Epistaxis (Nosebleed)

Anatomy

Classification

Anterior Epistaxis (90%)

• Arises from Kiesselbach's plexus
• Common in children and young adults
• Usually unilateral
• Typically self-limited

Posterior Epistaxis (10%)

• Originates from the posterior septum or turbinates
• More common in elderly patients with atherosclerosis or bleeding disorders
• More severe, harder to manage
• May require inpatient monitoring

Causes

Local Causes

• Nose picking (most common in children)
• Nasal trauma / blunt impact
• Upper respiratory infections (mucosal vasodilation)
• Nasal foreign bodies
• Nasal polyps
• Tumours (including juvenile angiofibroma in adolescent boys)
• Granulomatous disorders
• Environmental irritants, cocaine use
• Chronic use of nasal vasoconstrictors

Systemic Causes

• Hypertension (no proven causation, but associated with persistent bleeding)
• Anticoagulants - warfarin, rivaroxaban
• Antiplatelet agents - aspirin, clopidogrel
• Coagulopathies - haemophilia, von Willebrand disease
• Thrombocytopenia, leukaemia
• Hepatic disease / alcoholism
• Vitamin K or folic acid deficiency
• Hereditary Haemorrhagic Telangiectasia (HHT) / Osler-Weber-Rendu disease - recurrent multifocal bleeding from thin-walled vessels lacking muscle and elastic tissue

Clinical Evaluation

• Assess airway, hemodynamics, and tissue perfusion first
• Have the patient blow the nose to expel clots, then apply firm bilateral pressure on the cartilaginous part of the nose (not the bony bridge) for 10-15 minutes
• Administer 0.05% oxymetazoline (2 sprays) into the affected naris before applying pressure
• Examine the floor of the nose with the head parallel to the floor (not tilted back)

Management

Step 1 - First Aid (all patients)

1. Sit upright, lean slightly forward (prevents swallowing blood)
2. Compress the cartilaginous nose firmly for 10-15 minutes without releasing
3. Topical vasoconstrictor: oxymetazoline or xylometazoline spray

Step 2 - Anterior Epistaxis (if bleeding point identified)

• Applied from periphery to centre, superior to inferior
• Contact no longer than 15 seconds to avoid septal necrosis
• Never apply bilaterally at the same session (risks septal necrosis)

Step 3 - Anterior Nasal Packing (if above fails)

• Merocel (polyvinyl acetal nasal tampon) - inserted along the floor of the nose
• Rapid Rhino (inflatable nasal balloon) - procoagulant-coated, moistened before insertion, inflated with air
• Petroleum jelly (Vaseline)-impregnated ribbon gauze - packed posterior to anterior

A 2025 systematic review and meta-analysis (PMID 40546131) found no significant difference in efficacy between Merocel and Rapid Rhino devices.

Note: Routine prophylactic antibiotics with anterior nasal packing are NOT recommended.

Step 4 - Posterior Epistaxis

• Double balloon catheter device: Posterior balloon inflated first in nasopharynx, then pulled anteriorly and seated; anterior balloon then inflated
• Foley catheter alternative: Inserted into nasopharynx, inflated with 5-7 mL of water
• Requires inpatient monitoring (risk of airway compromise, hypoxia, vagal reactions)
• Elderly patients: nasal packing carries risk of pulmonary/cardiac complications

Step 5 - Refractory / Surgical Cases

Special Situations

When to Refer to ENT / Hospital Admission

• Posterior epistaxis
• Haemodynamic instability or large blood loss
• Failed anterior packing
• Suspected underlying vascular or haematologic disorder
• Juvenile angiofibroma or tumour suspected

Scoliosis - Complete Overview with OT and PT Management

Definition

Classification

By Aetiology

Idiopathic Scoliosis by Age of Onset

Key point: Earlier onset = higher risk of progression. Adolescent idiopathic scoliosis (AIS) is the most common structural type and affects girls more than boys.

Cobb Angle - Measurement and Clinical Significance

Posteroanterior spine radiograph showing right thoracic scoliosis with a 36-degree Cobb angle - Bailey & Love's Surgery, 28th Ed.

Scoliosis concave to the left with Cobb angle of 71.6 degrees between D6 and D12 - Grainger & Allison's Diagnostic Radiology

Risk Factors for Curve Progression

• Female sex (worse prognosis)
• Young age at diagnosis (more growth remaining)
• Risser grade 0-2 (iliac crest apophysis - more growth = higher risk)
• Curve magnitude >30 degrees
• Pre-menarchal or <1 year post-menarchal
• Curve progression of ≥5 degrees on two or more visits

Idiopathic scoliosis of >10 degrees occurs in 2-3% of children under 16. Larger curves (>30 degrees) are much rarer at 0.15-0.3%.

Clinical Features

• Usually painless - pain in scoliosis should raise suspicion for tumour or infection
• Visible trunk asymmetry, shoulder height difference, waist asymmetry
• Rib hump on Adams forward bend test
• Back pain may occur in lumbar or thoracolumbar curves
• Large curves (>60 degrees) cause restrictive pulmonary impairment and reduced vital capacity
• ~10% of patients have neurologic abnormality

Investigations

• Standing PA radiograph (full spine) - for Cobb angle, Risser grade
• Adams forward bend test + scoliometer - rib hump measurement (trunk rotation angle)
• MRI - indicated if: left thoracic curve, pain, abnormal neurological exam, atypical findings - to exclude syringomyelia, tethered cord, tumour
• CT - for complex congenital vertebral anomalies

Treatment Overview

Nonoperative

Physical Therapy (PT) Management

1. Physiotherapeutic Scoliosis-Specific Exercises (PSSE)

Schroth Method

• A 3D approach developed specifically for scoliosis
• Uses rotational angular breathing, postural correction, and muscular co-contraction
• Aims to elongate and de-rotate the spine
• Performed in scoliosis-specific corrective positions
• A 2025 meta-analysis (PMID 40656945) confirmed Schroth exercises significantly reduce Cobb angle and improve quality of life in AIS

Goals of PT in Scoliosis

• Reduce or stabilize the Cobb angle (in growing patients)
• Improve spinal alignment, posture, and balance
• Strengthen paravertebral and core stabilizing muscles
• Improve flexibility and range of motion
• Improve respiratory function (especially chest expansion and vital capacity)
• Reduce pain (particularly in adult scoliosis)
• Educate patient on self-management and home exercise program

Key PT Interventions

PT in Adult Scoliosis

• Core strengthening program - to eventually allow brace to be discarded
• Cognitive behavioural therapy is another key component for chronic pain
• PT combined with soft TLSO bracing during symptomatic periods

PT After Spinal Fusion Surgery

• Early mobilization - patients ambulate immediately post-surgery with modern instrumentation
• Bracing is rarely needed post-operatively with rigid segmental instrumentation
• Progressive rehabilitation: ROM, walking, return to function
• Pre-operative and post-operative PT/OT assessment is critical (especially in neuromuscular scoliosis such as SMA)

Occupational Therapy (OT) Management

Goals of OT

• Maximise independence in activities of daily living (ADLs) and instrumental ADLs
• Assess and adapt the patient's environment for safe function
• Optimise seating and positioning
• Address brace adaptation and compliance
• Manage fatigue, pain, and psychosocial wellbeing
• Return to work, school, and social participation

Key OT Interventions

1. Seating and Positioning

• Specialized wheelchair assessment at a comprehensive seating clinic - critical in neuromuscular scoliosis (SMA, CP)
• Maintaining an upright position in the wheelchair delays the development of scoliosis in non-ambulatory patients
• Custom-molded seating systems to correct pelvic obliquity and provide spinal support
• Pressure-relieving cushions to prevent pressure ulcers (especially with back braces in myelomeningocele)

2. Brace Management

• Patient and family education on brace donning/doffing
• Skin inspection and care - preventing pressure sores under the brace
• Adapting clothing for brace wear
• Problem-solving brace discomfort/compliance issues
• Compliance strategies - most braces require 16-23 hrs/day wear; OT helps integrate this into daily life

3. ADL Adaptation

• Adapt self-care tasks (dressing, bathing, grooming) to accommodate spinal restrictions
• Assistive devices for reaching, carrying, lifting
• Ergonomic assessment at school desk and workstation
• Energy conservation techniques for patients with respiratory compromise

4. Psychosocial Support

• Body image counselling - scoliosis and brace wear significantly affect self-esteem in adolescents
• Group therapy and peer support programs
• Anxiety management related to surgical procedures
• School reintegration support post-surgery

5. Vocational/School/Leisure Participation

• Return to school planning after surgery
• Modifications to sport, play, and leisure activities
• Adaptations for school environment

6. Neuromuscular Scoliosis - OT-specific Role

• In SMA: ensure any mobility device (scooter board, powered wheelchair) maintains function and delays contracture and scoliosis development
• Pre- and post-operative OT assessment is a critical step before spinal fusion in SMA patients
• Stretching programs for major joints as part of daily routine
• Maintain active mobility as long as possible - mobility devices, adaptations

Orthotic (Bracing) Management

Types of Braces

• Full-time bracing: 23 hours/day originally; now 16+ hours commonly used
• Efficacy is dose-dependent: more hours of wear = less curve progression
• Success rate: 72% in braced patients vs. 48% with observation alone (large bracing study)
• Bracing does NOT correct permanent deformity - it prevents progression while growth continues

Surgical Management

Indications

• Curves >50 degrees with documented progression
• Loss of pulmonary function (curves >60 degrees)
• Progressive neurologic changes
• Significant coronal or sagittal imbalance
• Refractory pain (adults)

Goals of Surgery

1. Prevent further progression (primary goal) via spinal fusion
2. Correct and improve the deformity
3. Maintain appropriate sagittal balance
4. Preserve pulmonary function
5. Minimize morbidity and maximize post-op function

Procedure

• Posterior spinal instrumentation and fusion (pedicle screws, rods)
• Lenke classification guides which curves to instrument and fuse
• Anterior + posterior approach in some cases (neuromuscular, congenital) - provides greater correction and lower pseudarthrosis rates

Post-Operative Considerations

• Early ambulation - immediately after surgery with modern rigid fixation
• Multimodal pain management protocol
• Hospital stay reduced with enhanced recovery protocols (2.9 vs 4.3 days)
• Complications: 13-40% overall; pseudarthrosis 13-17%; reoperation rate 20-40%

Special Scenarios

Early Onset Scoliosis (<10 years)

• Lung development occurs in early childhood - progressive deformity impairs this
• Management must preserve growth: serial casting (EDF - Elongation, Derotation, Flexion casts) or growing rods before fusion

Neuromuscular Scoliosis

• Occurs in up to 90% of myelomeningocele patients (100% with T12 lesion)
• More progressive, less responsive to bracing
• PT/OT multidisciplinary team is essential
• Surgery often required; posterior spinal fusion with pelvic fixation

Idiopathic Scoliosis + Pain

• Scoliosis itself is generally painless - pain warrants investigation for infection, tumour (especially osteoid osteoma), disc pathology, or spondylolisthesis

Recent Evidence

• A 2025 network meta-analysis (PMID 40183057) found Schroth-based exercises and yoga/pilates-type programs most effective for improving Cobb angle and quality of life in AIS
• A 2025 meta-analysis (PMID 40656945) confirmed Schroth exercises significantly reduce Cobb angle and improve trunk balance and quality of life