THE ROLE OF LASER RADIATION THERAPY IN MAXILLARY SINUSITIS

D. K. lsser ~, S. SeW, B. P. Saha 3

INTRODUCTION

Ruby LASER was invented in 1960. Thereafter, high output effect of LASERs is still being used in medical field for burning coagulation and vaporisation effect in treatment of different diseases. Previously LASER was produced by Ruby, CO2, ND-YAG, KTP etc. But first of all, in 1967, Mester G. et al. described the biomodulation- effect of low output LASERs, in the management of different inflammatory diseases. He defined 'biomodulation' as, "Reduction of inflammation and oedema as well as production of analgesia along with acceleration of natural process of wound healing by selective stimulation or inhibition of cellular activity, when triggered by low output LASER-Light".

Later on, various authors have reported biomudulation effect of low output LASERs on human tissue and its therapeutic effects on maxillofacial inflammatory conditions. We have not observed any report pertaining to the effect of low-dose Laser Therapy (LLT) in the management of 'sinusitis'.

Since long, various treatment modalities, including invasive ones and medicines have been advocated for the treatment of 'maxillary sinusitis'. After considering the non-invasive and atraumatic nature of LLT, we have planned to do a comparative study of low output GaA1AS-LASER Radiation effect on 'maxillary sinusitis' with all the available modalities.

We have done it within a period of 3 years (April'94 to March'97) in the Department of ENT, PMCH, Patna, Bihar, India.

MATERIALS, METHODS AND OBSERVATIONS

200 random cases of different age and both sex groups of 'maxillary sinusitis (Acute & Chronic)', after proper diagnosis, have been selected for the management. 190 cases were treated with existing prescribed mode(s) of treatment e.g. medicines, APW, Sinoscopy, intranasal Antrostomy and Caldwell Luc operation. Benefits and failure of the management by all these are shown in Table No. I, IA, Ib and Histogram No. I to llI.

10 cases (3 acute and 7. chronic) out of the total 200 cases of 'maxillary sinusitis', were directly subjected to LASER Irradiation (by 'Gallium-Aluminium-Arsenide Laser') for the external irradiation of inflammed antral mucosa with expectation to combat the symptom(s) and disease-process of'sinusitis' and 15 cases, who failed to respond to prescribed modes of therapy, were subjected to LLT with same technique of irradiation. As suggested by different researchers in different other conditions, the maxillary sinuses were irradiated

Fig. I : Gallium-Aluminium-Arsenide LASER Equipment.

JAssociate Prof., 2Post-graduate trainee, 3professor & Head of Department oi" ENT, PMCH, Patna, Bihar, India.

The Role of Laser Radiation Therapy in Maxillary Sinusitis 209

Table - I : Showing the outcome of differnt types of treatment as instituted in 200 cases of "maxillary sinusitis".

Types of Treatment

LASER Radiation Therapy without Medical Treatment Medical Treatment

No. of Cases

10

Percentage

5%

Response Satisfactory

No. of Cases

10

percentage

100%

Failure

No. of cases

190 95% 72 38% 118 62%

Total 200

percentage

Table - I (Contd.) : Showing the outcome of differnt types of treatment as instituted in 200 cases of "maxillary

sinusitis".

Treatment of 118 cases of 'Maxillary Sinusitis', not responded to 'Medical Treatment'.

Types of Treatment :

A. Antral Puncture & wash (APW)

No. of Cases

89

Percentage

75.4%

No. of Cases

74

Satisfactory

Percentage

83.1%

Response Failure

No. of Cases

15

Percentage

16.9% Out of these 15 cases, 3 were

B. Caldwell Luc Operation

C. LASER Radiation Therapy

Total �9

17

12

14.4%

10.2%

17

11

100%

91.6% 8.4%

further subjected to LASER Radiation Therapy

118

(incomplete therapy)

by 'single- Probe' and 'Cluster-Probe' (as shown in Fig.I to IV), once a day for 6 such on alternate days with 0.4 W/cm-'

power output (as shown in Table No. I and II and Histogram No. II).

Subsidence of symptoms and signs, as observed after the completion of the full course' of ' LASER Radiation Therapy', has been recorded and compared with the 'Post LASER Therapy X-ray-PNS', as shown in Table No. III 'A' and 'B' and Histogram No. II and Fig. No. AI, A2; Bj, B2; Cj, C 2 & D1, D 2. All these cases were followed upto March, 1997.

DISCUSSION In 1967, Mester G. et al. observed the effect of low-output LASERs on bacterial phagocytosis of the leukocytes and Fig. II : 'Single probe' & "cluster-probe'.

Indian Journal of Otolaryngology and Heqd and Neck Surgery Vol 54 No. 3 July =,.September 2002

210 The Role of Laser Radiation Therapy in Maxillary Sinusitis

Table -1A : Showing the outcome of 72 patients of 'maxi l lary sinusitis' , responded to 'Medical Treatment' .

Treatment Combination of percentage Symptomatic Relief

Regime drugs (used) Total

'a'

'b '

'C'

Total

no of

cases

Inhalation + -24 33.3%

Nasal Decon-

gestant +

Analgesics +

Antibiotics +

Antiallergics

Inhalation + - 18 25% Nasal Decon-

gestant + Antibiotics +

Antiallergics

Inhalation + -30 41.7%

Nasal Decon-

gestant +

Analgesics +

Antibiotics

Total : 72

No. of Percentage

Cases

5 21%

(approx

2 11.1%

6 20%

Initial

partial relief

No. of Percentage No. of Percentage

Cases Cases

16 66.5% 3 12.5%

12 66.7% 4 22.2%

18 60% 6 20%

(These 13 cases, having 'Initial Relief' , only, dropped out, being reluctant of undergoing other modes of therapy.)

Table - lb : Showing the response to 'Antral Puncture-Wash' (APW) with 'Medical Treatment' in 89 cases out of 200 cases of 'Maxillary sinusitis' who failed to respond to 'Medical Treatment, alone' :

Antral Puncture - & Total Symptomatic Relief Failure

- Wash (APW) no. of Total Partial

Bilateral

Unilateral :

(17 cases ) a) Right

b) Left

Cases

-72

-8

-9

No. of percentage

Cases

19 26.5%

2 25%

1 11.1%

Total �9 89

No. of

Cases

42

4

6

Percentage

58.3%

50%

66.7%

No. of

Cases

11

Percentage

15.2%

25%

22.2%

(No. ofAPW - one to three)

observed that this effect increases as the energy density is increased upto 0.05 Joules/cm 2. Endre Mester, in 1971, observed 4 Joules/crm as the optimum effective dose of Low- dose LASER Therapy (LLT) for biostimulation. Cseh G.

(1978) observed the change in prostaglandin content of inflammed tissues after LLT, Kovacs. L. (1981) and Yew D.T. et al. (1982) observed the effect of LLT on physiological healing process and cell mitosis, Mester E. and Rachischew

Indidn Journal of Otolaryngology and Head and Neck Surgery Vol. 54 No. 3, July - September 2002

The Role o f Laser Radiation Therapy in Maxillary Sinusitis 211

Table - 1I : Showing the efficacy of 'LASER Radiation Therapy' in 'Acute' & 'Chronic maxillary sinusitis', as seen in this group of 25 cases :

Disease

Acute

Maxillary 5

Sinusitis

Chronic

Maxillary 20

Sinusitis

Total

no. o f

cases

Response

with with medical with medical

LASER Treatment + Treatment +

LASER APW +LASER

No. o f Percent- Good Satis- No. o f Percent- Good Satis- No. of Percent- Good Saris-

Cases age factory (%) Cases age factory (%) Cases age factory (%)

3 3 2 2

(100%) (100%)

7 4 3 10 8 1 3 3 3

(57%) (43%) ( 8 0 % ) (10%) (100%)

(I case i.e. 10% dropped out)

Total : 25

N. B. ." 'Good response' is used to denote total absence o f all or most o f the symptoms and more than 30% resolution in antral-haziness and~or mucosal thickening on plain x-ray sinuses after 'LASER Radiation Therapy '. 'Satisfactory Response' is used to denote partial absence o f all or most o f the symptoms and less than 30% resolution in antral-haziness and~or mucosal thickening on plain X-ray sinuses after 'LASER Radiation Therapy.

Fig. III : 'Single -probe' in use

Histogam IA : Showing the outcome of 'Medical treatment' in 'maxillary Sinusitis' (Correlate with Treatment Regimes 'a', 'b' & 'c' in Table No. Ia).

Fig. IV : 'Cluster -probe' in use. Histogam I B : Showing the response to 'Antral Puncture & 'Wash' (APW)

with 'medical treatment'.

Indian Journal o f Otolaryngology and Head and Neck Surgery Vol. 54 No. 3, July - September 2002

212 The Role of Laser Radiation Therapy in Maxillary Sinusitis

Table - III 'A' : Showing the f indings after ' L A S E R Radiat ion Therapy' in 25 cases of 'Maxi l lary sinusitis' :

Parameters (Judged)

A. Symptoms : (I) Headache or

pain (lI) Nasal

Stuffiness (Nasal Blockage)

(III) Rhinorrhoea (IV) Epistaxis (V) Sneezing

B. Incomplete Therapy (Symptoms were assessed after the sole

dose of LASER Radiation Therapy)

Parameters found in (No. of

Cases) No. of Cases

Total Absence of Symptoms

Partial Absense of Symptoms

Percentage

No appreciable Alteration in Symptoms

22

15

3 2 5 1

18

14

Percentage

81.8%

93.3%

18.2%

6.7%

1

100% 100% 100%

No. of Cases

No. of Cases

Percentage

100%

N. B : No case reported any worsening o f symptom (s) nor increase in pain in face & head after completion o f total 6 doses o f LASER Radiation Therapy.

Table - III 'B' : S h o w i n g the Reso lut ion in antral radio-opac i ty /haz iness fo l lowing ' L A S E R Radiat ion Therapy ' in maxi l lary sinusitis' .

No. of Cases

Percentage Gradation of resolution of antral radio-opacity/haziness or mucosal thickening on 'Plain X-ray sinuses' after 'LASER Radiation Therapy'

8 33.3% +++ (i.e. more than 50% resolution in opacity/Mucosal Thickening) 12 50% ++ (i~.e. between 30% to 50% resolution in opacity/mucosal thickening) 4 16.7% + (i.e. less than 30% resolution in opacity/mucosal thickening)

24 (Total) - The patient, undergoing 'Incomplete LASER Radiation Therapy, being excluded.

N. B. : Complete resolution o f mucosal thickening/opacity (haziness)was not observed in any of the 'maxillary sinusitis-cases '.

A.R. (1983), Mester A.F. and Snow J. B. Jr. (1987) observed analgesic effect of LLT.

Its practical utility in the management of inflammatory disease processes of the maxillofacial region, nasoseptal ulcer, sialoadenitis (Kats A. G. et al. 1985) and diseases of teeth and gum were studied in Noto General Public Hospital, Japan, between 1980 to 1990. In 1993, Okada J. et al. used

the Gallium-Aluminium-Arsenide diode LASER in 'Pain Therapy'. Biomodulation effects were determined as per the energy density (Joule/era 2) achieved at the level of inflammed tissue(s) - considering the "absorption coefficient" of tissue(s). Energy density was calculated depending upon probe-surti~ce- area, expressed in diameter i.e. 4 mm. x exposure time per probe-point application i.e. w/cm2 x secs. i.e. J/cm 2. Pulse-

Indian Journal of Otolaryngology and Head and Neck Surgery Vol. 54 No. 3, July - September 2002

The Role of Laser Radiation Therapy in Maxillary Sinusitis 213

Histogam I[ : Showing the efficacy of "Laser Radiation Therapy' in "Acute' & 'Chronic Maxillary Sinusitis'.

Fig. A~ : Post-LASER Radiation sinus skiagram showing resolution in antra[ radio-opacity.

Histogam III : Showing the symptomatic relief after 'LASER Radiation Therapy'.

Fig. B~ : Pre-LASER Radiation sinus skiagram.

Fig. A, : Pre-LASER Radiation sinus skiagram

width (inversely proportional to 'pulsing-frequency') was

also important.

It has been observed that Incident Energy Density (IED)

beyond an optimal value (4 J/cm0 will not produce a desired

Fig. B, : Post-LASER radiation sinus skiagram showing resolution in antral radio-opacity.

effect. Therefore this IED has been strictly maintained between

660 to 820 nm.wavelengths for a good biomodulation effect

in the management o f 'maxillary sinusitis in the present series o f work.

Indian Journal of Otolaryngology and Head and Neck Surgery Vol. 54 No. 3, July - September 2002

214 The Role o f Laser Radiation Therapy in Maxillary Sinusitis

Fig. C~ : Pre-LASER Radiation sinus skiagram Fig. D~ : Pre-LASER radiation sinus skiagram

Fig. C 2 : Post-LASER Radiation sinus skiagram showing resolution in antral radio-opacity.

'Cluster-Effect ' gave good result not only to reduce

inflammatory oedema but also to kill the bacteria directly or by inhibiting their growth.

In the present work, 6 exposures were given to each patient on alternate days. First by 'Single-Probe' and after that

'Cluster-Probe' was used but only for the last 3/4 exposures. Each Probe-point area was irradiated for 10 secs. with a total time exposure of 3 minutes for single-probe and for 'Cluster-

Probe' 6 minutes time was given. For 'Single-Probe', diseased portion was irradiated with 660 and 820 nm. wavelengths at

pulsing frequency of 73 Hz for first 2/3 applications and then

1 KHz for the last 3/4 applications. In case of'cluster-probe-

application' again, the several wavelengths from 660 to 950

nm were used simultaneously with a power density of 0.055 W/cm 2 to 0.075 W/cm 2. Though wattage in 'Cluster-Probe' is

less than in 'Single-Probe', but it produces more effect because of larger area/large volume of tissue and greater varieties of cell-types being stimulated, simultaneously. To know the exact separate/individual efficacy of 'Single-Probe' and 'Cluster- Probe' in 'maxillary sinusitis', it needs a comparative study

with individual probes.

Fig. D 2 : Post-LASER Radiation sinus skiagram showing resolution in antral radio-opacity.

In this present series, in which 200 known cases or 'maxillary sinusitis' have been treated by different regimes of treatment, the results of management of 175 cases by conventional methods is shown in Table no. I.

The 25 cases, out of which 10 were directly treated by LLT after failure of conventional treatment, are shown in Table no. I and II. Out of 25 cases, 5 were of acute and 20 of chronic

maxillary sinusitis.

The effect of LLT in the management of 'maxillary sinusitis'

was observed in terms of relief in patients' symptom(s) and

sign(s) which was latter confirmed by sinus-skiagrams.

As shown in Table No. III 'A' that in 22 cases whose primary complaint was 'headache', total relief of'headache' occurred in 18 cases (81.8%) and partially in 4 cases. Out of 15 cases of nasal blockage, 14 reported total clearance (93.3%), only one reported partial, complaints of sneezing in 5 cases, rhinorrhoea in 3 cases, epistaxis in 2 cases got totally relieved.

In the present study, 'good response' was observed in 7 cases (3 acute and 4 chronic ) and 'satisfactory response' in 3 casess

Indian Journal of Otolaryngology and Head and Neck Surgery Vol. 54 No. 3, July - September 2002

of 'maxil lary sinusitis ' out o f those l0 cases, who were subjected only to LLT without any other treatment.

12 cases (2 acute and 10 chronic) failed to respond to medical therapy and 3 cases did not yield good response in terms of symptoms after medical-and-APW-treatment-regime. All these 15 cases were then subjected to LLT + medical therapy. After full course o f treatment with LLT + medical therapy,

it yielded good symptomatic relief.

In this series o f LLT management, 7 cases were o f age-group of 0 to 20 years, where 4 showed onset of symptomatic relief after 2 radiations and the rest 3 after 4 radiations. In the age group of 21 to 25 years, out o f 5 cases, one case showed improvement after 2nd dose, 2 after 4 doses and one after total 6 doses.

In the age-groups of 26 years-and-above, maximum relief of symptoms occurred after completion of 6 doses. In the present series, minimum age was observed 3 years, having bilateral maxillary sinusitis with epistaxis, responding very well by only LLT. It was also proved by pre-and post-LASER sinus skiagrams (Fig.A~ and A2). The maximum age subjected for LLT was 70 years, which responded only satisfactorily after full course o f treatment. This observation reveals that LLT is most effective in case o f maxillary sinusitis in younger age-group particularly of acute nature.

In the 25 cases o f present series, subjected to LLT, one dropped out midway. It has been also observed in our present series that maxillary simtsitis treated by APW and Caldwell- Luc operation had complained of pain, headache etc. during and even after the treatment for a long period and for this, they were in need of analgesics and antibiotics and NSAIDs for a long time. But not a single patient out o f the rest 24, treated by LLT complained any worsening of sympto(ns after completion o f LLT. Though, 3 cases above the age o f 25 years reported some increase in pain after the first 2 doses, it subsided after the 4th dose without any additional need of analgesics.

Post LLT sinus skiagrams (as shown in Table No. III B) demonstrated that nearly total resolution took place in 1 case, 50% resolution in antral opacity took place in 7 cases out o f 24 and in 16 cases, where antral opacities along with marked mucosal thickening were present showed partial resolution in antral haziness but slight to no change in antral mucosal thickening. This clearly indicates that the effect o f LLT on antral mucosal thickening in its resolution is not effective with this dose of therapy, which had been used in the present work. It needs further observations with an increased dose and increased number of days with pre- and post-therapeutic histopathological examination of the antral mucosa to evaluate the effect o f LASER on mucosal thickening, which was not done in the present study.

The Role of Laser Radiation Therapy in Maxilla O' Sinusitis 215

The effectiveness o f LLT in 'maxil lary sinusitis' may be explained on the basis o f its multi-point action on antral mucosa, ostiomeatal complex and bactericidal effect with reduction o f oedema and inflammation. Because this mode of treatment simultaneously acts on infective and allergic factors, it has been observed in this comparative study on management o f 'maxillary sinusitis' that LLT is an excellent efficient, non-invasive mode of treatment for uncomplicated cases o f "maxillary sinusitis' with good prognosis particularly in acute ones in children and young adults and also yields good result in younger and older age-groups, having 'maxillary sinusitis', in comparison to other invasive and radical modes o f treatment.

A C K N O W L E D G E M E N T

The authors are indebted & thankful to the superintendent, PMCH, Patna, Bihar, India for kindly allowing the use o f official records and also to Dr. S. S. Jha ( Consultant Orthopaedic Surgeon o f Patna, Bihar, India) for providing the L A S E R Equipment and guiding them in its proper utilisation in the present study.

R E F E R E N C E S

1. Cseh G. et al (1978) : "Changes in prostaglandin content in wounds and after laser treatment". Kiserl. Orvostud. 30 : 37-41.

2. Kats A. G. et al (1985) : "Remote results of the complex treatment of chronic sialoadenitis with the use of lasers". Vestn. Khir. 135 ; PP. 39-42.

3. Kovacs L. (1981) : "'Lasers in Surgery and Medicines". 1 : 241 - 252.

4. Mester E. & Mester G. (1967-73) : "Effect of laser on bacteria phagocytosis of the leukocytes". Orv. Hetil. 108 : 1546-1550; and "'Lasers in clinical practice". Acta. Chir. Acad. Hung. 9(3) : 349- 357 and "Effect of laser radiation on wound healing & collagen- synthesis" Studia Biophysica. 35 (3) : 227-230.

5. Noto General Public Hospital, Japan - Stomatology Research Group - Deptt. of Dental Surgery (1980-90) : " Low output laser beam treatment of the inflammatory diseases of the maxillofacial region". Hospital Bulletin, East Japan Research Group.

6. Okada J. et al (1993) : "The Gallium-Aluminium-Arsenide diode LASER in Pain Therapy". Masui. 32 : 246-252.

7. Rachischew A. R. et al (1983) : " Biological action of the Laser- beam". Cahiers de Biotherapie - No. 77 (bis - April, 1983).

8. Snow J. B. Jr. et al (1987) :"'Basic research in biostimulation'. Proc. Conf. on Laser Research in Med. ICALEO' 87, Laser Institute of America. L. I. A. 60 : 32-38.

9. Yew D. T. et al (1982) : "Stimulating effect of low-dose laser. A new hypothesis". Acta. Anat. 112 : 131-36.

Address for Correspondence :

Dr. D. K. Isser

M. O. Flat No. 1, PMCH Campus,

Patna - 800 004, Bihar, India.

Indian Journal of Otolaryngology and Head and Neck Surgeo' Vol. 54 No. 3, July - September 2002