ENT Essentials: From Dizziness to Airway Threats

Host

Welcome back to Charles Sturt Paramedic Pathways, and to Part B of this module. I'm Tara, I'm taking the lead this time, with Dan alongside me. In Part A we worked through the neurological presentations. Today we move into ear, nose and throat, and we start exactly where we left off, with dizziness.

Host

And the shape of today is the same one that's run through the whole subject. Most ENT you'll meet is minor and manageable, sore throats, earache, a blocked nose, a nosebleed. But a small number threaten the airway or signal a deeper infection, and those are the ones to catch. So let's start with the crossover symptom, and then work through the ear, the nose, and the throat.

Host

Vertigo isn't just feeling dizzy, it's a specific illusion that you or the room is spinning. And the whole clinical question is where it's coming from: the inner ear, which is usually benign, or the brain, which is not.

Host

Exactly. Peripheral vertigo comes from the balance apparatus in the inner ear, and there are three you'll hear about.

Host

BPPV, where brief bursts of spinning are triggered by moving the head, rolling over in bed. Vestibular neuritis or labyrinthitis, where it comes on and stays for days, often with nausea, usually after a virus. And Meniere's disease, which comes in attacks with hearing loss, ringing in the ear, and a feeling of fullness.

Host

That's vertigo coming from the brainstem or cerebellum, and the classic cause is a stroke, which is why this ties straight back to Part A. The tells are that it comes with other neurological signs: double vision, slurred speech, trouble swallowing, weakness, or a severe new headache. And the single most useful question is the one from last episode: can they walk? Someone with a simple inner-ear vertigo is miserable but can usually still stand and walk. Someone who genuinely cannot walk, or who has any other neurological sign, is a central problem until proven otherwise.

Host

Every time, Balance and Eyes especially. Isolated spinning with no other signs, that fits a positional or post-viral pattern, is likely the ear, and it's a GP or reassurance-and-referral problem. Spinning with any central sign, or a patient who can't walk, is a stroke pathway. Same symptom, completely different destination.

Host

To the ear itself, and the common one is otitis, an ear infection. Two flavours, and it's worth telling them apart.

Host

Otitis media is an infection of the middle ear, behind the eardrum, and it usually follows a cold. Ear pain, fever, reduced hearing, common in children, and sometimes some discharge if the drum perforates. Otitis externa is an infection of the ear canal itself, the outer part, often after swimming or water exposure, which is why it's nicknamed swimmer's ear. The giveaway there is that moving the ear hurts: tug gently on the outer ear or press the little flap at the front, and in externa that's painful.

Host

A really useful one. Pain on moving the ear points to the canal, externa. Pain deep inside after a cold points to the middle ear, media. And most of these are a GP problem: simple pain relief, and antibiotics if the GP judges they're needed.

Host

Mastoiditis. The mastoid is the bone just behind the ear, and infection can spread into it. So the warning signs are pain, redness and swelling behind the ear, the ear itself sometimes pushed forward, and a patient who's systemically unwell.

Host

That's not a GP-in-the-morning problem, that's an escalation.

Host

To the nose, and two things: the blocked, painful one, and the bleeding one. Sinusitis first.

Host

Inflammation of the sinuses, the air spaces in the face, usually following a cold. Facial pain or pressure that's worse when you lean forward, a blocked or runny nose, a reduced sense of smell, sometimes a fever. The important reassurance is that most sinusitis is viral and settles on its own, so it's pain relief, steam, time, and a GP if it drags on past about ten days or gets worse.

Host

When it moves toward the eye. Swelling or redness around the eye, pain on moving the eye, any change in vision, or a severe headache with any neurological sign. That's infection spreading beyond the sinus, and it escalates. But now the one you'll actually be called to: the nosebleed. Epistaxis.

Host

It really is, and it comes straight from how these calls go. Someone's had a nosebleed for twenty-five minutes and it 'won't stop,' and the assumption is that it's a bad bleed. Far more often, it's the technique that's wrong. Most nosebleeds, around ninety-five percent, are from the soft front part of the nose, and they'll stop with correct pressure. The classic error is that people pinch the hard, bony bridge, up high, which does nothing.

Host

On the soft part. You sit the patient up and lean them forward, so blood goes into a bowl and not down their throat, and you pinch the soft cartilage just below the bony bridge, firmly, both nostrils, and you hold it for fifteen to twenty minutes without letting go to peek. A cold pack helps. Nine times out of ten, correct technique is the treatment, and the fact that it 'wasn't stopping' was really that it was never being pinched in the right place.

Host

A few things raise the stakes, and they stack. Being on a blood thinner, warfarin especially, means a lower threshold and often straight to hospital. Uncontrolled high blood pressure, and repeated recent bleeds, each push it up too. So an ordinary anterior bleed that stops with correct technique is a GP follow-up at most. One that won't stop despite correct technique, or a patient who's anticoagulated, or bleeding heavily, or showing signs of losing too much, that's an emergency department problem.

Host

Last stop, the throat, and this is where ENT gets genuinely time-critical. Start with the common one, tonsillitis.

Host

Inflammation of the tonsils, viral or bacterial. Sore throat, fever, pain on swallowing, and you may see the tonsils red or with white patches, and tender glands in the neck. Most are managed with pain relief and fluids, and a GP decides about antibiotics. That's the routine picture, and it's usually both sides.

Host

Two things to watch for. The first is quinsy, a peritonsillar abscess, a collection of pus beside a tonsil. The tells are that it's one-sided and severe, the patient struggles to open their mouth, the voice goes muffled, like they're talking with a hot potato in their mouth, and they may drool because swallowing hurts too much. That needs escalation.

Host

The threatened airway. And there's a cluster of signs that should stop you in your tracks: noisy breathing in, that harsh stridor, drooling, sitting bolt upright and leaning forward to breathe, the tripod position, and that same muffled, hot-potato voice. Together those suggest the airway is under threat, from something like epiglottitis or a deep infection in the neck. And the single most important rule is this: do not distress the patient, and do not go poking around in the throat. Keep them calm, keep them upright, let them find their own position, and get moving with urgent help, because anything that upsets them can tip a narrowed airway into a closed one.

Host

There is, anaphylaxis. An allergic reaction that reaches the airway, the breathing, or the circulation is anaphylaxis, and the airway swelling can look like this too. The reversal there isn't gentle handling, it's adrenaline, intramuscular, without delay. So a threatened airway always asks the question: is this infection, or is this anaphylaxis, and if it's anaphylaxis, adrenaline is the answer.

Host

A few to sit with this week.

Host

How would you separate an inner-ear vertigo from a central one, and what's the single most useful question?

Host

For the nosebleed that 'won't stop,' where does the pressure actually go, and what three factors raise the stakes?

Host

No pressure, no perfect answers. This is where recognition embeds.

Host

So that closes the module. Across the two parts, the brain and the ear, nose and throat, the thread has been the same one that's run through everything: a structured look, a clear sense of the red flags, and knowing when a presentation has tipped from something you manage to something you escalate.

Host

That's the Neurological and ENT module, both parts. Until next time, stay curious, stay safe, and look after each other out there.