Laser Assisted Treatment of Chronic Sinusitis With and Without Light Activated Agents

Laser Microbial Killing With Photo Activated Agents

Chronic rhinosinusitis (CRS) is common disorder which affects up to 13% of the US population. CRS affects numerous Quality of Life (QOL) factors including smell, sleep and communication. The common treatment for medically noncompliant CRS is Functional Endoscopic Sinus Surgery (FESS).

As the disease course is generally idle, prolonged medical treatment guidelines are for antibiotic treatment, prescribed accordingly following appropriately obtained nasal cultures, lasting weeks with or without additional topical or oral steroid treatment. While FESS success rate is a general notion, a failure rate of primary FESS is as high as 2-24%2, with a Cochrane review even suggesting that FESS though a safe procedure is of no benefit more than medical management.

With that in mind as we address the failed FESS, new bacteria emerge. The new bacteria in CRS are Coagulase-negative staphylococci were the most common isolates (36%), followed by Staphylococcus aureus (25%), Streptococcus viridans (8.3%), Corynebacterium (4.6%), and anaerobes (6.4%).

Patients not relieved by primary FESS demonstrate a significant rise in Pseudomonas and MRSA bacteria positive cultures. Moreover surgical success for patients with Staphylococcus aureus and Pseudomonas aeruginosa positive cultures is usually reduced.

Bacterial killing, by usage of light-activated agents such as Indocyanine Green (ICG) with exposure to the specific wavelength, eventually produces bacterial killing. Mechanisms primarily involved are production of reactive oxygen species (i.e. singlet oxygen and free radicals) which can then kill bacteria. ICG by itself does not have any bacterial killing effect.

Low level laser therapy (LLLT) was shown to be effective as a bactericidal by single and multiple wave exposures.

The study purpose is to treat CRS with an alternative to antibiotics, thus sparing volunteers from prolonged antibiotics use and its possible side effects, not to mention the cost and growth of resistant bacteria. We believe that by combining ICG with light or even by light alone we can produce you a beneficial effect. Although this has been shown to kill bacteria in lab or animal studies it is still investigational for humans. The study will have two arms: ICG + laser and laser only arm. ICG will be applied locally in the nasal passage (internally) followed by laser activation with a power setting of 6W. The laser will be activated with a diffuser mode meaning light of a specific known wavelength will be delivered evenly in the nasal cavity and not as a beam. Laser only treatment plan will be the same only without ICG. Volunteers will be assigned to one of the groups randomly meaning you have a 50% chance of enrolling to each treatment group. Volunteers will not know to which group. Weekly visits with a total of three visits will follow. With each visit Volunteers will receive additional treatment as the initial treatment was and a nasal culture will be taken. Volunteers will have to fill a questionnaire with each visit.

Study Overview

• Status: Unknown
• Conditions: Rhinosinusitis
• Intervention / Treatment: Device: Laser + ICG; Device: Laser only

Detailed Description

A prospective randomized trial that will be performed over the period of 1 year or until 20 patients in each arm meeting inclusion criteria will be recruited. One arm will be treated with a NIR laser (ARC Lasers Gmbh, Germany) alone and another arm will have an ICG+ NIR laser treatment.

FDA approved NIR lasers in the range of 810- 980nm. FDA approved ICG (Akorn, Buffalo Grove, IL) applied locally total application will not exceed 2.5 mg Randomization method: first five volunteers will start the ICG+ laser followed by five from only laser treatment group. This will be followed by allocating one volunteer to each study arm alternatively.

Data to be collected: demographical data including age and gender, approximate duration of symptoms, culture results, SNOT 20 (QOL questionnaire) score.

Urine test will be done to rule out pregnancy prior to study enrollment. Treatment: ICG arm- will be defined as local application on a pledget soaked with ICG with a concentration of 200µg, upon removal of the pledget a NIR diode laser set at 6W with light emittance introduced intranasally with a 30mm diffuser fiber capable of radiating light circumferentially allowing the light energy to reach all treatable areas. Laser will be activated for 180 seconds. Assuming an approximate radius of the nasal cavity is 3mm, energy density will be around 200J/cm². Treatment will be repeated twice, 5-7 day apart. Cultures will be collected at the end of all treatments.

Non-ICG arm: same as above but without ICG appliance. Follow up will consist of an office visit upon end of treatment with an additional visit scheduled two weeks later Protective equipment: specifically designed eye goggles, draping preventing clothes stains from the dye

• Study Type: Interventional
• Enrollment (Anticipated): 40
• Phase: Not Applicable

Contacts and Locations

Study Locations

• United States
  • New York
    • New York, New York, United States, 10019
      • Recruiting
      • St.Luke's-Roosevelt, New York Head Neck Institute
      • Contact: Yosef Krespi, MD; Phone Number: 212-262-4444; Email: hnsg@aol.com
      • Contact: Victor Kizhner; Phone Number: 212 262 44444; Email: vkizhner@gmail.com
      • Principal Investigator: Yosef Krespi, MD
      • Sub-Investigator: Victor Kizhner, MD
    • New York, New York, United States, 10022
      • Recruiting
      • Head Neck Surgical Group
    • New York, New York, United States
      • Recruiting
      • New York Head Neck Institute
      • Principal Investigator: Yosef Krespi, MD
      • Contact: Yosef Krespi, MD; Phone Number: 212-262-4444

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years and older (Adult, Older Adult)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

Description

Inclusion Criteria:

• Patients over 18

• Patients with an established nasal culture of either

  • Staph aureus,
  • Strep species,
  • Pseudo monasaureginosa,
  • Proteus.mirabilis,
  • H. influenza
  • or other intranasal pathogens.

Exclusion Criteria:

• Patients without CRS,
• Patients known to have Iodide allergy or ICG allergy
• Patients scheduled for a thyroid scan
• Pregnant or breastfeeding.

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Non-Randomized
• Interventional Model: Parallel Assignment
• Masking: Single

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Laser + ICG; ICG arm- will be defined as local application on a pledget soaked with ICG with a concentration of 200µg, upon removal of the pledget a NIR diode laser set at 6W with light emittance introduced intranasally with a 30mm diffuser fiber capable of radiating light circumferentially allowing the light energy to reach all treatable areas. Laser will be activated for 180 seconds. Assuming an approximate radius of the nasal cavity is 3mm, energy density will be around 200J/cm². Treatment will be repeated twice, 5-7 day apart. Cultures will be collected at the end of all treatments	Device: Laser + ICG; ICG arm- will be defined as local application on a pledget soaked with ICG with a concentration of 200µg, upon removal of the pledget a NIR diode laser set at 6W with light emittance introduced intranasally with a 30mm diffuser fiber capable of radiating light circumferentially allowing the light energy to reach all treatable areas. Laser will be activated for 180 seconds. Assuming an approximate radius of the nasal cavity is 3mm, energy density will be around 200J/cm². Treatment will be repeated twice, 5-7 day apart. Cultures will be collected at the end of all treatments
Active Comparator: Laser only; same as above, without ICG	Device: Laser only; same only without ICG

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Time Frame
Quality of Life improvement with disease control. Disease control without antibiotics or steroids.	1-2 months

Secondary Outcome Measures

Outcome Measure	Time Frame
Laser safety without compromising disease progress	immediate and late

Collaborators and Investigators

• Sponsor: New York Head & Neck Institute
• Collaborators: Valam Corp.

Publications and helpful links

General Publications

• Omar GS, Wilson M, Nair SP. Lethal photosensitization of wound-associated microbes using indocyanine green and near-infrared light. BMC Microbiol. 2008 Jul 1;8:111. doi: 10.1186/1471-2180-8-111.
• Guffey JS, Wilborn J. Effects of combined 405-nm and 880-nm light on Staphylococcus aureus and Pseudomonas aeruginosa in vitro. Photomed Laser Surg. 2006 Dec;24(6):680-3. doi: 10.1089/pho.2006.24.680.

Study record dates

Study Major Dates

• Study Start: May 1, 2009
• Primary Completion (Anticipated): December 1, 2011
• Study Completion (Anticipated): December 1, 2011

Study Registration Dates

• First Submitted: July 28, 2009
• First Submitted That Met QC Criteria: July 28, 2009
• First Posted (Estimate): July 29, 2009

Study Record Updates

• Last Update Posted (Estimate): July 22, 2011
• Last Update Submitted That Met QC Criteria: July 21, 2011
• Last Verified: July 1, 2009

More Information

Terms related to this study

• Keywords: Rhinosinusitis, sinusitis, chronic, nasal polyps, phototherapy, laser,laser therapy, antibiotic, safety laser, ICG, indocyanine green; Chronic Rhinosinusitis with or without nasal polyposis
• Additional Relevant MeSH Terms: Infections; Respiratory Tract Infections; Respiratory Tract Diseases; Otorhinolaryngologic Diseases; Paranasal Sinus Diseases; Nose Diseases; Sinusitis
• Other Study ID Numbers: SLR 09-005