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Myocarditis is defined as a non-ischemic inflammatory disease of the myocardium. It remains a challenge to diagnose given non-specific symptoms and lack of specific blood biomarkers. Cardiac imaging plays an important role in the evaluation of myocarditis with unique strengths and limitations of different imaging modalities, including cardiac magnetic resonance imaging, echocardiography, cardiac computed tomography, and positron emission tomography. The purpose of this review is to discuss the strengths and limitations of various cardiac imaging techniques in the evaluation of myocarditis, review imaging findings in specific causes of myocarditis including COVID-19 and after vaccination, evaluate the role of imaging in differentiating myocarditis from potential mimics and differential considerations, identify current gaps in knowledge, and propose future directions.

Objectives: (1) To determine how otologic/neurotologic surgeons counsel patients with superior semicircular canal dehiscence (SSCD). (2) To understand the plethora of presenting symptoms associated with SSCD and appropriate management. (3) To suggest appropriate management; oftentimes avoiding surgery. Methods: This was a survey study of both community and academic physicians. A 23-question survey was distributed to all members of the American Neurotological (ANS) and American Otologic Societies (AOS) via email in the Fall of 2018. A total of 54 responses were received from a possible pool of 279 for a response rate of 19.4%. Inferences were made about the population through sample proportions and confidence intervals. Results: All respondents use computed tomography (CT) in diagnosing SSCD and 11.1% use CT exclusively. Cervical vestibular evoked myogenic potential (VEMP; 77.8%) are used more often than ocular VEMPs (38.9%). Magnetic resonance imaging (7.4%) is used infrequently; 96.3% of surgeons surveyed have seen patients with SSCD on imaging that are asymptomatic. Following surgical treatment, respondents reported balance issues and mild-to-moderate high-frequency sensorineural hearing loss (88.4%); 32.6% reported that the majority (>50%) of their patients needed further intervention after surgery, typically aggressive vestibular rehabilitation. Conclusions: There is a discrepancy in the systematic approach to SSCD between both the surgeons and the published literature. Patients with SSCD on ultra-high-resolution CT may have myriad symptoms while others are asymptomatic, and surgery may lead to additional complications. We will present a methodical recommendation to assist in the management of patients with SSCD depending upon their symptoms. This may improve patient selection, counseling, and outcomes.

A 48-year-old Haitian man with a history of hypertension presented to our hospital following an episode of loss of consciousness. The episode occurred while the patient was standing at a sink, and was preceded by several hours of non-exertional chest discomfort and a brief period of dizziness. He regained consciousness on the floor and felt diffusely weak. There were no lateralized symptoms, post-ictal confusion, incontinence, or tongue contusions. When he returned to a standing position, he saw prominent “beating, pulsating” movements of his periorbital and perioral muscles in the mirror, and also noted some blurred vision. There was additional muscle twitching involving the hands, legs, chin and neck, which the patient described as “a heart beating under the skin”. There was no associated pain, weakness, or numbness. The patient revealed that he had experienced intermittent but frequent abnormal beating of the periorbital muscles for approximately two months prior to presentation. He initially thought it was secondary to anxiety. One month after the onset of these symptoms, he developed similar sensations in his fingers and legs bilaterally, and then in the perioral muscles. In addition to these symptoms he had diarrhea as well as an unintentional 25 pound weight loss over three months, due to anorexia. He had not had fevers. He reported hyperlacrimation which he felt was the result of frequently rubbing his eyes. He denied dysphagia, paresthesias, muscle cramps, headaches, or difficulty with balance. He had had a few episodes of near syncope in the two months prior to presentation, which were not associated with falls. Past medical history included essential hypertension which had been diagnosed five years prior to presentation, as well as vitiligo of the bilateral hands and lips which had been noticeable for six months prior to presentation. He denied neonatal or childhood infections and achieved normal developmental milestones. There was no personal or family history of seizures or other neurological disease. Medications included nifedipine, hydrochlorothiazide, and lisinopril, and there had been no recent medication changes. On initial evaluation, the patient was afebrile, with supine blood pressure 90/50 and heart rate 65, and standing blood pressure 74/50 and heart rate 82. General examination revealed a thin but well developed man in no acute distress. Cardiac rhythm was regular without murmurs. Depigmented patches of skin were noted on the lips and dorsal surfaces of the fingers and hands. The lungs were clear and there was no costovertebral angle tenderness. The abdomen was not tender and no abdominal masses were palpated. There was no extremity edema. Neurological exam revealed normal cognition, language, and memory. There was mild ptosis of the right upper eyelid with no additional ptosis following sustained upward gaze. There was no dysarthria or inability to clear oral secretions, and speech was not nasal in quality or effortful. Muscle bulk, tone, and power were normal. Posture was normal with no rigidity. Continuous arrhythmic undulating myokymic muscle spasms were seen in the bilateral periorbital and perioral muscles, as well as within individual muscle fibers of the right forearm, bilateral hands, and interosseous muscles of the right fifth toe. These abnormal muscle contractions were not painful or bothersome to the patient. Deep tendon reflexes were symmetric and diffusely diminished, and no pathological reflexes were seen. Sensation was normal to all modalities and there was no dysmetria.

We describe the methodology and rationale behind the delivery of therapeutic medicines to the inner ear. The inner ear has long been impervious to pharmacologic manipulation. This is most likely the result of a protective mechanism called the blood-labyrinth barrier, whose function closely resembles that of the blood-brain barrier. This protective barrier impedes the clinician's ability to treat inner ear diseases with systemically administered medications. Since 1935, otolaryngologists have attempted to manipulate the inner ear with transtympanically injected medicines. Success has varied widely, but medicinal ablation of vestibular function can be achieved in this manner. Unfortunately, the auditory system is also at great risk from any medicine that is delivered to the inner ear via the middle ear. Over the past 10 years, significant improvements in drug delivery have allowed for more “titratable” treatment, which has reduced (but not eliminated) the risk of permanent hearing loss. In this article, we discuss both novel and time-tested methods of delivering medicines to the inner ear. We also review the classes of medications that alter inner ear function and the attendant risks of such treatments.

Clinical ethics is an intrinsic aspect of medical practice. Concerns for ethical conduct arise in the management of medical benefits, patient preferences, quality of life, and the relationship between patient care and its attendant familial, social, economic, and legal circumstances. Ethical concerns in surgical practice are central to the essence of the Hippocratic doctrine, “First do no harm.” In caring for our patients, particularly in light of the modern practice of medicine, we often use the risk-benefit calculus. The range of ethical concerns for the otolaryngologist who deals with the elderly and infirm covers many diverse situations. Superimposed over this spectrum is the idea of patient autonomy, which is considered to be a cardinal issue in any ethical discussion. Furthermore, increasing medical care costs have created a debate regarding the rationing of healthcare. Ethicists continue the discussion as to whether age should be a decisive factor in the rationing of this care. Definitions of “heroic” and “extraordinary” assume greater significance, and controversies of language become pivotal when the comprehension and cognitive orientation of the patient are compromised by disease and senescence.

We describe 6 new cases of palatal myoclonus (PM), a rare disorder that is characterized by involuntary rhythmic contraction of the palatal musculature. Although it has been reported that PM is a lifelong condition, one of our patients experienced a complete resolution of PM, which casts doubt on the accepted beliefs about the persistence of PM. Included in this report is the first published case of voluntary PM with objective tinnitus.

Intratympanic instillation of Depo-Medrol® (80 mg/cc), dexamethasone ophthalmic solution (1 mg/cc), or dexamethasone intravenous (4 mg/cc) solution produces improvement of cochlear function in certain patients with Meniere's disease, autoimmune inner ear disease and sudden sensorineural deafness. Tinnitus improved in 47%, most often in patients with Meniere's disease (9 of 15; 60%). The SRT improvement of greater than 10 dB or SD greater than 15% was documented in 41% (average improvement in SRT: 15 dB; SD: 24%). Patients with tinnitus and bilateral sensorineural hearing loss (i.e., presbycusis) did not benefit from the treatment. Prior to treatment with intratympanic medication, laser-assisted tympanostomy with middle ear exploration, using otoendoscopy to determine the status of the round window niche and remove mucosal folds, helps in making the round window membrane accessible to local application of drops. Placing Gelfoam into the round window niche under direct vision, and using a Venturi Bobbin tube in the tympanic membrane, appears to be a satisfactory method for delivering medication to the inner ear fluids. The medication can be injected by the physician through the tube into the middle ear, or the patient can perform self-treatment at home, placing medication in the external auditory canal. A double-blind, cross-over study in patients with Meniere's disease is now in progress with Institutional Review Board (IRB) approval, which will be reported at a later date. This preliminary study has shown that intratympanic steroids may affect the symptoms of hearing loss and tinnitus in patients with various inner ear problems. Patients with Meniere's disease appear to respond in the highest percentage of cases. Hopefully, additional research will suggest the appropriate drugs which can be used to treat inner ear disease. Direct application of the drug to the round window membrane may increase the concentration in the inner ear fluids, thus avoiding the systemic effects.

Immunoglobulin G4-related disease (IgG4-RD) is a systemic fibroinflammatory disorder affecting nearly all organs, including the kidney. Tubulointerstitial nephritis (IgG4-TIN) is the most common form of IgG4-related kidney disease (IgG4-RKD) and is the focus of this concise review.The study aims to describe when IgG4-TIN should be suspected and to summarize the diagnosis, treatment, and natural history of the disease.Ovid MEDLINE, Google Scholar, and PubMed were searched for full-text English language articles up to January 2016. References included in the manuscript were chosen at the authors' discretion based on their relevance to the subject of the review.IgG4-TIN should be considered in patients presenting with abnormal urinalysis, abnormal kidney function, renal lesions on imaging, and elevated IgG, IgE, or hypocomplementemia. Diagnosis of IgG4-TIN requires a combination of histologic features (plasma cell-enriched TIN with10 IgG4+ plasma cells/hpf, +/- TBM immune complex deposits in many cases) and at least one of the following:Characteristic radiologic findings (small peripheral low-attenuation cortical nodules, round or wedge-shaped lesions, or diffuse patchy involvement)Elevated serum IgG4 levelCharacteristic findings of IgG4-RD in other organs Other conditions such as lupus, vasculitis, diabetic nephropathy, and lymphoma must be excluded, as these can also present with IgG4+ plasma cells in the renal parenchyma. IgG4-TIN is generally responsive to steroids and B cell depletion with rituximab, but relapses are common and patients require close long-term follow-up.Available data on IgG4-TIN are from retrospective observational studies.IgG4-TIN is a distinct and emerging subtype of interstitial nephritis. Nephrologists must be aware of this entity and how to definitively diagnose and treat it. Prospective studies and ideally multi-center clinical trials are needed to study the epidemiology, treatment, and natural history of this disease.Les maladies associées aux immuglobulines G4 (IgG4) sont caractérisées par un désordre systémique d’ordre fibro-inflammatoire qui affecte pratiquement tous les organes, incluant les reins. La néphropathie tubulo-interstitielle (On a voulu faire le portrait de la néphropathie tubulo-interstitielle (IgG4-TIN) telle que nous la comprenons actuellement: les signes cliniques indiquant sa possible présence, les indices permettant son diagnostic, ainsi que le traitement et l’évolution naturelle de cette maladie.Tous les articles publiés en anglais sur ce sujet jusqu’en janvier 2016 ont été répertoriés sur Ovid MEDLINE, Google Scholar et PubMed. Les références choisies pour la présente revue ont été sélectionnées à la discrétion des auteurs, sur la base de leur pertinence au sujet.Une IgG4-TIN devrait être suspectée chez les patients présentant des anormalités lors d’une analyse d’urine, des troubles de la fonction rénale, des lésions aux reins observables par imagerie, des taux élevés d’IgG, d’IgE ou une hypocomplémentémie. Le diagnostic d’une IgG4-TIN demande la combinaison de paramètres histologiques (infiltrat tubulo-interstitiel riche en plasmocytes, avec10 plasmocytes IgG4+ par HPF, avec ou sans dépôts de complexes immuns dans la membrane basale tubulaire) ainsi qu’au moins une des manifestations suivantes:l’observation radiologique d'indices caractéristiques de la maladie (nodules corticaux périphériques de faible atténuation, cunéiformes ou d’atteinte inégale et diffuse)des taux élevés d’IgG4 sériquesla présence d’une maladie associée aux IgG4 dans d’autres organes Les maladies telles que le lupus, la vascularite, la néphropathie diabétique ou les lymphomes sont exclues puisque celles-ci sont également caractérisées par une présence élevée de plasmocytes sécréteurs d’IgG4 au niveau du parenchyme rénal. De façon générale, l’IgG4-TIN répond bien aux stéroïdes et à une déplétion des lymphocytes B avec le rituximab, mais les récidives sont fréquentes et les patients requièrent un suivi étroit et à long terme.Les données colligées sur la néphropathie tubulo-interstitielle pour cette revue proviennent d’études observationnelles rétrospectives.L’IgG4-TIN est un sous-type émergent et distinct de néphropathie interstitielle que les néphrologues doivent pouvoir identifier, diagnostiquer et traiter. Des études prospectives, idéalement des essais cliniques impliquant plusieurs centres de soins, sont nécessaires pour étudier l’épidémiologie et déterminer le traitement et l’évolution naturelle de cette maladie.