DYRK1A kinase triplication is the major cause of Otitis Media in Down Syndrome

Reviewer #1 (Public review):

Summary:

In this study, Hilda Tateossian et al. sought to identify the specific gene linked to hearing loss caused by otitis media effusion (OME) in individuals with Down syndrome (DS). They approached this by analyzing a series of mouse models of DS (referred to as the DpTyb lines), which include various duplications that encompass the regions of the mouse genome analogous to the human chromosome 21 (Hsa21). This allowed them to pinpoint genetic loci that may be associated with OME in DS. To control for external variables, such as genetic background and environmental influences, which could affect the development of chronic OME, all DpTyb mouse lines were maintained on a uniform C57BL/6J genetic background. The authors could show that chronic OME phenotypes were consistently reproducible across two research centers, the Francis Crick Institute and MRC Harwell Institute, supporting their conclusion while also reducing the likelihood that environmental factors could affect results.

The authors then focused on a significant locus on chromosome 16 in the Dp5Tyb mouse model that was strongly associated with OME. This locus contains only 12 genes, and it overlapped with the duplicated genomic regions in three additional mouse models (Dp1Tyb, Dp3Tyb, and Ts1Rhr), strengthening the link between this locus and OME. To identify the gene responsible within this critical interval, they conducted targeted crosses of Dp mouse lines (Dp1Tyb, Dp3Tyb, and Dp5Tyb) with gene knockout models. This strategy enabled them to normalize the copy number of specific genes within the progeny and assess the effect on OME. They found that reducing the gene dosage of Dyrk1a specifically restored a wild-type phenotype, implicating Dyrk1a as a key player in the development of OME in DS.

Given the broad biological roles of DYRK1A in various cellular pathways, the researchers also explored its effects on downstream proteins and pathways within the middle ear epithelium using immunohistochemistry and RT-qPCR. They uncovered several pathological mechanisms by which DYRK1A triplication could promote middle ear inflammation and increased vascular permeability. These mechanisms included the interaction between DYRK1A and TGFβ signaling, which affects proinflammatory cytokines IL-6 and IL-17, as well as elevated levels of VEGF in the middle ear that were accompanied by increased Hif1a expression.

At the morphological level, analyses by scanning electron microscopy further revealed a loss of cilia on the epithelial cells in the middle ears of 2-month-old Dp3Tyb and Dp5Tyb mutant mice, which likely contributes to the development of OME in DS.

Finally, to validate the relevance of their findings in humans, the researchers examined the expression of the 12 genes within the Dp5Tyb locus in samples from children with DS compared to unaffected parental controls, using qPCR. They found that among the 12 genes, DYRK1A showed the most significant fold increase in expression, further supporting its potential role in OME associated with DS.

Strengths:

(1) The manuscript is well-written and clearly presents both experimental design and results, together supporting the main conclusions.

(2) The experiments are carefully designed and executed, with data that convincingly support the identification of DYRK1A as a key gene involved in OME in DS. The use of gene knockouts to normalize Dyrk1a gene dosage within the Dp mouse lines was a thorough and successful strategy to strengthen and validate DYRK1A's causal inference in OME.

(3) The study goes beyond simple gene identification by exploring the downstream pathways and cellular effects of DYRK1A triplication. This mechanistic focus provides actionable insights into the potential molecular underpinnings of OME in DS.

(4) The study addresses a clinically important issue - OME in children with DS - and proposes DYRK1A as a practical therapeutic target. Based on data in mice and the high dose of DYRK1A in human clinical samples, the authors suggest that suppressing the activity of this gene by localized delivery of inhibitors to the middle ear cavity in DS patients can be a potential strategy for future treatment of OME.

Weaknesses:

No major weakness is identified.

The authors could discuss further the potential involvement of the other genes within the Dp5Tyb interval, and whether interactions among these genes could impact the disease or whether additional contributions to OME might be overlooked. Beyond DYRK1A expression, discussion of a more extensive analysis of the other genes within the locus in larger cohorts of individuals with DS and OME could add strength to the translational relevance of the findings.

Reviewer #2 (Public review):

This manuscript investigates the genetic basis of otitis media with effusion (OME) in children with Down syndrome (DS). Utilizing an impressive number of mouse models, the study identifies a significant locus on mouse chromosome 16 that contributes to the development of OME. Notably, the gene Dyrk1a is identified as a critical factor for OME in DS; Normalizing Dyrk1a dosage in Dp3Tyb mice restores the wild-type phenotype, highlighting its major contribution to OME in DS. The research also explores the downstream pathways affected by DYRK1A, revealing interactions with TGFβ signaling and the modulation of pro-inflammatory cytokines like IL-6 and IL-17, as well as increased VEGF levels linked to middle ear inflammation.

This work is novel in its comprehensive approach to linking specific genetic loci and genes to the development of OME in DS, and offers a refined genetic analysis, pinpointing Dyrk1a as a key gene. Additionally, the identification of some of the signaling pathways involved provides new insights into the pathophysiology of OME in DS. The findings have significant clinical implications, as they suggest that targeting Dyrk1a could be a potential therapeutic strategy for managing OME in children with DS. This could lead to improved treatment options that go beyond current surgical interventions, reducing the need for repeated tympanostomy tube placements and potentially mitigating the associated risks. Overall, this research enhances our understanding of the genetic factors underlying OME in DS, motivates future studies on the newly identified genetic loci, and opens avenues for future therapeutic developments.

Strengths:

(1) Robust methodology: The use of a comprehensive set of mouse models allows for precise localization of genetic loci associated with OME, an advancement over previous studies.

(2) Identification of Key Genes: The clear demonstration of Dyrk1a's role in OME provides a strong basis for further exploration of targeted therapies.

(3) Pathway Insights: The exploration of signaling pathways, including TGFβ and IL-6 interactions, enriches the discussion around the inflammatory mechanisms that contribute to OME in DS.

Weaknesses:

(1) Limited Human Data: While the mouse models are robust, the translation of findings to human populations could be further strengthened with comparative studies.

(2) Pathway Complexity: The study primarily focuses on Dyrk1a and its immediate inflammatory pathways, which may oversimplify the multifactorial nature of OME in DS; exploring additional genetic interactions, and further exploring the implications of the potential ciliogenesis role of DYRK1A in OME could provide a more complete view.

This study is a valuable contribution to the field of genetic research in Down syndrome, providing critical insights that could inform future therapeutic strategies for managing OME. The implications for treatment and understanding of DS phenotypes in mouse models are particularly noteworthy. The findings are well-supported and present clear avenues for further research.

Reviewer #3 (Public review):

Summary:

The authors used mouse models with nested duplications of genomic regions syntenic to human chromosome 21 to identify specific loci responsible for otitis media with effusion (OME) in people with Down syndrome. They identified two loci: one highly penetrant major locus containing the candidate gene Dyrk1a and one minor locus resulting in low penetrant OME. By normalizing the gene dosage of Dyrk1a, the authors showed it mitigated OME. Further investigation of the molecular mechanisms by which DYRK1A exerts its effect, unveiled interactions with TGFβ signaling, elevated proinflammatory cytokines (IL-6 and IL-17), and increased VEGF levels coupled with increased Hif1a activity in the middle ear.

Strengths:

(1) The manuscript is well-written and includes appropriate figures. I especially liked Figure 4, which provides an excellent graphical abstract for the genetic study.

(2) Using a panel of mouse models with nested duplications is an elegant, systematic approach to narrowing down the genetic loci linked to OME. This is a robust method for dissecting complex traits like those observed in Down syndrome.

(3) Identifying DYRK1A as a major genetic contributor to highly penetrant OME in DS could be extrapolated to individuals with isolated (nonsyndromic) OME, thus paving the way for broader exploration of its role in general OME susceptibility. This discovery also opens the door to developing genetic testing for individuals with recurrent or chronic OME, helping with diagnosis and personalized management.

(4) Identifying DYRK1A as a potential therapeutic target highlights the study's translational relevance and potential impact on treating OME in children with DS.

Weaknesses:

(1) While the mouse model findings are robust, the study lacks validation in humans. Collaborating with researchers studying OM in human cohorts to screen for DYRK1A variants and correlate these to human phenotypes could have significantly strengthened the study's translational relevance.

(2) More compelling evidence could have been provided by generating a DYRK1A overexpression knock-in mouse model in the ROSA26 locus. This approach would allow for the functional evaluation of the impact of the overexpression of this single gene. The authors could make the KI model inducible allowing for a more localized study of the gene in a subset of cells.

(3) The lack of histological findings in the cochlea does not rule out sensorineural hearing loss. The authors did not provide compelling evidence ruling out a sensorineural component. Given DYRK1A expression in various cochlear cell types (according to the gEAR resource), it is plausible that overexpression could cause dysfunction there too. Additional analysis of ABR waves, including amplitude and latency measurements, would help clarify whether the defect is exclusively middle ear-related.

(4) Although Dyrk1a is implicated as a critical gene, the study does not fully explore the potential contributions of the other 11 genes in the identified locus. These genes might also play roles in OME, whether independently or synergically.

(5) While TGFβ signaling and cytokine production are investigated, the study does not explore the full and broader pathway and network interactions. Using transcriptomics in these mice models could provide a deeper and more comprehensive understanding of the molecular mechanisms involved.

(6) The difference in wild-type phenotype restoration between double mutants: Dp3Tyb has the best rescue with no significant difference with wild type, versus Dp5Tyb failing to restore the wild-type phenotype needs further investigation. Understanding the factors accounting for these differences could identify additional modifiers within this locus.

(7) The authors stated, "We detected a one-third increase, as expected, of the number of cells positive for DYRK1A in Dp3Tyb mice (56.6%) compared to wild-type littermates (36.4%)". This measurement refers to the number of cells expressing DYRK1A rather than the actual level of DYRK1A protein expression within these cells. The number of expressing cells does not directly correlate with gene dosage, as it is likely the level of DYRK1A protein within individual cells that has a more significant impact on the phenotype. The authors should quantify the protein levels using Western blot, for example, to strengthen their findings. If the authors believe it is the number of expressing cells that is relevant, then they should provide a clear rationale for how this measure reflects gene dosage effects and its biological significance in this context.