BAX-dependent mitochondrial outer membrane rupture in cochlear hair cells facilitates cisplatin ototoxicity

Cisplatin is widely used in oncology yet causes dose-limiting, irreversible hearing loss through cochlear hair-cell injury. Although mitochondrial dysfunction is central to this ototoxicity, how the outer mitochondrial membrane (OMM) fails in hair cells remains unclear. We identify BAX-associated mitochondrial membrane rupture and abnormal permeabilization as key drivers. In HEI-OC1 cells and murine cochlear explants, super-resolution and transmission electron microscopy revealed cisplatin-induced BAX translocation and oligomerization on the OMM, forming ring-like assemblies with ultrastructural damage (rupture, herniation, fragmentation). Subcellular fractionation and functional assays demonstrated consequent mitochondrial outer membrane permeabilization, cytochrome c release, loss of membrane potential, and accumulation of reactive oxygen species (ROS). Pharmacologic inhibition of BAX oligomerization with BAX inhibitor peptide V5 (BipV5) preserved mitochondrial integrity, reduced ROS, and limited hair-cell loss in vitro. In vivo, repeated transtympanic delivery of BipV5 conferred sustained functional protection and reduced outer hair cell loss. These findings establish a structural mechanism linking mitochondrial membrane rupture to redox imbalance and apoptosis in cochlear hair cells and nominate BAX oligomerization as a drug-targetable node for preventing cisplatin ototoxicity without compromising anticancer therapy.