Fibroblast Growth Factor Regeneration of Tympanic Membrane Perforations
Phase: PHASE2
Conditions: Tympanic Membrane Perforation
Sponsor: D. Bradley Welling, MD, PhD

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TITLE PAGE 
Study Title: Fibroblast Growth Factor Regeneration of Tympanic Membrane Perforations  
MEEI IRB #: 16-043H 
Date: 28 May 2018 
Version:  5.0 
 
 
Principal Investigator: D. Bradley Welling, M.D., Ph.D. 
 
 
 
IND Number: 130892 
Study Phase: Phase II 
Study Product: Fibroblast Growth Factor-2 (bFGF/FGF-II) 
 
 
 

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1. 
SYNOPSIS 
Protocol No.: 16-043H 
TITLE:  Fibroblast Growth Factor Regeneration of Tympanic Membrane Perforations 
INVESTIGATIONAL PRODUCT:  Human fibroblast growth factor-2 (FGF-
2/bFGF/FGF-II) in a gelatin sponge, adhered by fibrin glue 
INDICATION:  Treatment of chronic non-healing tympanic membrane perforation 
PHASE OF DEVELOPMENT:  Phase 2 
INVESTIGATIONAL SITES/LOCATIONS:  Mass Eye and Ear Infirmary, Boston, 
Massachusetts  
 
STUDY DESIGN:  A Phase II randomized trial will be initiated to evaluate efficacy as the 
primary measureable outcome. Eligible and consented patients will be randomized in a 3:1 
ratio to the optimal biologic dose (OBD) of FGF-2 or placebo (sterile water) during the 
Randomized Treatment Phase.  
Application of the study treatment may occur at the initial Screening Visit (pending all 
eligibility requirements can be confirmed) or at Visit 1 and may be repeated at each follow 
up visit as needed for a maximum of three treatments in the Randomized Treatment Phase. 
These follow up visits will occur three weeks (+/- 7 days) from the last treatment 
application. During these visits, the subject’s tympanic membrane will be examined, 
photographed, and additional otologic tests will be performed.  If the perforation is found to 
be closed during these visits, then the subject will report in 2 months (+/-7 days) for a final 
study visit. 
If the subject’s TMP has not closed after the third and final application of their assigned 
treatment group, then the blind on the subject’s randomization status will be broken, and 
placebo patients will be crossed over to receive unblinded study drug. Again, the subject 
may be given up to three additional treatments in the unblinded crossover phase. The follow 
up visits will follow the same schedule, occurring three weeks (+/- 7 days) from the last 
treatment. The same otologic procedures will be performed as in the previous visits.  
All subjects will report for a final study visit 2 months (+/- 7 days) after their last follow up 
visit when the perforation is determined to be closed or when the subject has completed the 
maximum number of study visits without perforation closure. The study will be completed 
for reporting purposes after all subjects have completed the 2 month (+/- 7 days) follow up 
final visit.   
 
NUMBER OF SUBJECTS (PLANNED):  75  
 

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DIAGNOSIS AND MAIN CRITERIA FOR INCLUSION:   
Key inclusion criteria: 
 Age 18 years and older 
 Dry tympanic membrane perforation of greater than 3 months duration 
 If female, post-menopausal, sterile, or if she is of child-bearing potential, she must 
have a negative beta-HCG test and must agree to use an adequate form of birth 
control throughout the clinical trial. 
 
Key exclusion criteria: 
 
 
Active otitis media or chronic otorrhea from the middle ear 
 
Subjects receiving radiation therapy, corticosteroids, immunosuppressive agents, 
or chemotherapy 
 
Subjects who, at study entry, are taking systemic antibiotics 
 
Subjects who are immunosuppressed 
 
Subjects experiencing bacterial or viral infection or who may otherwise be febrile  
 
Life expectancy of less than 1 year 
 Active alcohol or drug abuse within 6 months prior to study entry 
 Significant medical condition that could prevent full participation in the procedures 
required for the study (see Section 7.2 for full list of exclusions)   
 Known or suspected allergies to any components used in the study, i.e. porcine 
collagen 
 Subjects who have cholesteatoma mass in the tympanic cavity 
 Subjects whose total perforation cannot be seen by an endoscope 
 Subjects with inadequately controlled diabetes mellitus (NGSP: HbA1c 6.9% or 
higher) 
 Subjects with a history of malignant ear canal tumors within 3 years of screening 
for eligibility 
 
TEST PRODUCT, DOSE, AND MODE OF ADMINISTRATION:   
 
Subjects will receive an estimated 0.2 mL of 100 μg/mL of FGF-2. The FGF-2 will be mixed 
from 250 μg (300,000 international units) of lyophilized FGF-2 with 2.5 ml of sterile water.  
After saturation of the gelatin sponge, it is estimated that the gelatin sponge will contain 
approximately 20 μg in 0.2 ml of the solution.  The actual size of the pledget may vary slightly 
depending upon the size and configuration of the perforation.  The application of the FGF-2 
will proceed according to the following protocol.  The fibrin glue consists of human 
fibrinogen, human blood coagulation factor XIII, aprotinin solution, thrombin, and calcium 
chloride hydrate. 
 
1)  In an outpatient examination, confirm that the patient has a tympanic membrane 
perforation and no active infection/inflammation is present, then insert a cotton ball soaked 
in 2% lidocaine jelly directly to the surface of the tympanic membrane under the microscopic 
visualization.  
 

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2)  After 15 minutes, the lidocaine infused cotton ball will be removed and the edge of the 
perforation roughened with a micropick to remove the epithelium circumferentially around 
the perforation edge.  
 
3)  Place a human fibroblast growth factor-2 (FGF-2) soaked pledget of bioabsorbable gelatin 
sponge larger than the tympanic membrane so the tympanic membrane is completely covered.  
 
4)  Secure the pledget in place with several drops of fibrin glue.  
 
5)  After the effects of the topical anesthetic have worn off, if any, the patient is released 
with the following instructions: 
a) Avoid violently sniffling or blowing the nose 
b) Sneeze and cough naturally through the mouth without occluding the mouth with 
the hand.                                                                                                                           
c)  Use cotton balls covered with petroleum jelly on the outer surface when washing 
the hair and bathing. This is needed to help keep water out of the ear. 
d)  Avoid using a hearing aid in the treated ear.                                                              
e)  Avoid flying, using elevators in tall buildings, and other situations involving 
substantial changes in air pressure.                                                                                  
f)  Avoid swimming. 
 
DISCONTINUATION FROM TREATMENT:   
Reasons for permanent discontinuation include the following: 
 
If the first treatment does not result in complete closure, subsequent treatments will 
not be administered if any ear complications occur in the treated ear, including but not limited 
to infection, moderate to severe pain, moderate to severe irritation, or clinically significant 
sensorineural hearing loss.  All subjects will complete all safety follow up visits. 
PRIMARY ENDPOINT: 
 
The tympanic membrane and surrounding structures will be examined every 21-days 
(+7 days) for up to three visits. Adverse events will be recorded at all visits. Routine 
laboratory tests will be performed at the screening visit and at the final study visit.  Vital 
signs will be assessed at each study visit and changes in clinical examination findings will 
be noted. 
SECONDARY ENDPOINTS: 
 Tympanic membrane perforation closure determined by otoscopic exam and 
photographic documentation 
 Pure-tone and speech discrimination scores as measured by pre- and post-treatment 
audiograms 
 Mobility of the tympanic membrane as measured by tympanometry 
 Salvage rate of FGF-2 in patients who fail placebo 
 
STATISTICAL ANALYSIS: 
The target enrollment of 75 subjects will provide sufficient power while also 
accounting for potential retention issues. The primary endpoint is to confirm the efficacy of 

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FGF-2 in subject with TMR by testing the hypothesis that the rate of subject with complete 
closure of the TMR will be superior to that placebo.  
The sample size is calculated in 3:1 ratio to FGF-2 treatment group or placebo to 
provide more than 90% power to detect a clinical significant difference at a two-sided 
significance level of 0.05 using a Fisher’s exact test. To allow for 5% dropouts, 45 patients 
of FGF-2 treatment group and 15 patients of placebo are required. 
Data after discontinuations for any reason will not be imputed through the final 
schedule visit. This subject will be considered as not-improvement. 
 
 
 1.2  Terms, Acronyms, Abbreviations 
Term 
Definition 
AA 
Amino acid 
AE 
Adverse Event 
ALT 
Alanine aminotransferase 
AST 
Aspartate aminotransferase 
BP 
Blood pressure 
°C 
Degree Celsius 
CBC 
Complete blood count 
CFR 
Code of Federal Regulations 
CRF 
Case Report Form 
CRA 
Clinical Research Associate 
dB 
Decibels 
DCF 
Data Collection Form 
DTF 
Data Transmittal Form 
DLT 
Dose-limiting toxicity 
ECG 
Electrocardiogram 
EDC 
Electronic data capture 
EGF 
Epidermal growth factor 

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Term 
Definition 
FDA 
Food and Drug Administration (U.S.) 
bFGF/FGF-2 Basic fibroblast growth factor-2 
GCP 
Good Clinical Practices 
HCG 
Human chorionic gonadotropin 
h(s) 
Hour(s) 
HS 
Heparin sulfate 
ICF 
Informed Consent Form 
ICH 
International Conference on Harmonization 
IRB 
Institutional Review Board 
kDa 
Kilodalton 
LLN 
Lower limit of normal 
mL 
Milliliters 
mm 
Millimeters 
MTD 
Maximum tolerable dose 
N/A 
Not applicable 
NCICTC 
National Cancer Institute Common Toxicity Criteria  
NLS 
Nuclear localization sequence 
NS 
Not significant 
NYHA 
New York Heart Association 
OBD 
Optimal biologic dose 
PBS 
Phosphate buffered saline 
PDF 
Portable document format 
PE 
Physical examination 

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Term 
Definition 
PP 
Per protocol 
SAE 
            SPL 
            Serious Adverse Event 
            Sound pressure level 
             T 
            Temperature 
           TBD 
            To be determined 
           TM 
            Tympanic membrane 
TMP 
            t-PA 
            Tympanic membrane perforation 
            Tissue plasminogen activator 
 
            ULN 
 
Upper limit of normal 
USP 
United States Pharmacopeia 
VT 
Ventilation tubes 
WBC White blood cell 

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2. 
Introduction 
The tympanic membrane, also called the eardrum, is a flexible, translucent, diaphragm 
like structure. Tympanic membrane perforations (TMP) can result from disease, trauma, or 
medical care. Perforations can be temporary or persistent. The effect of TMP varies with size, 
location on the drum surface, and associated pathologic conditions. Perforation symptoms 
include audible whistling sounds during sneezing and nose blowing, decreased hearing, 
especially with larger perforations, and a tendency to infection during upper respiratory 
infections and when water enters the ear canal.  
Up to 50 percent of TMPs are refractory to spontaneous healing and require surgical repair 
depending upon the etiology of the perforation. There is a higher incidence of middle ear 
contamination with resultant increased incidence of acute and chronic otitis media and chronic 
middle ear scarring or tympanosclerosis with a resultant conductive hearing loss.  Profound 
sensorineural hearing loss, balance dysfunction, meningitis or brain abscess are rare but serious 
complications, which may occur from middle ear infection.  Long-term effects may include speech 
and language acquisition delay in children as well. 
Some subjects undergo multiple attempts at surgical repair without attaining closure of the 
tympanic membrane.  The underlying cause of the perforation may be an important factor in the 
inability of the body to spontaneously close the perforation or the surgeon’s inability to get 
engraftment and surgical closure.  For example, traumatic perforations of the tympanic membrane 
generally, close spontaneously within three months of the injury.  Perforations caused by hot slag 
burns in welders are notoriously difficult to get to heal even with surgical intervention. Blast 
injuries from improvised explosive devices spontaneously heal in less than 50% of cases. The latter 
two conditions may be due to poor vascularity of the cauterized remnant TM and damaged external 
auditory canal skin.   
Other etiologies such as acute otitis media, poor eustachian tube function, or retained 
tympanostomy tubes can predispose to chronic perforations as well. Ingrowth of squamous 
epithelium from the outer layer of the TM around the edge into the middle ear through the 
perforation preventing fibroblast proliferation and contraction of this wound may prevent 
spontaneous healing also. While small perforations are not usually associated with hearing loss, 
large perforations can be associated with a significant conductive hearing loss (up to 30 dBSPL).  

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Several surgical techniques are available for repair of chronic perforations.  A 
myringoplasty involves placement of a paper patch, plug of fat, or gelatin sponge over the surface 
or in a smaller perforation (<4 mm).  This procedure provides a scaffold for fibroblast migration 
and contraction of the perforation.  Myringoplasty can be of some benefit for small perforations 
but is unlikely to be successful for large perforations.  Tympanoplasty uses the patients native 
fascia or perichondrium as a scaffold placed either under the remaining tympanic membrane or 
over the surface of the remnant drum (medial and lateral graft tympanoplasty respectively).  Both 
surgical procedures are usually performed in an outpatient operating room setting and require 
anesthesia.  
FGF has been shown to stimulate the division and differentiation of fibroblasts and promote 
angiogenesis thereby improving blood flow and healing.  Mondain and Ryan (1993) found 
expression of bFGF three days after a traumatic perforation, mainly in the perforated area, 
indicating involvement of bFGF in TM healing. They demonstrated acceleration of healing of TM 
perforations after a single application of bFGF in a rat model at dose levels of 0.4 and 2 μg (0.01–
0.05 mg bFGF/ml). They found hyperplasia of the connective tissue, with naturally-oriented 
fibroblasts in the lamina propria of the bFGF-treated ears.  
2.1 
Primary Disease Information 
2.2 
Natural History of TM Perforation 
Chronic TM perforation is a recognized complication of ventilation tube (VT, grommet) 
placement, and several papers have reported such iatrogenic perforations, defined expected 
incidence, and investigated various strategies for prevention. Few studies have investigated the 
natural history of TM abnormalities in general. One study followed a general population cohort of 
358 children, with a standardized examination at 8 and 18 years and showed a favorable prognosis 
for TM abnormalities (tympanosclerosis, atrophy, atelectasis, retraction, and perforation) with 
conservative management during the 10-year study period, although in this data set, perforations 
were quite unusual. 
A meta-analysis in 2001 calculated a post-VT perforation rate of 4.8% with all types of VT 
design included (964/20,222 ears from 62 studies), 2.2% with VTs designed for short-term use 
(175/8107 ears from 29 studies), and 16.6% with VTs designed for long-term use (556/3356 ears 

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from 21 studies). A single investigation of 2604 VT insertions showed a rate of persistent 
perforations of 3.1%. 
A study in 1996 examined 57 perforated membranes in 47 subjects and showed no 
particular difference in size and site of perforation, or level of conductive hearing loss, between 
41 VT-related and 16 non-VT- related perforations. Other investigations have centered on 
traumatic perforations. Several articles serve to confirm the widely held belief that early 
presentation and correct management improve outcomes, and articles investigating time to closure 
following perforation showed that spontaneous closure is unlikely if not complete in 2.5 years 
(Rollin et al, 2011). 
2.3 
 Study Drug Information 
The name "fibroblast growth factor" (FGF) is a limited description for this family of 
cytokines. The function of FGFs is not restricted to fibroblast cell growth. Although some of the 
FGFs do, indeed, induce fibroblast proliferation, the FGF molecule (FGF-2 or FGF basic) is now 
known to also induce proliferation of endothelial cells, chondrocytes, smooth muscle cells, and 
melanoacytes. It can also promote adipocyte differentiation, induce macrophage and fibroblast IL-
6 production, stimulate astrocyte migration, and prolong neuronal survival. Thus, the FGF 
designation is clearly limited by its description of one target cell and one implied biological 
activity. To date, the FGF superfamily consists of 22 members, all of which contain a conserved 
120 amino acid (AA) core region that contains six identical, interspersed amino acids. The 
superfamily members act extracellularly through four-tyrosine kinase G-coupled protein receptors, 
with multiple specificities noted for almost all FGFs.  This likely accounts for similar effects 
generated by many FGF molecules on common cell types. The FGFs are now known to play 
substantial roles in development, angiogenesis, hematopoiesis, and tumorigenesis. 
2.4 
Human FGF Structural Information 
The 22 human FGFs identified include FGF-1 through 14 plus 16 through 23. In general, 
their native molecular weights range from 7 kDa (FGF-1) to 38 kDa (FGF-5), and their AA lengths 
vary from 60 AA (an FGF-1 splice variant) to 288 AA (FGF-2). These AA lengths are generally 
determined by three coding exons. Over coding regions beginning with an AUG (methionine) start 
site, pairwise AA identity ranges from 17% to 72% (20-30% on average), with seven human 
subfamilies identified based on AA homology. These include FGFs-1 & 2, FGFs-3 & 5, FGFs-11, 

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12, 13 & 14, FGFs-4 & 6, FGFs-9, 16 & 20, FGFs-7 & 10, and FGFs-8, 17 & 18; human FGF-19 
is closest to mouse FGF-15, and human FGF-21 has no counterpart. In addition to AUG start sites, 
many FGFs utilize CUG (leucine) start sites, and this adds a 5' AA extension to many molecules. 
Further complexity is introduced by the fact that select FGFs (FGF-8 and -17) exhibit a division 
of the first exon into three or four mini-exons, creating the possibility for multiple N-terminal 
splice forms. Although there is only very modest AA identity between all 22 human family 
members, the one characteristic apparently shared among all members is the three-dimensional, ß-
trefoil motif (i.e., a fold which consists of 12 anti-parallel ß-strands). This configuration may prove 
to be critical for receptor recognition. There is considerable FGF AA identity across species, and 
species cross-reactivity is common among FGF superfamily members. 
Human FGF-2, otherwise known as FGF basic, HBGF-2, and EDGF, is an 18 kDa, non-
glycosylated polypeptide that shows both intracellular and extracellular activity. Like FGF-1, the 
18 kDa molecule is 155 AA in length when translated from an AUG (methionine) start codon. 
Unlike FGF-1, there are at least four alternate CUG (leucine) start codons that provide N-terminal 
extensions of 41, 46, 55, or 133 AA, resulting in proteins of 22 kDa (196 AA), 22.5 kDa (201 AA), 
24 kDa (210 AA) and 34 kDa (288 AA), respectively.  Although these extensions could be assumed 
to impart special activities to the higher molecular weight (HMW) forms, all FGF-2 forms have 
the potential to perform the same function. The fact that they do not seems more related to their 
anatomical location than their structure.  Differences noted for 18 kDa vs. 24 kDa FGF-2 include 
an up-regulation of tissue plasminogen activator (t-PA) for 18 kDa FGF-2 and a down-regulation 
of t-PA for 24 kDa in pancreatic carcinoma cells, and an increase in IL-6 expression for 24 kDa 
FGF-2 contrasted with a decrease in IL-6 expression for 18 kDa/FGF-2 in 3T3 fibroblasts. In 
general, the 155 AA/18 kDa form is considered cytoplasmic (secretable), while the high molecular 
weight (HMW) forms are considered nuclear in target. Although less is known about the secretion 
of FGF-2 than FGF-1, release of the 18 kDa form is reported to be an energy-dependent process 
that is independent of the ER-Golgi. Unlike FGF-1, FGF-2 is secreted as a monomer. Following 
secretion, FGF-2 is sequestered on either cell surface HS or matrix glycosaminoglycans. Although 
FGF-2 is secreted as a monomer, cell surface HS seems to dimerize monomeric FGF-2 in a non-
covalent side-to-side configuration that is subsequently capable of dimerizing and activating FGF 
receptors. Notably, FGF-2 responsive cells may be able to block cell surface dimerization of basic 
FGF by ribosylating 18 kDa FGF-2 in the receptor-binding domain (AA 106-120). In addition to 

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inducing FGF receptor signal transduction, bound 18 kDa FGF-2 can be internalized, either in 
association with HS or its receptor. Once internalized, FGF-2 can be degraded, possibly into 4-10 
kDa bioactive fragments, or translocated to the nucleus as a receptor-ligand complex. HMW forms 
of FGF-2 are associated with nuclear translocation. Although there is an nuclear localizing 
sequence (NLS) in the N-terminus of all HMW forms, it has been suggested that methylation of 
arginines 24-28 AA upstream of the first methionine of 18 kDa FGF-2 is responsible for nuclear 
entry. Entry into the nucleus is associated with FGF-induced effects such as casein kinase II 
activation, which is necessary for cell-cycle progression and proliferation. Human 18 kDa FGF-2 
is 97% AA identical to both mouse and rat FGF-2. Cells known to express FGF-2 include visceral 
and vascular smooth muscle cells, cardiac muscle cells, lining epithelium of the colon and 
bronchus, neurons, plus cerebellar Purkinjie cells, megakaryocytes and platelets, endothelial cells, 
mast cells, glomerular parietal epithelial cells and podocytes, astrocytes, CD4 + and CD8 T cells, 
fibroblasts (plus extracellular matrix), and numerous embryonic mesodermal and neuroectodermal 
tissues. 
3.  
Previous Human/Animal Experience 
3.1  
Nonclinical Use of FGF in Experimental TMR 
Investigators have examined growth factor expression and treatment in chronic 
perforations in animal models. Epidermal growth factor in our early studies showed complete TMP 
closure in a chinchilla model, however, epithelial ingrowth forming cholesteatomas was found in 
18% of animals. (Dvorak et al, 1995). 
FGF has been shown to stimulate the division and differentiation of fibroblasts and promote 
angiogenesis thereby improving blood flow and healing.  Mondain and Ryan (1995) found 
expression of bFGF three days after a traumatic perforation, mainly in the perforated area, 
indicating involvement of bFGF in TM healing. They demonstrated acceleration of healing of TM 
perforations after a single application of bFGF (Mondain and Ryan 1994, Mondain et al., 1991) in 
a rat model at dose levels of 0.4 and 2 μg (0.01–0.05 mg bFGF/ml). They found hyperplasia of the 
connective tissue, with naturally-oriented fibroblasts in the lamina propria of the bFGF-treated 
ears.  
Using a similar model, Vrabec et al. (1994) investigated a multiple dosing regimen of 5 μg 
bFGF (0.1 mg bFGF/ml) and also found an accelerated rate of healing in the bFGF-treated ears. 

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Fina et al.11 used a multiple dosing regimen of 1 μg bFGF (0.2 mg bFGF/ml) combined with a 
gelfoam scaffold in acute perforations in guinea pigs and found a more rapid rate of healing of the 
TM in comparison with that in placebo-treated ears. In a follow-up study, these investigators 
demonstrated more rapid healing of acute perforations with the use of bFGF solution alone, 
without using a gelfoam sponge to serve as a reservoir and mechanical scaffold (Fina et al., 1993)7. 
Kato and Jackler (1996)8 investigated the effects of bFGF with gelatin sponge carrier on the 
healing of TM perforations. bFGF (5 μg) in 25 ml of PBS (0.2 mg bFGF/ml) was administered to 
a gelatin sponge pledget placed over chronic TM perforations in chinchillas and they found an 
81% closure rate compared to 41% in the control group.  
No apparent risks of ototoxicity were observed in Kase et al’s 2007 study of two groups of 
21 healthy guinea pigs, in which 100μg of b-FGF was applied four times to the left external 
auditory canal and middle ear using a gelatin sponge container (Spongel; Astellas Pharma Inc, 
Tokyo, Japan) for Group A (n=10) or myringotomy and then a gelatin sponge insertion into the 
middle ear for Group B (n=11). The right ears served as the controls. The cochleae were examined 
one week post application in addition to measuring endocochlear DC potential (EP). Topical 
application of the drug did not cause significant reduction in EP or any degenerative changes in 
the cochlea.  
A more recent study conducted by Hakuba et al (2014) demonstrated that a sustained b-
FGF formulation could be applied to and successfully close eardrum perforations in guinea pigs 
using a gelatin hydrogel. In this equivalent 3-group model of 24 guinea pigs (b-FGF-gelatin 
hydrogel group, saline gelatin hydrogel group, and control group), total tympanic membrane 
perforations were formed using a CO2 laser. All 8 (100%) TMPs in the b-FGF gelatin hydrogel 
group achieved closure of the perforation, compared to 3 out of the 8 ears in the saline-gelatin 
group (37.%) and none of the control group (0%). In addition to improving closure rates, the 
application of b-FGF also induced improved regeneration of the fibrous layer in addition to the 
mucosal and epithelial layers. Overall, this study showed promising results in terms of in vitro and 
in vivo benefits. In vitro, there was fibroblast growth as well as migration and growth, via FGF 
receptors, of various cells involved in wound healing (including vascular endothelial cells, 
vascular smooth muscle cells, and epithelial cells). Application of b-FGF also promoted 
neovascularization and granulation tissue formation. 

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3.2  
Clinical Use of FGF-2 
A study in 87 subjects with chronic tympanic membrane perforation was recently 
published. The objectives of the study was to measure the rate of complete closure of chronic TMR 
using basic fibroblast growth factor (bFGF) combined with an atelocollagen/silicone bilayer 
membrane patch. The study assessed closure of TMR in 87 subjects using bFGF, which is thought 
to promote the regeneration of TM tissues by facilitating the growth of fibroblasts and collagen 
fibers. A dose of 10 mcg of bFGF was administered every 21-days.  Study methods included a 
procedure using an operating microscope. The results of the study reported mean perforation size 
before treatment of 14.4%. Complete closure of the TMR was achieved in 80 subjects (92.0%), 
whereas pinholes remained in 5 subjects (5.7%), and small perforations were observed in 2 
subjects (2.3%). In the subjects with complete closure, the TMR closed after an average 1.8 
treatments, and hearing improved by 13.6 dB. In conclusion the study demonstrated that bFGF 
combined with atelocollagen is effective for the conservative treatment of TMR (Hakuba et al, 
2009). 
Kanemaru et al (2011) have reported updated findings from their 2009 presentation 
involving 63 subjects, in which 53 received tympanic membrane repair using gelatin sponge and 
fibrin glue with b-FGF and 10 were assigned to the control group of gelatin sponge and fibrin glue 
alone. The study sought to determine closure rates, hearing level, and sequelae after 3 weeks post 
treatment. Of the 53 subjects who received b-FGF treatment, 52 had a complete closure of the 
TMP (98.1%) compared to 1 out of 10 (10%) of the control group subjects. Hearing level improved 
for all subjects with successful TM repair. No serious sequelae were observed. Some of the 
perforations were pan tympanic and included loss of nearly all of the tympanic membrane.  They 
concluded that bFGF may be a simple, cost-effective treatment option for subjects with chronic 
tympanic membrane perforations.  Human FGF-2 has been the most studied FGF isoform and its 
production and clinical applications in wound healing are well described. 
Zhang and Lou (2012) present findings on the direct application of b-FGF on TMPs due to 
direct traumatic penetration. Of the 104 subjects, 51 were assigned to control (spontaneous 
healing) and 53 were assigned to FGF treatment. Statistically significant findings were observed. 
After 3 months, of the 93 patients analyzed, there was 100% closure of all TMPs in the 
experimental group compared to 77% in the control/spontaneous healing group. The treatment 

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group also had significantly faster closing times compared to the control group, on average 12.6 
+ 1.2 days compared to 43.1 + 2.5 days, respectively. 
Lou, Wang & Yu (2014) present some of the most current research on the impact of basic 
fibroblast growth factor on human tympanic membrane perforations. In their 126-subject study, 
patients were dosed with either (Group 1) 2-3 drops of bFGF solution daily, approximately 0.1-
0.15 mL or (Group 2) 5-6 drops of bFGF solution daily, approximately 0.25-0.3 mL. Follow up 
occurred at 3 months, at which time closure rate, closure time, and rate of otorrhea between the 
higher- and lower-dose groups were compared. This study found that, for perforations of the 
same size, subjects who received the higher dose showed significantly improved purulent 
otorrhea rate compared with the lower-dose group (p < 0.01). Closure rate of the middle-sized 
perforations did not differ significantly between the two groups (p > 0.05). The lower-dose group 
had a significantly shorter closure time (5 days) compared with the higher-dose group (p < 0.05). 
This study suggests that continued daily application of a lower dose of bFGF has the capacity to 
1) shorten the closure time of human traumatic TMP and 2) avoids secondary purulent otorrhea.  
While there is now more human data available that allows us to be confident about safety and 
efficacy of the clinical use of FGF-2, these are no studies conducted outside of the civilian 
population. In addition to conducting novel research in the United States, this study serves as a 
unique opportunity to advance current knowledge within the military population.  
4.  
Study Objective 
The primary outcome will be to determine the TMP closure efficacy of up to 3 treatments when 
compared to placebo. 
4.1  
Primary Objective 
x To evaluate the efficacy of FGF-2 to repair chronic tympanic membrane perforations 
to complete closure as assessed by pre- and post-treatment photography when 
compared to placebo treated controls. 
 
4.2     Secondary Objectives 
x Determine the time to closure of tympanic membrane perforation for FGF-2 group 
and placebo group. 
x Measure changes in pure-tone and speech discrimination scores in all study subjects. 

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x Determine mobility of tympanic membrane as measured by tympanometry in all study 
subjects. 
x Observe salvage rate of FGF-2 treatment in subjects who failed placebo treatment. 
5.           Investigational Plan 
5. 1       Overall Study Design and Plan Description  
This study is a double blinded, placebo controlled phase II study evaluating the efficacy of 
FGF-2 for the treatment of chronic non-healing tympanic membrane perforations (TMP). The 
documentation of TM closure will be the main efficacy outcome measure.  Pretreatment 
photographs will document the area of the TM perforation and allow measurement of surface areas 
of the TMP for comparison of pre- and post-treatment. The study will be divided into two phases, 
the Randomized Treatment phase (part A), and the Unblinded Crossover phase (part B). In part A 
of the study, subjects will be randomized 3:1 to receive FGF-2 or placebo treatment up to 3 
treatments. Subjects that fail three study treatments will move on to part B of the study. Subjects 
who received placebo in part A and failed three placebo treatments will crossover to receive 
unblinded FGF-2 for up to 3 treatments. Subjects who received FGF-2 in part A and failed three 
experimental treatments will not have additional FGF-2 treatment, and will move on to study 
follow up.  
The primary outcome for the study will be to determine the TMP closure efficacy of FGF-
2 and placebo, with up to 3 treatments each. The OBD was determined to be 100μg of FGF-2 per 
1 mL with an estimated dose of about 20 μg in 0.2ml in prior studies by Dr. Kanemaru (Kanemaru 
et al., 2011). 
Secondary outcomes for the study include: (1) Determination of the time to closure of 
tympanic membrane perforation, (2) Measurement of changes in pure-tone and speech 
discrimination scores, (3) Determination mobility of tympanic membrane as measured by 
tympanometry, and (4) Observation of salvage rate of FGF-2 treatment in subjects who failed 
placebo treatment.  
If both ears are affected by chronic perforation, only one ear will be initially enrolled in the 
study and receive treatment.  The ear with the more significant symptoms will be the one enrolled 
in the study (i.e., greater conductive hearing loss).  The non-study ear will not be enrolled or 
undergo additional treatments during the study period. 

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1)  In an outpatient examination, the subject will be confirmed to have a tympanic membrane 
perforation by microscopic otoscopy and that no active infection and/or inflammation is present.  
Then a cotton ball soaked in 4% lidocaine jelly will be inserted with micro alligator forceps directly 
to the surface of the tympanic membrane under microscopic visualization.  
2)  After 15 minutes, the lidocaine infused cotton ball will be removed and the edge of the 
perforation roughened with a micropick to remove the epithelium circumferentially around the 
perforation edge.  
3)  A human fibroblast growth factor-2 (FGF-2) soaked pledget (approximately 20 μg in 0.2ml) of 
bioabsorbable gelatin sponge slightly larger than the tympanic membrane will then be placed 
against the lateral surface of the tympanic membrane to completely covered it.  For the placebo 
group, only sterile water will be delivered by the pharmacy for saturation of the gelatin sponge. 
4)  The pledget will be secured in place with several drops of fibrin glue (Tisseel, McKesson Health 
Solutions, Auburndale, MA). 
5)  After the effects of the topical anesthetic have worn off, if any, the patient will be released 
with the following instructions: 
a) Avoid violently sniffling or blowing the nose 
b) Sneeze and cough naturally through the mouth without occluding the mouth with the 
hand. 
c)  Use cotton balls covered with petroleum jelly on the outer surface when washing the 
hair and bathing, to keep water out of the ear. 
d)  Avoid using a hearing aid in the treated ear.  
e)  Avoid flying, using elevators in tall buildings, and other situations involving 
substantial changes in air pressure.  
f) Avoid swimming. 
6) The subject will then come back at three weeks (+/- 7 days) for a follow- up appointment. The 
tympanic membrane will be examined to see if the perforation has closed and photographed in the 
same fashion as during the IMP or initial administration visit. Additional otologic tests will be 
performed during this follow up exam as well (See 13.1 Schedule of Assessments). If the tympanic 

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membrane has closed, then the participant will be seen again in approximately 2 months  (+/-7 
days) for a final study visit. 
However, if the perforation has not closed, then the FGF-2 or placebo application will be 
duplicated in the same fashion at this follow up visit.  The subject will then be seen again at three 
weeks (+/- 7 days). The tympanic membrane will be assessed again. If the TMP is not healed, 
then a third application of the FGF-2 or placebo will be applied again at this visit. Additional 
otologic tests will be performed once again. If the TMP heals, then the subject will be seen again 
following this visit, or at approximately two months (+/-7 days). 
Once the subject completes Visit 1, Visit 2, and Visit 3, the subject will come back for 
Visit 4 (+/- 7 days). During this visit, the perforation will be examined again. If the perforation 
has not closed completely at this visit, then the blind on the subject’s randomization status will 
be broken. If the subject was randomized to placebo, s/he will be crossed over to receive 
unblinded FGG-2 treatment. If the subject was randomized to FGF-2 treatment, s/he will receive 
no further study treatment and return in two months (+/- 7 days) for the final follow up visit.  
If crossed-over to unblinded FGF-2 treatment, the subject may be given up to three 
additional treatments. The follow up visits will occur three weeks (+/- 7 days) and the same 
otologic procedures will be conducted as mentioned before (See Section 13.1, Schedule of 
Assessments). If the perforation is found to be closed during these visits or when the subject has 
completed the maximum number of study visits without perforation closure, then the subject will 
report in 2 months (+/- 7 days) for a final visit. The study will be completed for reporting 
purposes after all subjects have completed the 2 month (+/- 7 days) follow up final visit.   
6. 
Discussion of Study Design 
The investigator and the subject will be blinded to treatment assignment during the 
Randomized Treatment phase. Subjects whose perforations fail to close during the randomized 
treatment phase will crossover to the Unblinded Crossover Phase. During the crossover phase, 
only those subjects who failed placebo will receive unblinded FGF-2 treatment. The rationale for 
using a dose of 20 μg in 0.2ml is based on the maximum effective dosages as reported in humans 
of TMR closure with FGF-2 ( Kanemaru et al., 2011). 

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The subjects, physician, and other study staff members will remain blinded to the treatment 
arm during the randomized treatment phase as the pharmacy will oversee the randomization 
process. During the Randomized Treatment phase, the pharmacy will provide the appropriately 
blinded vial of either FGF-2 or placebo solution as needed upon the request from the physician. 
Only those subjects who fail the randomized treatment phase will crossover into the unblinded 
crossover phase. Documentation of the cross-over will be made in the Case Report Forms as well 
as in the randomization log managed centrally by the dispensing pharmacy.  
 
7. 
Selection of Study Population 
7.1    Inclusion Criteria 
The subjects must meet the following inclusion criteria: 
1. Age 18 years and older 
2. Dry tympanic membrane perforation of greater than 3 months duration 
3. If female, post-menopausal or sterile, or if she is of child-bearing potential, must have a 
negative beta-HCG test and must be using an adequate form of birth control such as birth 
control pills, birth control implants, intrauterine devices (IUDs), diaphragms, or condoms 
throughout the clinical trial. 
7.2    Exclusion Criteria 
The presence of any of the following excludes a subject from study enrollment: 
1. Active otitis media or chronic otorrhea from the middle ear 
2. Subjects receiving radiation therapy, corticosteroids, immunosuppressive agents or 
chemotherapy 
3. Subjects who, at study entry, are taking systemic antibiotics 
4. Subjects who are immunosuppressed 
5. Subjects experiencing bacterial or viral infection or who may otherwise be febrile  
6. Active alcohol or drug abuse within 6 months prior to study entry 
7. Significant medical condition that could prevent full participation in the procedures 
required for the study 

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8. Not able to complete all study procedures 
9. Subjects with known allergies to porcine collagen 
10. Subjects who have cholesteatoma mass in the tympanic cavity 
11. Subjects whose total perforation cannot be seen by an endoscope 
12. Subjects with inadequately controlled diabetes mellitus ( HbA1c 6.9% or higher).  
HbA1c will be measured at baseline to assure entry criteria are met. 
13. Subjects with a history of malignant ear canal tumors within 3 years of screening for 
eligibility 
14. Subjects who are judged by the investigator or sub-investigator(s) to be inappropriate 
to participate in the study 
 
7.3    Removal of Subjects from Treatment or Assessment 
Reasons for permanent discontinuation include the following: 
If three treatments do not result in complete closure, subsequent treatments will not be 
administered if any ear complications occur in the treated ear, including but not limited to, 
infection, requires other surgery, moderate to severe pain, moderate to severe irritation, clinically 
significant hearing loss.  All subjects will complete all safety follow-up visits. 
7.4    Premature Termination 
Potential reasons for removal of subjects from treatment include the following: 
x Withdrawal of consent  
x Adverse Events 
x Patient is lost to follow-up 
x Termination of study by the Sponsor 
x Pregnancy 
8. 
Treatments  
8.1    Identity of Investigational Product(s) 
FGF-2 is manufactured by Kaken Pharmaceutical Co., Ltd. and will be supplied by 
Nobelpharma Co Ltd.  

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The FGF-2 method of use comprises a pledget of gelatin sponge, with human fibroblast 
growth factor-2 (FGF-2) added to the pledget just before topical application to the tympanic 
membrane, and the use of fibrin glue used for applications in ear surgery. The concentration of the 
FGF-2 solution will be 100μg of FGF-2 per 1 mL with an estimated dose of about 20 μg in 0.2ml. 
9.  
Handling and Disposition of Study Drug 
9.1    Packaging and Labeling  
All packaging and labeling operations will be performed according to the requirements of 
Directive 2001/20/EC1 and in accordance with Good Manufacturing Practice for Medicinal 
Products. 
9. 
 Conditions for Storage and Use 
FGF-2 is to be stored in a cool location. The expiration date is as indicated on outer box 
and label. After reconstituting, FGF-2 is to be kept in a cool, dark place at ≤10°C and used within 
weeks. In this clinical study, the product will be prepared as needed, with 1 vial used for each case 
in this clinical study.  
10.1    Instructions to the Pharmacist 
Lyophilized FGF-2 in the amount of 250 μg will be supplied in vials along with 2.5 ml of 
sterile water to the clinical site pharmacy for preparing dosing levels at 10 μg/mL. The drug kits 
will also provide dilution instructions to the pharmacist.   The control solution will consist of the 
sterile water without any FGF-2. 
Fibrinogen tissue glue will be supplied in 4 vials to the pharmacist.  The first powdered 
fibrinogen (vial 1) is reconstituted with all of the aprotinin solution (vial 2) to prepare Solution A.  
The thrombin powder (vial 3) is reconstituted with a volume of calcium chloride solution (vial 4) 
equal to the volume of the aprotinin solution to prepare solution B.  Several drops of solution A 
and then solution B are applied in layers to the lateral surface of the gelatin sponge in the medial 
external auditory canal at the site of the adhesion. 
10.2    Method of Assigning Subjects to Treatment – Randomization  
To generate the randomization scheme, a random number generator program known as 
Research Randomizer will be used (Urbaniak & Plous, 2013). Subjects will be randomly 

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assigned to unequal treatment groups in a 3:1 ratio. A random number scheme will be created 
containing 15 sets of numbers with 4 unique numbers per set (1-4) [total of 75 numbers 
corresponding to 75 subjects]. Of the 4 numbers per set, patients assigned to numbers 1, 2, or 3 
will receive FGF-2 and patients assigned to number 4 will receive placebo. Once the random 
numbers are generated, the pharmacy will create an Excel spreadsheet with the FGF-2 and 
placebo assignments corresponding to the numbers that were generated.  
Randomization assignments will be done centrally by the MEE pharmacy.  Subjects are 
assigned to treatment by placing the subject’s name on the next available line of the 
spreadsheet.  For subjects treated at MEE, the pharmacist uses this information to prepare the 
proper treatment for the subject.  For subjects at the Willford Hall location, the randomization 
assignment will be communicated to designated staff at Willford Hall via secure email. 
10.3    Selection and Timing of Dose for Each Patient 
Dosing will be initiated after the informed consent has been obtained and all necessary 
study eligibility assessments have been completed.  Dosing will be according to the schedule of 
visits. 
11.1    Blinding 
This is a double blinded, placebo controlled study. 
10. 
Prior and Concomitant Therapy 
All prior and concomitant therapies will be assessed by the principal investigator if 
needed.  
12.1    Prohibited Medications or Therapies During Study 
Medications having the potential to interfere with the evaluation of efficacy are excluded 
throughout the trial and include: 
x Antibiotic ear drops 
x Steroid ear drops 
12.2    Treatment Compliance 
Treatment compliance will be assessed by the principal investigator following 
administration of FGF-2. 

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13.1 Schedule of Assessments  
 
 
 
1To be completed prior to administration of the investigational drug.  
2 This may be performed during the screening visit or during Day 1 Visit. Note: The first audiogram may have been performed within 60 days prior to 
subjects’ enrollment.  
3 Women of child bearing potential will be required to have a negative pregnancy test. Either serum or urine tests are acceptable. Until study 
completion, adequate form of contraception must be ensured. 
4 Treatment given if the perforation has not closed at this visit. 
5 If the perforation has not closed at this visit, then the subject will be assigned to the other treatment group. The subject will then follow the same  
schedule of procedures as stated for Visit 5, Visit 6, Visit 7, and Final Visit. 
6 These visits will be completed by subjects that have been assigned to the other treatment arm and whose perforation still has not closed. 
7The final study visit occurs 2 months (+/- 7 days) after the subject's last follow-up visit. The subject's last follow-up visit occurs when the subject's 
perforation is determined to be closed, or when the subject has completed the maximum number of study visits without perforation closure
Visit 
0 
1 
2 
3 
4 
5 
6 
7 
Final 
Visit 
 
 
Screening 
 
Day 1 
 
Day 22 
(+ 7 days) 
 
Day 43 
(+ 7 days) 
As Needed 
 
Day 64 5 
(+ 7 days) 
As Needed 
 
Day 85 6 
(+ 7 days) 
As Needed 
 
Day 106 6 
(+ 7 days) 
As Needed 
 
Day 127  6 
(+ 7 days) 
As Needed 
 
F/U 7 
(+7 days) 
Informed Consent 
X 
 
 
 
 
 
 
 
 
Inclusion/Exclusion Criteria 
X 
 
 
 
 
 
 
 
 
Medical History Related to the 
Tympanic Membrane 
X 
 
 
 
 
 
 
 
 
Otologic Exam 
X 
 
 
 
 
 
 
 
X 
Vital Signs 
X2 
X2 
X 
X 
X 
X 
X 
X 
X 
Laboratory Evaluation [CBC, 
Basic Metabolic Panel, HbA1C] 
X 
 
 
 
 
 
 
 
X 
Pregnancy Test3 
X 
 
 
 
 
 
 
 
 
Prior/Concomitant Medication 
X 
X 
X 
X 
X 
X 
X 
X 
X 
TM photography 
X1,2 
X1,2 
X1 
X1 
X1 
X1 
X1 
X1 
X 
Audiology 
 
X1, 2 
X1 
X1 
X1 
X1 
X1 
X1 
X 
Tympanometry 
 
 
 
 
 
 
 
 
X 
Study Drug Administration 
 
X 
X4 
X4 
X4 
X4 
X4 
 
 
Review of Adverse Events 
 
X 
X 
X 
X 
X 
X 
X 
X 

 
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13.2    Efficacy Measurements 
x Dose limiting toxicity/Optimal Biologic Dose is as defined in section 7.1 
x TM closure is defined as complete closure of the tympanic membrane durable at both 
21-days (+7 days) and the test-of-cure Visit 5. 
x TM Photographs will be obtained at every visit. A series containing pre- and post-
treatment images will be digitally secured with Leica M320 high definition digital camera 
mounted with the Leica Microscope or with a 2.7 mm rigid Storz endoscope. 
 Audiometric studies including pure tones (0.25, 0.5, 1, 2, 4, and 8 kHz) and speech 
discrimination scores will be recorded pretreatment and post treatment.  A change of >10 
dB across two frequencies or a change in speech discrimination of > 20% will be 
considered clinically significant on an NU-50 word list. 
x Mobility of the tympanic membrane as measured by a Grayson Stadler GSI 37 Autotymp 
(Madison, WI) or equivalent tympanometer will be recorded when the TM appears healed 
otoscopically.  
13.3    Safety Measurements 
x Adverse events by severity and causality as described in section 7.7 
x Laboratory evaluations including SMA-21 and CBC with differentials. 
x Clinically meaningful changes in vital signs including temperature, blood pressure, 
weight, pulse, and respiratory rate 
13.4    Pharmacokinetic and Bioanalytical Methods 
No pharmacokinetics will be performed. 
13.5    Treatment Requirements 
Subjects must complete at least 1 treatment and have a follow up visit at 21 days (+ 7 
days) to be evaluated for efficacy.  
13. 6    Timing of the Therapeutic Dose 
Therapy will be administered every 21 days (+ 7 days) for up to three applications or 
until there is complete closure of the perforation.  A cross over will occur if the perforation is 

 
Version 2.0: 17 Feb 2017 
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not completely closed at Visit 4. A Final Visit will occur in 2 months (+ 7 days) following the 
subject’s last appointment. 
14. 
Study Conduct  
14. 1    Visit 0, Screening 
The following procedures will be performed: 
x Administration of Informed Consent Form 
x Review of inclusion and exclusion criteria 
x Medical history of the Tympanic Membrane 
x Otologic Exam  
x Vital Signs 
x Laboratory evaluation (hematology and chemistry): CBC, Basic Metabolic Panel Test, 
HbA1c 
x Pregnancy Test if applicable 
x Review of Prior/ Concomitant medication(s) 
x Optional: Study drug administration (if all eligibility requirements can be confirmed at 
this visit)  
x Optional: TM photography 
x Optional: Audiogram 
14. 2    Visit 1, Day 1, IMP Administration 
The following procedures will be performed: 
x Review of inclusion and exclusion criteria 
x Vital Signs 
x Review of Prior/ Concomitant medication(s) 
x TM photography- if not done at the time of screening 
x Audiogram- if not done at the time of screening 
x Study Drug Administration- if not done at the time of screening 
x Assessment of Possible Adverse events 
14.3    Visit 2, Day 22 (± 7 Days) 
The following procedures will be performed: 
x Study drug administration - if the TMP is not completely closed 
x Vital Signs 
x Review of Prior/ Concomitant medication(s) 
x TM photography 
x Audiogram 
x Assessment of Possible Adverse events 
14.3    Visit 3, Day 43 (± 7 Days) 
The following procedures will be performed: 
x Study drug administration- if the TMP is not completely closed 

 
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x Vital Signs 
x Review of Prior/ Concomitant medication(s) 
x TM photography 
x Audiogram 
x Assessment of Possible Adverse events 
14.4    Visit 4, 64 days after the first treatment (±7 Days) 
The following procedures will be performed: 
x Study Drug administration- If the TMP is not completely closed, then the blind on the 
subject’s randomization status will be broken. Placebo subjects will be crossed over to 
FGF-2 treatment arm at this visit.  
x Vital Signs 
x Review of Prior/ Concomitant medication(s) 
x TM photography 
x Audiogram 
x Assessment of Possible Adverse events 
14. 5    Visit 5, 85 days after first treatment (±7 Days) 
This is a follow up visit for all subjects who were crossed over to the other treatment group at 
Visit 4. The following procedures will be performed: 
x Study Drug administration- if the TMP is not completely closed  
x Vital Signs 
x Review of Prior/ Concomitant medication(s) 
x TM photography 
x Audiogram 
x Assessment of Possible Adverse events 
14. 6    Visit 6, 106 days after first treatment (±7 Days) 
This is a follow up visit for all subjects who were crossed over to the other treatment group at 
Visit 4. The following procedures will be performed: 
x Study Drug administration- if the TMP is not completely closed  
x Vital Signs 
x Review of Prior/ Concomitant medication(s) 
x TM photography 
x Audiogram 
x Assessment of Possible Adverse events 
14. 7    Visit 7, 127 days after first treatment (±7 Days) 
This is a follow up visit for all subjects who were crossed over to the other treatment group at 
Visit 4. No treatment medication will be given. The following procedures will be performed: 
x Vital Signs 
x Review of Prior/ Concomitant medication(s) 
x TM photography 
x Audiogram 

 
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x Assessment of Possible Adverse events 
14. 8    Final Visit (2 Months Following Last Appointment, + 7 Days) 
In order to complete the study, a final follow up visit will be completed. The following procedures will 
be performed:  
x Otolgic Exam 
x Vital Signs 
x Laboratory evaluation (hematology and chemistry): CBC, Basic Metabolic Panel Test, 
HbA1c 
x Review of Prior/ Concomitant medication(s) 
x TM photography 
x Audiogram 
x Tympanometry 
x Assessment of Possible Adverse events 
15. 
Primary Safety and Efficacy Variable(s) 
15.1    Adverse Events (AE) 
An Adverse Event will be considered any unfavorable or unintended change in structure, 
function, signs, or symptoms temporally associated with the use of a medicinal product 
experienced by a person administered a pharmaceutical product, whether or not a causal 
relationship with the product has been established.  Clinically significant laboratory 
abnormalities may be considered AEs if deemed appropriate by the Investigator.  Worsening of 
a pre-existing condition is also considered an AE as is the discovery of an abnormal finding 
during physical exam that was not included in the medical history. 
Subjects will be encouraged to spontaneously report any AE.  Study personnel will ask 
open-ended questions to obtain information about AEs at every visit.  Date and time of onset 
and resolution (if applicable) of the AE will be documented. 
15.2    Causality 
Events will be considered drug related if classified by the Investigator as possible, 
probable, or definite.  Association of events to the study drug will be made using the following 
definitions: 

 
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Term 
Definition 
Definitely Not 
The event is definitely not associated with study 
medication. 
Probably Not 
The temporal association, patient history, or clinical 
condition is such that the study medication is not likely to 
have had an association with the observed event. 
Possible 
The event: a) follows a reasonable temporal association with 
the study medication administration, but b) could have been 
produced by the patient’s clinical condition or other therapy. 
Probable 
The event: a) follows a reasonable temporal association with 
the study medication, b) abates upon discontinuation of 
study medication, and c) can’t be reasonably explained by 
the patient’s clinical condition or other therapy. 
Definite 
The event: a) follows a reasonable temporal association with 
the study medication, b) abates upon discontinuation of 
study medication, c) cannot be reasonably explained by the 
patient’s clinical condition or other therapy, and d) reappears 
on re-exposure to the study medication. 
Unknown 
Not enough information exists for the assessment of 
causality at the time of occurrence. 
15.3    Severity 
Signs and symptoms will be graded by the Investigator using the NCI Common 
Toxicity Criteria and graded as mild, moderate, severe, or life-threatening according to the 
following definitions: 
Grade 
Definition 
Mild 
Causing no limitation of usual activity 

 
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Grade 
Definition 
Moderate 
Causing some limitations of usual activities 
Severe 
Causing inability to carry out usual activities 
        Life- 
Threatening 
Subject was at immediate risk of death from the event 
15.4    Serious Adverse Event (SAE) 
A Serious Adverse Event is an AE that: 
x Is fatal 
x Is life-threatening, meaning the subject was, in the view of the Investigator, at 
immediate risk of death from the reaction as it occurred, i.e., it does not include a 
reaction that, had it occurred in a more serious form or progressed, might have caused 
death 
x Is a persistent or significant disability or incapacity 
x Requires or prolongs inpatient hospitalization. [Inpatient hospitalization will be 
considered a hospitalization that is longer than 24 hours, or a hospitalization that 
requires an intervention to treat emergent symptomatology (non-diagnostic)] 
x Is a congenital anomaly or birth defect. 
 
Other important medical events may be considered SAEs when, based upon appropriate 
medical judgment, they may jeopardize the subject and may require medical or surgical 
intervention to prevent one of the outcomes as listed (# 1-5 above) in this definition. 

 
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All SAEs, including death, due to any cause that occurs during this study and until 30 
days after the last dose of study medication, whether or not expected and regardless of causality, 
must be reported to the Medical Monitor immediately upon discovery of the event, using an 
SAE Form, by fax and, if necessary, by phone. 
The Medical Monitor will advise the Investigator regarding the nature of any further 
information or documentation that is required.  The Investigator should provide the following 
documentation at the time of notification if available: 
x SAE Form 
x AE (CRF) page 
x Concomitant and support medication pages 
x Relevant diagnostic reports 
x Relevant laboratory reports 
x Admission notes 
x Hospital discharge summary (when available). 
Nobelpharma will make available to the Investigator any reports of serious, unexpected, 
and drug-related AEs by fax within eight (8) days of notification of the event using a MedWatch 
3500A Form.  The Investigator must promptly (within 2 days) inform the IRB of such events 
and retain a copy of the notification in the site’s Regulatory Binder. 
All SAEs must be followed until the event resolves, returns to baseline or, in the opinion 
of the Investigator, becomes stable.  Hospitalization of subjects for the administration of 
chemotherapy will not be considered an SAE. 
16. 
Data Quality Assurance 
16. 1    Source Data and Records 
Source data are all the information in original records and certified copies of original 
records of clinical findings, observations, laboratory reports, data sheets provided by the 
sponsor or other activities in the study, which are necessary for the reconstruction and 
evaluation of the study. The investigator will permit study-related monitoring, audit(s), IRB 
review(s) and regulatory inspection(s), with direct access to all the required source records. 

 
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In the event the Investigator retires, relocates or for any other reason withdraws from the 
responsibility for maintaining records for the period of time required, custody of the records 
may be transferred to any other person who will accept responsibility for the records.  Notice 
of such a transfer must be given in writing to the Sponsor.  The Investigator must contact the 
Sponsor prior to disposal of any records related to this study.  
16. 2    Reporting of Results 
The Case Report Form (CRF) is an integral part of the study and subsequent reports.  The 
CRF must be used to capture all study data recorded in the subject’s medical record.  The CRF 
must be kept current to reflect subject status during the course of the study.  Only a Subject 
screening and randomization number and subject initials will be used to identify the Subject.   
The principal investigator and/or study coordinator is responsible for performing on-site 
monitoring at regular intervals throughout the study to verify adherence to the protocol; verify 
adherence to local regulations on the conduct of clinical research; and ensure completeness, 
accuracy, and consistency of the data entered in the CRF. 
The Data Safety and Monitoring Committee and the principal investigator will monitor 
completed Case Report Forms (CRFs).  A case report form will be provided for each screened 
subject. 
All protocol-required information collected during the study must be entered by the 
Investigator, or designated representative, in the CRF.  All details of the CRF completion and 
correction will be explained to the investigator.   
If the Investigator authorizes other persons to make entries in the CRF, the names, 
positions, and signatures of these persons must be supplied to the sponsor. 
The Investigator, or designated representative, should complete the CRF as soon as 
possible after information is collected, preferably on the same day that a study Subject is seen 
for an examination, treatment, or any other study procedure.  Any outstanding entries must be 
completed immediately after the final examination.  By design, an explanation must be provided 
for all missing data, altered data, and/or out of range data. 
The completed case report form must be reviewed and signed by the Investigator named 
in the study protocol or by a designated sub investigator. 

 
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Final monitored and audited CRFs will be provided to the sites at the end of the study in 
the format of a PDF file. 
16. 3    Confidentiality of Subject Data 
The investigator will ensure that the confidentiality of the subjects' data will be preserved. 
In the CRF or any other documents submitted to the sponsor, the subjects will not be identified 
by their names, but by an identification system, which consists of their initials and number in 
the study. The investigator will maintain documents not meant for submission to the sponsor, 
e.g., the confidential subject identification code and the signed informed consent forms, in strict 
confidence. 
17. 
 Statistical Methods and Determination of Sample Size 
17. 1    Determination of Sample Size 
The target enrollment of 60 subjects will provide sufficient power while also accounting 
for potential retention issues. With recruitment of only 44 subjects, we will reach a power of 
.80. This gives room for some attrition, although we think it will not be more than 5%. 
17. 2    Subject Populations 
The following populations will be used for the analysis of data for this study: 
Per Protocol (PP) Population:  All subjects who have been selected and received the 
specified drug at Visit 1 and do not have any important protocol deviations will be included in 
the PP population. The PP population will be the primary population for the analysis of efficacy. 
Safety Population:  All subjects who received the drug will be included in the safety 
population.  The safety population will be the primary population for analysis of demographic, 
accountability, and safety measures. 
17. 3    Subject Disposition 
The number and percentage of subjects in each of the analysis populations and number 
and percentage of subjects who discontinued the study prematurely will be summarized by 
treatment and overall.  The reasons for early study termination will also be presented.  Details 
of study disposition and inclusion/exclusion criteria for all subjects will be listed. 

 
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17. 4    Demographics and Baseline Characteristics 
Demographic and baseline characteristics including age, gender, race and relevant 
baseline medical conditions will be summarized by treatment and overall.  Descriptive statistics 
will be presented, but no statistical testing will be performed.  Subject demographic and baseline 
characteristics and medical conditions will be listed. 
17. 5    Efficacy Analysis 
Efficacy data from the Randomized Treatment phase we be evaluated by inspection, 
using student T-test, Cochran Mantel Hansel, or Kruskal-Wallis tests as appropriate; without 
conservation of alpha at 0.05. An interim analysis will be completed after approximately 50% 
of the study subjects (n=30) have been accrued.  
17.6     Secondary Efficacy Analysis 
Secondary analysis of categorical data will be performed using Fisher’s exact test for 
paired samples. 
18. 
 Safety Analysis 
Safety will be assessed by evaluation of adverse events and clinical laboratory results and 
derived as data sets and frequency methods. 
An independent Data and Safety Monitoring Board (DSMB) will follow the DSMB 
charter for this study. The DSMB Charter is commensurate with the level of risk of the study 
to its participants, complexity of the protocol, and ensure compliance with the principles and 
process of informed consent as well as privacy related regulations (e.g., HIPAA); and to 
monitor safety by recording (un-)expected adverse events (AEs) and their severity and 
attribution. The DSMB Charter includes a plan for periodic reviews of primary results and 
summary data as well as assessment of completeness and quality of collected data.  All 
unexpected and/or serious adverse events as well as premature study withdrawals will be 
brought to the attention of the DSMB as early as possible in order for the DSMB to make 
judgments about participant safety, study modifications, and/or continuation.  Not beyond the 
commencement of the proposed subsequent dose escalated cohorts, the DSMB will review 
study status to determine study progression.  These will be based upon discussions between the 
research team and DSMB, and the decision of the board; no set stopping or escalating rules will 
be employed.  The DSMB membership list is as follows:  

 
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Edwin Choy, MD, PhD - Chair and Research Monitor 
MGH, Dana Farber/Harvard Cancer Center 
Division of Hematology Oncology 
55 Fruit Street 
Boston MA 02114 
Phone: (617) 643-0230 
Fax: (617) 724-3166  
Email: echoy@partners.org 
 
Christopher Moertel, MD, - Member 
University of Minnesota 
Department of Pediatrics 
MMC 484 
420 Delaware Street S.E. 
Minneapolis, MN 55455 
Phone: (612) 625-3229 
Fax: (612) 626-2815 
Email: moert001@umn.edu 
 
Domenic Reda, PhD, Member (Statistician)  
Director, Cooperative Studies Program Coordinating Center  
Hines VA Hospital, CSPCC (151K) 
5000 South 5th Avenue, Building 1, Room B240, 
Hines, IL 60141-3030 
Phone: 708-202-5853 
Fax: 708-202-2116 
domenic.reda@va.gov 
 
19. 
 Research Monitor 
The Research Monitor, Edwin Choy MD, PhD, is responsible to oversee the safety of the 
research and report observations/findings to the Human Studies Committee (HSC) or a 
designated institutional official. The Research Monitor will review all unanticipated problems 
involving risks to subjects or others associated with the protocol and provide an independent 
report of the event to the HSC. The Research Monitor may discuss the research protocol with 
the investigators; shall have authority to stop a research protocol in progress, remove 
individual human subjects from a research protocol, and take whatever steps are necessary to 
protect the safety and well-being of human subjects until the HSC can assess the monitor's 
report; and shall have the responsibility to promptly report their observations and findings to 
the HSC or other designated official and the HRPO. 

 
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20. 
Adverse Events 
Adverse events will be coded to system organ class and preferred term using MedDRA.  
All adverse events occurring after the initiation of the study treatment (treatment emergent 
adverse events) will be reported, including events present at baseline that worsened during the 
study. 
Adverse events will be summarized by treatment group to provide visual comparison 
among the treatment groups with respect to incidence of adverse events (the number of subjects 
reporting at least one episode of a specific adverse event), incidence of adverse events by 
severity within body system, incidence of adverse events by attribution within body system, 
and incidence of adverse events causing withdrawal and incidence of serious adverse events.  
Regarding severity and attribution summaries, the most extreme outcome (highest severity and 
closest to study drug related) will be used for those subjects who experience the same adverse 
event on more than one occasion.  
Written narratives will be provided for all serious, unexpected or other significant 
adverse events that are judged to be of special interest because of their clinical importance. 
21. 
Clinical Laboratory 
Clinical laboratory results will be summarized with descriptive statistics at baseline each 
study timepoint and with shifts from baseline. 
22. 
Data Handling and Recordkeeping 
22.1     Case Report Form (CRF) 
MEEI will be the central location for data processing and management utilizing the 
biostatistician on site. All protocol-required information collected during the study will be 
entered by the investigator, or designated representative, in the appropriate study forms and 
patient medical records.  The investigator, or designated representative, should complete the 
forms as soon as possible after information is collected, preferably on the same day that a study 
subject is seen for an examination, treatment, or any other study procedures.  Any outstanding 
entries will be completed immediately after the final examination.  By design, an explanation 
must be provided for all missing data, altered data, and/or out of range data.  The completed 
case report form will be reviewed and signed by the investigator named in the study protocol 
or by a designated sub- investigator. 

 
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A Case Report Form will be completed for each subject for each study visit. Subjects 
will not be identified by name on any study documents.  Any requested information that is not 
obtained as specified in the protocol should have an explanation for the omission noted on the 
applicable study form.   
Source data are all the information in original records and certified copies of original 
records of clinical findings, observations, laboratory reports, data sheets provided by the 
sponsor or other activities in the study, which are necessary for the reconstruction and 
evaluation of the study. The investigator will permit study-related monitoring, audit(s), IRB 
review(s) and regulatory inspection(s), with direct access to all the required source records.  
Hard copies of any individual’s study documents will be kept in separate subject binders in the 
locked office of the study coordinator at each site.   
22.2      Patient Registry 
No patient registry will be maintained. 
23. 
Ethics 
23.1  Institutional Review Board (IRB) / Ethics Committee 
Before the start of the study, the study Protocol, Informed Consent Form (ICF), and/or 
other appropriate documents will be submitted to the IRB in accordance with local legal 
requirements.  It is the responsibility of the Investigator to ensure that all aspects of the IRB 
review are conducted in accordance with current local and U.S. regulations.  Phage and the 
Investigator must inform each other in writing that all ethical and legal requirements have been 
met before the first patient is enrolled at the study site.   
24. 
Ethical Conduct of the Study 
The study will be conducted in accordance with the ethical principles of the current 
version of the Declaration of Helsinki.  Sponsor and Investigator will comply with their 
responsibilities as defined in 21 CFR 312.50-312.70 [Appendix D] and ICH Guidance for 
Industry: E6 Good Clinical Practice (April 1996). 

 
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24.1 
Subject Information and Consent 
The Investigator or delegated research staff will obtain informed consent from each 
subject enrolled in the study, in accordance with the U.S. Food and Drug Administration (FDA) 
regulations 21 CFR 50.20 - 50.27 and the laws and regulations of the state in which the 
investigation is being conducted [Appendix C]. 
Informed consent will be obtained prior to the initiation of any study related procedures 
including screening. Screening procedures for this study include vital signs, laboratory evaluations, a 
pregnancy test (if applicable), and a photograph of the tympanic membrane. Non- study related 
procedures that will be part of the routine medical care include a comprehensive medical history of the 
subject’s tympanic membrane, otologic exams, and audiograms. Audiograms that have been completed 
within 60 days prior to enrollment may be reviewed by the subject’s study physician. Should a Protocol 
amendment be made, the subject ICF may be revised to reflect the changes of the Protocol.  If 
the ICF is revised, it is the responsibility of the Investigator to ensure that an amended ICF is 
reviewed and approved by the IRB and signed by all subjects subsequently entered in the study. 
This study will be consenting subjects that are non-English speaking. In these cases, 
the person obtaining the consent will present the IRB-approval English version of the consent 
form orally to the subject through a medical interpreter fluent in English and in the language 
that is understandable to the subject.  If an Interpreter is not available, then video interpreting 
will be used. The subject will be given a HSC-approved 'short form’ consent document in the 
language understandable to him/her to read.The entire consent process will be witnessed 
ideally by an individual who is fluent in both English and the language understandable to the 
subject. The witness who is not bilingual will observe that the presentation of the information 
in the consent form is in the language understandable to the subject and will verify the subject 
has had the opportunity to ask and receive answers to questions in a non-coercive, private, and 
unhurried setting. The IRB-approved English version of the consent form will be signed by 
the person obtaining informed consent and the witness to the consent process. The written 
translation of the ‘short form’ will be signed by the subject. If the witness is bilingual, then the 
witness can also sign the short form. The subject will be given signed copies of both the IRB-
approved English version of the consent form and the written translation of the ‘short form’ 
consent document. The original signed English version of the consent form with the original 
signed written translation of the ‘short form’ document will then be placed in the subject’s 

 
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research record.  
24.2   Protocol Amendments 
Amendments will be made only in exceptional cases once the study has started at the 
discretion of the Investigator and with confirmation from Nobelpharma Co Ltd.  Changes must 
be agreed to in writing, and signed by all parties concerned.  The changes then become part of 
the study Protocol.  Any changes in the Protocol, even local/site requirements, will be written 
in an amendment.  The IRB must be informed of amendments and, if necessary, approval must 
be sought for ethical aspects.  Approval of amendments must also be obtained from the local 
regulatory authority, if necessary. 
25. 
Confidentiality 
All local legal requirements regarding data protection will be enforced.  All study 
findings and documents will be regarded as confidential.  The Investigator and members of 
his/her research team must not disclose such information without prior written approval from 
Phage. The anonymity of participating subjects must be maintained. Throughout documentation 
and evaluation, the subjects will be identified on CRFs and other documents submitted to Phage 
by their initials, birth date, and their subject number.  Documents that are not to be submitted 
to Phage, and which identify the subject (i.e. the signed ICF), must be maintained in confidence 
by the Investigator onsite.  The subjects will be told that all study findings will be stored and 
handled in strictest confidence, according to local requirements.  Subjects will be informed that 
authorized research investigators and agents of the FDA, other recognized regulatory 
authorities, and authorized representatives of the Sponsor, Phage, have the right to inspect their 
medical records. 
26. 
Investigators and Study Administrative Structure 
This is a Phase 2 trial involving two sites located in the United States. The 
Investigator(s) responsible for the conduct of the study at their site, are responsible for 
maintaining all local IRB approvals and documenting all required information per regulations 
of guidelines stipulated by the respective Institutional Review Boards and the DoD. Participants 
will include trained otologists in the MEE clinic and at Willford Hall AFB (Dr. Carols Esquivel) 

 
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27. 
Sponsor Contacts 
All questions regarding the enrollment of subjects, regulatory requirements for the 
conduct of the study, safety reporting, or study conduct should be addressed to the Medical 
Monitor: 
28. 
Maintenance of Study Records 
The Investigator must retain a copy of all study documents, including reports to the IRB, 
regulatory authorities, and Phage in accordance with FDA regulations. 
The Investigator must maintain study documents: 
x For a minimum of two (2) years following the date the marketing application 
(NDA/BLA) is approved for the indication for which the drug was investigated; 
or, 
x For a minimum of two (2) years following the release date of the final report, if 
no marketing application is to be filed by Phage, or if the marketing application 
is not approved for the indication for which the drug was investigated or is 
discontinued and the FDA has been notified; or, 
x For a minimum of fifteen (15) years after the completion or discontinuation of 
the study to be filed in support of the registration in the European Union. 
If the Investigator relocates, retires for any reason, or withdraws from the study, the 
study records may be transferred to an acceptable designee, such as another investigator, 
another institution, or to Phage.  The Investigator must obtain Phage’s written permission before 
disposing of or transferring any records. 
29. 
Final Report 
Upon terminating the study, the Investigator will submit a final report to the IRB in 
keeping with local IRB regulations.  This report should include any deviations from the 
Protocol, the number and types of subjects evaluated, the number of subjects who discontinued, 
including reasons, results of the study, AEs, and a conclusion summarizing the results. 
If requested by the Investigator, at the completion of the study and following analysis 
of the data, Phage will supply a tabulated listing of data and a final clinical statistical report.  A 

 
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copy of the final study report and corrected CRFs, including a receipt to be returned to the 
Phage Clinical Monitor, will be provided to each Investigator following its release by Phage. 
30. 
Publication and Use of Study Findings 
By signing the study Protocol, the Investigator agrees with the use of results of the study 
for the purposes of national and international registration, publication, and information for 
medical and pharmaceutical professionals.  If necessary, the authorities will be notified of the 
Investigator's name, address, qualifications, and extent of involvement.  Phage will prepare an 
Integrated Clinical/Statistical Report.  Any publication/presentation of data must include the 
entire study population.  Submission of data for publication/presentation will be coordinated 
and approved by Phage in collaboration with the Investigator.  Phage will determine authorship 
of any publication by enrollment in consultation with the Principal Investigator. 
31. 
Liability and Insurance 
NobelPharma Co. will take out reasonable third-party liability insurance coverage in 
accordance with all local indemnification requirements.  The civil liability of the Investigator, 
the persons instructed by him, the hospital, practice, or institute in which they are employed, 
and the liability of the Sponsor in respect of financial loss due to personal injury and other 
damage, which may arise as a result of the carrying out of this study, are governed by the 
applicable law.  As a precautionary measure, the Investigator, the persons instructed by him or 
her and the hospital, practice or institute are included in such cover in regards to work done by 
them in carrying out this study to the extent that the claims are not covered by their own 
professional indemnity insurance.  The Sponsor will arrange for subjects participating in this 
study to be insured against financial loss due to personal injury caused by the pharmaceutical 
products being tested or by medical steps taken in the course of the study.  The Sponsor in 
accordance with regulations in the country concerned takes out such insurance.  To the extent 
that payments are made under such insurance, the right to claim damages from the Sponsor 
extinguishes. 

 
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32.      References  
1. Mondain M, Ryan A. Histological Study of the Healing of Traumatic Tympanic 
Membrane Perforation after Basic Fibroblast Growth Factor Application. 
Laryngoscope. 103: 312-318 (1993). 
2. Rollin M, Rogers P, Robinson P. Natural History of Pediatric Tympanic Membrane 
Perforation. Otology & Neurotology. 32: 246-251 (2011). 
3. Dvorak DW, Abbas G, Ali T, Stevenson S, Welling DB. Repair of Chronic Tympanic 
Membrane perforations with Long-Term Epidermal Growth Factor. Laryngoscope. 
105(12):1300-1304 (1995). 
4. Mondain M, Ryan A. Epidermal Growth Factor and Basic Fibroblast Growth Factor are 
Induced in Guinea-pig Tympanic Membrane Following Traumatic Perforation. Acta 
Otolaryngol (Stockh). 115: 50-4 (1995). 
5. Mondain M, Ryan A. Effect of Basic Fibroblast Growth Factor on Normal Tympanic 
Membrane. Am J Otolaryngol. 15: 344-350 (1994). 
6. Mondain M,Safe edine S, Uziel A. Fibroblast Growth Factor Improved the Healing of 
Experimental Tympanic Membrane Perforations. Acta Otolaryngol (Stockh). 111: 337-
341 (1991). 
7. Fina M. Baird A. Ryan A. Direct Application of Basic Fibroblast Growth Factor 
Improved Tympanic Membrane perforation Healing. Laryngoscope. 103: 804-809 
(1993). 
8. Kato M, Jackler RK. Repair of Chronic Tympanic Membrane Perforations with 
Fibroblast Growth Factor. Otolaryngol Head Neck Surg. 115: 538-547 (1996). 
9. Hakuba N, Iwanage M, Tanaka S, Hiratsuka Y, Kumabe Y, Konishi M, Okanoue Y, 
Hiwatashi N, Wada T. Basic Fibroblast Growth Factor Combined with Atelocollagen 
for Closing Chronic Tympanic Membrane Perforations in 87 Patients. Otology & 
Neurotology. 31: 118-121(2009). 
10. Hakuba N, Yasuhiko T, Naohito H, et al. Gelatin hydrogel with basic fibroblast growth 
factor for tympanic membrane regeneration. Otol Nuerotol. 35(3): 540-44. (2014). 
11. Kanemaru SI, Umeda H, Kitani Y, et al. Innovative Regenerative Treatment for the 
Tympanic Membrane Perforation. Poster Presentation. Combined Otolaryngology 
Society Meeting. Phoenix, Arizona, May 28-31, (2009). 
12. Kanemaru SI, Umeda H, Kitani Y, et al. Regenerative treatment for tympanic membrane 
perforation. Otol Neurotol. 32 (8): 1218-23. (2011) 
13.  Kase K, Iwanaga T, Terakado M et al. Influence of topical application of basic 
fibroblast growth factor upon inner ear. Presentation at the 2007 Annual Meeting of the 
American Academy of Otolaryngology – Head and Neck Surgery, Washington D.C. 
September 16-19. (2007). 
14. Fina M, Bresnick S, Baird A, et al. Improved Healing of Tympanic Membrane 
Perforations with Basic Fibroblast Growth Factor. Growth Factors. 5: 265-272 (1991). 
15. Lou, Wang & Yu. Effects of basic fibroblast growth factor dose on traumatic tympanic 
membrane perforation. Growth Factors. 32 (5) 150-4. (2014) 

 
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16. Vrabec JT, Schwaber MK, Davidson JM, et al. Evaluation of Basic Fibroblast Growth 
Factor in Tympanic Membrane Repair. Laryngoscope. 104: 1059-64 (1994). 
17. Zhang Q and Lou Z. Impact of basic fibroblast growth factor on healing of tympanic 
membrane perforations due to direct penetrating trauma: a prospective non-
blinded/controlled study. Clin Otolaryngol. 37 (6): 445-51. (2012). 
18. Dilwali, S., Landegger, L., Soares, V., Deschler, D., & Stankovic, K. Secreted Factors 
from Human Vestibular Schwannomas Can Cause Cochlear Damage. Scientific 
Reports, 1-13. 10: 1038. (2015). 
19. Urbaniak, G. C., & Plous, S. (2013). Research Randomizer (Version 4.0). {Computer 
Software]. Retrieved, from http://www.randomizer.org.  
 
 
 

 
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Appendix A: NCI Common Toxicity Criteria 
Please reference the National Cancer Institute Cancer Therapy Evaluation Program’s 
Common Toxicity Criteria Manual, Version 4.0.   
Retrieved from,  
http://ctep.cancer.gov/protocolDevelopment/electronic_applications/docs/ctcmanual_v4_10-
4-99.pdf  
 
Appendix B: FDA Regulations 
Please reference the electronic code of federal regulations for the most up-to-date federal 
regulations on the protection of human subjects:  
 
21 CFR part 50 
http://www.ecfr.gov/cgi-bin/text-
idx?SID=b0c39f9f49cefa4e1423e8b274183684&mc=true&tpl=/ecfrbrowse/Title21/21cfr5
0_main_02.tpl 
 
21 CFR part 56 
http://www.ecfr.gov/cgi-bin/text-
idx?SID=b0c39f9f49cefa4e1423e8b274183684&mc=true&node=pt21.1.56&rgn=div5