPs) play a fundamentalrole in mediating bidirectional water transport across membranes by

AQP1, an osmotic water channel in the kidney, brain, vascular system, and other tissues, has been hypothesized to function as a cGMP‐gated cation channelThe role of AQP1 that localizes to mesenchymal

lowering the energy used for water permeationPresently, 13 members of the AQP family (AQP0 AQP12) are known

The role of AQP1 that localizes to mesenchymalcells in the animal and human cochlea and vestibule has been proposed to be the transport of water molecules external to the transport of water molecules external to the endolymphaticendolymphatic compartmentcompartment, regulating the osmotic environment adjacent to the scalafamily (AQP0–AQP12) are known

At least eight AQPs have beendescribed in the inner earThe immunolocalization of AQP1 4

osmotic environment adjacent to the scalamedia

AQP4 is critical for the movement of water from the blood or cerebrospinal fluid into and out ofThe immunolocalization of AQP1, 4,

and 6 has recently been described in the human inner ear obtained from subjects with normal hearing and

the blood or cerebrospinal fluid into and out of the brain tissue and is localized in the endfeetmembranes directly in contact with the basement membranes In the inner ear, AQP4 is restricted to epithelial cells in the organ of Corti and vestibularj g

balance, and the localizationdemonstrates conservation acrossanimal models .

cells in the organ of Corti and vestibular supporting cells and has been hypothesized to offset local increases in K+ ion concentration in supporting cells AQP4 probably plays a critical role in hearingcritical role in hearing, as th AQP4 k k t d l hibitthe AQP4 knockout mouse models exhibit impaired auditory function, although the inner ear morphology is normal

IPOACUSIE GENETICHE IPOACUSIE GENETICHE SINDROMICHE recessive SINDROMICHE recessive USHERUSHER

(geni USH, MYO, CDH, PCDH, SANS,VLGR)

25% delle sindromi recessive, 3-6% delle 5 de e s ndrom recess e, 3 6 de e sordità infantili, 50% delle sordità associate a cecità.L l i I li è i 1/35001/3500La prevalenza in Italia è circa 1/35001/3500abitanti, negli USA 1/170001/17000

IPOACUSIE GENETICHE IPOACUSIE GENETICHE SINDROMICHE recessive SINDROMICHE recessive USHER

La sordità è neurosensoriale dipende da un’atrofia delle cellule ciliate e della stria vascolare, alterazione del ganglio spirale. Può essere classificata in 3 tipi:

f d flI con ipoacusia profonda congenita, areflessiavestibolare e retinite pigmentosa nella 1° decade di vitaII con ipoacusia progressiva e retinite pigmentosa nella 1°-2° decade di vitaIII con ipoacusia progressiva funzione vestibolare III con ipoacusia progressiva, funzione vestibolare variabile e retinite con insorgenza variabile

Genetica della S di UsherGenetica della S. di Usher_____________________________________________________Genetic subtype Locus Gene Protein________________________________________________USH 1A 14q32USH 1A 14q32 USH 1B 11q13.5 MYO7A myosin VIIAUSH 1C 11p15 USH 1C harmoninUSH 1D 10q21‐22 CDH23 cadherinqUSH 1E 21q21 USH 1F 10q21‐22 PCDH15 protocadherin 15

USH 2A 1q32‐42 USH 2A usherinUSH 2B 3p23‐24USH 2C 5q14.3‐q21.3 VLGR1 G‐protein

USH 3 3q21‐q25 USH3a clarin

Type I Vs Type IIType I Vs Type IIType I Vs Type IIType I Vs Type II

0

‐10H

0

‐100

‐10

0

10

20

30

40

50

earing

in

0

10

20

30

40

50

0

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40

50

TYP 60

70

80

90

100

g

Leve

dB

50

60

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80

90

100

60

70

80

90

100

PE

I125 250 1000500 2000 4000 8000

Frequency

110

H ‐10

125 250 1000500 2000 4000 8000

Frequency

l 110

125 250 1000500 2000 4000 8000

Frequency

110

‐10‐10

I

earing

in

0

10

20

30

40

50

0

10

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0

10

20

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TYP g

Leve

dB

50

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50

60

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80

90

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50

60

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PE

II125 250 1000500 2000 4000 8000

Frequency

l 110

125 250 1000500 2000 4000 8000

Frequency

110

125 250 1000500 2000 4000 8000

Frequency

110II

d l f h dGenetic epidemiology of Usher syndrome

3,0 / 100, 000 type I

5 0 / 100 000 t II5,0 / 100, 000 type II

Type II more common than type I

50% f ll d f/bli d50% of all deaf/blind

5% of children in schools for the deaf

More common in certain regionsNorthern Sweden 8 /100.000 type 1b,d

Southern Louisiana/Acadian (type 1c)Southern Louisiana/Acadian (type 1c)

Finland (type III)

Myosins are hmechanoenzymes

upon interaction with ti i tactin, myosins convert

energy from ATP hydrolisis to mechanicalhydrolisis to mechanical force as they pull against or move along against or move alongactin filaments

Locus: 11q13.5Gene: MYO7AProtein: Myosin VIIa

≈ 60‐70% of all Usher type I patients

‐A member of the unconventional myosin family. Myosins are motor proteins that bindActin and ATP to produce energy

‐expressed in the photoreceptors in the retina

‐expressed is in the hair cells of the organ of Corti and the cupula in the vestibular organ

‐Phenotype: it l d f‐congenital deafness,

‐vestibular areflexia and RP

Localization of Myosin VIIa in the EarLocalization of Myosin VIIa in the Ear

Orten and Usami unpublished data and Hasson et al. 1997 J. Cell Biol. 137:1287-1306.

Cli i l di l i l d ti d tClinical, radiological and genetic data of EVA syndromey

Alessandro Martini Cattedra di Audiologia e UOC di ORL‐Otochirurgia,

Azienda Ospedaliera Università di PadovaAzienda Ospedaliera Università di Padova

Enlarged Vestibular Aqueduct (EVA)Enlarged Vestibular Aqueduct (EVA)

Enlarged Vestibular Aqueduct (EVA) is known as the most common form of inner ear anomaly and it may be radiologically diagnosed using temporal bone computed tomography (CT) and inner ear Magnetic Resonance Imaging (MRI).tomography (CT) and inner ear Magnetic Resonance Imaging (MRI).


The vestibular aqueduct is enlarged if its diameter exceeds 1.5 mm, measured in the middle of the

daqueduct. The location of the measurement (halfway between h f h f d h b l )the orifice at the posterior fossa and the vestibule) is of great importance for the correct diagnosis.

TemporalTemporal bone bone CCCTscanCTscan

axialaxial projectionsprojections: : Normale Normale anatomyanatomy

EnlargedEnlarged VestibularVestibular AqueductAqueduct (EVA) (EVA)


CT shows the enlargement of the vestibular aqueduct, d T2 i h d MRI d h l dand T2‐weighted MRI demonstrates the enlarged

endolymphatic duct within the bony canal and the i f th d l h tisize of the endolymphatic sac.


The association between hearing loss and EVA was firstly described by Valvassori and Clemis in 1978 in afirstly described by Valvassori and Clemis in 1978 in a retrospective study, in which they reported findings of 50 patients with EVA, frequently bilateral. p , q yIt is reported that the EVA results from an arrest of the inner ear development at the 7th week of fetalpdevelopment.In 40% cases EVA in an isolated inner ear anomaly, ywhile in 60% it can be associated to other inner ear malformations (i.e. enlargement of lateral semicircular

l hl h l )canal, cochlear hypoplasia...)

The association between h i l d EVA h bhearing loss and EVA has been described in diverse systemic syndromes (i.e. Pendred Syndrome, distal renal tubularSyndrome, distal renal tubular acidosis, Waardenburg’s syndrome) and non‐syndromic familial or isolated forms (non‐

d i EVA EVA) EVA & EVA & PendredPendred

syndromic EVA, ns.EVA). In both cases, phenotypic expressions associated with EVA are heterogeneous; as it PendredPendred

syndromesyndromeEVA are heterogeneous; as it can be seen as bilateral deafness, progressive sensorineural hearing loss, fluctuating sensorineural hearing loss or sudden sensorineural hearing loss, sometimes subsequent to headsometimes subsequent to head trauma. The clinical picture can also include vestibulopathy p y

DFNB4

Nonsyndromic SNHLNonsyndromic SNHL

May be congenitalOften pro ressi eOften progressiveVestibular dysfunctionTemporal bone abnormalities

PendredPendred & & abnormalitiesNormal thyroid function

DFNB4DFNB4Pendred syndrome

Severe‐to‐profound bil SNHLCongenitalCongenitalNon‐progressiveVestibular dysfunctionTemporal boneTemporal bone abnormalitiesEuthyroid goiter late childhood early adulthoody

PendredPendred & DFNB4& DFNB4

PendredMay be progressive postlingual HL developed after injury(cases)

V ib l d f i i 66% (( ildild il lil l ii bilbilVestibular dysfunction in 66% ((mildmild unilateralunilateral paresisparesis toto bilbilabsenceabsence ofof functionfunction))

Temporal bone abnormalityTemporal bone abnormality:

1. 100% deficiency of modiolus

2 75% b t f th hl2. 75% absence upper turn of the cochlea

3. 80% vestibular acqueduct > 1.5 mm


DFNB4

Hearing may be normal at birth and progressive

HL: no correlation with EVA size

Vestibular dysfunction may be abnormal withoutcorrelation with EVA size

EVA in 75% bil or unilateral


Genetics:

2 genes are associated with Pendred s. and DFNB4:g

SLC26A4 SLC26A4 (50% affected individuals)

FOXI1FOXI1 (1% affected individuals)FOXI1FOXI1 (1% affected individuals)

Sequence analysis identifies disease‐causing mutationsin 50% of affected individuals from multiplex families and in 20% in simplex families

The gene responsible for sensorineural hearing loss

i t d ith EVA i l t dassociated with EVA is located in the chromosome region 7q31, the same region also described as being responsibledescribed as being responsible for Pendred Syndrome.Particularly when considering the SLC26A4 gene, a recessive

Genetics of Genetics of trait that codifies for a membrane transporter able to exchange anions between the cytosol and extracellular fluid EVAEVAcytosol and extracellular fluidIt has been described that its mutation can be responsible of PDS (sensorineural deafness (and goiter) and DFNB4, a type of autosomal recessive nonsyndromic deafness in which by definition affectedwhich, by definition, affected persons do not have thyromegaly.

In Caucasians:In Caucasians:

p.Leu236Pro 26%

p Thr416Pro 15%Genetics: Genetics: mutationsmutations

p.Thr416Pro 15%

c.1001+1G>A 14% (o IVS8+1G>A) mutationsmutations

SLC26A4 geneSLC26A4 gene(o IVS8 1G A)

In Japanese population:In Japanese population:

p.His723Arg 53%

Genetics: Genetics: mutationsmutations SLC26A4 geneSLC26A4 gene

Mutation scanningMutation scanning

DHPLC detect 100% of allelic variants

SSPC only 63% !!!!!!!!!!!

Sequence analysis of all 21 exons 100% of disease‐causing mutationscausing mutations

PendredPendred SyndromeSyndrome

congenital, severe-to-profound or progressive sensorineural HLb lit f th b l b i th abnormality of the bony labyrinth

euthyroid goiter in early puberty or adulthoodabnormal vestibular functionabnormal vestibular function

Locus Name Location GenePDS 7q21-34 SLC26A4

PDS 5q35.1 FOXI1

PENDREDPENDRED

PendredPendred syndromesyndrome

Absence of anterior and lateral sem canals, enlarged vestibular aqueductenlarged vestibular aqueduct

1mm

Sindrome di Sindrome di PendredPendred

►► Displasia tipo Displasia tipo MondiniMondini►► Organo del Corti assenteOrgano del Corti assente

Efficient molecular genetic diagnosis of enlarged vestibular aqueducts in East Asians.q

Choi BY Stewart AK Nishimura KK Cha WJ Seong MW Park SS Kim SW Chun YS Chung JW Park SN Chang SOKim CS Alper SL Griffith AJ Oh SH

CONTEXT: Enlargement of the vestibular aqueduct (EVA) is a commonly detected inner ear anomaly related to hearing loss and often associated with mutations of SLC26A4 encoding pendrin, a transmembrane exchanger of Cl(‐), I(‐), and HCO(3)(‐). Here we d ib h h f 27 K EVA bj d h i SLC26A4describe the phenotypes of 27 Korean EVA subjects and their SLC26A4 genotypes determined by bidirectional nucleotide sequencing.

RESULTS: The detected variants include two novel missense substitutions (p.V138L and p P542R) We characterized the ability of p V138L and p P542R pendrin products to trafficp.P542R). We characterized the ability of p.V138L and p.P542R pendrin products to traffic to the plasma membrane in COS‐7 cells and to transport Cl(‐), I(‐), and HCO(3)(‐) in Xenopus oocytes. The results indicate that p.P542R is a benign polymorphic variant, whereas p.V138L is a pathogenic mutation. Since this and other studies of East Asian EVA cohorts show that the majority of SLC26A4 mutations affect either or both of twocohorts show that the majority of SLC26A4 mutations affect either or both of two amplicons (exons 7‐8 and 19), we developed a hierarchical protocol that integrates direct sequencing with denaturing high‐performance liquid chromatography analyses for detection of SLC26A4 mutations in these populations. We validated the cost efficiency of the integrated protocol by a simulated screen of published East Asian EVA cohorts with known SLC26A4 genotypes.

CONCLUSIONS: Our study further defines the spectrum of SLC26A4 mutations among East Asians and demonstrates a rapid and efficient protocol for their detectionAsians and demonstrates a rapid and efficient protocol for their detection.

Hipoacusia en niños con acueducto vestibular dilatado Estudio de 55 casosdilatado. Estudio de 55 casos Acta Otorrinolaringológica Española, 61: sept 2010

S. Santos, L. Sgambatti, A. Bueno, G. Albi, A. Suárez, M.J.Domínguez

55 cases55 cases

6 cases syndronic

67% bilateral EVA

33% il l33% unilateral

Familial HL 22%

Personal dataPersonal dataPersonal dataPersonal data

i f 35 i i 19 f l d 16a series of 35 caucasians patients, 19 females and 16 males (5 ‐ 68 years, mean age 20 years) affected by h i l d EVAhearing loss and EVA

evaluated between January 2003 and December 2009, at the Audiology Department of the University Hospital of Ferrara (Italy).

Patients affected by syndromes not related to SLC26A4 gene mutations (ie BOR, Waardenburg) were g ( g)excluded.

X XX

X X XX

CA=CO

DATI PZ:

ANACUSIA DESTRADonna, 28 aa

Anacusia dx congenita;

ipoacusia improvvisa sin ,

vertigine sogg episodicavertigine sogg. episodica

DATI PZ:

Donna, 29 aa

Ipoacusia congenita, progressiva, no vertigini; patologia tiroidea all’esordio

>

Indagine genetica PDS negativa

>

O

>

OX

>X

O O

O OX

XXX>>

O

Group 1. Non Non syndromicsyndromic EVA EVA (ns‐EVA): 18/35 patients (51,4%), p yy ( ) p ( )mean age 19 years, 9 females and 9 males: presence of hearing loss and enlarged vestibular aqueduct, but no pendrin gene (SLC26A4) i d h id d f i ( h l(SLC26A4) mutations and no thyroid dysfunction (thyromegalywas detected in 5% of the cases).

Group 2 EVA with DFNB4EVA with DFNB4 8/35 patients (22 8%) mean age 13Group 2. EVA with DFNB4EVA with DFNB4. 8/35 patients (22.8%), mean age 13 years, 4 females and 4 males: presence of hearing loss, enlarged vestibular aqueduct with single SLC26A4 pathologicalenlarged vestibular aqueduct with single SLC26A4 pathological mutation and no thyroid dysfunction (thyromegaly was detected in 12,5% of the cases). (DFNB4).

Group 3. EVA in EVA in PendredPendred Syndrome Syndrome (PDS). 9/35 patients (25.7%), mean age 26 years, six females and three males:

f h l l d b l d hpresence of hearing loss, enlarged vestibular aqueduct with two pathological mutation of pendrin gene (SLC26A4) and thyromegaly with thyroid dysfunction (Pendred Syndrome)thyromegaly with thyroid dysfunction (Pendred Syndrome).

audioprofiles

Patients of group 1 (ns‐EVA) show various degrees of hearing g p ( ) g gloss from mild (55%) to severe‐profound (45%).

In groups 2 (DFNB4) and 3 (PDS), the degree of hearing loss is t f d i 70 75% f th iddl d hi hsevere to profound in 70‐75% of the cases; middle and high

frequencies are mainly involved.

hearinghearinghearinghearing

At the statistical evaluation it has been possible to notice aAt the statistical evaluation, it has been possible to notice a significative threshold difference only between patients of group 1 and those of groups 2 and 3 (p<0,05).g p g p (p , )

Groups EVA vs DFNB4 EVA vs PDS DFNB4 vs PDSp

p‐value 0,032 0,002 0,352

Among the onset of hearing loss, patients of group 1 (ns‐EVA) havepatients of group 1 (ns EVA) have presented hearing loss since childhood in 66.5%, while patients of group 2 (DFNB4) and group 3 (PDS) have all presented an early onsetan early onset.

A progression or a post‐traumatic onset of hearing loss occurred in onset type and evolution of hearing lossonset of hearing loss occurred in 50% of group 1 patients, in 37.5% of group 2 and in 55.5% of

onset, type and evolution of hearing loss

66,5 % 55,5 %

100 %PDS

group 3.

A conductive or mixed hearing loss 62,5 % 37,5 %

100 %DFNB4

have been noticed in 50% of group 1 patients, in 62.5% of group 2 and 66 5% of group 3

50 % 50 %

66,5 %EVA

transmission deafness

progressive deafness

early onset

group 2 and 66.5% of group 3. 0 20 40 60 80 100 %

group 1: 77.8% of pts t d bil t l EVApresented a bilateral EVA

and 22.2% other minor inner ear malformations. group 2: 87, 5% of pts had a bilateral EVA, while 12 2% d h

neuroradiologicalneuroradiological12.2% presented other minor inner ear malformations (such as

evaluationevaluation(

Mondini dysplasia and hypoplasia of the lateral semicircular canal)semicircular canal).group 3: all pts revealed a bilateral EVA, and 22% ,other minor inner ear malformations

II lf ilf iInnerInner earear malformationmalformation

100 %22 %

Inner ear malformations

87 5 %12,5 %

0 %

100 %PDS

22 %

12,5 %

87,5 %DFNB4

22,2 %

77,8 %EVA

0 20 40 60 80 100 %other innear ear malformationsbilateral EVAunilateral EVA

SLC26A4 genotypescompound

heterozygosis

heterozygosis2/35 = 5,71 %

7/35 = 20 %compound heterozygosis (no clear evidence for pathogenic role)pathogenic role)6/35 = 17,14 %

homozygosis2/35 = 5,71 %

compound heterozygosiscompound heterozygosishomozygosiscompound heterozygosis (no clear evidence for pathogenic role)heterozygosis

GeneticGenetic evaluationevaluation

pat 42 :mutation R409H (citata da Coyle et al, 1998, Van Hauwe et al, 1998, Fugazzola et al 2002, Bogazzi et al 2004, pBlons et al 2004) in omozigosi esone 10

pats 18 e 19 : mutation T405N in eterozigosi esone 10 non ritrovata in letteratura

pats 35 e 38 pendred mutation L445W (citata da Cremers et al 1998 Van Hauwe et al 1998 Coucke et al 1999pats 35 e 38 pendred mutation L445W (citata da Cremers et al 1998, Van Hauwe et al 1998, Coucke et al 1999, Reardon et al 2000, Lopez‐Bigas et al 2002, Prasad et al 2003, Blons et al 2004 Pryor et al 2005 ) in eterozigosi esone 11, [5 loopintracellulare] nota per dare gozzo, sordita’, +/‐ PDT e DVA.

paziente 8 bil EVA mutation L445W in eterozigosi esone 11, [5 loop intracellulare] +e mutazione G557D in p g , [ p ]eterozigosi in esone 15 nella regione C terminale intracellulare.Mutazione non presente in letteratura ma vicina a Y556C/H citata da Coyle et al, 1998e da Lopez‐Bigas et al 1999.

pats 13 e 15 mutation IVS 8+1 G>A in introne 8 in omozigosi per la figlia e in eterozigosi per il padre (citata da Coylel l b ll l l l l l l k let al, 1998, Bogazzi et al 2000, Campbell et al 2001, Fugazzola et al 2002, Bogazzi et al 2004,Blons et al 2004, Tsukamoto et al

2003, Pryor et al 2005

pat 11 EVA sin mutazione X374 in esone 9 non riscontrata in letteratura ma vicina a A372V tipica di EVA (ma non PDS)PDS)

pat 13 mutation I425L in eterozigosi in esone 11 non riscontrata in letteratura da ricontrollare

Le mutazioni tipicamente legate alla manifestazione di EVA ma non alla sindrome di Pendred [X308, A372V, X722, T721M, H723R] non sono state riscontrateH723R] non sono state riscontrate.La mutazione L445W identificata in 3 pazienti può determinare EVA e anche in associazione alla sindrome di Pendred.

thyroid functionthyroid function

thyromegaly was present in all group 3thyromegaly was present in all group 3 patients (EVA with Pendred Syndrome)

some thyroid hormones dysfunction was also detected in 5.5% of group 1 cases as

ll i 12 5% f 233 % 33 %

35

Thyroid Pathology

well as in 12.5% of group 2 cases

25

30

35

5,5 %

12,5 %

10

15

20%

0 % 0 %

0

5

10

EVA DFNB4 PDSEVA DFNB4 PDS

thyroid disfunction morphological abnormalities on thyroid ultrasound

GusherGusher & & cochlearcochlear implantationimplantation

Out of 700 CI: 82 cases of inner ear abnormalities

7 h7 cases severe gusher

3 normal CTscan and ear MR

2 EVA not Pendred

2 cochlear hypoplasia with normal post lab2 cochlear hypoplasia with normal post lab

I h 8 f EVA d 12 f M di i hIn other 8 cases of EVA and 12 of Mondini: no gusher

conclusionsconclusions

hearing and endocrine function surveillance ismandatory in all cases of EVA

sequencing analysis of all 21 SLC26A4 gene is more informative

in negative cases FOXI1 gene has to be analysedin negative cases FOXI1 gene has to be analysed

may be other genes involved

se ere sher is a possible ompli ation of a CIsevere gusher is a possible complication of a CIsurgery

Inner Inner earear malformationsmalformations

sindromisindromi genetichegenetichecheche coinvolgonocoinvolgono

l’ hil’ hil’orecchiol’orecchio

Alessandro Martini *, Ferdinando Calzolari °,Ferdinando Calzolari ,

Alberto Sensi §Audiology Dept *, Neuroradiology

Dept ° and Clinical Genetics §Dept ° and Clinical Genetics §, Universitary Hospital, Ferrara, Italy

Ad oggi sono state descritte più di 450 differenti condizioniAd oggi, sono state descritte più di 450 differenti condizionigenetiche associate con ipoacusia. Negli ultimi 15 anni, sono stati clonati oltre 60 geni per le ipoacusie non sindromiche e altre 30 per quellesindromicheUna diagnosi genetica di ipoacusia sindromica ha molteUna diagnosi genetica di ipoacusia sindromica ha molteconseguenze pratiche: può implicare una prognosi specifica, uno specifico trattamento, uno specifico rischio diricorrenza nei congiunti e se la diagnosi è confermata aricorrenza nei congiunti e, se la diagnosi è confermata a livello molecolare,la possibilità di una specifica diagnosiprecoce prenatale per le forme più severe.

N ll’ bit d ll ti t d ll tiNell’ambito delle recenti scoperte della genetica molecolare della sordità, due sono gli aspetti che riteniamo particolarmente rilevanti.riteniamo particolarmente rilevanti. Un primo dato molto importante è la definizione del rapporto tra presenza di una certa mutazione e la comparsa della ipoacusia (correlazione tra genotipo e fenotipo). È t t t h l l t òÈ stato scoperto che non solo lo stesso gene può dare origine a “forme” diverse di sordità (sia autosomica recessiva che dominante, ma ancheautosomica recessiva che dominante, ma anche non‐sindromica o sindromica), ma anche che la stessa mutazione dello stesso gene, può causare

i di lt di i di i iper esempio gradi molto diversi di ipoacusia. Ruolo dei cosiddetti geni “modificatori”.

possibile approccio diagnostico molecolare in alcune sindromi monogeniche con ipoacusia

Autosomal recessive Autosomal dominant X‐linkedh ( d b ) d b ( ) lUsher (I‐III and subtypes) Waardenburg (I‐IV) Alport

Pendred Branchio‐oto‐renal(I‐II) NorrieJervell and Lange‐Nielsen Treacher CollinsJervell and Lange‐Nielsen Treacher CollinsBiotinidase deficiency Stickler (I‐III)Wolfram VohwinkelLAMM Craniosinostosi* Agenesia Orecchio Interno/microdontia/ microtia

* queste sindromi non sono sempre incluse perché l’ipoacusia non è costante o elemento caratteristico

Fi 1 Mi ti d III ithFig.1 Microtia grade III with ear remnants

Fi 2 E t l l t iFig. 2. External ear canal stenosis

Fig. 3 Right external auditory canal atresia malleoincudo joint fusion

Fig. 4. “double” external ear canal

Fi 5 Ab lit f th ti lFig 5. Abnormality of the vertical portion of the facial nerve

Fig. 6. Right external auditory canal atresia, malleoincudo joint fusion with adhesion to the epitympanum

Fig 7 Inner ear absence and Fig 8 Inner ear absence internalFig. 7. Inner ear absence and stapes dysplasia

Fig. 8. Inner ear absence, internal auditory canal stenosis and stapes

dysplasia

Fig 9 Inner ear malformationFig. 9. Inner ear malformation

Incomplete partition type 2

Fig. 10. Inner ear bilateral malformation:

dysplastic cochleas, dilated vestibule, hypoplastic LSCs, incomplete CSSs, incomplete CSPs, dilated tib l d t d d l h tivestibular ducts and endolymphatic sacs

Fig. 11. semicircular canals gabsence

Fig. 12. Bilateral EVA

Fig. 13. hemifacial microsomia in Godenhar syndrome

Fig. 14. bulbar dermoid in Goldenhar syndrome

Fig. 15. small pit on the root of the helix (BOR)

Fig. 16. branchial fistula (BOR)

Fig. 17. Syndactyly in Apert syndrome (O.Calabrese Courtesy)

Fig. 18. Crouzon syndrome

Fig. 19. mild II‐III finger syndactyly, common in Sathre Chotzen syndrome

Protocol for routine aetiological evaluationProtocol for routine aetiological evaluation

Thorough clinical evaluationHearing threshold determination ( including parents, siblings and other family members)members) Classification of the HI (i.e. site of lesion)Vestibular testingOphthalmological assessmentCT/MR s anninCT/MR scanningBlood testing: e.g.

Viral antibodies (rubella, CMV, HIV, and others)Bacterial antibodies (syphilis, toxoplasmosis, others)Thyroid function (TSH, T3, T4, others)Cytogenetic testing ( FISH for Velocardiofacial/DiGeorge, microdeletiveBOR and complex sundromes)

Urine analysisUrine analysisElectrocardiogramMutation analysis in Connexins ( GBJ2 and GBJ6) and other relevant genes such as WFS1 and SLC26A4.Specific e g perchlorate testSpecific e.g. perchlorate test.

Sensi A Ceruti S Trevisi P Gualandi F Busi M Donati I Neri M Ferlini A Martini A

labyrinthine aplasialabyrinthine aplasiamicrotia, microdontia

Developmental milestones in mouse inner ear Developmental milestones in mouse inner ear formation formation

BMC Genet. 2010 Jul 16;11:68.A symphony of inner ear developmental control genes. Chatterjee S, Kraus P, Lufkin T.

Representative expression patterns of genes controlling cochlear Representative expression patterns of genes controlling cochlear d tib ld tib l ifi tiifi tiand vestibular and vestibular specification specification

(A) Shh functions to maintainPax2 and restrict Dlx5/Dlx6 in the medial wall of the otic vesicle in order to specify cochlear fate Dlx5/Dlx6 specify the medial toto specify cochlear fate. Dlx5/Dlx6 specify the medial to dorsal most cells of the otic epithelium that give rise to the endolymphatic duct and vestibular apparatus. (B) Secretion of Shh from the notochord specifies the ventral most cells of the otic epithelium that express Otx1/Otx2 and possibly Pax2 which contribute toOtx1/Otx2 and possibly Pax2 which contribute to cochlear morphogenesis and outgrowth. In addition, Dlx5/Dlx6‐dependent vestibular specifications and morphogenesis is dependent upon the activation of Gbx2 and Bmp4 function (not shown) and partial activation/expression of Otx1. Dlx5/Dlx6 also functions

i 2 i h di l ll f hto restrict Pax2 expression to the medial wall of the otic vesicle epithelium. Thus, Dlx5/Dlx6 and Shhmay functionally antagonize each other, through repression, to generate compartments of activities that specify the vestibular and cochlear cell fates. (C) Both Hmx2 and Hmx3 are required for cell fate determination andHmx3 are required for cell fate determination and subsequent morphogenesis of the developing inner ear. Loss of both Hmx2 and Hmx3 results in the absence of the entire vestibular system. Msx1/Msx2 are expressed in the adjacent periotic mesenchyme and are critical for middle ear development. (D) Fgfsp ( ) gffunction with Shh in the periotic mesenchyme to initiate ventral otic capsule chondrogenesis via Brn4 and Tbx1 function (not shown). Fgfs are also expressed in the hindbrain epithelium adjacent to the otocyst and are important for induction of the otic placode.


Abnormal vestibular structure and morphogenesis in wholeAbnormal vestibular structure and morphogenesis in whole‐‐mount βmount β‐‐


galactosidasegalactosidase stained midstained mid‐‐gestation embryos lacking either gestation embryos lacking either Hmx2 Hmx2 or or Hmx3Hmx3

Early in development Hmx2 (A) is expressed throughout both the vestibular portions of the inner ear of heterozygous (A) embryos. Embryos that are homozygous for the absence of Hmx2 (C) have relatively normal cochlear development in the presence of severely dysmorphic vestibularrelatively normal cochlear development in the presence of severely dysmorphic vestibular development. The endolymphatic duct morphogenesis is retarded and the superior (SD), posterior (PD), and lateral or horizontal (HD) semicircular ducts appear to form a fused and primitive vestibular diverticulum (VD) and is associated with decreased maculae of the utricle (MU) and saccule (MS). In contrast, Hmx3 expression in the inner ear of heterozygous (D) and homozygous (F) embryos demonstrates expression throughout only the vestibular apparatus, including the ED and all three semicircular ducts. Embryos that are homozygous for the absence of Hmx3 (F) have mild faulty development of vestibular structures including a fusion of the utricular and saccular chambers (U‐S) and a dysmorphic utricular maccula (MU) in the presence of circling behavior.

Abnormal vestibular morphogenesis in wholeAbnormal vestibular morphogenesis in whole‐‐mount βmount β‐‐galactosidasegalactosidase


stained E11.5 and E14.5 embryos lacking both stained E11.5 and E14.5 embryos lacking both Dlx5 Dlx5 and and Dlx6Dlx6

E b i Dl 5 d Dl 6Embryonic Dlx5 and Dlx6 expression in the inner ears of heterozygous (A, C) and homozygous (B, D) Dlx5/Dlx6 embryos demonstrates that vestibular morphogenesis is arrested by E11.5 with the absence of presumptiveabsence of presumptive semicircular ducts and endolymphatic duct (ED, asterisk). At E14.5, Dlx5/Dlx6 expression

ll d fi th j it fnormally defines the majority of the vestibular apparatus, including the anterior (AD), posterior (PD), and lateral (LD) semicircular ducts, ampullae (A) and ED. In contrast, the cell lineage of the presumptive vestibular apparatus is absent (asterisk) from Dlx5/Dlx6is absent (asterisk) from Dlx5/Dlx6 null embryos, which develop a rudimentary pinna (P)

Nele Hilgerta, Richard J.H. Smithb and Guy Van Campa, ,

Mutation Research/Reviews in Mutation Research Volume 681, Issues 2‐3

Hearing impairment is the most common sensory disorder, present in 1 of every 500 newborns. With 46 genes implicated in nonsyndromic hearing loss, it is also an extremely heterogeneous trait. The most frequent genes implicated in autosomal recessive nonsyndromic hearing loss are GJB2, which is responsible for more than half of cases, followed by SLC26A4, MYO15A, OTOF, CDH23 and TMC1. None of the genes associated with autosomal dominant nonsyndromic hearing loss accounts for a preponderance of cases, although mutations are somewhat more frequently reported in WFS1, KCNQ4, COCH and GJB2. Only a minority of these genes is currently included in genetic diagnostics, the selection criteria typically reflecting: (1) high frequency as a cause of deafness (i.e. GJB2); (2) association with another recognisable feature (i.e. SLC26A4 and enlarged vestibular aqueduct); or (3) a recognisableaudioprofile (i.e. WFS1). New and powerful DNA sequencing technologies have been developed over the past few years, but have not yet found their way into DNA diagnostics. Implementing these technologies is likely to happen within the next 5 years, and will cause a breakthrough in terms of power and cost efficiency. pp y g p yIt will become possible to analyze most – if not all – deafness genes, as opposed to one or a few genes currently. This ability will greatly improve DNA diagnostics, provide epidemiological data on gene‐based mutation frequencies, and reveal novel genotype–phenotype correlations.

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Patologie vestibolari su base - Altervistacenavest.altervista.org/pdfrelazioni/Martini.pdf · Patologie vestibolari su base ... Cattedra di Audiologia e UOC di ORL‐Otochirurgia,