11 Electromagnetic Waves for Therapy
We saw, in chapter 9, that Maxwell's equations predict that whenever charges are
accelerated electromagnetic waves are produced. In this chapter we consider the
electromagnetic waves used in therapy: how they are produced and why they are
useful to physiotherapists.
Ultraviolet and infrared
radiation have low
penetration depth but are
useful for therapy in
applications other than
Three main kinds of electromagnetic wave are used in therapy: microwaves, infrared
and ultraviolet radiation. Of these, only microwaves are able to penetrate tissue
significantly and so be classed as diathermic.
The different therapeutic applications of these radiations arise from their differing
effect on tissue. These effects, in turn, are determined by the wavelength (or
frequency) of the waves. Before considering the effect on tissue we examine the way
in which each kind of electromagnetic wave is produced: this gives a first insight into
their physical and physiological effects.
In what follows we consider the way in which infrared and ultraviolet radiation are
produced for therapy. Both kinds of radiation are normally produced by similar
apparatus: more fundamental are the similarities in the molecular processes
Production of Ultraviolet Radiation
When discussing ultraviolet
radiation it is a common
convention to talk in terms of
wavelength rather than
Electromagnetic waves with frequencies from 0.75 x 10
Hz to 3.00 x 10
Hz are
classified as ultraviolet radiation (see figure 9.5). Their frequencies are above those
of visible light and below those of X-rays. Ultraviolet radiation has wavelengths
between 400 nm and 100 nm. The wavelengths used in therapy are restricted to the
high end of this range: 190 nm to 400 nm, as wavelengths less than 190 nm are
strongly absorbed in air.
By international convention the ultraviolet spectrum is divided into three regions.
to table of contents
When deciding whether to
use UV for therapy, the
clinician must, as with all
interventions, weigh the
benefits against the risks.
Indeed, we have evidence for
gaseous conduction at
normal temperature and
pressure with every lightning
flash in a thunderstorm.
These are:
* UV-A: wavelengths between 400 nm and 315 nm
* UV-B: wavelengths between 315 nm and 280 nm
* UV-C: wavelengths between 280 nm and 100 nm.
UV-C radiation is used to sterilize things when you don't want to boil them. This is
because UV-C, at sufficiently high intensities, destroys bacteria. It does this by
damaging the bacterial DNA. UV-C exposure will also damage human cells in the
same way and can produce malignancies (cancer). UV-C and, in fact, UV-B and -A
have an extremely low penetration depth, so most of the absorption of UV is by the
skin. The low penetration depth of UV is the reason that UV exposure (in particular,
exposure to UV-C) is associated with skin cancer.
The usual means of producing ultraviolet light is by the passage of an electric current
through an ionized gas or vapour. Gases at normal temperature and pressure are
very poor conductors. They can, however, be made to conduct at high temperature or
low pressure in the presence of a sufficiently strong electric field.
Ultraviolet radiation for therapeutic application is usually produced by current flow
through mercury vapour. Mercury under reduced pressure is contained in a sealed
envelope of quartz or special glass with an electrode inserted in each end. The device
is similar to the strip-lights (fluorescent lights) commonly found in the
kitchen at home and the office or tutorial room. The difference is that UV
lights operate at lower pressures than household or business lights. This
means that more energy is required to initiate conduction and charges are
accelerated over greater distances so that when they collide, the energy
release is larger and, as a result of the higher energies, UV rather than
visible light is produced. The arrangement used with a mercury vapour
lamp is shown in figure 11.1.
Figure 11.1
Schematic diagram of a mercury vapour lamp.
to table of contents
Ionization occurs continuous-
ly in all materials: it is brought
about by various radiations
always present at low levels;
cosmic rays and natural
radioactivity are examples.
The reduced pressure in the lamp ensures that mercury vapour is present, but in
order for current to flow the vapour must be ionized. This means that electrons must
be separated from the parent atoms. Cosmic rays and gamma-rays are high
frequency and high energy and can 'kick' electrons from their orbitals, so producing
positive ions and free electrons. Under normal circumstances the electron returns to
its parent atom, because of the attraction between positive and negative charges.
However, in a sufficiently strong electric field (as in the lamp) the excited electron can
accelerate and collide with other atoms. If the electric field is strong enough, the
electron can gain enough energy to cause further ionization and produce an
'avalanche' effect: one electron is accelerated and collides, producing more metal
ions and free electrons which in turn accelerate, collide and cause further ionization.
The glow of a mercury-vapour lamp is a consequence of the avalanche of ionization.
After participating briefly in the avalanche, electrons reattach to ions, dropping into a
particular orbital and releasing energy in the form of electromagnetic waves.
It is generally necessary to
help initiate the avalanche, or
discharge, by pulsing the
lamp with a high voltage.
Once the discharge is started
the current must be regulated
to limit and control the output
of light from the lamp.
In the discharge process ions are being continually formed and are continually
recombining with electrons. As ions and electrons recombine energy is released in
the form of electromagnetic radiation which has frequencies characteristic of the
parent atom. The range of frequencies put out by the lamp is modified by the
pressure within the lamp and further modified in passing through the glass envelope
which contains the vapour.
Figure 11.2 compares the range of wavelengths over which various lamps put out
appreciable energy. The spectral range for an ordinary incandescent (tungsten
filament) lamp, a fluorescent tube (strip-light) and for sunlight is also included for
Also indicated in the figure are approximate proportions of ultraviolet, visible and
infrared radiation expressed as a percentage of the total energy output. The
proportions vary with the pressure of mercury vapour in the lamp or tube and with the
thickness and composition of the lamp envelope. Percentages are not shown for
fluorescent tubes ('strip lights') or incandescent lamps (normal globes) as the
to table of contents
proportions vary depending on the construction of the device, the power rating and
whether filters are used to block-out certain wavelengths.
Figure 11.2
Spectral range of various lamps
and sunlight
Mercury vapour lamps operating
at lower pressure put out more
radiation in the high frequency
region of the spectrum (towards
the far ultraviolet region). Even
so, all ultraviolet lamps produce
a considerable amount of energy
in the infrared and visible region.
Both the visible and far ultraviolet
radiation can be removed by the
use of filters. If water cooling of
the lamp is used - as with the
Kromayer lamp - the water
serves the dual role of keeping
the lamp cool and absorbing the
infrared radiation.
to table of contents
Quartz or special composition
glass must be used for the
envelope of all ultraviolet light
sources as normal glass
absorbs strongly over almost
the whole of the ultraviolet
The presence of a vapour,
even at atmospheric
pressure, enables a
discharge to be sustained
with a gap up to around 5 cm
when about 80 volts potential
difference is applied.
Within the ultraviolet region of the spectrum there are significant differences in the
output of mercury vapour lamps and tubes:
* Low pressure mercury vapour lamps, otherwise known as cold quartz lamps
when the envelope material is quartz, emit most of their ultraviolet radiation in the
UV-C region, at a wavelength of 253.7 nm. The operating temperature of the
lamp envelope rarely exceeds about 60
* High pressure mercury vapour lamps, known as hot quartz lamps when the
envelope material is quartz, put out a proportion of their ultraviolet energy at a
wavelength of 366.0 nm (in the UV-A region). There is also significant output at
specific wavelengths in the UV-B and UV-C regions. The amount of energy in
each region depends on the construction of the lamp. The normal operating
temperature of these lamps is several hundred degrees Celsius: if they are to be
used close to, or in contact with the patient they must be cooled by a water jacket
(Kromayer lamps) or an air blower.
* Fluorescent ultraviolet tubes are usually low pressure mercury lamps in the form
of a long tube. The tube is coated on the inside with fluorescent substances
(phosphors). The purpose of the phosphor is to absorb the original ultraviolet
radiation and re-emit it at longer wavelengths. Different phosphors have different
wavelengths for re-emission of radiation. The commonly used ultraviolet tubes
put out most of their energy in the UV-A region. Special tubes are available which
produce a maximum output in the UV-B region. A negligible amount of UV-C
radiation is emitted from any of these light sources.
In the past carbon arcs were used extensively for the production of ultraviolet radiation.
Two carbon rods are brought into contact with each other and a current is passed
through them. With a small point of contact the high current density heats and
vapourises the carbon. The rods are then separated and the presence of carbon
vapour enables a current to flow in the form of an arc discharge between the ends of
the rod. The spectrum produced by carbon arcs has a range close to that of sunlight
(figure 11.2): the proportions of ultraviolet, visible and infrared radiation are also
to table of contents
Carbon arcs are rarely used today in physiotherapy departments: they have been
largely superseded by mercury vapour lamps which are cleaner and easier to operate.
Production Of Infrared Radiation
Infrared radiation - sometimes referred to as radiant heat - is produced (and
absorbed) by all materials at temperatures above absolute zero.
Absorption of infrared radiation results in changes in molecular and atomic motion of
a material; the continuous agitation and changes in the motion of molecules, and
within molecules also results in the emission of infrared radiation. For example,
chemical bonds in molecules can absorb energy and 'stretch', changing the bond
length and thus the energy of the bonding electrons. When the bond reverts to its
original size, infrared radiation is produced at a frequency characteristic of the bond.
Any object will be emitting
and absorbing infrared
radiation on an ongoing
basis. Whether emission
outweighs absorption
depends on the temperature
of the object relative to its
Any molecule may, as a result of absorption of radiation or collision, change its state
of rotation or vibration, or both simultaneously. On changing to a rotation or vibration
state of lower energy, infrared radiation is produced. A particular kind of molecule has
very many possible states of rotation and vibration and therefore many options for
going from one state to some other.
At a given temperature a body will emit a continuous spectrum of radiation - the
maximum intensity occurring at a particular frequency but with significant intensities
extending over a wide range of frequencies. The frequency of maximum production of
radiation is directly proportional to the absolute temperature of the source. Since
wavelength and frequency are inversely related (by equation 9.1, v = f.λ), it follows that
the wavelength of maximum production of radiation is inversely proportional to the
absolute temperature of the source. (This is called Wien's Law).
As the source of radiation becomes progressively warmer, the wavelength of
maximum emission becomes progressively shorter: thus an iron bar turns from black
to 'red-hot' to 'white hot' to 'blue hot' as its temperature increases. In the black to red-
hot temperature range both near infrared (770 to about 4000 nm) and far infrared
to table of contents
For an ordinary household
light bulb the tungsten
filament is at about 3000 K
and the wavelength of
maximum emission is about
960 nm - that is, in the near
infrared. For skin at about
300 K it would be 9600 nm, in
the far infrared.
(4000 to 15 000 nm) radiation is produced in appreciable amounts.
A suitable device for producing such radiation consists of a coil of wire through which
a current is passed. If the coil is wound on an insulator such as a ceramic rod, both
the wire and the ceramic will emit radiation. The ceramic, being at a lower
temperature will produce more far infrared radiation. The common household electric
heater is usually of this kind. A way of producing most radiation in the far infrared
region of the spectrum is to encase the heating element inside a ceramic rod or
mount it behind a plate so that the major source of radiation is the rod or plate. If a
reflector is used, the reflector will absorb some radiation and re-emit it at higher
wavelengths thus adding to the far infrared component. These devices are often used
for therapy. Use is also made of incandescent infrared lamps which produce a
significantly greater proportion of near infrared radiation.
Incandescent infrared lamps (similar to household lamps - consisting of a tungsten
filament mounted in a glass envelope) have maximum emission at a wavelength
around 1000 nm: some visible and ultraviolet light is produced but the ultraviolet is
absorbed by the glass envelope and not transmitted. Use may be made of specially
shaped lamps with internal reflectors. The reflectors may be shaped to give a
floodlight beam - suitable for treating large areas - or a spotlight beam for treatment of
localized areas. Some lamps have a clear glass lens while others have a red lens:
there is little difference in the therapeutic effects of each.
Infrared and ultraviolet radiation share the common feature that their effects are
produced in the surface layers of the skin. This was mentioned briefly in chapter
9(link to p227). Figure 11.3 summarizes the penetrating properties of these
radiations. The penetration depth of waves of these frequencies clearly distinguishes
them from waves used for diathermy.
Considering first the infrared radiation (wavelengths of 770 nm and above) the figure
indicates that shorter infrared waves (770 to 1200 nm) penetrate to the deeper parts of
the dermis while the longer wavelengths are absorbed in the superficial epidermis.
to table of contents
From a penetration depth of a few millimetres at 1200 nm there is a decrease to about
0.1 mm at 3000 nm. Wavelengths above 3000 nm are absorbed by moisture on the
surface of the skin. The trend does not continue indefinitely and we find that in the far
infrared region from 10 000 to 40 000 nm, the penetration depth increases to several
centimetres. In effect, the tissues become much more transparent.
Figure 11.3
Penetration of radiation into skin in the
infrared to ultraviolet region of the
electromagnetic spectrum
Over the whole of the near infrared spectrum and
up to about 20 000 nm in the far infrared, reflection
is minimal. Close to 95 per cent of energy
incident perpendicular to the skin is absorbed -
only about 5 per cent is reflected. To a reasonable
approximation then, we can consider infrared
radiation to be wholly absorbed by tissue.
The region of the ultraviolet spectrum of interest in
therapy extends from about 180 nm to 390 nm.
From figure 11.3 we can see that most of this
radiation is absorbed in the epidermis. In the
region from 220 nm to 300 nm about 5 to 8 per
cent of incident radiation is reflected. The
reflectance increases to about 20 per cent at 390
nm. Within the range there are regions of very low
reflectance corresponding to specific absorption
by particular molecules in the skin - for example,
to table of contents
nucleic acids absorb strongly at frequencies between 250 and 260 nm and at 280 nm.
Heating by Infrared Radiation
The physiological effects of
infrared radiation differ from
those of other forms of
heating (e.g. shortwave
diathermy) only in the
location of heat production.
From the foregoing discussion it is clear that the major effect of infrared radiation is
thermal: to increase the temperature of cutaneous tissue. The penetration depth is
very small but some heat will be transferred to the subcutaneous tissues via the
The main effects of treatment are:
* An increase in metabolic rate in the superficial tissues. This is the direct effect of
temperature on the rate of chemical reactions generally. As a result there will be
an increased demand for oxygen and an increased output of waste products.
* Dilatation of capillaries and arterioles due directly to the heating and also as a
reflex reaction to the presence of increased concentrations of metabolites. The
flow of blood to the superficial tissues is thus increased producing a reddening
of the skin (erythema) and an increased supply of oxygen and nutrients. The
erythema produced by infrared therapy, unlike that resulting from ultraviolet
treatment, appears quite rapidly and begins to fade soon after treatment ceases.
The effects of infrared
radiation are not damaging
unless the temperature
elevation is too high.
* Sensory sedation. Mild heating has a 'sedatory' effect on sensory nerves and is
thus useful for the relief of pain.
* Muscle spasm relief. This results from both the effect of heat on nerve fibres and
the direct effect of heat which is transferred to muscle from the superficial
Effects of Ultraviolet Radiation
The effects of ultraviolet radiation are mainly non-thermal and due to cellular damage
and protective responses. While damage might seem an undesirable consequence,
there are therapeutic benefits of treatment. Five principal effects of therapeutic
significance are found to result from treatment with ultraviolet radiation:
to table of contents
* An increased blood supply to the skin results from dilation of the capillaries and
arterioles. Dilation does not result from heating of the tissue but as a reflex
response to destruction of cells. Cells are destroyed as a result of chemical
changes caused by the absorption of radiation, and reddening of the skin
(erythema) results. The effects are similar to the changes observed in
inflammation. Two groups of waves produce this reaction, one with wavelengths
in the UV-C region around 250 nm and one with wavelength close to 300 nm
Nowadays, vitamin tablets
provide a means of achieving
results more quickly and
economically when treating
vitamin D deficiency.
* Production of vitamin D. Ultraviolet radiation in the range 250 to 300 nm initiates
a sequence of chemical reactions by which vitamins of the D group are
synthesized. The effect has been used in the past for the treatment of rickets and
tetany, but is not used any longer.
* Pigmentation. The amino-acid tyrosine is converted, via a sequence of reactions,
to the pigment melanin. The accumulation of melanin in the epidermis is
triggered by the same wavelengths of ultraviolet radiation responsible for
erythema production - in addition UV-A wavelengths around 340 nm in low doses
can produce tanning without erythema.
In laboratories and
pharmaceutical preparation
areas, contamination by
bacteria must be avoided, so
lamps producing UV-C are
used to irradiate the areas.
* Sterilization. Shorter wavelength ultraviolet radiation (UV-C, around 250 nm) is
effective in destroying bacteria. In therapy this effect finds application in the
treatment of indolent ulcers: ultraviolet treatment is found to promote and
accelerate the healing process. It is not clear to what extent the sterilization
contributes as compared to erythema production. The increased blood supply
evidenced by erythema will increase the number of white blood cells and
antibodies in the area, hence reinforcing the body's defence mechanism.
* Desquamation occurs some time after exposure to ultraviolet rays - it is a
casting-off of dead cells from the surface of the body. The amount of peeling
varies with the strength of the dose: it ranges from virtually imperceptible through
powdery peeling to free peeling of epidermal layers. This can be of value in the
treatment of skin diseases such as acne and psoriasis.
to table of contents
The degree of erythema production is used to characterize the dose in ultra-violet
therapy using UV-B fluorescent tubes or mercury vapour lamps. The reaction is
graded into four levels:
* A first-degree erythema is a slight reddening of the skin which takes from six to
eight hours to develop. The erythema has faded in about twenty four hours
leaving the skin apparently unchanged. A minimum erythema dose (MED) is also
a slight reddening which takes from six to eight hours to develop but in this case
the erythema is still just visible at twenty four hours.
* A second-degree erythema is a more marked reddening of the skin (resembling
mild sunburn). There is a slight soreness. The reaction fades in about two days
and is followed by pigmentation. After one or two weeks desquamation (peeling,
usually powdery) occurs.
* A third-degree erythema resembles severe sunburn. The skin may begin to
show the effects as soon as two hours after treatment. The reaction is severe and
the skin becomes hot, sore and oedematous. Effects subside gradually over
several days and the skin often peels off in sheets or flakes.
The counter-irritation effect of
a fourth degree erythema has
been used in the past as a
quick and effective method of
relieving pain from joints and
other deep structures in
degenerative arthritis and
rheumatic conditions.
* A fourth-degree erythema is similar to a third-degree reaction but exudation and
oedema are so marked that blisters form. Production of a third or fourth degree
erythema in a small localized area results in a counter-irritation effect.
Dose characterization in this way is appropriate for sources which produce an
appreciable proportion of UV-B radiation. When using UV-A fluorescent tubes,
dosage can not be assessed in this way as erythema production is minimal except at
extremely high dose levels. In practice this is not a problem as the principal use of
UV-A is in conjunction with a photosensitizing drug, 8-methoxy-psoralen, for the
treatment of psoriasis. For psoralen - UV-A, therapy a special procedure is used for
dose characterization. The procedure is described in chapter 12.
to table of contents
Electromagnetic waves travel
more slowly in biological
tissues than air. The higher
the dielectric constant and
conductivity, the lower the
wave velocity.
As we will see, a frequency of
2450 MHz is not the best
choice for therapeutic
applications and for some
years the use of lower
frequencies has been
Having considered the low penetration electromagnetic waves - infrared, visible and
ultraviolet - we now turn to lower frequency waves used in therapy; microwaves.
Microwaves occupy the region of the electromagnetic spectrum between radio waves
and infrared radiation: their wavelengths are in the range from about a centimetre to a
meter - corresponding to frequencies in the range 300 MHz to 30 000 MHz. Three main
frequencies are used for physiotherapy, 2450 MHz (wavelength 12 cm), 915 MHz
(wavelength 33 cm) and 433.9 MHz (wavelength 69 cm). Note that the wavelengths
quoted are in air. In biological tissues the wavelength is significantly lower because
the wave velocity is lower.
Radio waves can be produced by first generating a very high frequency AC signal in an
ordinary electronic circuit and then applying this signal to a suitable antenna. The high
frequency alternating current in the antenna results in radio frequency waves being
produced and radiated. The limit to the frequencies that can be produced by standard
electronic circuits is determined by the time it takes for an electron to travel through a
transistor. If the transit-time, the time taken, becomes comparable to the time of
oscillation or period of the wave we wish to produce, then the transistor can no longer
function at this frequency. Microwave frequencies are extremely high, by electronic
standards, and are at the limit of those which can be produced by transistors.
Although vacuum tubes (valves) are an older design and are generally more inefficient
than transistors, two vacuum tube devices which can operate at microwave
frequencies were developed many years ago: these are the magnetron and the
klystron. The magnetron valve, first described by Hull in 1921, was developed for radar
use during the second world war. It is more useful for high power applications than
the klystron. After the war, apparatus operating at a frequency of 2450 MHz (the
standard radar frequency) was made available to physiotherapists.
Microwave apparatus (figure 11.4) consists of a device (a magnetron or klystron),
powered by an electronic circuit. The high frequency alternating current which is
produced is fed to an antenna. The current flowing in the antenna results in the
to table of contents
production of electromagnetic waves (chapter 9) which are beamed by the reflector.
Figure 11.4
Schematic diagram: microwave
The frequency of the microwaves is equal to the frequency of the AC produced by the
magnetron. This is determined by the physical construction of the magnetron and is
fixed during manufacture.
A number of differently shaped antennas and reflectors may be used for directing the
beam. Each gives a different beam shape though none gives a perfectly uniform
beam. To obtain a collimated uniform beam (like a searchlight) would require a
parabolic reflector with a point source of radiation as shown in figure 11.5(a). If a point
source of radiation is placed at the focus of the parabola the beam emerges with a
uniform cylindrical shape as shown.
In the case of microwaves used by physiotherapists, the most common frequency is
2450 MHz and the wavelength in air is 12 cm. The source of radiation is normally a
half-wave antenna; a rod shaped conductor about 6 cm long. Placed in a small
parabolic reflector the antenna would produce a highly non-uniform beam (figure
11.5b). To produce a reasonably uniform beam the antenna would need to be placed
in a reflector very much larger than its 6 cm length. A reflector with a focal length of a
to table of contents
metre or more and a diameter of several metres would be needed - producing a
beam which is metres in diameter.
Figure 11.5
(a) a uniform beam from a parabolic reflector and
point source, (b) a non-uniform beam from a
parabolic reflector and extended source
For therapeutic application, a microwave beam only 10
to 20 cm in diameter is desirable, in order to localize
the microwave energy. Reflectors 10 or 20 cm in
diameter with antennas about 6 cm in length cannot
produce a uniform beam but can be designed to
produce a diverging beam. The beams obtained from
reflectors presently used in therapy diverge
considerably - the wave intensity decreasing rapidly
with distance from the reflector. The reflectors must be
designed this way: if a less divergent beam is
produced part of the beam will be divergent, part will be
parallel and part focussed at some point in front of the
reflector as in figure 11.5(b). This has the obvious risk
of producing a local hot-spot in the patient's tissue and
causing tissue damage.
Microwave applicators are available to produce a number of beam patterns. The
pattern is not obvious from inspection of the shape of the reflector but the
manufacturers do supply this information.
to table of contents
The penetration depth of microwaves (table 9.1) indicates that the waves are useful for
The three factors determining the depth efficiency of waves generally are (chapter 9)
the penetration depth (δ) of the waves in a particular tissue and the extent of reflection
and refraction at tissue interfaces.
Considering first penetration depth, we make the observation that tissues with high
values of dielectric constant (ε) and conductivity (σ) absorb electromagnetic radiation
more rapidly than tissues with low values of ε and σ. The reasons were given in
chapter 9 previously. Values of ε and σ are significantly different at microwave
frequencies to those appropriate to shortwave diathermy at 27 MHz (table 6.2). Table
11.1 lists the values applicable at microwave frequencies.
Notice that fatty tissue and bone
marrow have quite similar values of
ε and σ - this explains why the
penetration depth of microwaves
(table 9.1) is almost the same in
both tissues. The relatively high
values of ε and σ for muscle result
in a greater rate of microwave
absorption and hence a lower
value for the penetration depth in
this tissue.
The extent of reflection at an
i nterface i s cal cul ated from
equation 9.5: it is determined by the
mismatch in impedance of the
tissues. Since we are talking about
electromagnetic waves the imped-
Table 11.1
Dielectric constant and conductivity of tissue
at microwave frequencies.
to table of contents
Clearly if we wish to calculate
the pattern of heating in
tissue we must take account
of both the penetration depth
in each tissue and the
amount of reflection and
refraction at each tissue
interface. Each factor will
have a significant effect on
the heating pattern.
See the chapter by Schwan
in: Licht, S H, Therapeutic
Heat and Cold, (2nd Edition),
New Haven (1968).
ance of interest is the electrical impedance - determined by the dielectric constant (ε)
and conductivity (σ) of the tissue. Reflection of microwaves at the fat/muscle and
muscle/bone interfaces will be pronounced due to the difference in electrical
properties (changed by a factor of 10) on either side of the boundary concerned.
The amount of refraction at an interface is calculated from equation 9.12: it is
determined by the mismatch in wave velocity of the tissues. The wave velocity in turn
is determined by the dielectric constant and conductivity of the tissue.
Because of the large difference in the electrical properties (ε and σ) of air, fatty tissue,
muscle and bone, refraction effects will be significant unless the microwave beam
strikes each boundary at a right angle (zero angle of incidence).
The Fraction of Total Energy Absorbed
A knowledge of the dielectric constant and conductivity of each tissue enables us to
calculate the relative rate of heating of each tissue. This information alone does not
allow us to predict the actual amount of heat produced since much of the microwave
energy is reflected at the air/skin interface.
The significant difference in the electrical properties of air (for which ε ≈ 1 and σ ≈ 0)
and soft tissue will result in a considerable amount of the energy incident upon the
skin being reflected. The total percentage of microwave energy absorbed deeper in
the body tissues and hence converted into heat also depends on the thickness of the
skin/fatty tissue layer. This is because a proportion of the wave energy reflected from
the fat/muscle interface will penetrate the skin and be re-radiated into the air.
Some decades ago, H. P. Schwan (see Licht (1968)) calculated the percentage of
total energy reflected at different frequencies and various thicknesses of skin and fat.
His results show that:
* At frequencies less than 1000 MHz, 60 to 70% of the energy is reflected this
almost independently of skin and fat thickness.
to table of contents
* Between 1000 and 3000 MHz reflection depends critically and in a complex way
on tissue thickness. Between 0 and 80% of the energy is reflected.
* Above 3000 MHz around 60% of the energy is reflected - again almost
independently of tissue thickness.
Another practical implication
of the large amount of
reflection is the need to avoid
unintentional exposure of
body parts (including those of
the therapist).
One major implication of the above results is that at a frequency of 2450 MHz the
effective dosage is virtually impossible to determine in a clinical situation, due to the
practical difficulty in establishing skin and fat thickness which may vary considerably
in the treated area. Clearly a frequency above or below the range 1000 to 3000 MHz is
to be preferred on these grounds. As we will see in what follows, a lower frequency is
The Distribution of Absorbed Energy
We examine now the absorption of the proportion of microwave energy which is not
reflected by the skin or re-radiated. Consider a 2 cm fatty tissue layer adjoining
muscle tissue. For simplicity we begin by making two assumptions:
* that no bone is present. We will take bone into account in subsequent examples.
* that refraction can be ignored. In other words the angle of incidence is assumed
to be zero. Refraction effects will be described separately.
The relative rate of heating can be calculated from the dielectric constant and
conductivity of each tissue: the two factors which determine the amount of reflection
and the penetration depth. The method of calculation is described by Schwan (see
Licht (1968)).
Figure 11.6 shows the pattern of heat production for microwaves at the relatively high
frequency of 8500 MHz (wavelength 3.5 cm in air). A standing-wave pattern (see
chapter 9) is produced in the fatty tissue: this is because of reflection at the fat/muscle
to table of contents
Figure 11.6
Heating pattern predicted for microwaves of
frequency 8500 MHz in a specimen of 2 cm fatty
tissue over muscle.
When unequal size waves
interfere, the standing-wave
effect produces peaks and
troughs in the heating-rate
pattern, but there are no true
nodes (points where the
intensity is zero).
figure 9.12).
At this frequency, most heat is produced in the fatty tissue close to the skin and in the
superficial region of the muscle. A reasonable heating rate is obtained at the muscle
surface but the effect extends to only a fraction of a centimetre into the muscle tissue.
The total amount of heat produced in each tissue is indicated by the area under the
curves in figure 11.6. It is evident that there is greater overall heat production in the
fatty tissue. This problem is typical of higher microwave frequencies.
The peaks in the heating pattern in the fatty tissue are separated by one half of a
wavelength (see chapter 9 - this is close to 1 cm in figure 11.6) so the wavelength of
the microwaves in fatty tissue is about 2 cm.
The standing-wave pattern in the fatty tissue is not ideal since reflection is not 100%
and the wave is progressively absorbed in its travel. The actual pattern is a
combination of an exponential decrease (determined by the penetration depth, δ) and
interference of unequal size waves (
to table of contents
At a frequency of 2450 MHz, the frequency most commonly used in therapy, the relative
rate of heating is as shown in figure 11.7.
Figure 11.7
Heating pattern predicted for microwaves of
frequency 2450 MHz in a specimen of 2 cm fatty
tissue over muscle.
Again a standing wave pattern is found in the fatty
tissue where most heat is produced. At this lower
frequency, the wavelength is greater (since equation
9.1 holds: v = f.λ) so only a single peak is seen in
the heating pattern in fatty tissue. Heat production in
the muscle tissue is improved over the 8500 MHz
results but is still limited to the first centimetre or so.
Evidently the lower frequency is preferable from a
'deep heating' point of view - but we saw earlier that
frequencies in the range 1000-3000 MHz result in
uncertain dosage.
What of frequencies below 2450 MHz? Figure 11.8
shows the relative rate of heating predicted for a
microwave frequency of 915 MHz in a tissue
specimen with the same dimensions as used
Figure 11.8
Heating pattern predicted for microwaves of
frequency 915 MHz in a specimen of 2 cm fatty
tissue over muscle.
to table of contents
The wavelength in fatty tissue
at 915 Mhz is about 18 cm so
a peak and a trough would be
separated by 4.5 cm (one
quarter of a wavelength).
At 915 MHz, a standing wave pattern is still produced in the fatty tissue but the
wavelength is so large that no peaks are evident.
Figure 11.9 shows the relative rate of heating predicted for a microwave frequency of
434 MHz in the same tissue specimen.
Figure 11.9
Heating pattern predicted for microwaves of
frequency 434 MHz in a specimen consisting
of 2 cm fatty tissue over muscle.
The depth efficiency of lower frequency microwaves
is apparent from figures 11.8 and 11.9. Both
frequencies give maximum heating in the muscle
with much the same decrease in heating rate with
distance into the tissue. The lowest frequency (434
MHz) produces least heating of fatty tissue; the
difference being most noticeable near the tissue
Both frequencies give a heating pattern which is
suitable for diathermy and dosage is reasonably
The heating of the fatty tissue surface with 915 MHz microwaves can be compensated
for by using a contact applicator with surface cooling. The microwave director
(applicator) is designed to be used in direct contact with the patient. Cooling air is
blown through the applicator and on to the patients' skin during treatment in order to
minimize the temperature elevation of superficial tissues.
to table of contents
Figure 11.10
Heating pattern predicted for a microwave
frequency of 2450 MHz in a tissue combination
of 2 cm fat, 2 cm muscle and 2 cm bone.
Figure 11.11
Heating pattern predicted for a microwave
frequency of 915 MHz in a tissue combination
of 2 cm fat, 2 cm muscle and 2 cm bone.
When we consider the three-layer system of
fat/muscle/bone we predict reflection at both
the fat/muscl e i nterface and at the
muscle/bone interface. In consequence a
complex heating pattern is produced in both
the fat and muscle tissue. Figures 11.10,
11.11 and 11.12 show the patterns predicted
for frequencies of 2450 MHz, 915 MHz and
434 MHz respectively. Tissue dimensions are
the same as those chosen to illustrate the
heating pattern for ultrasound (figures 10.6
and 10.7).
to table of contents
Figure 11.12
Heating pattern predicted for a microwave
frequency of 434 MHz in a tissue combination
of 2 cm fat, 2 cm muscle and 2 cm bone.
For each frequency, heat production in bone is
minimal. Both 915 and 434 MHz microwaves
produce maximum heating in the muscle layer:
the lower frequency having greater depth
efficiency. Not too much significance can be
attributed to the actual positions of maxima
and minima of heat production as these vary
with the tissue dimensions and electrical
properties assumed. The general implicat-
ions of the figures are, however, clear:
frequencies below 1000 MHz are needed if
tissues located beneath a few centimetres of
fat are to be effectively heated. For treating
structures located closer to the skin surface -
for example a knee or elbow joint which is not
covered by a thick layer of fat - a frequency of
2450 MHz is adequate, though the dose will be
somewhat unpredictable. More deeply located
structures - for example, the hip joint - are not
heated appreciably at this frequency.
The heating patterns shown in figures 11.6 to 11.12 were calculated ignoring
refraction effects. This is appropriate for a uniform microwave beam incident upon a
plane surface with tissues of constant thickness beneath. When microwaves are
incident upon a curved surface then, even if the beam is uniform, refraction will occur.
This is illustrated in figure 11.13, where reflected waves are omitted for clarity.
The amount of refraction depends on the curvature of the tissue surfaces an the
electrical characteristics of the tissues. When the curvature of the tissues is
pronounced, as for example with an arm or leg, the amount of refraction is
considerable. The smaller is the radius of the limb, the greater is the refraction effect.
to table of contents
Tissues of high dielectric constant and conductivity have a low electrical
impedance and consequently a low wave velocity. Thus the velocity decreases as
the wave progresses from air to fatty tissue and then to muscle. This means that
waves will be refracted to produce convergence of the beam. A focussing effect is
produced in the tissues.
What effect will the beam convergence have on the heating pattern? As the beam
travels through fatty tissue and muscle it is progressively absorbed. The wave
energy is converted into heat energy and the wave intensity (energy per unit area)
decreases. Convergence of the beam will result in the energy remaining any
particular depth being concentrated in a smaller area. This tends to increase the
beam intensity. Thus with curved tissue surfaces as shown in figure 9.12 the
beam intensity does not diminish as rapidly as would occur with plane surface.
Consequently the depth efficiency for heat production is greater.
Figure 11.13
Refraction of a microwave beam
at tissue interfaces.
H. S. Ho (1976) has calculated the relative rate of heating for cylindric models
with dimensions approximating to adult human arms and legs. His results are
qualitatively similar to those shown in figures 11.10 to 11.12 but the relative rate of
heating of muscle is significantly higher. Nonetheless the conclusions to be
drawn from Ho's work are those described earlier. For patient treatment, better
heating patterns are produced with frequencies lower than the 2450 MHz currently
used. Ho's results indicate an optimum frequency of around 750 MHz for efficient
and relatively uniform heating of muscle tissue.
Ho HS. Health Physics, 31,
97-108 (1976).
Lehmann, J F, Therapeutic
Heat and Cold, (3rd Edition),
Williams and Wilkins (1982).
For a description of depth efficiency calculations using different frequencies and
other geometric shapes resembling parts of the human body see A. W. Guy in
Lehmann (1982), chapter 6.
In summary we may conclude that 2450 MHz microwaves have low depth
efficiency. This frequency is best suited to heat production in fatty tissue and the
superficial region of muscle. 915 MHz and 434 MHz microwaves produce greater
depth heating of muscle and less heating of fatty tissue. The optimum frequency
for selective and uniform heating of muscle tissue being around 750 MHz.
to table of contents
Microwaves are intrinsically unsuited to heating of bone (see figures 11.10 to 11.12)
because of its electrical characteristics: for this reason joints can only be heated when
the overlying tissue layers are very thin. For heating of deeply located joints,
ultrasound or shortwave diathermy would be more effective.
The difference between
heating rate and rate of
temperature increase, and
the relationship between
these quantities, was
discussed in chapter 7.
As a final point it should be stressed that the graphs shown in figures 11.6 to 11.12
show where heat is produced but not the temperature increase in each tissue. The
temperature increase depends on such factors as the specific heat capacity of the
tissue and heat transfer within and between tissues and to the bloodstream (see
chapter 7).
The acronym 'laser' stands for 'light amplification by stimulated emission of radiation'.
Lasers are electromagnetic wave amplifiers which can produce beams of electro-
magnetic waves with two special properties:
* the beam has very little divergence. It has a pencil-like shape.
* the beam is coherent. That is, all the waves in the beam are of exactly the same
frequency and wavelength and are synchronized with each other.
The divergence of a laser
beam is so small that a
beam pointed at the moon
could illuminate a target less
than a metre across.
The pencil-like beam of the laser means that the wave energy is always concentrated
on the same area: the intensity (which is the energy per unit area) does not decreased
appreciably with distance due to beam-spreading.
Production of a laser beam
Visible light can be produced by excitation of atoms. For example if crystals of a
copper salt, such as copper sulphate, are heated in a flame, the flame turns blue.
When strontium salts are heated, the flame turns violet. Sodium salts produce a
yellow colouration. This is because electrons in the copper, strontium or sodium
atoms are kicked from their 'ground state' orbitals by the heat energy of the flame and
to table of contents
The light emitted by a
burning salt is usually at a
mixture of waves of different
frequency. The different
frequencies correspond to
electrons returning to different
'ground state' orbitals.
The term 'monochromatic'
literally means 'one colour'.
In most contexts this means
that each wave has the same
when they fall back into their original orbitals, the energy released is radiated as light
of a particular frequency. Because electrons may be kicked out of, and fall back to,
different orbitals, the light emitted is a mixture of several specific frequencies. By
contrast, laser radiation has but a single frequency.
The light emitted by a burning salts is also incoherent, meaning that electrons drop
back into their ground-state orbitals randomly so there is no synchronization of the
radiated electromagnetic waves. By contrast, lasers are devices which force
electrons to drop back into one particular orbital in an avalanche effect, i.e. almost
simultaneously. The result is that the emitted waves are all synchronized (coherent)
and have the same frequency.
The avalanche effect and resulting coherence of a laser beam is achieved by
bouncing waves back and forth between two reflectors. For example, a helium-neon
laser consists of a cylindrical tube containing helium and neon gas. Each end of the
tube has a reflector, one is fully reflecting and the other is partially reflecting so as to
allow some light (the laser beam) to escape. The back-and-forth reflection triggers a
resonance effect where electrons to drop back into a specific ground-state orbital
synchronously and a coherent, monochromatic beam of waves is produced. each
wave having the same frequency.
To keep the laser operating it is necessary to bump electrons out of their ground-state
orbitals and into a higher-energy orbital, ready to drop. For this reason a power
supply (a source of energy) is required. Sometimes the energy is provided by an
electric current, sometimes by a by a burst of light energy. In the case of a helium-
neon laser, a power supply is used to energise a flashlight (rather like a camera
flash) which provides rapid-fire bursts of light energy to push electrons into an excited
state. In the case of diode lasers, current flow through the diode provides the
necessary energy.
We can summarize the differences between laser light and light from a common,
incandescent light bulb as follows. Light from a normal incandescent source has a
spectrum of frequencies and the waves are incoherent. Lasers are beams of
coherent waves of identical frequency. There is some clinical evidence that laser
to table of contents
High power lasers are used
to cut steel sheets several
centimetres thick. Much
lower powers are used in
microsurgery, where focused
beams are used to cut tiny
regions of tissue.
Lasers are often applied with
only a thin film of plastic
separating the laser from the
skin surface, so beam
divergence is not important.
beams can be therapeutically beneficial. What has not been established is whether
laser beams have any advantage over simpler (and cheaper) torch beams. No
comparisons have yet been reported.
Beam Intensity
The output of a laser can vary from tens of milliwatts to tens of kilowatts, depending on
the type and the physical construction. Lasers used therapeutically have power levels
between these two extremes. They are typically of relatively low power and intensity.
Intensities are normally in the range 1 mW.cm
to 50 mW.cm
The beam diameter of the low power lasers used clinically is about 3 mm (an area of
about 7 mm
). Thus if the output intensity is, for example, 20 mW.cm
and the area is
7 mm
= 0.07 cm
, the power of the beam is 20/0.07 mW ≈ 300 mW or 0.3 W.
By way of comparison, a torch might have a beam 8 cm in diameter (an area about 50
) and use a 12 W light bulb. As far as visible light output is concerned, the bulb is
about 25% efficient (75% of the energy is emitted at infrared frequencies). Hence the
power of the visible light-beam is approximately 3 W. The visible-light beam intensity
is 3/50 = 0.06 W.cm
or 60 mW.cm
. The intensity of the infrared component is
approximately 180 mW.cm
A torch beam thus has a similar and, if anything, a higher power and intensity than a
clinical laser but is polychromatic. The wave energy is spread over a range of
frequencies. Any clinical significance of the polychromatic/monochromatic difference
has yet to be established.
Beam Divergence
Light from a light bulb can be formed into a pencil-like beam (as in a searchlight) by
using a parabolic reflector but the beam divergence is larger than that of a laser
because of the practical difficulty of producing a perfectly shaped reflector. This
difference would be of no clinical significance for beams between a light source and
the patient, a distance of only a few centimetres or tens of centimetres.
to table of contents
Beam Diameter
The beam diameter of the low power lasers used clinically (commonly referred-to as
'low level lasers') is about 3 mm (an area of about 7 mm
= 0.07 cm
). A
consequence is that if the area of the skin surface which is to be treated is several
, the beam must be scanned over the area. This means that both the average
intensity and the energy delivered per unit area are reduced. For example, if the area
to be treated is 5 cm x 5 cm (25 cm
), the reduction in average intensity and energy
delivered per unit area is 25/0.07 = 3500 times. By contrast, a torch beam would
illuminate the same area with no reduction in intensity or energy delivered.
Coherence is only possible
if waves have identical
frequencies. If the
frequencies (and thus, the
wavelengths) are different,
they cannot stay in-phase.
The light from a light-globe is incoherent. The radiated waves have different
frequencies (a spread of frequencies about some mean) and the waves are not 'in
synch' with each other. Synchronization is impossible because the wavelengths are
different. The coherence of a laser beam is not likely to be of practical significance as
biological tissues are quite inhomogeneous at a microscopic level. This means that
waves will be scattered and slowed to varying extents so coherence will be lost. A
coherent beam striking the skin surface will be incoherent after traversing a distance
through tissue of only a few cell diameters. Although coherence is rapidly lost in
biological tissue, the beam remains monochromatic i.e. the waves still have identical
Since coherence is lost
when lasers are beamed
through tissue, whether the
light source is a laser or
superluminous diode
appears irrelevant.
Producing a coherent beam using diode lasers is technically difficult. Superluminous
diodes are easier to manufacture. These are devices which produce monochromatic,
laser-like beams which are non-coherent. It should be noted that some diode 'lasers'
used in physiotherapy produce relatively incoherent beams and should more correctly
be described as 'superluminous diodes'. The lack of coherence in the beam of
radiation produced would appear to be of no clinical significance.
Laser Light Wavelengths
The particular wavelength of radiation emitted by a laser is determined by the physical
to table of contents
The range of wavelengths
which can be produced by
laser action is quite large,
from the microwave region
of the spectrum to the X-ray
design; in particular its chemical composition. Thus helium-neon lasers emit red
light with a wavelength of 632.8 nm. Ruby lasers, which consist of a cylindrical rod of
synthetic ruby (a gemstone made of aluminium oxide) emit red light with a wavelength
of 694.3 nm.
Gallium aluminium arsenide (GaAlAs) diodes emit radiation at a frequency
determined by the ratio of gallium to aluminium. The particular wavelength can be
between 650 nm (in the visible, red part of the spectrum) and 1300 nm (in the near
Two types of lasers are commonly used in physiotherapy: helium-neon lasers, which,
as noted above, produce red light of wavelength 632.8 nm and gallium aluminium
arsenide diode lasers, operating at near-infrared wavelengths (normally between 810
and 850 nm).
Penetration Depth
The penetration depth of laser radiation is the same as ordinary electromagnetic
radiation of the same frequency. The wave coherence and the monochromatic nature
of the laser beam make no difference. Thus the penetration depth of visible light from
a helium-neon laser is a mm or so and most of the wave energy is absorbed in the
epidermis (figure 11.3). The infrared radiation produced by commercial GaAlAs
diodes has greater penetration depth but most of the wave energy is absorbed in the
epidermis and dermis.
Consideration of beam area
and average intensity
indicates that torch-beam
therapy might be a cheaper
and more effective treatment
than laser therapy.
This perhaps explains why laser irradiation has been shown to be of value for treating
ulcers and other skin conditions. What has not been shown, and is not likely to be
shown, is that laser treatment is any better than shining a torch beam on the area.
Similar considerations indicate that laser irradiation is not likely to be of value for
treating deeper tissue injuries.
The therapeutic benefit and relative cost effectiveness of laser therapy must thus be
to table of contents
1 (a) What are the similarities and differences between infrared, ultraviolet and
microwave radiation?
(b) State the wavelength range and frequency range of each kind of radiation.
2 Figure 11.1 shows a schematic diagram of a mercury vapour lamp.
(a) Describe the mechanism whereby ultraviolet radiation is produced in the
(b) Why must the power supply used for the lamp be current limiting?
(c) Why must special glass be used for the lamp envelope?
3 Compare the output of UV, visible and infrared radiation of air and water cooled
UV lamps and fluorescent tubes (figure 11.2).
(a) Why do water-cooled lamps put out a negligible proportion of infrared
(b) Why do fluorescent tubes put out a negligible amount of radiation at
wavelengths less than 280 nm?
4 (a) Describe the process of production of infrared radiation by lamps and
electric heaters.
(b) What effect does the use of a reflector have on the directionality and
wavelength of the radiation produced?
5 The filament of a light bulb is at a temperature of 3000 K and its wavelength of
maximum emission is 960 nm. If the filament temperature was lowered to 1000
K by decreasing the current what would be the new wavelength of maximum
emission? In what part of the electromagnetic spectrum is this wavelength?
to table of contents
6 (a) Use figure 11.3 to describe the variation with frequency of the penetration
depth of near infrared radiation.
(b) Describe the ways in which heat produced by near infrared radiation is
transferred to subcutaneous tissue. Which would you expect to be the
most efficient transfer mechanism?
7 Compare and contrast the principal effects of infrared and ultraviolet radiation on
tissue. How are the differences related to the wavelength of the radiation?
8 (a) What is meant by the term erythema as related to dosage in ultraviolet
(b) Briefly list the characteristics of a first, second, third and fourth-degree
erythema reaction to ultraviolet radiation.
9 Figure 11.4 shows a schematic diagram of apparatus used for the production of
(a) Briefly describe the function of each subsection.
(b) Why is a magnetron valve rather than conventional electronic circuitry used
in microwave apparatus?
(c) What is the relationship between the size of the antenna in figure 11.4 and
the wavelength of the microwaves produced?
(d) What determines the frequency of the microwave radiation produced by the
10 Figure 11.5 shows the beam produced by a point source of radiation positioned
at the focus of a parabolic reflector. Draw diagrams to show the effect on the
beam shape of:
(a) mounting the point source between the focus and the reflector surface (still
on the central axis)
to table of contents
(b) mounting the point source on the central axis but further from the reflector
than the focus.
11 (a) Explain why parabolic reflectors are not used with microwave diathermy
(b) What are the most important factors determining the size and shape of the
reflectors used with microwave diathermy apparatus?
12 (a) Give a brief explanation (in molecular terms) of why tissues with high
dielectric constant and conductivity have low values of penetration depth for
microwave radiation
(b) Refer to the figures given in table 11.1 and comment on the relative values
of penetration depth for microwaves in fat, muscle and bone. Which tissues
would be expected to have similar values of penetration depth and why?
13 It has been said that a frequency of 2450 MHz represents a very poor choice for
microwave radiation used in therapy because of the unpredictability of dosage.
14 Using data in table 11.1 determine the thickness of fat required to absorb 50% of
the transmitted microwave energy at a frequency of:
(a) 1000 MHz
(b) 2000 MHz
(c) 4000 MHz
15 For microwaves of frequency 2000 MHz (table 9.1) calculate the fraction of energy
remaining after travelling through
(a) 2 cm fat
(b) 2 cm muscle
(c) 2 cm bone.
In which tissue is the energy absorbed most rapidly?
to table of contents
16 Refer to figure 11.6 and explain the origin of the peaks and troughs (maxima and
minima) in the heating pattern.
17 Refer to figure 11.6. Draw the corresponding graph of relative rate of heating
which would be expected if the reflection coefficient of the fat/muscle interface
(a) 0.0
(b) 1.0
18 Compare figures 11.7, 11.8 and 11.9 and explain how the microwave wavelength
is related to the differences in heat production in each case.
19 H. P. Schwann has shown that from the point of view of reliable dose prediction
microwaves with frequencies either below 1000 MHz or above 3000 MHz are
preferred. Compare figures 11.6 and 11.9 and say whether high frequencies or
low frequencies would be preferred from the point of view of the pattern of heating
20 Compare figures 10.6 and 10.7 with figures 11.10 to 11.13 and explain the
differences in heat production in terms of:
(a) the wavelength associated with the modality
(b) the penetration depth in each tissue.
21 Figure 11.13 shows a beam of microwaves striking an arm or leg. Briefly explain
why the beam converges in fatty tissue and muscle.
22 The diagram below shows a uniform microwave beam striking a tissue surface.
The fat and muscle layers have only slight curvature. The bone surface is
markedly curved. Fatty tissue and bone have low values of dielectric constant
and conductivity. The corresponding values for muscle are high.
to table of contents
Complete the diagram to show the refraction effects. Briefly explain what
happens to waves at each boundary and why.
to table of contents