LLLT - laser therapy -
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|Low Level Laser Therapy of Sinusitis|
|Combining nanotechnology with LLLT: visions for
the next 10 years
By Andrei P. Sommer
M. Hacarova, ENT and Allergology, Dobnerova 26, Olomouc, CZ
J. Hubacek, Faculty Hospital, ENT Clinic, I. P. Pavlova 6, Olomouc, CZ
The authors have been monitoring influence of a therapeutic laser (LLLT), wavelength 830 nm, output 40 - 120 mW, on treatment of acute sinusitis in 194 patients in group I (consisting of 20 patients with diagnosis of sinusitis maxillaris unilat., bilateralis - 145, frontalis unilat. - 2, pansinusitis - 24 patients). Control group II consisted of 241 patients with the same diagnosis, treated without the use of a laser. Energy density applied on children was 1.6 J/cm2, 3 times every other day, on adults 2.5 J/cm2, 5 times every other day on every affected sinus. Laser probe was applied externally on the skin of frontal wall of the sinus. 30 patients were treated with laser only, 91 patients were treated with laser and antihistaminics, 73 patients were treated with laser, antihistaminics and antibiotics. A significant analgetic effect of laser irradiation was noticed in all groups, the number of punctures decreased substantially in comparison with group II, presumably thanks to release of outlets of the sinus and improved drainage, the time of treatment decreased significantly. No complications were noticed.
Key words: acute sinusitis, LLLT, 830 nm
Diagnosis sinusitis acuta is one of common types of diseases in out-patients medical practice, however it can cause patients severe problems. Majority of patients is mostly affraid of punctures which have become for our population the most feared ambulatory intervention. Some patients just cannot be convinced, and it was their negative attitude that made us consider thoroughly another way how to help them.
Laser irradiation has biostimulative, anti-inflammatory, and analgetic effects. Laser irradiation especially effects cellular membranes, membrane canaliculi and pumps, mitochondrias, cytoskeleton, nociceptors, fibroblasts, lymphocytes, polymorphonuclears and Langerhans cells. (1)
Irradiation of red lasers penetrates several milimeters into tissue, in infrared part of the spectrum the penetration goes up to several centimeters, usually 4 - 6 cm. This is a very advantageous fact for the treatment of sinusitis for laser irradiation can be applied externally. However, when applying a red laser it is necessary to introduce a lightguide in the sinus. This appears to be the main reason why laser treatment of sinusitis in clinical ENT practice has been lagging behind, since at first we had had for a long time only He-Ne lasers at our disposal.
We have iniciated laser treatment of sinusitis with a therapeutic diode laser with wavelength 830 nm, the beam of which penetrates more than 4 cm into tissue. With 40 and 80 mW output power we used continuous mode as well as pulsed frequency 9.12 Hz.
We irradiated the whole area above the sinuses, children three times with energy density 1.6 J/cm2 every other day on each sinus, adults five times with energy density 2.5 J/cm2 every other day on each sinus.
Group I consisted of 223 patients with diagnosis of sinusitis acuta with manifestations on maxillar sinuses, frontal sinuses and with pansinusitis.
We rejected 29 patients due for their clear evaluation was not possible due to the following reasons: condition after a surgery on sinuses, relapsing sinusitis on a rugged chronic operation field, or polyposis. With these patients x-ray pictures after the therapy could only hardly be evaluated.
Furthermore, other patients with immune system disorders and patients on whom LLLT had not been applied since the beginning of the treatment were rejected. Finally, one patient was rejected due to absence on his check up visit, too.
For comparative evaluation a retrospective monitoring of group II was used, where no laser was applied. Group II consisted of 241 patients, followed in our office between January 1 and December 31, 1997. Criteria for putting on group II was identical with those of group I, our surgery was not equipped with a laser at that time. The parameters followed in groups I and II (data in brackets) are presented in Table 1.
Table 1: Affection of individual sines
In total 194 patients were evaluated in group I (69 children, 91 women, 34 men) with the age ranging from 4 to 70 years (Diagram 1), average age of adults was 43 years.
In group II 241 patients were evaluated (71 children, 112 women, 58 men), age ranging from 5 to 83 years (see Diagram 1), average age 38,5 years.
Therapy was chosen in correspondence with the health condition of a patient and with regard to his/her clinical diagnosis, verified by a conventional x-ray picture of the sinuses. All our patients had taken standard nasal anaemic drops even before determination of the diagnosis sinusitis acuta.
On patients gathered in set A we applied laser (LLLT) only. Set B was treatred with laser + antihistaminics (loratadine or cetirizine), set C with laser + antihistaminics + antibiotics (usually amoxilines only, or enriched with potassium clavulanate or cefalosporines, in the event of preceding adverse reaction to ATB we used quite extraordinarily macrolides or clindamycine) in accordance with experience of ENT specialists of University of Irvine, California (7). (See Table 2).
Table 2: Group I
In group II set A (laser) was excluded, other groups received the same medication as in group I. (See Table 3)
Table 3: Group II
Average length of treatment was set from determination of diagnosis till clinical physiological ENT finding. Three patients from monitored group suffered from sinusitis maxillaris acuta twice in one year with 6 months interval, the group was monitored from December 1, 1998, till July 1, 2000, i.e. one and a half year in total.
Table 4: Average length of treatment in days - group I
All patients were always monitored in the first day of treatment (once in the course of therapy) and upon the day of termination of therapy, all patients presented themselves for an ENT check up 6 months after the termination of therapy. Upon termination of treatment control x-rays of sinuses of patients with homogeneous veil or of patients with the findings of liquid levels were taken, whilst control x-rays of patients with minor forms of sinusitis were taken only exceptionally. Average length of treatment in group II without LLLT application varied from 11.1 to 18.8 days.
Table 5: Average length of treatment in days - group II
Only few papers on laser treatment of sinusitis can be found in literature. Kruchinina et al. (2) irradiated catarrhal and purulent maxillar sinusitis, both acute and chronic in 120 children inpatients in the age of 6 to 15 years, with He-Ne laser. A lightguide was inserted in the cavity by a drain, laser output power was 7mW/cm2, irradiation time 3 - 6 minutes daily. Consolidation came after 5 - 9 applications. Prior to therapy immunological examination showed decreased sIgA in the secret of the cavity, however values increased significantly after the treatment.
Plouzhnikov et al. (3) consider LLLT of acute and chronic sinusitis an important part of a comprehensive medicine. They irradiate with He-Ne laser 10mW/cm2 by a lightguide inserted in the sinus through a puncture needle, 2 - 3 times on acute, and 5 - 9 times on chronic sinusitis. Energy density 2.1 - 8.4 J/cm2 has anti-inflammatory, anti-oedematous and analgesic effects.
Prazak (4) uses a semicinductor laser 830 nm. In case of an acute frontal sinusitis he applies 3 J/cm2 on the area of foramen supraorbitale, and on another two frontal points of metopantron 1.5 J/cm2 on each. In case of inflammation of gnathic sinus he irradiates the area of foramen infraorbitale by 3 J/cm2 , and the areas of fossa canina a processus zygomaticus by 2 J/cm2 . Simultaneously, he administers antipyretics, or antibiotics per os. LLLT decreases subjective complaints, especially headaches. He irradiates every day till consolidation, on chronic sinusitis 8 - 10 applications every other day.
Moustsen (5) with a group of colleagues from Aarhus Universitet conducted a double blind randomized study in 60 patients, on whom they applied laser irradiation of 30 mW, 830 nm, for 90 seconds, in three sessions on each sinus in 1 - 3 days interval. They found no statistically important difference between laser and placebo as far as pain feeling, disease duration, nor overall condition are concerned.
Simunovic (6) presents in the chapter "LLLT in ENT" treatment of sinusitis with a diode IR laser. He recommended energy density 2 - 4 J/cm2 on mucous inflammations. Compared to other specialties, the chapter devoted to ENT is unusually brief - 3 pages of text only.
Therapy of sinusitis is focussed on suppressing infection, influencing unpleasant symptoms - especially pain, shortening duration of disease, preventing relapses and transformation into chronic phasis of the disease. These were our main concerns when monitoring the influence of laser irradiation on sinusitis.
1. We can quite unambiguously confirm a positive effect of laser on diminishing pain. In all monitored sets a relief of pressure and pain was noticed within 24 hours after the first irradiation in group I.
2. In therapy of sinusitis it is important to attain re-ventilation of the cavity and functional mucocilliar transportation of the secretion, depending on interaction of the mucus and function of cilia.
Significant decrease of number of patients, who had to undergo a puncture, bears witness to an influence of laser irradiation on release of outlets of sines and restoration of mucocilliar transportation. In gnathic and metopic sines the transportation is circular and it is directed by determined drainage paths, leading to natural sinusal outlets. The transportation ceases due to various reasons - toxins, medicaments, temperature, relation between liquid and viscose layers of the mucus, surfactants,or bilateral contact of the surface of the mucose, especially in the area of the outlets.
Most punctures, 8 of total 11 monitored patients with punctures in our group I, were performed in the cathegory with homogenous obscure of the sines treated with laser and antihistaminics (set B), whilst only one of 29 patients in the cathegory with homogenous obscure of the sinuses had to undergo punctures when treated with laser + antihistaminics + antibiotics (set C). Puncture empyema in set B was both blennoid and purulent. The number of patients with punctures in group II was also highest in the group with homogenous obscure - 23 patients (neither number of punctures, nor laterality was not taken into account). Laser irradiation is expected to bring a positive influence due to its anti-inflammatory and anti-oedematic effects especially in the area of the outlets. In the case of a homogenous obscure quantity, composition, and pressure of the mucus substantially impairs mucociliar transportation and, furthermore, the mucus prevents penetration of laser irradiation. Addition of antibiotics may contribute to a quicker elimination of inflammation.
3. Acute rhinogenous sinusitis is usually primarily viral, with secondary bacterial superinfection. According to our experience (8) laser irradiation has no bactericidal effect, however it causes reduction of cytopatogenous effect of herpes simplex virus, and the same effect can be presumed on other viruses. However, laser irradiation substantially stimulates non-specific as well as specific imune actions - it increases lysozyma in saliva, increases phagocytal activity, stimulates T and B lymphocytes and thus it through immunostimulation significantly contributes to healing processes.
4. All patients in group I were clinically checked up after six months. Patients with homogenous obscure of the sines or with levels were x-ray screened before and after therapy. It was not necessary to hospitalize any patient, nor had any patient complications nor relapses within six months after therapy. No symptoms of chronic sinusitis were noticed.
Average duration of therapy varied between 6.3 to 10.5 days in group I (with LLLT), average duration of therapy in group II (without the use of laser) ranged from 11.1 to 18.8 days.
We are of the opinion that negative evaluation by Moustsen et al. (5) may be influenced by short application time.
LLLT irradiation is a benefit for treatment of acute sinusitis. External irradiation with a laser with 830 nm wavelength, enabling the beam to penetrate 4 - 6 cm deep is recommended. Irradiation with red light emitting lasers is also effective, but due to the need of application through a lightguide inserted into the cavity this method has been already discarded from clinical practice.
Laser irradiation works through its analgetic, anti-inflammatory and biostimulative effects on ease of pain, or even on its elimination, its also causes a quicker withdrawal of inflammation and oedema of the mucose and thus brings restoration of drainage of sines as well as normalisation of mucociliar function.
Immunomodulative effect - improvement of both specific and non-specific immunities by stimulation of T and B lymphocytes, lysozyme and phagocytosis - is also significant. Stimulation of Langerhans cells of the mucose of sines is presumed, too.
Laser irradiation in treatment of sinusitis has no contraindications (with the exception of general contraindications, i.e. malignant tumors in the irradiation area, or epilepsy), and as a physiotherapy it can suitably complement therapy with antibiotics, mucolytics, and antihistaminics.
The use of laser with 830 nm wavelength appears to be the most beneficiary on diagnosis sinusitis acuta with liquid levels in paranasal sinuses, the treatment of which was cut down by 59 per cent in average, and on a group of patients with plain catarrhal obscure and decreased transparency (the most frequent) where duration of therapy was shortened by 39 per cent.
Total number of patients with punctures was cut down by about six times when using LLLT simultaneously.
1. Navratil, L., Hubacek,J.: Biologicke ucinky svetelne energie, pages 53 - 93. In Moderni fototerapie a laseroterapie, Manus, Praha, 2000.
2. Kruchinina, I. L., Pekli, F. F., Rybalkin, S. V.: Vlijanije lazeroterapii na mestnyj sintez imunoglobulina klasa u detej bolnych ostrym i chronicheskim gaimoritom. Vest. Otorinolaryng.,1988, No. 2, pg.19 - 21.
3. Plouzhnikov, M. S., Lopotko, A. I., Gagaus, A. M.: Lasery v otorinolaryngologii. Kishinev, Shtiinca, 1991, 157 s.
4. Prazak, P.: oral representation 1996, 1999.
5. Moustsen, P.A., Vinter, N., Aas-Andersen, L., Kragstrup, J.: Laser Treatment of Sinusitis in General Practice Assessed by a Double-blind Controlled Study. Ugeskrift for Laeger, 153 (32), 1991 Aug 5., pg. 2232 - 4.
6. Simunovic, Z.:Laser therapy in the diseases of ear,nose and throat. p.381-383. In Laser in Medicine and Dentistry. Editor Zlatko Simunovic, Rijeka: Vitagraf 2000, 544 pgs.
7. Ahuja, G. S., Thompson, J.: What Role for Antibiotics in Otitis Media and Sinusitis?, Medicina po promoci, 1 (2000), Jan - Feb., pgs.50 - 59.
8. Hubacek, J.: Neinvazivni laseroterapie v otorinolaryngologii, pgs.130 -150. I Moderni fototerapie a laseroterapie, Manus, Praha 2000.
by Andrei P. Sommer
Department of Biomaterials, ENSOMA-Lab
Wound healing via laser light goes back to Prof. Endre Mester. First reports on his pioneering work started in 1967. For biostimulation he used the coherent light of powerful 50mW He/Ne-lasers (632.8nm). The Mester group has been continuously successful from the beginning. But only a minority of researchers could reproduce the success of the biostimulation experiments.
33 years after introducing the paradigm of photobiostimulation, the LILAB-equation has been anchored into LLLT  - establishing the biological limits of the dose (energy density) and the light intensity. Recent laboratory experiments, demonstrating that various individually administered wavelengths of laser light applied at energy densities of the same order induced comparable biological effects in rats, could be interpreted as additional evidence in support of the LILAB-equation .
During the 1st NOA Conference  a multidisciplinary group of ten scientists from Brazil, Denmark, Finland, France, Germany, Hungary, Israel, Saudi Arabia and U.S.A. evaluated possibilities of validating LLLT. One of the discussed visions has been to directly investigate the molecular mechanisms of light-induced wound healing processes occurring in LLLT via Nearfield Optical Analysis (NOA). The vision has been so promising that Attila Pavláth - President ACS - became eventually interested in supporting the group, and the ACS officially cosponsored the 1st NOA Conference for "evaluating the molecular mechanism of accelerated and normal wound healing processes", thus ignoring the insurmountable gap which persisted between the vision and the experimental possibilities: Nearfield Optical Analysis (NOA) via Nearfield Scanning Optical Microscopy (NSOM) existed since 10 years, however, nobody has so far succeeded to image a living cell under physiological conditions with this method. Two particular reasons seemed to oppose any substantial progress: the problem of operations in aqueous environments, and the "low optical contrast", characteristic of optically investigated unlabeled living cells. The first problem has been solved at the European Nearfield Scanning Optical Microscopy (ENSOMA) Laboratory by the use of hydrophobically coated biosensors, and the milestone could be presented during the 1st NOA Conference in November 2000 .
NSOM  has produced highest optical resolution that has ever been achieved, a method exploiting the energy transfer from the tip of an optical element (tip diameter 20nm) oscillating within the characteristic range of the energy transfer (~ 10nm) in the nearfield of the surface to be analyzed. Irradiation-induced energy transfer between excited molecules (emitter) and receptor molecules (acceptor) positioned in the proximity of the emitter molecules via spacer molecules, has been confirmed experimentally (Kuhn, 1970).
During the 2nd NOA Conference, held in May 2001, and cosponsored by NASA and DARPA: 2nd International NASA/DARPA Photobiology Conference on Nearfield Optical Analysis (NOA), at the National Aeronautics and Space Administration - Johnson Space Flight Center (NASA-JSC), Houston, TX, U.S.A., we went, en route to solve the "low optical contrast" problem, one step further and demonstrated that clear NOA images could be obtained from nanobacteria in an aqueous environment - an encouraging advance . The 2nd NOA - with more than 40 international photobiology peers - promoted both LLLT and NOA, with the special result that LLLT/LILAB could advance in less than six month to scientific acceptance in three fields: civil, military and space relevant.
The scientific breakthrough came just before the 3rd NOA (Brazil, June, 2002) in form of the publication of clear nanoscale images of human dentin in an aqueous environment , and the very first images of living endothelial cells in liquid cell culture medium , thus opening an optimistic perspective to a direct analysis of LLLT mechanisms. The cells were attached to polished titanium discs and analysed with hydrophobically coated optical biosensors mounted to a conventional NSOM microscope. We are presently in an era where cellular imaging and photobiology is becoming important to wide ranging disciplines. The recent advances in NOA have provided us with the technology necessary for identifying relationships between cellular activities and various photonic stimuli - on Earth and in space. Cellular imaging of living cells via NOA has been recognized as extremely beneficial, in particular for biomedical applications  and in tissue bioengineering . Our vision, presumably realizable via NOA, could be generalized as: Time resolved analysis of the LLLT induced molecular mechanisms in living cells, with the light energy densities and intensities conform to the LILAB-equation, and with different wavelengths of coherent and non-coherent light, allowing to systematically understand and optimise the LLLT parameters.
 Sommer, A.P, Pinheiro, A.L.B., Mester, A.R., Franke, R.P., Whelan,
 Al-Watban, F. Comparison between Laser Therapy and Pharmacological Treatments in Accelerating Wound Healing - an extended study in: Proc. 2nd International conference on nearfield optical analysis: photodynamic therapy & photobiology effects. Johnson Space Flight Center, May 2001, Houston, TX, NASA Conference Publication, in press.
 Preface, Proc. 1st International Workshop on Nearfield Optical Analysis, Reisensburg, Germany, November 2000, (ed. A.P. Sommer) J. Clin. Laser Med. & Surg., 19, 109-112, 2001.
 Sommer, A.P. Components for NOA of Biosystems and Nanoscale Resolution,
in: Proc. 1st International Workshop on Nearfield Optical Analysis,
Reisensburg, Germany, November 2000, (ed. A.P. Sommer), J. Clin. Laser
Med. & Surg., 19, 112, 2001.
 Sommer, A.P. Nearfield Optical Analysis (NOA) via Hydrophobic Optical Elements & Low Intensity Light Activated Biostimulation (LILAB) Effect of NOA. Proc. 2nd International conference on near-field optical analysis: photodynamic therapy & photobiology effects. Johnson Space Flight Center, May 2001, Houston, TX, NASA Conference Publication, in press.
 Sommer, A.P., Franke, R.P. Hydrophobic optical elements for near-field optical analysis (NOA) in liquid environment - a preliminary study. Micron, 33, 227-231, 2002. (Medline)
 Sommer, A.P., Franke R.P. Near-Field Optical Analysis of Living Cells in Vitro. Journal of Proteome Research, 1, 111-114, 2002. (ACS/ASAP-article)
 A.P. Sommer, Novel Low Intensity Light Activated Biostimulation
Paradigm, in: Abstracts of the Second Congress of the North American
Association for Laser Therapy & First Consensus Conference on Laser
Medicine, Photobiology and Bioengineering of Tissue Repair, Atlanta,
GA, March 2002.
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