■ Note on middle ear diseases ( part N ) :
● The commonest part to be eroded in CSOM is long process of incus
● Benign tumors of middle ear the most common is glomus tumor 
● Petrous site is the commonest site for cholesteatoma
● Tubo -tympanic disease is the most common type of CSOM
● secretory OM is the commonest cause of bilateral CHL in children
♧ Tympanoplasty should be combined with cortical mastoidectomy if there is discharge
● cholesteastoma :
♧ perforation in pars flaccida
♧ CHL except if there is erosion of inner ear leads to SNHL
♧ Facial paralysis & vertigo& earache  may be 1st presentation
♧ it is always treated surgically and the best is canal wall down technigue
●in case of CNSOM  : the tympanic membrane is intact
● secretory OM : the tympanogram is type B curve while in adhesive OM is type C
● secretory OM that treated by surgical the incision in ear drum should be in Antero superior part
● the early & most common complaint in glomus tumor is pulsating tinnitus
● the cr.nr affected is 7, 8 ,9, 10 , 11 , 12
● A Patient with unilateral conductive deafness & pulsatile tinnitus  : Glomus tumor
● the biopsy is CI in glomus tumor
● SCC of middle ear :
♧ it is common in male above 60 years old
♧ there is mixed hearing loss
 

■ Note on complication of SOM :
● Stapedial otosclerosis is the commonest type
●Stapedectomy is the TTT of choice in otosclerosis , while NaF used if surgery is CI 
● Sagging of  EAC is the early & diagnostic sign of Acute mastoiditis
● The post auricular groove is preserved in acute mastoiditis
● _ve fistula test :
* dead ear & very small & closed by cholesteastoma
● Labyrinthine fistula & diffuse serous :
♧ the nystagmus to the same side of lesion
While in diffuse suppurative to normal side
● Diffuse serous labyrinthitis :
♧Mixed HL
♧ will be improved with medical TTT
● Pertrositis & Extradural abscess is commonly associated with mastoiditis
●  In Extradural abscess :
♧ the granulations over the dura should be left intact for fear of CSF leak & infection
● Do CT before Lumber puncture in case of meningitis to exclude SAH
● Tempral lobe is the more common affected in case of brain abscess
● Griesinger's sign : it is edema over the mastoid
● MRA is the most diagnostic in case of Lateral sinus thrombophelibitis
● Lateral sinus thrombophelibits : Anemia & leucocytosis
● Given Anticoagulants  after removal thrombus & Cavernos sinus thrombosis
 

■ NOTES On TBL : -

● Part 1 :
https://t.me/med_Notes2/83
● part 2 :
https://t.me/med_Notes2/92
● Part 3 :
https://t.me/med_Notes2/94

صباح الخير يا شباب كده كل النوتس كتبتها اللي دخلة ف TBL و حاولت اركز على الحاجات اللي بتيجي ف MCQ فيها
دعواتكم و لا تنسوني من صالح دعائكم نلتقي في أيام قادمة بإذن الله و بالتوفيق لينا جميعاً .

■ Tympanogram : -

● ossicular disruption : type Ad ( hypermoile)

● secretory OM : type B

● adhesive OM : type C

● E T dysfunction : type C

● otosclerosis : type As ( restricted curve)

Affect last 4 cranial nerves : 9 , 10, 11 and / or 12

I say that again more & more
● hemotympanum is one of signs of transverese fracture
بمعنى لما يحصل الدم اللي جاي من ال inner ear بيتجمع ف middle ear وراء ear drum
Which mean the ear drum is intact
يعني مش هشوفها غير لما ادخل بالمنظار و هشوف ال blood وراءها
اعتقد كده وصلت و مش محتاجه يعني شرح .

■Notes on EOM :-
● The nearest EOM to macula is IO
● The nearest EOM to limbus is MR
● when you bring viusal axis to longitudunial axis to ms is called main action
● when the viusal axis is perpendicular to longitudinal axis of ms is called subsiadiary action
● MR is the largest & strongest ms in the eye
● So is the only depressor when the eye is adducted
● SR is the only elevator when the eye is abducted
● All EOM supplied by oculomotor nerve except ( SO by IV nerve , LR by VI nerve) 
● insertion of EOM :
*MR > 5.5 mm
* IR > 6.5 mm
*LR > 7mm
*SR > 7.7mm
From limbus
● Action of EOM :-
*SO & SR : intortion
* IO & IR : extortion
♧ Recti ms : Adduction except LR ( Abduction)
♧ oblique ms : Abduction
♧ SO & IR : depression
♧ IO & SR : elevation 

ده جدول مقارنة مهم لل types of squint

■ Notes on squint ( part 1 ) :

● the most important procedure in a child with unilateral squint is fundus examinaton
● Pseudo squint : two  visual axises are normal  , while true squint  the abnormal direction of visual axis of one or both eyes
■ Apparent squint :
♧ high mypia : angle alpha are -ve
♧ hypermetropia: angle alpha are + ve
♧ Angle alpha is b.t  visual axis & optical axis & it is normally + 5 degree & measured by ambyloscope
♧ corneal light reflex in the center of pupil
♧ TTT of cause such as epicanthus by skin re-distribution not Excision
■ Latent squint :-
● the most common cause is errors of refraction
● if not treated lead to manifest squint
● correct of errors of refraction is the most important step in ttt
● surgical TTT is done in case of large deviations
● examination :
♤ firstly the pt has no squint before & even after the examination but during the examination the pt has it
♤ Cover test is done to detect manifest squint in other eye
♧ un-cover test is done to detect latent squint in affected eye which mean the eye is cover
♧ Maddox Rod & maddox wing is done for dissociation of binocular vision for far object & near object respectively . 

■ NOTES on Squint : -

● Part 1 :
https://t.me/med_Notes2/108
● comparison between the types of squint :
https://t.me/med_Notes2/110

● Part 2 :
https://t.me/med_Notes2/112

● Part 3 :
https://t.me/med_Notes2/119
https://t.me/med_Notes2/126

● Cover & un cover test :
https://t.me/med_Notes2/117
https://t.me/med_Notes2/127

في حد عاوز يفهم جزء cover & un-cover test في درس latent squint
قبل ما اعمل test بشوف هل في ocular deviation و لا لأ ؟ عشان استبعد وجود manifest squint
طيب بغطي العين اللي فيها latent squint و بشوف هل العين الثانية فيها manifest squint و لا لأ يعني cover test detect manifest in other eye
طيب العين ال cover هشيله و بعد كده هيظهرلي أنه العين كان فيها latent squint لأنها عاوزه تعمل fixation to object ترجع لوضعها الطبيعي بمعنى
Un-cover test is detecting latent squint in affected eye which is cover

■ Notes :-
● Paralytic squint :
♧ it is the most serious type of squint
♧ Corneal light reflex is not at the centre of pupil
♧ Angle of deviation is variable in all directions of gaze
♧ All the manifestations are in the same direction of action of paralyzed ms EXCEPT squint itself
♧ False projection occur in the direction of action of paralyzed ms
♧ un-crossed squint diplopia occur with LR paralysis , while crossed with MR paralysis
♧ TTT of the cause in the 1st 6 months firstly
♧ paralytic squint with no diplopia :
* single eye , deep amblyopia , 3rd nerve palsy (unilateral marked ptosis) , young age

♧ 6th nerve palsy+ horner syndrome = cavernous sinus syndrome
♧ 3rd nerve palsy + dilated pupil + paralysis of accommodation = post.communicating aneurysm
♧ 3rd nerve palsy + spared accommodation + dilated pupil = DM & HTN
♧ AHP in case of EOM paralysis :
♤ MR & LR paralysis = face turn
♤ SR & IR prarlysis = chin elevation & depression
♤ SO& IO paralysis = head tilt

■ Note :-
● concomitant squint :-
♧ The most important cause  is errors of refraction ( excessive hypermetropia)
♧  Convergent squint ( esotropia ) is more common in children d.t strong MR
♧ the angle of deviation is constant in all directions of gaze
♧ Normal ocular motility
♧unilateral concomitant : ambylopia , while alternating there is no ambylopia
♧ there is no diplopia & face turn
●infantile esotropia :
♤ low hyperopia
♤  it Starts at age of 6 m
♤ it is not  caused by errors of refraction
♤Large angle of deviation
♤ Latent nystagmus
♤ Common ambylobia (30%)
♤ Cross fixation
♤ttt: Correct ambylobia + Early surgical ttt before age of 12 m (Bilateral MR recession)
● TTT of concomitant squint :- ( GOOS)
♧ Glasses : to improve VC
♧ occulsion : to correct amblyopia
♧ orthoptic exercise : to gain SBV
♧Surgery: to correct deviation 

■Cover & uncover test in concomitant squint :
If you cover the squint eye
مفيش حاجة هتحصل للعين السليمة اللي عاملها fixating
If you cover normal eye
العين اللي فيها squint تتحرك عشان تبقى fixating و العين السليمة تبقى squinting
* طيب لو شلت cover :
• العين ترجع لوضعها الطبيعي = unilateral squint
• أو العين تبقى زي ما هي fix هتبقى alternating squint