Targeted Medicines for the Ear - OTO-413 Program Review

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Targeted Medicines for the Ear - OTO-413 Program Review
Targeted
Medicines
for the Ear

              OTO-413 Program Review
                      November 5, 2018
Targeted Medicines for the Ear - OTO-413 Program Review
Forward-Looking Statements

                                                          Safe Harbor Statement

These slides and the accompanying oral presentation (the “Presentation”) contain forward-looking statements within the meaning of
the Private Securities Litigation Reform Act of 1995. Forward-looking statements generally relate to future events or future financial or
operating performance of Otonomy, Inc. (“Otonomy”). Forward-lookingstatements in this Presentation include, but are not limited to,
the timing of the Phase 1/2 clinical trial for OTO-413, the potential market opportunity for OTO-413, and expectations regarding
program advancement. Otonomy’s expectations regarding these matters may not materialize, and actual results in future periods are
subject to risks and uncertainties. Actual results may differ materially from those indicated by these forward-looking statements as a
result of these risks and uncertainties, including but not limited to: Otonomy’s limited operating history and its expectation that it will
incur significant losses for the foreseeable future; Otonomy’s ability to obtain additional financing; Otonomy’s dependence on the
regulatory success and advancement of product candidates, such as OTO-413; the uncertainties inherent in the drug development
process, including, without limitation, Otonomy’s ability to adequately demonstrate the safety and efficacy of its product candidates,
the nonclinical and clinical results for its product candidates, which may not support further development, and challenges related to
patient enrollment in clinical trials; the risk of the occurrence of any event; Otonomy’s ability to obtain regulatory approval for its
product candidates; side effects or adverse events associated with Otonomy's product candidates; Otonomy’s ability to successfully
commercialize its product candidates, if approved; competition in the biopharmaceutical industry; Otonomy’s dependence on third
parties to conduct nonclinical studies and clinical trials; Otonomy’s dependence on third parties for the manufacture of its product
candidates; Otonomy’s dependence on a small number of suppliers for raw materials; Otonomy’s ability to protect its intellectual
property related to its product candidates in the United States and throughout the world; expectations regarding potential market size,
opportunity and growth; Otonomy’s ability to manage operating expenses; implementation of Otonomy’s business model and strategic
plans for its business, products and technology; and other risks. Information regarding the foregoing and additional risks may be found
in the section entitled "Risk Factors" in Otonomy's Quarterly Report on Form 10-Q filed with the Securities and Exchange Commission
(the "SEC") on November 5, 2018, and Otonomy’s future reports to be filed with the SEC. This Presentation is dated as of November 5,
2018, and Otonomy undertakes no obligation to update any forward-looking statements, whether as a result of new information,
future events or otherwise, except as required by applicable law.

                                                                                                                                              2
Targeted Medicines for the Ear - OTO-413 Program Review
Hearing Loss: Large and Growing Unmet Need

                                 Hearing Loss is 4th Leading Cause of Disability Globally1
                                                 1 Lancet, July                  2017                                                                                                            NEJM, Dec 2017
                                                                                                                           Review                                            The   n e w e ng l a n d j o u r na l     of   m e dic i n e

                                                                                                                                                                                            Review Article

Global hearing health care: new findings and perspectives                                                                                                                                   Allan H. Ropper, M.D., Editor

Blake S Wilson, Debara L Tucci, Michael H Merson, Gerard M O’Donoghue
                                                                                                                                                                                   Hearing Loss in Adults
In 2015, approximately half a billion people had disabling hearing loss, about 6·8% of the world’s population. These     Published Online
numbers are substantially higher than estimates published before 2013, and point to the growing importance of            July 10, 2017                                Lisa L. Cunningham, Ph.D., and Debara L. Tucci, M.D., M.B.A.
                                                                                                                         http://dx.doi.org/10.1016/
hearing loss and global hearing health care. In this Review, we describe the burden of hearing loss and offer our and

                                                                                                                                                             H
                                                                                                                         S0140-6736(17)31073-5
others’ recommendations for halting and then reversing the continuing increases in this burden. Low-cost
possibilities exist for prevention of hearing loss, as do unprecedented opportunities to reduce the generally high
                                                                                                                         Division of Head and Neck                   earing loss in adults is encountered in all medical settings                From the Section on Sensory Cell Biology,
                                                                                                                         Surgery and Communication                                                                                               National Institute on Deafness and Other
treatment costs. These possibilities and opportunities could and should be exploited. Additionally, a comprehensive      Sciences, Department of                     and frequently influences medical encounters. This disorder constitutes a
                                                                                                                                                                                                                                                 Communication Disorders, Bethesda, MD
worldwide initiative like VISION 2020 but for hearing could provide a focus for support and also enable and facilitate   Surgery, Duke University                    substantial burden on the adult population in the United States, yet        (L.L.C.); and the Division of Head and
                                                                                                                         Medical Center, Durham, NC,
the increased efforts that are needed to reduce the burden. Success would produce major personal and societal
                                                                                                                         USA (Prof B S Wilson DSc,
                                                                                                                                                             screening for hearing loss is not routine,1 and treatments are often inaccessible   Neck Surgery and Communication Sci-
gains, including gains that would help to fulfil the “healthy lives” and “disability inclusive” goals in the UN’s new    Prof D L Tucci MD); Duke Global     because of the high cost or perceived ineffectiveness.                              ences, Duke University Medical Center,
2030 Agenda for Sustainable Development.                                                                                 Health Institute                                                                                                        Durham, NC (D.L.T.). Address reprint re-
                                                                                                                         (Prof B S Wilson, Prof D L Tucci,                                                                                       quests to Dr. Tucci at the Division of
                                                                                                                                                                                                                                                 H d dN kS                   dC         i

  • Most prevalent neurologic health issue: > 360M people have disabling hearing loss2
  • High economic burden: medical costs + impact of lower work productivity
  • Leads to social isolation, lower QoL, and higher rates of dementia and depression
  • Common causes: aging, noise, ototoxic drugs and genetics
  • Established clinical outcome measures that are objective patients assessments
  2 World Health Organization, Global Estimates on Prevalence of Hearing Loss, 2012.                                                                                                                                                                                                   3
Targeted Medicines for the Ear - OTO-413 Program Review
OTO-413 Addresses Significant Population with Cochlear Synaptopathy

  Speech-in-Noise (SiN)                   ILLUSTRATIVE
    Hearing Difficulty
• Problem hearing in presence
                                                                       PTA Hearing Deficit
  of background noise                                               • Hearing loss in standard
• U.S. prevalence1 ≈ 9M with                                          test (soundproof booth)
  SiN only (no PTA changes)
                                                                    • U.S. prevalence2-5 ≈ 42M
• Loss/damage to cochlear
  synapses                                                          • Loss/damage to hair cells
                                                                      and/or synapses
                                   SIN Difficulty and PTA Deficit

                                     Mixed Pathology

       OTO-413                  • Includes patients with age-
                                  related and noise-induced
    Target Patient                hearing loss
      Population
                                • Prevalence ≈ ??                      1 Tremblay et
                                                                       2 Hoffman
                                                                                       al., Ear Hear, 2015
                                                                                  et al., JAMA Otolaryngol HNS, 2017
                                                                       3 Nash et al., Arch Otolaryngol HNS, 2011
                                                                       4 Morton et al., N Engl J Med, 2006
                                                                       5 Brooke et al., JAMA Otolaryngol HNS, 2017

                                                                                                                 4
Cochlear Synaptopathy and Hearing Loss

                                                                • In the last decade, research has
                                                                  identified loss or dysfunction of
                                                                  synaptic connections between inner
                                                                  hair cells (IHC) and spiral ganglion
                                                                  neurons (SGN) as playing important
                                                                  role in hearing loss pathology
                                                                • Synapses can be damaged or lost due
                                                                  to loud noise, aging, and/or exposure
                                                                  to ototoxic chemicals
                                                                • “Cochlear synaptopathy” contributes
                                                                  to speech-in-noise difficulties as well
                                                                  as age-related and noise-induced
                                                                  hearing loss
                                                                • Potential to repair synaptopathy using
                                                                  neurotrophic factors

Figure from Moser and Starr, Nature Reviews: Neurology (2016)                                               5
Extensive Support for Synaptopathy and Repair by Neurotrophins
                                                                        Hearing Research xxx (2015) 1e9

                                                               Contents lists available at ScienceDirect

                                                                      Hearing Research
                                               journal homepage: www.elsevier.com/locate/heares
                                                                                                                                                                       F1000Research 2017, 6(F1000 Faculty Rev):927 Last updated: 16 JUN 2017

Synaptopathy in the noise-exposed  and aging cochlea: Primary neural
                               REVIEW
                               Noise-induced
degeneration in acquired sensorineural            and age-related
                                       hearing loss                                                                                                            hearing loss: new perspectives                                      Hearing Research xxx (2017) 1e10

                                           and
Sharon G. Kujawa a, b, c, M. Charles Liberman      potential
                                              a, b, *
                                                                                                             therapies [version 1; referees: 4 approved]
                                                                                                                                                  Contents lists available at ScienceDirect
a
  Department of Otology and Laryngology, Harvard Medical School, Boston, MA, USA

                                                                       M Charles Liberman
b
  Eaton-Peabody Laboratory, Massachusetts Eye & Ear Infirmary, Boston, MA, USA
c
  Department of Audiology, Massachusetts Eye and Ear, Boston, MA, USA
                                                                       Department of Otolaryngology, Harvard Medical School, Eaton Peabody Laboratories, Massachusetts Eye and Ear, 243 Charles
                                                                                                                                                                                 Otology        St., Boston,
                                                                                                                                                                                         & Neurotology
                                                                                                                                                                                                                                Hearing Research
                                                                       MA, 02114, USA                                                                                            37:1223–1230  2016, Otology & Neurotology, Inc.
a r t i c l e i n f o                                   a b s t r a c t                                                                                         journal homepage: www.elsevier.com/locate/heares

Article history:                       The classic view of sensorineural hearing loss (SNHL) is that the “primary” targets are hair cells, and that
                                       cochlear-nerve lossFirst
                                                                       v1
                                                                     published:to 16 Juncell2017,   6(F1000 Faculty     Rev):927    (doi:                                 Open Peer Review
Received 2 December 2014                                       is “secondary”     hair         degeneration.   Our recent Review
                                                                                                                            work in     Article
                                                                                                                                       mouse    and guinea pig
Received in revised form               has challenged that10.12688/f1000research.11310.1
                                                                view. In noise-induced hearing loss,   )     exposures causing only reversible threshold
26 January 2015
Accepted 25 February 2015
                                       shifts (and no hair cell loss) nevertheless cause permanent loss of >50% of cochlear-nerve/hair-cell
                                                              Latest published: 16 Jun 2017, 6(F1000 Faculty Rev):927 (doi:                     Cochlear synaptopathy in acquired sensorineural hearing loss:
                                                                                                                                                                          Referee Status:
                                                                                                                                                Manifestations and mechanismsApplying Neurotrophins                                                                    to the Round Window Rescues Auditory
                                       synapses. Similarly, in age-related hearing loss, degeneration of cochlear synapses precedes both hair
Available online xxx                                          10.12688/f1000research.11310.1)
                                       cell loss and threshold elevation. This primary neural degeneration has remained hidden for three
                                       reasons: 1) the spiral ganglion cells, the cochlear neural elements commonly assessed in studies of SNHL,

                                       nerve fibers The
                                                      Abstract
                                       survive for years   despite loss of synaptic connection with hair cells, 2) the synaptic terminals of cochleara, b
                                                      are unmyelinated     and  difficult  to    see in the  light         M.
                                                                                                                  microscope,   Charles
                                                             classic view of sensorineural hearing loss has been that the primary
                                                                                                                                and    3) the   Liberman
                                                                                                                                                degeneration    is  ,  Sharon         G. Kujawa a, b, *
                                                                                                                                                                                                1
                                                                                                                                                                                                       Invited Referees
                                                                                                                                                                                                          2        3         4
                                                                                                                                                                                                                                            Function and Reduces Inner Hair Cell Synaptopathy After
                                                                                                                                                                                                                                                                ISAAR Special Issue

                                                      damage targets
                                       selective for cochlear-nerve    fibersare hair
                                                                              with    cells
                                                                                    high       and thatAlthough
                                                                                         thresholds.       auditory
                                       quiet (e.g. threshold audiometry or auditory brainstem response threshold),
                                                                                                                      nerve
                                                                                                                    not

                                                      to hair cell degeneration. Recent work has challenged that view. In
                                                                                                                          a
                                                                                                                          b
                                                                                                                              lossforisthreshold
                                                                                                                        required
                                                                                                                            Department   typically   secondary
                                                                                                                                          of Otologydetection
                                                                                                                                these high-threshold
                                                                                                                            Eaton-Peabody
                                                                                                                                                               in
                                                                                                                                                     and Laryngology,
                                                                                                                                                            fibers
                                                                                                                                                                      Harvard Medical School, Boston MA, USA
                                                                                                                                              Laboratories, Massachusetts Eye & Ear Infirmary, Boston MA, USA                                                   Noise-induced Hearing Loss                                                                                Trends in Hearing
                                                                                                                                                                                                                                                                                                                                                                         2016, Vol. 20: 1–9
                                       are critical for hearing in noisy environments. Our research suggests that 1) primary neural degeneration                            version 1
                                                                                                                                                                                                                                                David J. Sly, Luke Toward     a Diagnostic Test for
                                       is an importantnoise-induced
                                                           contributor tohearing    loss, exposures
                                                                           the perceptual      handicap incausing
                                                                                                              SNHL, andonly
                                                                                                                          2) reversible
                                                                                                                             in cases where  threshold
                                                                                                                                                  the hairshifts
                                                                                                                                                             cells          published
                                                                                                                                                                                                                                                                                                                                                                         ! The Author(s) 2016
                                                      (and no hair
                                       survive, neurotrophin           cell loss)
                                                                   therapies       nevertheless
                                                                              can elicit               cause permanent
                                                                                          neurite outgrowth       from spiralloss
                                                                                                                          a r t iofc >50%  l e iofnthe
                                                                                                                                ganglion neurons         and re-
                                                                                                                                                        f o                 16 Jun 2017
                                                                                                                                                                                      a b s t r a c t
                                                                                                                                                                                                                                                                     Campbell, Aaron Uschakov, Saieda Tasfia Saief,                                                    Reprints and permissions:
                                       establishment  synaptic     connections
                                                         of their peripheral      between hair cells and the auditory nerve. Similarly, in
                                                                              synapses.
                                          This article is part of a Special Issue entitled .
                                                                                                                                                                                                                                                                     Hidden
                                                                                                                                                                                                                                                               yMatthew        Hearing
                                                                                                                                                                                                                                                                         Lam, and Stephen J. Loss
                                                                                                                                                                                                                                                                                              O’Leary
                                                                                                                                                                                                                                                                                                                                                                         sagepub.co.uk/journalsPermissions.nav
                                                                                                                                                                                                                                                                                                                                                                         DOI: 10.1177/2331216516657466
                                                      age-related hearing loss, degeneration of cochlear Article           synapses
                                                                                                                                  history:precedes both                               Common causes of hearing loss in humans - exposure to loud noise or ototoxic drugs and aging - often                                                                               tia.sagepub.com                                                                                                                                                                                    www.nature.com/scientificreports
                                                                                                                                                                                                                                                                                                                                                           RESEARCH ARTICLE
                                                      hair cell loss and threshold elevation. This primary neural
                                                                                                                          Received 13 June 2016
                                                                                                                                     degeneration has                     F1000 Faculty
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                                                                                                                                                                                                sensoryarehaircommissioned
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                                                                                                                          Received in revised form
                                                                                                                  © 2015 Elsevier B.V. All rights reserved.                           animal models suggest, however,    Otolaryngology,
                                                                                                                                                                                                                              that well before Department       of Surgery,
                                                                                                                                                                                                                                                this overt hearing  loss can beUniversity
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                                                                                                                                                                                                                                                                                              insidious,
                                                      remained a “hidden hearing loss” for two reasons: 1)                19 the   neuronal
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                                                                                                                                                                                                                                                                             Christopher J. Plack , Agnès Léger , Garreth Prendergast ,                  1  Improved Auditory Nerve Survival with
                                                      degeneration is selective for auditory nerve fibers with high thresholds.                                                       alters auditory information processing, whether accompanied by threshold elevations or 1not, and is a
                                                      Although not required for threshold detection whenKeywords:          quiet, these high-threshold
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                                                                                                                                                                                                                                                                             Karolina Kluk , Hannah Guest , and Kevin J. Munro
                                                                                                                                                                                                                         of perceptual abnormalities, including speech-in-noise difficulties, tinnitus
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                                                                                                                                                                                                    Hypothesis:  and Applying
                                                                                                                                                                                                                       will considerneurotrophins        to the    rounditswindow
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1. Primary vs. secondary neural degeneration in
sensorineural hearing loss
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                                                                                                                          Cochlear synaptopathy
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                                                                                                                                     the perceptual
                                                                                                                                               histopathology
                                                                                                                                                                                      cochlear synaptopathy
                                                                                                                                                                          referees sion
                                                                                                                                                                                      are listed
                                                                                                                                                                                           in earsbelow,   but their
                                                                                                                                                                                                    immediately
                                                                                                                                                                                                     with and         reports
                                                                                                                                                                                                                withoutafter  aare
                                                                                                                                                                                                                                      possible mechanisms
                                                                                                                                                                                                                                 single
                                                                                                                                                                                                                          traditional     noiseloss’
                                                                                                                                                                                                                                      ‘hearing    exposure
                                                                                                                                                                                                                                                              underlying
                                                                                                                                                                                                                                                              willseveral
                                                                                                                                                                                                                                                     arising from    prevent   noise-causes inchange,
                                                                                                                                                                                                                                                                           common               humans. but the amplitude growth of the auditory brainstem    Neurotrophin Delivery into the Deafened
                                                      handicap in sensorineural          hearing loss,
                                                                          is poorly understood,          theand   it may be
                                                                                                              dysfunction      keyhearing
                                                                                                                             can
                                                                                                                          Hidden     to thelossgeneration
                                                                                                                                   theoretically              of
                                                                                                                                                      originate           not formally published.   induced hidden hearing loss.                                 2017 Elsevier B.V. All rights response
                                                                                                                                                                                                                                                              © Abstract                       reserved.   was significantly reduced in control ears in
   Sensorineural hearing loss (SNHL), as a category tinnitus      and other
                                                          of hearing        associated
                                                                         anywhere    fromperceptual    anomalies.
                                                                                           hair cell synaptic        In cases
                                                                                                               transmission   to where     the hair of
                                                                                                                    Noise-induced hearing loss
                                                                                                                                 the conduction                                                                                  Background: Loud noise can eliminate neural      connections
                                                                                                                                                                                                                                                                             Cochlear  synaptopathyresponse to 16hearing
                                                                                                                                                                                                                                                                                                     (or hidden   and 32loss),
                                                                                                                                                                                                                                                                                                                         kHz tones.
                                                                                                                                                                                                                                                                                                                               due toThe amplitude
                                                                                                                                                                                                                                                                                                                                      noise        growth
                                                                                                                                                                                                                                                                                                                                            exposure      was Cochlea
                                                                                                                                                                                                                                                                                                                                                      or aging, has been demonstrated in animal models
impairment, includes those etiologies in which the cells      survive, neurotrophin
                                                         underlying                    therapies
                                                                         action potentials         can elicit
                                                                                            in auditory        neurite
                                                                                                           nerve  fibersoutgrowth
                                                                                                                         (ANFs). One from    surviving
                                                                                                                                         clearcut   eti-                                                                         between inner hair cells and their afferent neurons (thereby      also reduced neurotrophin ears, but to a lesser degree and
pathology involves the sensory cells and/or the sensoryauditory
                                                          neurons neurons
                                                                   of    ology                                                                                   1 Christoph Schreiner                                 , Kavli Institute for                                                                    using histological techniques. However, diagnosis of the condition in individual humans is problematic because of (a) test
                                                                            andisre-establishment
                                                                                   a genetic mutation     in otoferlin
                                                                                                      of their          (Santarelli
                                                                                                               peripheral   synapses;et al.,  2009), a
                                                                                                                                           thus,                                                          diminishing sound perception) without causing a detectable                                                                                             the reduction was not significant. Similar results were                                     1,2,3                  3                4
                                                                                                                                                                        Fundamental Neuroscience,                                                         of This phenomenon isreliability                                          and (b) lack of                  a gold standard validation measure. Wave I of the transient-evoked auditory                   *, Justin Tan
                                                                                                                                                                                                                                                                                                                                                                                                                                                                   brainstem     response
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      , YajunisWang
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               a       , Frank Caruso4, Robert K. Shepherd1,2,3
the inner ear. Although primary neural degeneration, i.e. neural loss    protein expressed in inner hair cells (IHCs)
                                                        treatments may be on the horizon.
                                                                                                                           and thought to control
                                                                                                                    Contents                                                                              change onUniversity          audiogram.                                                                    termed hidden                               obtained from control ears exposed to 95 dB, but amplitude Andrew K. Wise
                                                                                                                                                                                                                                                                                                                                                                                                                                                             OPEN              Round-window delivery of
without hair cell loss, is recognized as a subclass of SNHL, it has      vesicle release at the synapses with ANFs (Beurg et al., 2010).                                                                                                                                                                        noninvasive electrophysiological                                measureinofneurotrophin-treated
                                                                                                                                                                                                                                                                                                                                                                                             auditory nerve function
                                                                                                                                                                        California, USA hearing loss.                                                                                                                                                            growth recovered                                  ears, and
                                                                                                                                                                                                                                                                                                                                                                                                                          this has been validated in the animal models. However, in
                                                                                                                                                                                                                                                                                                                                                                                                                                reaching 1 The Bionics Institute, 384–388 Albert Street, East Melbourne, Melbourne, Australia, 2 The Department of
been considered rare, comprising mainly cases of congenital and/or           In cases of acquired SNHL, far and away 1. the   most
                                                                                                                           Overt      common
                                                                                                                                 vs. ‘hidden’     formloss . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .humans,
                                                                                                                                               hearing
                                                                                                                                                                                                          Methods: Guinea pigs were exposed for 2. .hours                                                            . . . . . . . .Wave
                                                                                                                                                                                                                                                                                                                                  to. . .4. . to
                                                                                                                                                                                                                                                                                                                                              . .I . amplitude
                                                                                                                                                                                                                                                                                                                                                     . . . . . . . . . . . shows
                                                                                                                                                                                                                                                                                                                                                                           00
                                                                                                                                                                                                                                                                                                                                                                 statistical       high variability
                                                                                                                                                                                                                                                                                                                                                                                significance        both between
                                                                                                                                                                                                                                                                                                                                                                                              in response   to 16 kHzand tones.
                                                                                                                                                                                                                                                                                                                                                                                                                           within There
                                                                                                                                                                                                                                                                                                                                                                                                                                   individuals.
                                                                                                                                                                                                                                                                                                                                                                                                                                         MedicalThe   frequency-following
                                                                                                                                                                                                                                                                                                                                                                                                                                                 Bionics, University   of         response,
                                                                                                                                                                                                                                                                                                                                                                                                                                                                          Melbourne,           a Australia, 3 Department of Otolaryngology, University
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        Melbourne,
hereditary defects (Starr et al., 2000, 1996). As a clinical entity,     of SNHL, it has been widely believed 2.      thatCochlear
                                                                                                                            the hair    cells  are  the
                                                                                                                                     synaptopathy and neurodegeneration                    in noise-exposed                  and      aging and  mice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
                                                                                                                                                                 2 Richard Salvi , Center                 8 kHz fornoise       Hearing       at either 95 or 105 dB SPL.                                        sustainedImmediately evoked potential            were reflecting
                                                                                                                                                                                                                                                                                                                                                                            significantly  morea11111
                                                                                                                                                                                                                                                                                                                                                                                       synchronous    neural activity
                                                                                                                                                                                                                                                                                                                                                                                                  presynaptic   ribbons,in postsynaptic
                                                                                                                                                                                                                                                                                                                                                                                                                           the rostral ofbrainstem,
                                                                                                                                                                                                                                                                                                                                                                                                                                            Melbourne,isMelbourne,
                                                                                                                                                                                                                                                                                                                                                                                                                                                          potentially     more4robust       thanof Excellence in Convergent Bio-Nano Science and
                                                                                                                                                                                                                                                                                                                                                                                                                                                                               neurotrophin 3 regenerates
auditory neuropathy, as it is called, is defined by normal hair cell      primary targets, and that the degeneration  3.       of sensory
                                                                                                                           Glutamate          neurons
                                                                                                                                       excitotoxicity as an instigating factor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00                                                                                                       Australia,   ARC Centre
function (as seen in normal otoacoustic emissions) despite absent        occurs almost exclusively as a secondary4.consequence
                                                                                                                           Functional effects
                                                                                                                                        of theofloss
                                                                                                                                                  synaptopathy
                                                                                                                                                     of            . . .Deafness,
                                                                                                                                                                         . . . . . . . . . . .University   . . . . .at
                                                                                                                                                                                               . . . . . .afterward  . . Buffalo,
                                                                                                                                                                                                                         . . . . . . .a. . New
                                                                                                                                                                                                                                           .4    . . York,
                                                                                                                                                                                                                                             . . ml  . . . bolus
                                                                                                                                                                                                                                                           . . . . . . . . .of
                                                                                                                                                                                                                                                                             . . . .neurotrophins                . . (brain-derived
                                                                                                                                                                                                                                                                                     . . . . . . . . . . . . . .auditory
                                                                                                                                                                                                                                                                                                                     . . . . . . . .brainstem              . . . glutamate
                                                                                                                                                                                                                                                                                                                                    . . . . . . . . . . . response
                                                                                                                                                                                                                                                                                                                                                                 . . . . . 00Wavereceptors, and colocalized
                                                                                                                                                                                                                                                                                                                                                                                    I. However,               ribbons after response
                                                                                                                                                                                                                                                                                                                                                                                                  the frequency-following      neurotro- Technology,
                                                                                                                                                                                                                                                                                                                                                                                                                                          is a measure
                                                                                                                                                                                                                                                                                                                                                                                                                                                     andof thecentral   activity
                                                                                                                                                                                                                                                                                                                                                                                                                                                               Department          and may
                                                                                                                                                                                                                                                                                                                                                                                                                                                                             of Chemical   andbe
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               Biomolecular Engineering, the University of Melbourne,
                                                                                                                                        5. Johnsson,
                                                                                             their hair cell targets (Bohne et al., 2000;     Cochlear1974).
                                                                                                                                                       neurodegeneration
                                                                                                                                                             This view and SR types:                          neurotrophic factor 1 mg/ml, and neurotrophin-3
                                                                                                                                                                                 USA special vulnerability of low-SR neurons . . . . . . . . . . . . . . . . . . . . . . . . . . .dependent                            . . . . 1. .mg/ml)        . .was
                                                                                                                                                                                                                                                                                                                                    . . . . . . on        . . . . . . . . phin
                                                                                                                                                                                                                                                                                                                                                     . .individual             . . . treatment.
                                                                                                                                                                                                                                                                                                                                                                           . . differences
                                                                                                                                                                                                                                                                                                                                                                                     00         in central processing. Psychophysical measuresMelbourne,     Australia by intersubject variability
                                                                                                                                                                                                                                                                                                                                                                                                                                                    are also affected

                                                                                                                                                                                                                                                                                                                                                                                                                                                                               cochlear synapses after acoustic
                                                                                                                                              5.1.
                                                                                             arises from observing the time course of histopathologySingle unit evidence
                                                                                                                                                            in the  two for low-SR vulnerability . . .delivered. . . . . . . . . . . .to
                                                                                                                                                                                                                                       . . . the
                                                                                                                                                                                                                                             . . . . . round
                                                                                                                                                                                                                                                       . . . . . . . . window
                                                                                                                                                                                                                                                                       . . . . . . . . . . .of
                                                                                                                                                                                                                                                                                             . . . one
                                                                                                                                                                                                                                                                                                    . . . . .ear,
                                                                                                                                                                                                                                                                                                              . . . . and
                                                                                                                                                                                                                                                                                                                      . . . . .saline
                                                                                                                                                                                                                                                                                                                                 . . . . . . .to. . .the
                                                                                                                                                                                                                                                                                                                                                      . . . . . . . . . .Conclusion:
                                                                                                                                                                                                                                                                                                                                                                            . . . . 00         A single dose of neurotrophins delivered to the
                                                                                                                                              5.2.  Morphology of synaptic vulnerability . . . . . . . . . . .other.
                                                                                                                                                                                                               . . . . . . . .Auditory
                                                                                                                                                                                                                               . . . . . . . . . . . .brainstem
                                                                                                                                                                                                                                                       . . . . . . . . . . . . .responses
                                                                                                                                                                                                                                                                                 . . . . . . . . . . . .to      . . . in
                                                                                                                                                                                                                                                                                                                      . . . central
                                                                                                                                                                                                                                                                                                          . . .pure-tone               . . . .processing.
                                                                                                                                                                                                                                                                                                                             . . . . .pips        . . . . . . . . . . . Differential
                                                                                                                                                                                                                                                                                                                                                . were                    .round
                                                                                                                                                                                                                                                                                                                                                                            . . . . 00window  measures   may help to reduce intersubject variability due to unrelated factors. A measure
                                                                                                                                                                                                                                                                                                                                                                                                   reduced synaptopathy and recovered high- * awise@bionicsinstitute.org
                                                                                             most common animal models of acquired SNHL i.e. acoustic trauma                  3 Tobias     Moser , Universitätsmedizin
  * Corresponding author. Eaton-Peabody Laboratories, Massachusetts Eye and Ear                                                         6.    Cochlear synaptopathy and relevance to human SNHL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .can           . . . . be
                                                                                                                                                                                                                                                                                                                                . . . .compared,
                                                                                                                                                                                                                                                                                                                                        . . . . . . . . . . . . within
                                                                                                                                                                                                                                                                                                                                                                  . . . . . . .an     individual,
                                                                                                                                                                                                                                                                                                                                                                                 . . 00           between   conditions that  aredBaffected  differently by cochlear synaptopathy. Validation of
Infirmary, 243 Charles St., Boston, MA 02114-3096, USA. Tel.: þ1 617 573 3745;
                                                                                             and ototoxic antibiotics. Numerous studies over the last 5 decades
                                                                                                                                              6.1.                               Göttingen,
                                                                                                                                                    Synaptopathy in human temporal   bones . .Germany
                                                                                                                                                                                                              acquired              preoperatively,                      and        at    1    and       2   weeks’
                                                                                                                                                                                                   . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . the
                                                                                                                                                                                                                                                                                                                              postexposure.
                                                                                                                                                                                                                                                                                                                      . . . . .metrics
                                                                                                                                                                                                                                                                                                                                 . . . . . . . . .is. . also
                                                                                                                                                                                                                                                                                                                                                         . . . . . an
                                                                                                                                                                                                                                                                                                                                                                           frequency
                                                                                                                                                                                                                                                                                                                                                                   . . . .issue.
                                                                                                                                                                                                                                                                                                                                                                            . . . . 00
                                                                                                                                                                                                                                                                                                                                                                                             hearing  in ears exposed   to  95       noise. These
                                                                                                                                                                                                                                                                                                                                                                                       Comparisons with animal models, computational modeling, auditory nerve imaging, and human
                                                                                                                                                                                                                                                                                                                                                                                                                                                                               overexposure
fax: þ1 617 720 4408.                                                                        have shown that within 24 h, or less, after a noise exposure or drug
                                                                                                                                                        6.2.                                               Cochleae
                                                                                                                                                                Synaptopathy, low-SR neuropathy and human auditory      were
                                                                                                                                                                                                                   function . . . .removed
                                                                                                                                                                                                                                    . . . . . . . . . . . and
                                                                                                                                                                                                                                                          . . . . . whole
                                                                                                                                                                                                                                                                    . . . . . . . . .mounted
                                                                                                                                                                                                                                                                                     . . . . . . . . . . .for      . . . . . . . . . . . . . . . . . . .findings
                                                                                                                                                                                                                                                                                                           . . . .immunohis-                             . . . . 00   suggest that hidden hearing loss may be reduced by recei�e�: 11 �anuar� 2016
    E-mail address: Charles_Liberman@meei.harvard.edu (M.C. Liberman).                       treatment, there can be massive hair cell 6.3.
                                                                                                                                       loss, whereas
                                                                                                                                             Monitoringthe
                                                                                                                                                        for first        4 Robert
                                                                                                                                                            synaptic injury         Fettiplace
                                                                                                                                                                            and treatment       , Department
                                                                                                                                                                                             tochemical
                                                                                                                                                                                          efficacy                   . . .of
                                                                                                                                                                                                   . . . . . . . . . analysis,
                                                                                                                                                                                                                           . . . . . . . . .with
                                                                                                                                                                                                                                            . . . . . . .presynaptic                  . . . . . temporal
                                                                                                                                                                                                                                                          . . . . . . . . . . . . . . ribbons   . . . . of    . . . .bone
                                                                                                                                                                                                                                                                                                        . . . inner       . . . histology
                                                                                                                                                                                                                                                                                                                     . . .hair                  . . .are
                                                                                                                                                                                                                                                                                                                                                      . 00all potential
                                                                                                                                                                                                                                                                                                                                . . . . . . . .providing                optionstofor
                                                                                                                                                                                                                                                                                                                                                               trophic support    thevalidation, but
                                                                                                                                                                                                                                                                                                                                                                                      cochlea after        there
                                                                                                                                                                                                                                                                                                                                                                                                           injury.are Key
                                                                                                                                                                                                                                                                                                                                                                                                                      technical and practical hurdles and difficulties in
                                                                                                                                                  7.    Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .cells
                                                                                                                                                                                                                     Neuroscience, University
                                                                                                                                                                                                                                                        . . . . . . . .and
                                                                                                                                                                                                                                                                        . . . . . . associated
                                                                                                                                                                                                                                                                                    . . . . . . . . . . . . . .postsynaptic
                                                                                                                                                                                                                                                                          of Wisconsin
                                                                                                                                                                                                                                                                                                                  . . . . . . . . . . . . . . .glutamatergic. . . . . . . . . . AMPA
                                                                                                                                                                                                                                                                                                                                                . . . . . .interpretation.                    . . . . . . . Words:
                                                                                                                                                                                                                                                                                                                                                                                . . . . . . .Despite        . . the
                                                                                                                                                                                                                                                                                                                                                                                                                . . . 00 BDNF—Glutamate
                                                                                                                                                                                                                                                                                                                                                                                                                       obstacles, a diagnostic   Abstract
                                                                                                                                                                                                                                                                                                                                                                                                                                        OPENreceptor—Hidden
                                                                                                                                                                                                                                                                                                                                                                                                                                                ACCESS
                                                                                                                                                                                                                                                                                                                                                                                                                                                  test for hidden hearing
                                                                                                                                                                                                                                                                                                                                                                                                                                                                        hearingloss—      accepte�: 04 �pri�
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                loss is a worthwhile     goal,2016
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                with important impli-
http://dx.doi.org/10.1016/j.heares.2015.02.009                                                                                                          Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .receptors   . . . . . . . . . . . . .identified
                                                                                                                                                                                                                                                                                   . . . . . . . . . . . . . using
                                                                                                                                                                                                                                                                                                             . . . . . . . .CtBP2
                                                                                                                                                                                                                                                                                                                             . . . . . . . . and
                                                                                                                                                                                                                                                                                                                                             . . . . . .GluA2
                                                                                                                                                                                                                                                                                                                                                         . . . . . . . . antibodies
0378-5955/© 2015 Elsevier B.V. All rights reserved.
                                                                                                                                                        References . . . . . . . . . . . . . . . . . . . . . . . . . Medical
                                                                                                                                                                                                                     . . . . . . . . . School,
                                                                                                                                                                                                                                       . . . . . . . . .USA
                                                                                                                                                                                                                                                                                                                                                           cations. .for     . . . . . . . . . . . . . . . .Neurotrophin—Noise—NT-3—Synaptic
                                                                                                                                                                                                                                                                                                                                                                                    clinical practice        . . . . 00
                                                                                                                                                                                                                                                         . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
                                                                                                                                                                                                                                                                                                                                                                                                                      and health surveillance.                 ribbon.
                                                                                                                                                                                                                                                                                                                                                                                                                                    Citation: Wise AK, Tan J, Wang Y, Caruso F,
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          Pu��is�e�: 2� �pri� 2016
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         Suzuki1,2,3
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     Junstimulate    , Gabriel Corfas4
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       & M.(SGNs)
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            Charlesin
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    Liberman   1,2
                                                                                                                                                                                                                                 respectively.                                                                                                       Otol Neurotol 37:1223–1230,     2016.                                                                                            Cochlear implants electrically              spiral ganglion  neurons            order to provide
                                                                                                                                                                                                                                                                                                                                                                        Shepherd RK (2016) Improved Auditory Nerve
                                                                                                                                                                                                                                                                                                                                                      Survival with Nanoengineered Supraparticles for                                            speech cues to severe-profoundly deaf
                                                                                                                                                                                                                                                                                                                                                                                                                                                                          In acquired   patients. In hearing
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      sensorineural  normal loss,
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             hearing
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  suchcochleae  the SGNs
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       as that produced by noise or aging, there can be massive
    Please cite this article in press as: Kujawa, S.G., Liberman, M.C., Synaptopathy in the noise-exposed and aging cochlea: Primary neural
    degeneration in acquired sensorineural hearing loss, Hearing Research (2015), http://dx.doi.org/10.1016/j.heares.2015.02.009
                                                                                                                                                                                                    Discuss this article                                                                                     Keywords
                                                                                                                                                                                                                                                                                                                                                      Neurotrophin Delivery into the Deafened Cochlea.                        loss of the synaptic
                                                                                                                                                                                                                                                                                                                                                                                                       depend on endogenous neurotrophins          connections
                                                                                                                                                                                                                                                                                                                                                                                                                                            secreted           between
                                                                                                                                                                                                                                                                                                                                                                                                                                                      by sensory  cells incochlear sensory
                                                                                                                                                                                                                                                                                                                                                                                                                                                                           the organ       cells
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      of Corti forand primary sensory neurons, without
                                                                                                                                                                                                                                                                                                             noise-induced hearing loss, aging, cochlear nerve, auditory brainstem response, frequency-following response
                                                                                                                                                                                                                                                                                                                                                      PLoS ONE 11(10): e0164867. doi:10.1371/journal.                         loss of the sensory cells themselves. Because the cell bodies and central projections of these cochlear
                                                                                                                                                                                                    Comments (0)                                                                                                                                                                                          survival. SGNs gradually degenerate following deafness and consequently there is consid-
                                                                                                                                                1. Overt vs. ‘hidden’ hearing loss                                                    (SNHL) has been that cochlear hair cells are among the most
                                                                                                                                                                                                                                                                                                            damage       hair 25 cells,  pone.0164867
                                                                                                                                                                                                                                                                                                                                            with     excitotoxicity           causing                                                     neurons survive for months to years, there is a long therapeutic window in which to re-establish
                                                                                                                                                                                                                The classic view          of hearing loss over the last   Datefew      decades
                                                                                                                                                                                                                                                                                 received:    24 November
                                                                                                                                                                                                                                      vulnerable elements in the cochlea and that, in the vast majority of
                                                                                                                                                                                                                                                                                                                2015; revised:       January   2016;   accepted: 2 March           2016 a wide- erable interest in developing clinically relevant strategies to provide exogenous neurotro-
                                                                                                                                                                                                                                                                                                            spread loss of connections                       between inner University       hair cells phins to preserve SGN survival.    functional connections and improve hearing ability. Here we show in noise-exposed mice that local
                                                                                                                                                    A longstanding view of acquired sensorineural hearing       has been    loss thatcases,
                                                                                                                                                                                                                                        aftercochlear
                                                                                                                                                                                                                                                exposurenerveof   thedegenerate
                                                                                                                                                                                                                                                                       ear to aif,noxious
                                                                                                                                                                                                                                                                                        and only long after, the                         Editor: Olivia Bermingham-McDonogh,                                                                        The
                                                                                                                                                                                                                                                               fibers                                                                                                                                                                      delivery       ofpresent        study investigated
                                                                                                                                                                                                                                                                                                                                                                                                                                                             neurotrophin-3          (NT-3) to thethe      safety
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       round   windowand efficacy
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           niche, 24of     a after an exposure that causes an
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        hours
                                                                                                                                                                                                                stimulus, such loss    as excessively     loud sound,
                                                                                                                                                                                                                                           of their peripheral    hair cellthere        This view arose,(IHC)
                                                                                                                                                                                                                                                                                    is primary
                                                                                                                                                                                                                                                                             targets.                          funda-and their afferent          neurons
                                                                                                                                                                                                                                                                                                                                         of Washington,       (2). STATES
                                                                                                                                                                                                                                                                                                                                                           UNITED    This ‘‘synaptopathy’’
                                                                                                                                                                                                                                                                                                                                                                                                          drug delivery system for theimmediate
                                                                                                                                                                                                                                                                                                                                                                                                                                             cochlea using    loss ofnanoengineered
                                                                                                                                                                                                                                                                                                                                                                                                                                                                        up to 50% loss ofsilica   synapses   in the cochlear
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        supraparticles.            basal region, can regenerate pre- and post-
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               In the
                                                                                                                                                                                                                damage to the mentally,sensory hair    cellsofofthe
                                                                                                                                                                                                                                                  because         thetemporal
                                                                                                                                                                                                                                                                      inner ear,offsetfollowed              results in the loss of both presynaptic ribbons on the IHC
                                                                                                                                                                                                                                                                                            between post-insult
                                                                                                                                                                                                                                                                                                                                         Received:   January   24, 2016                                                                   synaptic        elements       at the hair cell     / cochlear   nerve
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              overinterface.
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     a period This      synaptic regeneration, as documented
                                                                                                                                                  * Corresponding author. Eaton-Peabody Laboratories, Massachusetts
                                                                                                                                                                                                                byEye   and Ear
                                                                                                                                                                                                                      secondary       degeneration ofofhair
                                                                                                                                                                                                                                      degeneration
                                                                                                                                                                                                                                     Page 1 of 11
                                                                                                                                                                                                                                                                cells and auditory
                                                                                                                                                                                                                                                            connected       loss of the      spiral ganglion
                                                                                                                                                                                                                                                                                         nerves                   cell
                                                                                                                                                                                                                                                                                                            and postsynaptic          receptors on the afferent nerve. It does not present study we deliveredby                            Brain-derived
                                                                                                                                                                                                                                                                                                                                                                                                                                               confocal
                                                                                                                                                                                                                                                                                                                                                                                                                                                                    neurotrophic
                                                                                                                                                                                                                                                                                                                                                                                                                                                               microscopy       of
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        factor
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    immunostained
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   (BDNF)
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          cochlear     sensory
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  of four
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  epithelia,   was coupled with a corresponding
                                                                                                                                                Infirmary, 243 Charles St., Boston, MA 02114-3096, USA.
                                                                                                                                                                                                                (1). However, (SGC)
                                                                                                                                                    E-mail address: Sharon_Kujawa@meei.harvard.edu (S.G. Kujawa).
                                                                                                                                                                                                                                             bodies of the primary auditory neurons with which
                                                                                                                                                                                                                                       a series   of recent studies has changed this                             theythe detectionAccepted:
                                                                                                                                                                                                                                                                                                            affect                         of quiet     sounds
                                                                                                                                                                                                                                                                                                                                                     October        (3), but is expected to weeks and evaluated SGN functional
                                                                                                                                                                                                                                                                                                                                                              3, 2016                                                                      survival as a measure of efficacy. Supraparticles were bilater-
                                                                                                                                                                                                                                                                                                                                                                                                                                                            recovery, as seen in the suprathreshold amplitude of auditory brainstem response
                                                                                                                                                                                                                view by showing that after noise exposure,                Introduction
                                                                                                                                                                                                                                                                               neural injury                make it difficult to Published:
                                                                                                                                                                                                                                                                                                                                          differentiate       between competing sound ally implanted                      into the basal     turn 1.  of  cochleaedeliveryin profoundly       deafenedinguinea         pigs.    Oneachievable
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      ear
                                                                                                                                                http://dx.doi.org/10.1016/j.heares.2017.01.003                                                                                                                                                        October 27, 2016 neuropathy, cochlear                          synaptopathy,        and
                                                                                                                                                                                                                                                                                                                                                                                                                                          Wave         popularly
                                                                                                                                                                                                                                                                                                                                                                                                                                                         Cochlear                   of neurotrophins          humans      is likely                 as an office procedure via
                                                                                                                                                0378-5955/© 2017 Elsevier B.V. All rights reserved.
                                                                                                                                                                                                                occurs       at  exposure     levels    lower    than  those
                                                                                                                                                                                                                                                                          Hearingrequiredabilityto   is     sources,
                                                                                                                                                                                                                                                                                                        usually         such
                                                                                                                                                                                                                                                                                                                    assessed    as   a
                                                                                                                                                                                                                                                                                                                                 using  speaker      among
                                                                                                                                                                                                                                                                                                                                             pure-tone           background
                                                                                                                                                                                                                                                                                                                                                              audi-            hidden   noise.     Con-
                                                                                                                                                                                                                                                                                                                                                                                             hearing    loss  (Schaette  &  McAlpine,     transtympanic
                                                                                                                                                                                                                                                                                                                                                                                                                                             2011),       because  injection,      making    our
                                                                                                                                                                                                                                                                                                                                                                                                          received BDNF-loaded supraparticles and the other ear control (unloaded) supraparticles.  results highly    significant   in  a translational   context.
                                                                                                                                                                                                                                                                                                            sequently,                   Copyright:  © 2016 Wise
                                                                                                                                                                                                                                                                          ometry (Johnson, 1970),                    whichthismeasures
                                                                                                                                                                                                                                                                                                                                   so-called       ‘‘hidden
                                                                                                                                                                                                                                                                                                                                                  the    smallest hearing
                                                                                                                                                                                                                                                                                                                                                                     et al. Thisloss’’
                                                                                                                                                                                                                                                                                                                                                                               the     loss(HHL)
                                                                                                                                                                                                                                                                                                                                                                                   is an open
                                                                                                                                                                                                                                                                                                                                                                                                is notisthought to be detectable using pure-tone
                                                                                                                                                                                                                                                                                                            not    detected      on      access article distributed
                                                                                                                                                                                                                                                                                                                                        conventional          hearing under testing            the the After one month of treatment the cochleae were examined histologically. There was signifi-
                                                                                                                                                                                                                                                                                                                                                                              the terms of(i.e.,
                                                                                                                                                 Please cite this article in press as: Liberman, M.C., Kujawa,AddressS.G., Cochlear   synaptopathy
                                                                                                                                                                                                                                correspondence    andinreprint
                                                                                                                                                                                                                                                        acquired          detectable
                                                                                                                                                                                                                                                                  sensorineural
                                                                                                                                                                                                                                                                requests to   Prof.hearing  level
                                                                                                                                                                                                                                                                                      Stephenloss:   of pure tones at a range
                                                                                                                                                                                                                                                                                                 J. Manifestations                            of Commons
                                                                                                                                                                                                                                                                                                                                         Creative
                                                                                                                                                                                                                                                                                                                                                   frequencies.Attribution
                                                                                                                                                                                                                                                                                                                                                                               audiometry.
                                                                                                                                                                                                                                                                                                                                                                             License,    which
                                                                                                                                                                                                                                                                                                                                                                                                      The    loss greater
                                                                                                                                                                                                                                                                                                                                                                                                          cantly  seems to   affectofselectively
                                                                                                                                                                                                                                                                                                                                                                                                                          survival      SGNs       in     the low that received BDNF supraparticles compared
                                                                                                                                                                                                                                                                                                                                                                                                                                                        cochleae
                                                                                                                                                                                                                                                                          The    resulting       audiogram  audiogram),
                                                                                                                                                                                                                                                                                                                  is sensitive butto nonetheless
                                                                                                                                                                                                                                                                                                                                        dysfunction      is anticipated
                                                                                                                                                                                                                                                                                                                                                             ofuse,
                                                                                                                                                                                                                                                                                                                                                                 thedistribution,to impede com-                                           Recent work on noise-induced and age-related hearing loss shows that the most vulnerable elements in the inner
                                                                                                                                                 and mechanisms, Hearing Research (2017), http://dx.doi.org/10.1016/j.heares.2017.01.003
                                                                                                                                                                                                                O’Leary, M.D., Ph.D., Otolaryngology, Department              of Surgery,     Uni-                                                                             spontaneous            rate (SR) fibers that have high                thresholds
                                                                                                                                                                                                                                                                                                            munication           dailypermits     unrestricted                     Soand                                                  ear are not (repeated
                                                                                                                                                                                                                                                                                                                                                                                                          to the contralateral control cochleae             the sensorymeasures
                                                                                                                                                                                                                                                                                                                                                                                                                                                                             cells, but their
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           ANOVA,synapsesp with   cochlear
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            = 0.009).     SGN nerve   terminals1. A noise exposure causing a large,
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  survival
                                                                                                                                                                                                                versity of Melbourne, 5th Floor, Peter Howson Wing,       outerRoyalhair      cells. However,
                                                                                                                                                                                                                                                                                        Victorian                      it isinbecoming     listening
                                                                                                                                                                                                                                                                                                                                         reproduction
                                                                                                                                                                                                                                                                                                                                                          situations
                                                                                                                                                                                                                                                                                                                                                   increasingly            (4).and
                                                                                                                                                                                                                                                                                                                                                        in any medium, provided
                                                                                                                                                                                                                                                                                                                                                                                         far,
                                                                                                                                                                                                                                                                                                                                                                                         are
                                                                                                                                                                                                                                                                                                                                                                                        the
                                                                                                                                                                                                                                                                                                                                                                                                synapt-
                                                                                                                                                                                                                                                                                                                                                                                                  thought to be responsible forbut
                                                                                                                                                                                                                                                                                                                                                                                             original                                        coding
                                                                                                                                                                                                                                                                                                                                                                                                                                                ultimately  sound
                                                                                                                                                                                                                                                                                                                                                                                                                                                                reversible,The  elevation   of cochlear thresholds,       can immediately, and permanently, destroy these syn-
                                                                                                                                                                                                                Eye and Ear Hospital, 32 Gisborne St, East Melbourne,                 3002theVIC,audiogram  opathy has been found              to occur      after noise exposure,                 drug- was observed over a wide extent               ofKujawa,
                                                                                                                                                                                                                                                                                                                                                                                                                                                          the cochlea.                supraparticles       were well tolerated
                                                                                                                                                                                                                                                                          clear that                                is much less author   sensitive      to inner
                                                                                                                                                                                                                                                                                                                                                 and source   are credited. intensity at moderate-to-high levels (Furman,                 apses, thereby        silencing up to 50% of the fibers in the cochlear nerve, despite no immediate or delayed loss of hair
                                                                                                                                                                                                                Australia; E-mail: sjoleary@unimelb.edu.au                                                  induced hearing loss              (ototoxicity)        (5,6), and also presby- within the cochlea with a tissue               cells   response
                                                                                                                                                                                                                                                                                                                                                                                                                                                 1,3
                                                                                                                                                                                                                                                                                                                                                                                                                                                     . Although     that
                                                                                                                                                                                                                                                                                                                                                                                                                                                                      this was    localised
                                                                                                                                                                                                                                                                                                                                                                                                                                                                           cochlear              to
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       synaptopathy  the site
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         does of
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               notimplantation
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    elevate         in  thethe loss of neural channels likely causes
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              thresholds,
                                                                                                                                                                                                                    This work was funded by the National Health andhair            cellResearch
                                                                                                                                                                                                                                                                             Medical      (IHC) loss (up to 80% IHC loss may occur
                                                                                                                                                                                                                                                                                                            acusis in human ears            (7).
                                                                                                                                                                                                                                                                                                                                         Data     It has been
                                                                                                                                                                                                                                                                                                                                               Availability        found
                                                                                                                                                                                                                                                                                                                                                             Statement:
                                                                                                                                                                                                                                                                                                                                                                               & Liberman, 2013). This may explain why the loss
                                                                                                                                                                                                                                                                                                                                                                            Allin   the mouse
                                                                                                                                                                                                                                                                                                                                                                                relevant    data are (2),
                                                                                                                                                                                                                Council (Australia) and the Garnett Passe and without                    affecting audiometric
                                                                                                                                                                                                                                                                            Rodney Williams                                    thresholds;          Lobarinas,                 does(7).   notThere        cochlear base.
                                                                                                                                                                                                                                                                                                                                                                                                 affectissensitivity        Although
                                                                                                                                                                                                                                                                                                                                                                                                                       to quiet  sounds.  difficulties
                                                                                                                                                                                                                                                                                                                                                                                                                                       mild,    the tissue  understanding
                                                                                                                                                                                                                                                                                                                                                                                                                                                                  responsespeech          in noisy or reverberant
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  was significantly        greater inenvironments
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         cochleae and may also cause tinnitus , the phan-
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          2                            3,4

                                                                                                                                                                                                                Memorial Foundation.
                                                                                                                                                                                                                                                                                                            guinea pig (8),       and within
                                                                                                                                                                                                                                                                                                                                         primates      including humans
                                                                                                                                                                                                                                                                                                                                                the paper.                                                                                tom sounds commonly brought on by acoustic overexposure. This type of cochlear synaptopathy has been called
                                                                                                                                                                                                                                                                          Salvi, & Ding, 2013)also              andcompelling
                                                                                                                                                                                                                                                                                                                      to some clinical
                                                                                                                                                                                                                                                                                                                                     types ofevidenceperipheral  that   tinnitus     Themay   extent
                                                                                                                                                                                                                                                                                                                                                                                                 also  totreated
                                                                                                                                                                                                                                                                                                                                                                                                      be   which with
                                                                                                                                                                                                                                                                                                                                                                                                                   hidden
                                                                                                                                                                                                                                                                                                                                                                                                                        BDNFhearing    loss
                                                                                                                                                                                                                                                                                                                                                                                                                                supraparticlesis a contribu-
                                                                                                                                                                                                                                                                                                                                                                                                                                          “hidden       compared
                                                                                                                                                                                                                                                                                                                                                                                                                                                         hearing         to5,the
                                                                                                                                                                                                                                                                                                                                                                                                                                                                     loss”         controls
                                                                                                                                                                                                                                                                                                                                                                                                                                                                              because   the     (repeated
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             auditory         measures
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         deficits  can  hide  ANOVA,
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              behind    a   p
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          normal   threshold audiogram.
                                                                                                                                                                                                                    The authors disclose no conflicts of interest.                                                                       Funding:   This work   was funded by
                                                                                                                                                                                                                    DOI: 10.1097/MAO.0000000000001191
                                                                                                                                                                                                                                                                          neural dysfunction. aInclinical         particular,       results
                                                                                                                                                                                                                                                                                                                          manifestation          from
                                                                                                                                                                                                                                                                                                                                                  of       rodent
                                                                                                                                                                                                                                                                                                                                                      synaptopathy             torNational
                                                                                                                                                                                                                                                                                                                                                                               (9).
                                                                                                                                                                                                                                                                                                                                                                                               Health
                                                                                                                                                                                                                                                                                                                                                                                       to hearing        difficulties   experienced
                                                                                                                                                                                                                                                                                                                                                                                                          = 0.003). These              by humans
                                                                                                                                                                                                                                                                                                                                                                                                                            data support       In the
                                                                                                                                                                                                                                                                                                                                                                                                                                               the           is still
                                                                                                                                                                                                                                                                                                                                                                                                                                                          adult
                                                                                                                                                                                                                                                                                                                                                                                                                                                       clinical   ear,  cochlear
                                                                                                                                                                                                                                                                                                                                                                                                                                                                  potential      of nerve   fibers often degenerate
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     this technology        particularly  after
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            as cochlear
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 the        insult, including noise damage and oto-
                                                                                                                                                                                                                                                                          models suggest that noise exposureandand                            Medical Research Council Project Grant
                                                                                                                                                                                                                                                                                                                                                     aging can                                            supraparticles can be loaded    toxicwithantibiotics
                                                                                                                                                                                                                                                                                                                                                                                                                                                        a variety. This
                                                                                                                                                                                                                                                                                                                                                                                                                                                                   6
                                                                                                                                                                                                                                                                                                                                                                                                                                                                             degenerationdrugs.
                                                                                                                                                                                                                                                                                                                                                                                                                                                                       of therapeutic          occurs with a variable time course, depending on the nature and severity of
                                                                                                                                                                                                                                                                                                                                         APP1005071 and APP1064375, Australian                                                            the insult; however, the unmyelinated terminal dendrites within the organ of Corti disappear first (within hours
                                                                                                                                                                                                                                                                          cause permanent           1223 loss of synapses between the IHCs
                                                                                                                                                                                                                                                                                                                                         Research Council under the Australian Laureate                                                   to days), followed more slowly by the peripheral axons in the osseous spiral lamina (within days to weeks), and,
                                                                                                                                                                                                                                                                          and auditory nerve fibers, without permanently                                 affecting              1
                                                                                                                                                                                                                                                                                                                                         Fellowship scheme (120100030),University and Nationalof Manchester, UK                           only on a much slower time course, the cell bodies in the spiral ganglion and their central axons that compose
                                                                                                                                                                                                                                                                          sensitivity to quiet sounds (Kujawa & Institutes                 Liberman,of Health2009,
                                                                                                                                                                                                                                                                                                                                                               (USA) HHS-N-263-2007-                                                      the cochlear nerve (over weeks to months and longer)7–9. Given that cochlear implants can continue to provide
                                                                                                                                                                                                                                                                                                                                                                               Corresponding author:
                                                                                                                                                                                                                                                                          2015; Sergeyenko, Lall, Liberman, &00053-C.                       Kujawa, 2013).                                                                                useful hearing
                                                                                                                                                                                                                                                                                                                                                                               Christopher J. Plack, University of Manchester, Ellen Wilkinson                   for years after hair cell loss, these long-surviving neurons must remain electrically excitable and
                                                                                                                                                                                                                                                                                                                                                                                                                                                          Building,
                                                                                                                                                                                                                                                                          The disconnected nerve fibers subsequently degenerate.                                               Manchester M13 9PL, UK.                                    appropriately connected to their central targets10. Thus, in many types of sensorineural hearing loss, there is
                                                                                                                                                                                                                                 Copyright © 2016 Otology & NeThis          urotolodisorder
                                                                                                                                                                                                                                                                                       gy, Inc. Unhas   authbeen
                                                                                                                                                                                                                                                                                                              orized variously
                                                                                                                                                                                                                                                                                                                       reproductioCompeting
                                                                                                                                                                                                                                                                                                                                          n  of thisInterests:
                                                                                                                                                                                                                                                                                                                                          termed       acochlear
                                                                                                                                                                                                                                                                                                                                                          rticle The
                                                                                                                                                                                                                                                                                                                                                                  is pauthors
                                                                                                                                                                                                                                                                                                                                                                         rohEmail:
                                                                                                                                                                                                                                                                                                                                                                               ibhave
                                                                                                                                                                                                                                                                                                                                                                                   itedchris.plack@manchester.ac.uk
                                                                                                                                                                                                                                                                                                                                                                                          .
                                                                                                                                                                                                                                                                                                                                                                                          declared                                        a long therapeutic window wherein a treatment to elicit neurite outgrowth could reconnect silenced cochlear
                                                                                                                                                                                                                                                                                                                                         that no competing interests exist.                                                               ganglion cells with hair cells, and thereby potentially improve speech in noise performance and reduce tinnitus.
                                                                                                                                                                                                                                                                                                                                                                                                                                               Neurotrophin-3 (NT-3) is a member of the neurotrophic factor family that contributes to neuronal differen-
                                                                                                                                                                                                                                                                                               Creative Commons CC-BY-NC: This article is distributed under the terms of the Creative Commons Attribution-NonCommercial 3.0 License (http://www.
                                                                                                                                                                                                                                                                                                                                                                                                                                          tiation,
                                                                                                                                                                                                                                                                                               creativecommons.org/licenses/by-nc/3.0/) which permits non-commercial use, reproduction and distribution of the work without further permission providedsurvival    and axonal outgrowth via its interactions with TrkC receptors11,12. Neurotrophins are necessary
                                                                                                                                                                                                                                                                                                                                                                                                                                                           the original
                                                                                                                                                                                                                                                                          work is attributed as specified on the SAGE and Open Access pages (https://us.sagepub.com/en-us/nam/open-access-at-sage).                                       for normal development of cochlear innervation13–16, and NT-3 is necessary for the formation and maintenance
                                                                                                                                                                                                                                                                                                                                                                                   PLOS ONE | DOI:10.1371/journal.pone.0164867 October 27, 2016
                                                                                                                                                                                                                                                                                                                                                                            Downloaded from tia.sagepub.com at UCI MEDICAL CENTER on September 12, 2016
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                                                                                                                                                                                                                                                                                                                                                                                                                                               Scientific RepoRts | 6:24907 | DOI: 10.1038/srep24907                                                                                                           1

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   6
Background on OTO-413 Program

• Selected BDNF after extensive evaluation of multiple neurotrophic
  factors and Trk antibodies
 - Cochlear explant assay, in vitro testing and in vivo evaluations

• OTO-413 comprised of BDNF in thermosensitive polymer (same
  used for OTIPRIO® and OTIVIDEX™)

• IP covers proprietary formulation and manufacturing know-how
• Single intratympanic injection of OTO-413 provides sustained-
  exposure of BDNF to the inner ear
• Therapeutic potential of OTO-413 demonstrated in cochlear
  synaptopathy animal model – presentation selected as “Hot Topic”
  at 2018 Society for Neuroscience Annual Meeting (November 6)

                                                                      7
Therapeutic Effects of BDNF in the Cochlea
Brain-derived neutrophic factor (BDNF) activates TrkB receptors on SGNs to:
• Promote survival of SGNs

                                       SGN survival (normalized to 1nM NT-3)
                                                                                 140%

                                                                                 120%

                                                                                 100%

                                                                                     80%
                                                                                                                                                       BDNF
                                                                                     60%
                                                                                                                                                       Control
                                                                                                                                                       hIgG4
                                                                                     40%

                                                                                     20%

                                                                                         0%
                                      0.001                                                        0.01          0.1           1            10
                                                                                                                       concentration (nM)

• Increase neurite outgrowth of SGNs
   Control              10nM BDNF                                                              35
                                                                                                                                       **
                                                                                               30             **p
OTO-413 Proof-of-Concept in Synaptopathy Animal Model
                                      Recovery of both synapse numbers and auditory function with OTO-413

                                 30
                                       Synapse Counts                               Visualization of Synapses on Hair Cells
    Synaptopathy (Punctae/IHC)

                                 25

                                 20

                                 15

                                 10
                                       4    10        20     40   Naïve
                                           Frequency (kHz)
                                                                  Noise + Vehicle
                                                                  Noise + OTO-413
                           1.6
                                       Auditory Function
                           1.4
 Wave 1 amplitude (µV)

                           1.2

                           1.0

                           0.8

                           0.6

                           0.4

                           0.2

                           0.0
                                       4    10        20     40
                                           Frequency (kHz)                                                                    9
OTO-413 Program Status and Plan

• Pre-IND meeting completed with FDA
• IND enabling activities ongoing

• Expect to initiate Phase 1/2 study in hearing loss patients in 1H19
• Initial study population: speech-in-noise hearing difficulty
 - Common and growing problem not improved by hearing aids

 - Objective clinical endpoints

 - Extensive discussions with KOLs about study design

• Will outline clinical trial plan and timing in January

                                                                        10
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