1. TONSILLECTOMY FOR PSORIASIS: DOES IT HELP
TONSILLECTOMY FOR PSORIASIS: DOES IT HELP? N MANI, V PRASAD, A SURULIRAJ, K BUROVA, TJ HOARE BEDFORD HOSPITAL NHS TRUST
INTRODUCTION AND BACKGROUND
Psoriasis is a chronic inflammatory disorder that affects approximately 2.5% of the population. It mainly occurs in fair skinned races and in northern hemisphere regions
Psoriasis can occur at a variety of sites and can significantly impair patients’ quality of life (Pic 1)
There is a well recognised immunological link between streptococcal infection and psoriasis. Guttate psoriasis in particular has a strong association
Approximately 70% of patients with psoriasis find that it is exacerbated by tonsillitis. Early literature on the link between psoriasis and tonsillitis were mainly from Russian and Japanese papers
A recent survey of ENT Surgeons practising in the UK showed that less than 30% perform tonsillectomy for psoriasis
Conventional treatment for psoriasis involves a multitude of topical agents along with UV light based methods (Pic 2)
We use a dermatological scoring system for the severity of psoriasis to objectively measure the treatment value of tonsillectomy for psoriasis
No Redness
Slight Pink
Pink
Red
Dark Red
Colour
No Thickness
Feels Firm
Raised
Thick
Very Thick
Thick-ness
No Scaling
Slight Scaling
Scaly
Flaky
Very Flaky
Scaling
Body map to describe affected area
Visual analogue scale to describe an average psoriatic lesion
SAPASI = [(AH0.1)+(AU0.2)+(AT0.3)+(AL0.4)][0.033(VASE+VASI+VASS)]
Formula to calculate SAPASI score. AH- Head area score, AU- Upper limbs score, AT- Trunk area score, AL- Lower extremity score ( A scores from 0 to 6). VAS- Visual analogue scale, E- Erythema, I- Induration, S- scaling
Figure 2
RESULTS
13 out of 16 patients responded to the questionnaire
12 ♀, 1 ♂. Average age 25 (range 5 – 36)
10 out of 13 patients reported a subjective improvement in their psoriasis. All of these 9 patients would recommend tonsillectomy to other patients with psoriasis
11 out of 13 patients had an improved SAPASI score when grading their average level of psoriasis before and after surgery (Fig. 3)
All 13 patients had improved SAPASI scores for severe episodes of psoriasis when compared both before and after surgery (Fig. 3)
Picture 1. Guttate Psoriasis
Picture 2. Topical agents and UV therapy
MATERIALS AND METHODS
A retrospective study was carried out looking at patients referred from the department of dermatology to the department of otolaryngology for consideration of tonsillectomy for psoriasis
16 patients referred underwent tonsillectomy in a seven year period from 1998 – 2005
These patients were sent a postal questionnaire to complete. (Fig 1)
The psoriasis area severity index (PASI) is used by dermatologists to assess severity of psoriasis. The self administered PASI (SAPASI) allows patients to evaluate the severity of their psoriasis themselves
SAPASI scoring uses 2 criteria to calculate an overall score: body area affected and a visual analogue scale to describe an average psoriatic lesion. The score ranges from 0 – 72 (Fig 2)
We aimed to quantify the severity of patients’ psoriasis before and after tonsillectomy, both on average and during severe episodes, using SAPASI scores
Change in psoriasis severity post tonsillectomy
Much Better (7)
Slightly Better (3)
No Change (1)
Slightly Worse (2)
Pre–op average level of psoriasis 29 14 38 12
Pre-op severe level of psoriasis 34 28 48 20
Post-op average level of psoriasis 2 6
Post op severe level of psoriasis 19
At what age did you develop Psoriasis?
Was your Psoriasis made worse when you had tonsillitis or a sore throat?
Yes No
Have you noticed any difference in your Psoriasis since you had your tonsils removed? Please choose one of the following:
Much worse
Slightly worse
Slightly better
Much better
Figure 3
CONCLUSIONS
Our results have shown that using a validated scoring system for psoriasis severity, there is an improvement in psoriasis in patients who have undergone tonsillectomy
We propose that tonsillectomy be considered as a surgical option for psoriasis which is exacerbated by tonsillitis
We recommend further larger prospective randomised controlled studies to investigate correlation with our findings
Would you recommend that other patients should have their tonsils removed to help their Psoriasis?
Yes No
From the point of view of your Psoriasis, are you pleased that you had your tonsils removed?
Using our scoring system on the next page could you grade your Psoriasis before and after your tonsils were removed?
We would like you to think about the following times:
The average in the 6 months before the operation
The worst in the 6 months before the operation
The average in the 6 months after the operation
The worst in the 6 months after the operation
Figure 1