RU2379073C2 - Method of laser treatment of chronic tonsillitis with using photosensitiser - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention concerns medicine, otorhinolaryngology, and can be used for laser treatment of chronic tonsillitis with using a photosensitiser. That is ensured by irrigation of tonsil lacunas with isotonic solution of sodium chloride with using a Hartmann cannula. A mixed photosensitiser solution and a pharmaceutically acceptable gel are prepared ex tempore. Herewith as a photosensitiser, water-soluble porphyrin of chlorine series is used. The prepared gel is introduced into tonsil lacunas. And amount thereof is 0.7 to 2 g for both tonsils and depends on size thereof, number and depths of lacunas. The gel is left in tonsils for 5-40 minutes. Tonsils are irrigated by lavage or above-stated technique with isotonic solution of sodium chloride to complete removal of residual photosensitiser. Then the tonsil surface is irradiated distantly at the end face of a light guide spaced 0.1-1.5 cm from tonsil surface. The irradiation is characterised with power density 80-400 J/cm², radiation power 0.35-1.5 Wt and exposure 4-20 min for each tonsil.

EFFECT: method allows improving clinical effectiveness, reducing its cost and number and frequency of procedures, lowering collateral actions and treatment complications.

4 cl, 1 tbl, 3 ex

Description

The invention relates to medicine, namely to photodynamic therapy (PDT), and can be used in otorhinolaryngology.

A widely known method of treating chronic tonsillitis with antibiotics. However, due to the development of the inevitable resistance of pathogenic microbes to antibiotics, various complications often arise: allergic reactions, ototoxicity, hepato-, nephro-, cardiotoxicity, and others. Currently, due to the registration of a large number of side effects from the use of antibiotics in therapy and the low sensitivity of microbes to them, in vitro experiments have begun to investigate photochemotherapy methods, where blue toluidine, protoporphyrin-IX, hematoporphyrin, aluminum phthalocyanine are used as an antibiotic which are activated by radiation of a gas-discharge helium-neon and semiconductor InGaAl lasers (De Simone NA, Christiansen C., Dore D. Bactericidal effect of 0.95-mW helium - neon and 5-mW indium-gallium-aluminum-phosphate laser irradiation at exposure times of 30, 60, and 120 seconds on photosensitized Staphylococcus aureus and Pseudomonas aeruginosa in vitro. Phys. Ther. 1999. Vol.79 (9). P.839-846), or physical suppression of microflora (Wilson M., Yianni C. Killing of methycillin - resistant Staphylococcus aureus by low-power laser light. J. Med. Microbiol. 1995. Vol. 42 (1). P. 62-66).

In clinical practice, otolaryngologists know a method for the treatment of chronic tonsillitis, including surgical intervention (lacunotomy) to normalize the evacuation of the contents of the lacunae of the tonsils (RF patent No. 2136229, priority from 02/11/1997), characterized in that the anterior palatine arches and soft palate are excised, exposing the upper pole and pharyngeal surface of the tonsils and act on the tonsils by known methods. The disadvantage of this method is its invasiveness.

There is also a method of treating chronic tonsillitis with laser destruction (RF patent No. 2056874, priority 10.06.1993), characterized in that laser destruction is carried out by a laser at three points - in the upper, middle and lower tonsils to a depth of half the thickness of the section, in pulse -periodic mode, wavelength 1.06; 1.32 μm, with a power of 10-40 W at the time of administration, for 3-4 s at each point of the parenchyma. Laser destruction was carried out by a NIAH laser (AIG-Nd ⁺³ ). The disadvantage of this method is invasiveness (the fiber is immersed in the tonsil, a necrotic cavity is formed in it, the tonsils are reduced by 2 times already at the time of surgery) and a sore throat for several days after the procedure.

There is a method of treating chronic tonsillitis (USSR AS No. 1469626 of 02/19/1986), which consists in contacting the irradiation of each tonsil lacunae daily with helium-neon laser radiation, as stated, at a power density of 600-700 mW / cm ² lasting 5-20 s within 4-6 days. The disadvantage of this method is the low effectiveness of treatment due to the lack of antibacterial effect, as well as the duration (4-6 days).

A known method of treating chronic tonsillitis [Cherednichenko Yu.I., Azbel D.I., Deribas A.A. A practical guide to laser therapy in clinical practice (guidelines). Novosibirsk: Institute of General Pathology and Human Ecology SB RAMS, 1994, p. 54], including tongue pressing with a spatula and subsequent diffuse irradiation of the tonsils and posterior pharyngeal wall with laser radiation at a power density of 10-15 mW / cm ² with an exposure of 3 min each side for 5-7 sessions. The disadvantages of this method are the small effectiveness of the treatment due to the lack of an antibacterial effect, the high cost of the equipment used in the treatment, and the duration (5-7 procedures).

A known method of treating chronic tonsillitis in children [Cherednichenko Yu.N., Azbel D.I., Deribas A.A. A practical guide to laser therapy in clinical practice (guidelines). Novosibirsk: Institute of General Pathology and Human Ecology SB RAMS, 1994, p.39], including squeezing the tongue with a metal spatula, subsequent exposure to the tonsils and posterior pharyngeal wall with scattered IR laser radiation with a light spot diameter of 30-50 mm at an average power density 1-2 mW / cm ² with an exposure of 10 min. Treatment is recommended for 10-15 days. The disadvantage of this method is the lack of an antibacterial effect that reduces the effectiveness of treatment. In addition, the method is applied for too long (2 weeks), which is inconvenient.

A known method of treating chronic tonsillitis (RF patent No. 2152773, priority from 02/18/1999), similar to the proposed method, by sanitizing palatine tonsils by exposure to them with a physical factor and therapeutic agents, characterized in that the drug Malavit is used as a therapeutic agent, and the treatment is carried out in three stages, first, ultrasound debridement of the tonsils is carried out for 3-10 minutes using an aqueous solution of Malavit in a dilution of 1: 5, then low-frequency phonophoresis for 5-15 minutes with a dilution of 1: 2, p What follows is carried patients oral rinse solution The Family at a dilution 1:20. The course of treatment is carried out for 10-15 days. The disadvantage of this method is its complexity (three stages) and duration (10-15 days).

Another method is also known (RF patent No. 2110301, priority from 01/30/1997), similar to the proposed one — a method of treating tonsillitis in children, mainly with strangulated tonsils, by means of laser and irrigation therapy, characterized in that 125 additional zinnat is administered to the patient -250 mg per dose 2 times a day for 5-7 days orally against a background of laser and irrigation therapy, moreover, for irrigation therapy, a 2% ascorbic acid solution is used, after which irrigation is carried out by laser therapy: 20 seconds tonsils and additionally for 5 min - to the submandibular region. The disadvantage of this method is multi-course (5-7 days) and the use of an antibiotic of systemic action - zinnata (cefuroxime).

A closer analogue of the claimed invention is a method for treating chronic tonsillitis with the PDT method (RF patent No. 2235568, priority 01/20/2003), which uses irradiation of the tonsils with an LED matrix device after washing the tonsils lacunae with methylene blue and chlorophyllipt solutions. It includes squeezing the tongue with a spatula and subsequent exposure to scattered tonsils on the palatine tonsils daily for 10-15 days, characterized in that they carry out sensitization by washing the gaps of the palatine tonsils with a syringe equipped with a Hartmann cannula until the photosensitizer (FS) is clean (0.01) -0.1% aqueous solution of methylene blue, absorbing from 625 to 940 nm, or chlorophyllipt, absorbing radiation with a wavelength of 640 to 660 nm), rinsing the throat with 100 ml of 0.9% saline, then alternating irradiation of each palatine tonsil at a distance of 0.5-1 cm from the surface by optical radiation of an LED matrix phototherapy apparatus that emits in the spectral range from 625 to 700 nm and from 840 to 1270 nm, with an exposure of 2-3 minutes. The disadvantage of this analogue is the duration of treatment (10 days) and the use of incoherent radiation, the depth of penetration of the visible part (625-700 nm) of which is small and amounts to 2-3 mm.

The closest analogue (prototype) of the claimed invention is a method for the treatment of chronic tonsillitis using the PDT method (RF patent No. 2234959, priority 11/11/2002), comprising 5-7 sessions of exposure to tonsils, characterized in that each lacunae is pre-treated with a 1% solution methylene blue in glycerol for 10 min and perform intralacunar exposure to a helium-neon laser with a wavelength of 0.63 μm and an exposure of 5 min for one amygdala with a power output of 15-20 mW from the fiber. This method is close to that proposed both in the use of FS and in the use of a laser. The disadvantage of this method is its multi-course and insufficiently deep (with inflamed tonsils) penetration of laser radiation with a wavelength of 631 nm into the tissue (2-3 mm).

The objective of the present invention is to increase the effectiveness of the treatment of chronic tonsillitis, reduce its cost, reduce the number of procedures and the interval between procedures and reduce side effects.

The problem is solved by using a semiconductor laser with a wavelength taken from a range of 654-670 nm, together with a water-soluble FS of the chlorine series.

A semiconductor laser with a wavelength of 654-670 nm, in particular 657 ± 3 or 662 ± 3 nm, has an effective penetration depth of up to 5 mm in tissue, unlike the helium-neon laser of the prototype method, which uses radiation with a wavelength of 630 nm and effective penetration into the fabric to a depth of 3 mm. It is also deeper than the radiation of the LED matrix apparatus for phototherapy used in the analogue method. In addition, in contrast to the analogue and prototype, where phenazathionium derivatives (methylene blue) or a mixture of chlorophylls a and b (which is part of the well-known Chlorophyllipt preparation) are used as PS, the proposed method uses new water-soluble chlorine-type porphyrins as PS , in particular the FS "Photochlorin II" or "Radachlorin".

The proposed method does not cause the development of complications inherent in other known methods of treating tonsillitis. The proposed method is effective, safe, simple and fast in practical implementation. In addition, it has a low cost, since it does not require the use of expensive equipment. Its cost compared to other methods of treating chronic tonsillitis using a laser, depending on the type of laser, is 4-10 times lower.

This method is successfully used for the treatment of acute and chronic purulent sinusitis (RF Patent No. 2228775), however, at the moment, the effective use of the PDT method using semiconductor lasers of the range 654-670 nm together with water-soluble chlorine-type porphyrins as an FS for the treatment of chronic tonsillitis is not known .

Under the influence of light radiation on the FS, a photochemical reaction is triggered, resulting in a local antibacterial, antiviral, antiparasitic and antifungicidal effect, while there is no systemic effect of FS on the body, the patient’s treatment time is shortened (1-3 procedures), there is an opportunity for outpatient treatment and cost of treatment.

The lasers used in the present invention have a radiation wavelength in the range of 654-670 nm (in each case, coinciding with the maximum absorption of the drug ± 3 nm, which is important for the efficient generation of active particles), are characterized by the presence of semiconductor components for radiation generation (increased reliability and length stability radiation waves, low cost), low weight and overall dimensions (ease of use).

In specific embodiments of the method, “Photochlorin II” or “Radachlorin” (Reg. No. LS-001868 of 08.08.2006) can be used as a PS, the exposure time of PS on the mucosa can be from 5 to 40 minutes. Unlike prototypes, the drug is introduced into the gaps of the tonsils, in the present invention is used in the form of a gel. This makes it possible to hold the drug longer in the gaps of the tonsils, preventing it from leaking out, and, unlike analogues, it allows you to distribute the drug deeper and more evenly in the crypts, since when lubricating the drug is injected only to the depth of the probe (and in this case it comes under a small pressure, penetrating even into the branches of the gaps).

As the activating laser radiation can be used for "Photochlorin II" and "Radachlorin" radiation with a wavelength of 657 ± 3 and 662 ± 3 nm, respectively, with a power of 0.35-1.50 W for 4-20 min 1-3 times with an interval in 3-5 days.

To correctly determine the dose of light, literature data are used on the sensitivity of certain microorganisms to PDT with FS of the chlorin series, and in the absence of data, by direct experiment, based on data from a microbiological examination (smear) from gaps of palatine tonsils. The size and shape of the light spot (field) is determined by the size of the tonsils. Depending on the area of the tonsil, it is irradiated with 2 or 3 light fields. For example, PDT using a chlorine-type PS gel with a known PS substance content (from 8 μg / ml to 1.75 mg / ml), eliminates the inflammatory processes caused by antibiotic-resistant strains of PDT resistant Bacterioides fragilis, while decreasing the CFU titer in vitro up to 10 ⁵ , with a light dose of 400 J / cm ² .

FS "Radachlorin" is characterized in that it includes an alkaline salt of 13-carboxy-17- [2-carboxyethyl] -15-carboxymethyl-17,18-trans-dihydro-3-vinyl-8-ethyl-2,7,12, 18-tetramethylporphyrin (chlorin e ₆ ) formula

in the amount of 70-90%; alkaline salt of 13-carboxy-17- [2-carboxyethyl] -15-formyl-17,18-trans-dihydro-3-vinyl-8-ethyl-2,7,12,18-tetramethylporphyrin (purpurine 5) of the formula

in the amount of 1-15%; as well as the alkaline salt of 13-carboxy-17- [2-carboxyethyl] -15-carboxy-17,18-trans-dihydro-3-vinyl-8-ethyl-2,7,12,18-tetramethylporphyrin (chlorin p ₆ ) formulas

in quantity - the rest.

FS "Photochlorin II" is characterized in that it includes an alkaline salt of 13-carboxy-17- [2-carboxyethyl] -15-carboxymethyl-17,18-trans-dihydro-3- [1-ethoxyethyl] -8-ethyl-2 , 7,12,18-tetramethylporphyrin (2-desvinyl-2- [1-ethoxyethyl] chlorin e ₆ ) of the formula

Sodium or potassium can be used as an alkali metal in PS.

From the point of view of physical chemistry, the Radachlorin and Photochlorin II FSs have the ability to absorb light in the visible region, resulting in their photoactivation and subsequent relaxation of the excited state with energy transfer to molecular oxygen and organic substrates dissolved in the tissues. The latter leads to oxidative and free-radical processes in biological tissues, contributing to their release from pathogenic microorganisms. The most preferred excitation band is the long wavelength band, because with increasing wavelength, the penetration of light into biological tissues increases.

Thus, the FS “Radachlorin” and “Photochlorin II” are able to destroy microorganisms and aseptically act on the tissues of the pharynx after excitation with light with a wavelength of 654-670 nm to a depth of 7 mm.

The amount of energy supplied in the method varies from 80 to 400 J / cm ² (power 0.35-1.5 W for 4-20 minutes). With a laser radiation power of less than 0.35 W, the PDT procedure becomes excessively long, with a power of more than 1.5 W and a time longer than 20 minutes, significant damage to the normal mucosa is observed, leading to an increase in its regeneration period, and less than 4 minutes, the efficiency decreases. Light doses of less than 80 J / cm ^{2 are} not sufficient for an antibacterial effect, while more than 400 J / cm ² are excessive and can lead to damage to healthy tissues of the pharynx.

The proposed method of treatment is as follows. Tonsil lacunae are washed with an isotonic sodium chloride solution using a Hartmann cannula (pathological contents are mechanically removed from the gaps), a mixture of a solution of water-soluble chlorine-type PS with any pharmaceutically acceptable gel in a 1: 1 ratio is prepared. The FS gel obtained ex tempore is introduced into the gaps of the tonsils (the amount of gel depends on the size of the tonsils, the number and depth of the gaps and ranges from 0.7 to 2 g for both tonsils). The exposure time of the gel is from 5 to 40 minutes. The tonsils are washed with irrigation method or the isotonic sodium chloride solution specified in point 1 above (the photosensitizer residues are thoroughly removed, since they can shield the laser radiation). The choice of method depends on the size of the tonsils, their “immersion” beyond the anterior palatine arch, the width of the crypts, the remainder of the PS on the surface and in the gaps. Irradiate the surface of the tonsils using a semiconductor laser apparatus with a radiation wavelength of any in the range of 654-670 nm remotely - the distance from the end of the diffuser to the surface of the tonsil from 0.1 to 1.5 cm with an energy density of 80 to 400 J / cm ² , power radiation from 0.35 W to 1.5 W, exposure time from 4 to 20 minutes per each amygdala. The exposure time is calculated based on the data of microbiological studies of the smear and the surface area of the tonsils, using the literature (or in vitro experiments) and table 1. To get the exposure time (in seconds), the recommended light dose (in J) must be divided into table data ( in W / cm ² ), taken at the used distance from the fiber to the amygdala (in cm).

Table 1. DENSITY OF POWER DEPENDING ON THE DIMENSIONS OF LIGHT SPOT Power of laser radiation at the exit from the fiber (SMA-906, diameter 600 μm, flat end), W Power density with a light spot area of 0.18 cm ² (light spot diameter 0.5 cm) W / cm ² Power density with a light spot area of 0.37 cm ² (light spot diameter 0.7 cm) W / cm ² Power density with a light spot area of 0.78 cm ² (diameter of the light spot 1.0 cm) W / cm ² Power density with a light spot area of 1.76 cm ² (diameter of the light spot 2.0 cm) W / cm ² The distance from the surface of the tonsil to the fiber, cm 0.5 1,0 1,5 0.35 1.94 0.94 0.44 0.19 0.5 2.77 1.35 0.64 0.28 0.75 4.16 2.02 0.96 0.42 1,0 5.55 2.70 1.28 0.56 1,5 8.3 4.0 1.92 0.85

The procedure is anesthetized with a solution of lidocaine 10% spray on the tonsils and on the back of the throat. If lidocaine is part of the gel, then the use of a spray is not necessary. The course of treatment is from 1 to 3 procedures, depending on the results of the first session (sterilization of gaps), the form of tonsillitis, microbiological, immunological or clinical examination data. The first result of a photochemical reaction is sometimes a slight local inflammation. After subsiding of the inflammatory phenomena (phases of the inflammatory process), but not earlier than 72 hours later, if necessary, repeat the session. The interval between procedures is 3-5 days.

Under the influence of radiation, PS produces active (singlet oxygen) forms of oxygen. As a result of the action of singlet oxygen and the products formed with its participation (hydroxyl radicals and peroxides), microorganisms die and damage (photochemomodification).

Water-soluble porphyrins of the chlorin series used as PS in the proposed method have a significant photodynamic effect on pathologically altered tissues compared to healthy tissues. When exposed to such PS by radiation with a specific, specially selected wavelength, a photochemical reaction occurs, which leads to the death of pathogenic microorganisms. Radiation exposure to adjacent normal tissues that were not affected by the sensitizer does not lead to any negative consequences for the tissue.

Most bactericidal factors and mechanisms of the immune system are capable of significant activation by the proposed method, since the result of its implementation can be not only the complete destruction of microorganisms, but also their damage. A suppressed microbe-inducer can provoke the development of an inflammatory reaction and promote immunization with the formation of an extended type of immune response. In addition, the development of an immunoactivation reaction of an immediate type is possible. In particular, during the photodynamic inactivation of S. aureus, E. coli, and Candida albicans, the results of the PDT effect study were compared only in a bacterial culture and in a bacterial culture in the presence of blood cells using thermo-optical microscopy. This study allowed us to obtain experimental evidence on the essential role of the immune system in enhancing the bactericidal action of blood cells on microorganisms on the one hand, and the much greater survival of healthy cells compared to microorganisms in the presence of FS, on the other hand.

EXAMPLES

(Permission for clinical trials of the Ministry of Health and Social Development of the Russian Federation No. 29 dated 01/23/07 according to protocol PX1-7 / 02-1 of 05/19/05.)

Example 1. Patient P, was admitted to the ENT clinic MONICA with complaints of purulent plugs in the tonsils, bad breath, sore throat. Periodically sick with tonsillitis (1-2 times a year).

From the anamnesis: sick for 6 years. He was treated at the place of residence with antibacterial drugs, and repeatedly underwent physiotherapy courses. Over the past 6 months, sore throats have been constantly disturbing.

At admission: the general condition is satisfactory, according to internal organs without visible pathological changes. Status localis: submandibular lymph nodes are not enlarged. The mucous membrane of the oropharynx is pink, moist, the anterior palatine arches are hyperemic, the edges of the anterior palatine arches are swollen. Palatine tonsils friable, hypertrophy of the I degree. When pressed with a spatula, the tonsils are mobile, caseous contents are released from the gaps. General clinical blood and urine tests are within normal limits. Microbiological examination of the contents of palatine tonsil lacunae revealed microbial associations with a predominance of gram-positive flora (Streptococcus, group D 5 × 10 ⁶ , Enterococcus faecalis 4 × 10 ⁶ ; Staphilococcus aureus 6 × 10 ⁴ ; fungi of the genus Candida 1.2 × 10 ⁴ CFU) . When immunological examination indicators within the lower limit of normal. Rheumatoid factor and dermatol test are negative. Indicators of antistreptolysin “O” (ASL-O) 200 AE, streptococcal antigialuronidase (CA-G) 200 AE HVS. A cytological study of the contents of palatine tonsil lacunae revealed dystrophically altered lymphoid elements, a moderate amount of mixed bacterial flora.

Given the minimal effect of previously performed conservative therapy, the patient is offered treatment with photodynamic therapy (PDT). After washing the tonsil lacunae with sterile physiological saline using a Hartmann cannula, 0.7 ml of gel was introduced into the lacunae of both palatine tonsils, prepared ex tempore from 0.35 ml of Photochlorin-II FS solution, intravenous solution, 0.5%, 10 ml ”and 0.35 ml of a 2% lidocaine gel. Within 5 minutes, “staining” of the gaps was made, after which the remaining gel was removed by rinsing. Then, at a power of 0.35 W, a LACHTA-MILON semiconductor laser with a wavelength of 657 produced an irradiation of the surface of the tonsils with a fiber-optic cone-shaped indicatrix of radiation, which was carried out by contactless scanning at a distance of 1.5 cm from their surface. Due to the small size of the tonsils, their surface was irradiated with 2 fields. According to Table 1, for a distance of 1.5 cm, a light dose of 80 J / cm ² and a laser power of 0.35 W, the time allowed to achieve the start of the photochemical reaction, which was 182 seconds (3 minutes 2 seconds) (6 minutes each tonsil, respectively 12 minutes on both tonsils).

During the session, the patient did not complain, but noted moderate “tingling” in the area of the impact of laser irradiation on the tonsil. 3 hours after the PDT session, there was a slight swelling of the tonsils and moderate soreness in the throat. 1 day after the PDT session with pharyngoscopy, a decrease in tonsils was noted in size, their mucosa is pink, lacunae are free. Within 3 days after the treatment, the patient was recommended oral care (rinsing the oropharynx with infusions of herbs - sage, chamomile, St. John's wort). On the 3rd and 6th day, PDT sessions were again conducted with the same parameters. On the 7th day after the PDT session, a repeated microbiological, cytological examination of the contents of the tonsil lacunae was performed, as well as a clinical and immunological examination of the patient. In the general blood test, no changes were recorded. Cytological examination of the contents of tonsil lacunae revealed hyperplasia of lymphoid tissue elements, accumulation of squamous cells. Microbiological examination revealed a lack of microflora growth. In immunological indicators, no changes were detected.

At subsequent examinations after 3, 6 and 12 months after the treatment, the patient did not complain. With mesopharyngoscopy, the oral mucosa is pink, tonsils behind the arches, lacunae are wide, free.

Example 2. Patient M., was admitted to the ENT clinic MONICA with complaints of discomfort in the throat, purulent plugs in the tonsils, bad breath. Periodically sick with tonsillitis (1-2 times a year).

From the anamnesis: sick for 11 years. She was treated independently with antibacterial drugs, herbs, and repeatedly underwent physiotherapy courses. The patient did not satisfy the effect of the treatment (from 1 to 3 months), after which the above complaints reappeared.

At admission: the general condition is satisfactory, according to internal organs without visible pathological changes. Status localis: submandibular lymph nodes are not enlarged. The mucous membrane of the oropharynx is pink, moist, the anterior palatine arches are hyperemic, the edges of the anterior palatine arches are swollen. The palatine tonsils are friable, hypertrophy on the right I degree, left II degree. When pressed with a spatula, the tonsils are moderately mobile, caseous contents stand out from the gaps. General clinical blood and urine tests are within normal limits. Microbiological examination of the contents of palatine tonsil lacunae revealed microbial associations with a predominance of gram-positive flora (St.spp. 2 × 10 ⁴ CFU, Streptococcus, viridans 2 × 10 ³ KOE, Enterococcus faecalis 1.4 × 10 ² KOE). When immunological examination indicators within the lower limit of normal. Rheumatoid factor and dermatol test are negative. Indicators of antistreptolysin “O” (ASL-O) 400 AE, streptococcal antigialuronidase (SAG) 200 AE HVS. A cytological study of the contents of palatine tonsil lacunae revealed an abundant amount of mixed bacterial flora, a picture of moderate inflammation, lymphoid elements of various degrees of activity.

Given the minimal effect of previously performed conservative therapy, the patient was offered treatment with photodynamic therapy (PDT). After washing the tonsil lacunae with sterile saline using a Hartmann cannula, 1.5 ml of gel prepared ex tempore from 0.75 ml of Radachlorin, solution for intravenous administration, 0.35%, 10 ml was introduced into the lacunae of both palatine tonsils and 0.75 ml of a 2% lidocaine gel. Within 20 minutes, “staining” of the gaps was carried out, after which the remaining gel was removed by rinsing. Then, at a power of 0.75 W, a LACHTA-MILON semiconductor laser with a wavelength of 662 nm was used to irradiate the surface of the tonsils with a cone-shaped indicatrix of luminescence, which was carried out by contactless scanning at a distance of 1.5 cm from their surface. Due to the varying degree of tonsil hypertrophy, their surface was irradiated on the right with 2 fields, on the left with 3 fields. According to Table 1, for a distance of 1.5 cm, a light dose of 200 J / cm ² and a laser power of 0.75 W, the irradiation time for one field was 208 seconds (3 min 28 sec), respectively, the irradiation time was 7 minutes on the right palatine tonsil , on the left palatine tonsil 11 minutes 30 seconds), which totaled 18.5 minutes on both tonsils. Given the duration of exposure, the procedure was carried out lying down; Tonsils were irradiated by alternating sides.

During the session, the patient complained of moderate "tingling" in the area of impact on the tonsil. 3 hours after the PDT session, there was a slight swelling of the tonsils and moderate soreness in the throat. 1 day after the PDT session with pharyngoscopy, a decrease in tonsils was noted in size, their mucosa is pink, lacunae are free. Within 3 days after the treatment, the patient was recommended oral care (rinsing the oropharynx with infusions of herbs - sage, chamomile, St. John's wort). On the 4th day, a similar PDT session was performed. After 7 days, a repeated microbiological, cytological examination of the contents of the tonsil lacunae was made, a clinical and immunological examination of the patient. In the general blood test, no changes were recorded. Cytological examination of the contents of tonsil lacunae revealed hyperplasia of lymphoid tissue elements, minimal signs of inflammation, and the presence of squamous cells. Microbiological examination revealed a lack of microflora growth. In immunological parameters, a decrease in ASL-O titer to 200 ME, SAG 200 ME was detected, which confirms the elimination of the causative agent of chronic tonsillitis - group A β-hemolytic streptococcus and allows treating the treatment as etiopathogenetic.

At subsequent examinations after 3, 6 and 12 months after the treatment, the patient did not complain. With mesopharyngoscopy, the oral mucosa is pink, tonsils behind the arches, lacunae are wide, free.

Example 3. Patient K was admitted to the ENT clinic MONICA with complaints of bad breath, sore throat, purulent plugs in the tonsils, frequent SARS. Angina is sick 1 time per year - in 2 years.

From the anamnesis: sick for 9 years. He was treated at the place of residence with antibacterial drugs, and repeatedly underwent physiotherapy courses. Due to the lack of effect of conservative treatment, he turned to the ENT department of MONICA.

At admission: the general condition is satisfactory, according to internal organs without visible pathological changes. Status localis: submandibular lymph nodes are palpable, painless. The mucous membrane of the oropharynx is pink, moist, the anterior palatine arches are hyperemic, the edges of the anterior palatine arches are swollen. The palatine tonsils are loose, hypertrophy of the II degree, when pressed with a spatula, the tonsils are mobile, caseous contents are released from the gaps. Curved right septum of the nose. General clinical blood and urine tests are within normal limits. Microbiological examination of the contents of palatine tonsil lacunae revealed microbial associations: Streptococcus, gr. D 3 × 10 ⁴ , Enterococcus faecalis 2 × 10 ³ ; Streptococcus, viridans 4 × 10 ³ Nesseria flava 1.5 × 10 ³ CFU). When immunological examination indicators within the lower limit of normal. Rheumatoid factor and dermatol test are negative. Indicators of antistreptolysin “O” (ASL-O) 200 AE, streptococcal antigialuronidase (CA-G) 200 AE HVS. Indicators of cellular and humoral defense factors are reduced (the phagocytic activity of neutrophils is reduced, the lack of completeness of phagocytosis) A cytological study of the contents of palatine tonsil lacunae revealed an abundant amount of mixed bacterial flora, a moderate amount of neutrophils.

The patient is offered treatment with photodynamic therapy (PDT). After washing the tonsil lacunae with sterile physiological saline using a Hartmann cannula, 2 ml of gel prepared ex tempore from 1 ml of Radachlorin, solution for intravenous administration, 0.35%, 10 ml and 1 ml 2 was introduced into the lacunae of both palatine tonsils % gel lidocaine. For 40 minutes, “staining” of the gaps was carried out, after which the remaining gel was removed by rinsing. Then, the FS was activated by a LAHTA-MILON semiconductor laser with a wavelength of 662 nm and a power of 1.5 W by non-contact scanning at a distance of 1.0 cm from the surface. The surface of the tonsils was irradiated with 3 fields each.

According to Table 1, for a distance of 1.0 cm, a light dose of 400 J / cm ² and a laser power of 1.5 W, the time was obtained allowing the photochemical reaction to start, which was 100 seconds (1 min 40 sec) (5 minutes each tonsil, respectively, 10 minutes on both tonsils).

During the session, the patient did not complain, noted moderate "tingling" and a sensation of warmth in the area of laser irradiation on the tonsil. 3 hours after the PDT session, there was a slight swelling of the tonsils and moderate soreness in the throat. 1 day after the PDT session with pharyngoscopy, a decrease in tonsils was noted in size, their mucosa is pink, lacunae are free. Within 3 days after the treatment, the patient was recommended oral care (rinsing the oropharynx with infusions of herbs - sage, chamomile, St. John's wort). On the 3rd and 6th day, PDT sessions were again conducted with the same parameters. On the 7th day after the PDT session, a repeated microbiological, cytological examination of the contents of the tonsil lacunae was performed, as well as a clinical and immunological examination of the patient. In the general blood test, no changes were recorded. Cytological examination of the contents of tonsil lacunae revealed elements of lymphoid tissue of various degrees of activity, the absence of neutrophils, squamous cells. Microbiological examination revealed a lack of microflora growth. In immunological parameters, normalization or improvement of indicators of cellular and general humoral immunity, a significant increase in the decreased concentration of secretory IgA was revealed, which indicates an increase in local protection of the mucous membrane.

At subsequent examinations after 3, 6 and 12 months after the treatment, the patient did not complain. With mesopharyngoscopy, the oral mucosa is pink, tonsils behind the arches, lacunae are wide, free.

Claims (4)

1. A method of laser treatment of chronic tonsillitis, including the introduction of a photosensitizer and exposure to a semiconductor laser with a wavelength selected from the range of 654-670 nm, characterized in that the tonsils are pre-washed with isotonic sodium chloride solution using a Hartmann cannula, an ex tempore mixture of a photosensitizer solution is prepared with a pharmaceutically acceptable gel, while using as a photosensitizer water-soluble porphyrin of the chlorine series, the resulting gel is introduced into the lacunae of the tonsils, the amount of gel depends on the size of the tonsils, the number and depth of the gaps and ranges from 0.7 to 2 g on both tonsils, the gel is kept on the tonsils for 5-40 minutes, the tonsils are washed by irrigation or the above method with isotonic sodium chloride solution until the photosensitizer remains completely , then the surface of the tonsils is irradiated remotely at a distance from the end of the fiber to the surface of the tonsils of 0.1-1.5 cm, irradiation is carried out at an energy density of 80-400 J / cm ² , radiation power of 0.35-1.5 W and exposure time 4 -20 min per car I'm waiting for the tonsil. 2. The method according to claim 1, characterized in that before irradiation, the tonsils and the posterior pharyngeal wall are anesthetized with a solution of lidocaine, 10% spray, except when lidocaine is part of the photosensitizer preparation. 3. The method according to claim 1, characterized in that from 1 to 3 procedures are carried out depending on the microbiological, immunological or clinical results of treatment after the first session and the form of tonsillitis. 4. The method according to claim 1, characterized in that the interval between sessions, if necessary to repeat treatment, is from 3 to 5 days.