10.14639/0392-100X-N0907
Objective. The aim of the present study was to objectively and subjectively evaluate the effects of adding rhinophototherapy to intranasal beclomethasone dipropionate to treat nasal congestion in patients with seasonal allergic rhinitis. Method. Seventy-five seasonal allergic rhinitis patients were randomly divided into two groups. Patients in Group 1 received intranasal beclomethasone dipropionate for two weeks and patients in Group 2 had rhinophototherapy added to the same medical therapy as Group 1. The effectiveness of treatments was evaluated with the Rhinoconjunctivitis Quality of Life Questionnaire (RQLQ), Nasal Obstruction Symptom Evaluation scale (NOSE) questionnaires and active anterior rhinomanometry. Results. After treatment, significant improvement was observed in Group 2 vs Group 1 in terms of RQLQ (p = 0.011) and NOSE (p = 0.001) scores. In Group 2, significant differences were observed between before and after treatment for inspiratory total nasal resistance (p = 0.004). However, no significant differences vs. baseline were observed in Group 1. Conclusions. Our study shows that adding intranasal phototherapy with a combination of UVA, UVB and visible light therapy to nasal beclomethasone dipropionate treatment objectively improves nasal patency in patients with seasonal allergic rhinitis.
application/xml
1827-675X
907
en
Oya Kalaycioglu
https://creativecommons.org/licenses/by-nc-nd/4.0
ACTA Otorhinolaryngologica Italica
total nasal resistance
Effect of rhinophototherapy on nasal congestion in patients with seasonal allergic rhinitis
Text.Serial.Journal
https://www.actaitalica.it/
41
Rhinology
2021-05-14
2020-06-05
2021-05-17
2021-05-17
151-158
1
Oya Kalaycioglu
2021/05/14
10.14639/0392-100X-N0907
151
Department of Bioistatistics and Medical Information, Bolu Abant Izzet Baysal University Medical Faculty, Bolu, Turkey
1827-675X
total nasal resistance
158
Effect of rhinophototherapy on nasal congestion in patients with seasonal allergic rhinitis
https://www.actaitalica.it/article/download/907/578
41
ACTA OTORHINOLARYNGOLOGICA ITALICA 2021;41:151-158; doi: 10.14639/0392-100X-N0907




Rhinology


Effect of rhinophototherapy on nasal congestion
in patients with seasonal allergic rhinitis
Effetto della rinofototerapia sulla congestione nasale nei pazienti con rinite allergica
stagionale
Elif Karali1, Akif Gunes1, Ahmet Ural1, Isa Akin1, Emine Ozsari2, Oya Kalaycioglu3
1
  Department of Otorhinolaryngology, Bolu Abant Izzet Baysal University Medical Faculty, Bolu, Turkey; 2 Department of Pulmonology
Bolu Abant Izzet Baysal University Medical Faculty, Bolu, Turkey; 3 Department of Bioistatistics and Medical Information, Bolu Abant
Izzet Baysal University Medical Faculty, Bolu, Turkey


SUMMARY
Objective. The aim of the present study was to objectively and subjectively evaluate the ef-
fects of adding rhinophototherapy to intranasal beclomethasone dipropionate to treat nasal
congestion in patients with seasonal allergic rhinitis.
Method. Seventy-five seasonal allergic rhinitis patients were randomly divided into two
groups. Patients in Group 1 received intranasal beclomethasone dipropionate for two weeks
and patients in Group 2 had rhinophototherapy added to the same medical therapy as Group
1. The effectiveness of treatments was evaluated with the Rhinoconjunctivitis Quality of
Life Questionnaire (RQLQ), Nasal Obstruction Symptom Evaluation scale (NOSE) ques-
tionnaires and active anterior rhinomanometry.
Results. After treatment, significant improvement was observed in Group 2 vs Group 1 in
terms of RQLQ (p = 0.011) and NOSE (p = 0.001) scores. In Group 2, significant differenc-         Received: June 5, 2020
es were observed between before and after treatment for inspiratory total nasal resistance        Accepted: October 8, 2020
(p = 0.004). However, no significant differences vs. baseline were observed in Group 1.
Conclusion. Our study shows that adding intranasal phototherapy with a combination of             Correspondence
UVA, UVB and visible light therapy to nasal beclomethasone dipropionate treatment objec-          Elif Karali
tively improves nasal patency in patients with seasonal allergic rhinitis.                        Department of Otorhinolaryngology, Bolu Abant
                                                                                                  Izzet Baysal University Medical Faculty, Bolu,
KEY WORDS: rhinophototherapy, nasal congestion, seasonal allergic rhinitis,                       Turkey
rhinomanometry, total nasal resistance                                                            Tel. +90 3742534656. Fax +90 3742534615
                                                                                                  E-mail: elifkarali8181@gmail.com

RIASSUNTO                                                                                         Funding
Obiettivo. Valutare in maniera oggettiva e soggettiva gli effetti del dipropionato beclometa-     None.
sone con l’aggiunta della rhinofototerapia nel trattamento della rinite allergica stagionale.
Metodi. Settantacinque pazienti affetti da rinire allergica stagionale sono stati randomizza-     Conflict of interest
ti in due gruppi. Gruppo 1, trattamento con dipropionato beclometasone per due settimane.         The Authors declare no conflict of interest.
Gruppo 2, rinofototerapia in aggiunta al trattamento del gruppo 1. L’efficacia dei tratta-
menti è stata valutata con il Rhinoconjunctivitis Quality of Life Questionnaire (RQLQ), il          How to cite this article: Karali E, Gunes A, Ural
Nasal Obstruction Symptom Evaluation scale (NOSE) e la rinomanometria attiva anteriore.             A, et al. Effect of rhinophototherapy on nasal
Risultati. È risultata una differenza statisticamente significativa fra il gruppo 2 e 1 in ter-     congestion in patients with seasonal allergic rhi-
mini di RQLQ (p = 0,011) e NOSE (p = 0,001). Nel gruppo 2 sono risultate delle differenze           nitis. Acta Otorhinolaryngol Ital 2021;41:151-
nelle resistenze nasali (p = 0,004) prima e dopo il trattamento e nessuna differenza statisti-      158. https://doi.org/10.14639/0392-100X-N0907
camente significativa nel gruppo 1.
Conclusioni. L’aggiunta della fototerapia intranasale con UVA, UVB e luce bianca miglio-          © Società Italiana di Otorinolaringoiatria
ra i sintomi nei pazienti con rinite allergica stagionale.                                        e Chirurgia Cervico-Facciale

PAROLE CHIAVE: rinofototerapia, congestione nasale, rinite allergica stagionale,                                 OPEN ACCESS
rinomanometria, resistenza nasale totale
                                                                                                  This is an open access article distributed in accordance with
                                                                                                  the CC-BY-NC-ND (Creative Commons Attribution-Non-
                                                                                                  Commercial-NoDerivatives 4.0 International) license. The
                                                                                                  article can be used by giving appropriate credit and mentio-
Introduction                                                                                      ning the license, but only for non-commercial purposes and
                                                                                                  only in the original version. For further information: https://
Allergic rhinitis (AR) is a common inflammatory disease that affects 10%-                         creativecommons.org/licenses/by-nc-nd/4.0/deed.en




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40% of the population worldwide 1. Common symptoms               Table I. Allergen variance of the group 1and the group 2 according to skin
of AR are sneezing, itching, rhinorrhoea, nasal congestion,      prick test (SPT).
erythema and tearing eyes. Nasal congestion is usually                                               Treatment group
the most disturbing symptom experienced by AR patients            Allergen                   Group 1                          Group 2
and negatively affects the quality of life 2. Many different                                 (N = 33)                         (N = 31)
methods are used in medical treatment of AR. Intranasal           Grass mix                 23 (69.7%)                       21 (67.7%)
corticosteroids (INCS) are recommended by international           Tree mix                  15 (45.5%)                       13 (41.9%)
                                                                 Group 1: Intranasal beclomethasone dipropionate therapy. Group 2: Rhinophototherapy
guidelines as first-line drugs for patients with AR. INCS        with intranasal beclomethasone dipropionate therapy.
are considered to have high efficacy in controlling nasal
symptoms in AR 1,3. In particular, nasal beclomethasone di-
propionate has been shown to have positive effects on the        criteria 1. In addition to clinical symptoms, diagnosis was
severity of nasal symptoms and quality of life. It is also ef-   confirmed by a positive skin prick test performed using in-
fective in terms of decreasing eosinophils and lymphocytes       halant allergen extracts (Dermatophagoides pteronyssinus,
in nasal mucosa and is well-tolerated 4,5.                       Dermatophagoides farinea, grass mix, trees mix, dog, cat,
In some patients, symptoms cannot be reduced by medical          Cladosporium Herbarum, Aspergillus Fumigatus, Piume
treatment alone; in others, medical treatment options may        mix) (ALK, Hørsholm, Denmark). Histamine (10 mg/mL)
be limited for a variety of reasons. Alternative treatment       was used as a positive control and saline as a negative con-
modalities are thus required in these patients. Phototherapy,    trol. All patients had a positive skin prick test for tree and/
which has been used to treat inflammatory skin diseases,         or grass pollen allergens (wheal diameter ≥ 3 mm) (Tab. I).
has become an alternative treatment option for AR in re-         Patients with hypersensitivity to allergens other than pollen
cent years. Intranasal phototherapy in patients with AR has      were excluded from the study.
been reported to have similar effects to those seen in der-      All otorhinolaryngological physical examinations, includ-
matological diseases 6. The efficacy of the combination of       ing endoscopic examination, were performed.
UV-B, UV-A and high-intensity visible light (Rhinolight®)        Exclusion criteria were: significant nasal structural abnor-
in seasonal allergic rhinitis (SAR) has been demonstrated        malities such as nasal polyp, nasal septal deviation, naso-
in double-blind, placebo-controlled randomised clinical tri-     pharyngeal pathology, upper and lower acute respiratory
als 7-9. The therapeutic features of phototherapy are mostly     infection within two weeks, asthma and pregnancy. All pa-
attributed to its local immunomodulatory and immunosup-          tients in the study refrained from the following treatments
pressive effects. Phototherapy inhibits the synthesis and re-    for the duration indicated in the weeks before the start of the
lease of proinflammatory mediators from eosinophils, mast        study: systemic steroids for four weeks prior; nasal steroids
cells, basophils and T cells 8.                                  for two weeks prior; antihistamines for one week prior; and
Previous studies have reported an improvement in nasal           nasal decongestant drugs for the last three days prior.
congestion with rhinophototherapy in patients with AR;           Patients were divided into two randomly selected groups
however, the number of studies that have included objec-         in a 1:1 ratio, using a simple randomisation system for
tive evaluations is small 10. The aim of the present study       different treatment regimens. Simple randomisation was
was to objectively and subjectively evaluate the effects of      achieved with a sequence of random numbers from a com-
adding rhinophototherapy to intranasal beclomethasone di-        puter-generated sequence. A random number list was gen-
propionate to treat nasal congestion in patients with SAR.       erated in Microsoft Office Excel 2016.
                                                                 Intranasal beclomethasone dipropionate (200 mcg/day)
                                                                 was given to Group 1 (n = 33) for two weeks, and rhino-
Materials and methods
                                                                 phototherapy (5% UVB, 25% UVA, 70% visible light three
Study design                                                     times weekly for two weeks) was added to the intranasal
The study protocol was approved by the local ethics commit-      beclomethasone dipropionate (200 mcg/day) treatment in
tee in accordance with the Helsinki declaration (13.12.2018      Group 2 (n = 31).
n. 2018/239). Both written and verbal informed consents          Intranasal phototherapy was performed with the same de-
were obtained from all participants in the study.                vice (Rhinolight III; Rhinolight Ltd, Szeged, Hungary) by
This prospective randomised controlled study was con-            the same examiner. Each nostril was irradiated with in-
ducted between March and November 2019. Seventy-five             creasing doses three times per week for two weeks. Treat-
patients were included, each of whom had SAR for at least        ments lasted 2-3 minutes. The highest dose administered
two years. The study was carried out during the pollen           while gradually increasing doses was 2.4 J/cm2 given after
season. Diagnosis of SAR was based on the 2016 ARIA              an initial dose of 1.6 J/cm2 was applied for two minutes.



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The effectiveness of treatment was evaluated by the RQLQ         package in R version 3.6.1 (R Development Core Team,
and NOSE questionnaires, and active anterior rhinoma-            2010; www.R-project.org) 15.
nometry. The Rhinoconjunctivitis Quality of Life Ques-
tionnaire (RQLQ) and Nasal Obstruction Symptom Evalu-            Results
ation scale (NOSE) questionnaire were applied before and
after treatment together with rhinomanometry.                    Eleven patients (five in Group 1 and six in Group 2)
                                                                 dropped out for either poor compliance or upper respiratory
Efficacy of treatment                                            tract infections. Thus, 64 patients (33 in Group 1 and 31 in
The RQLQ is a 28-question diagnostic tool used to evalu-         Group 2) completed the study. Data from the dropouts was
ate adult patients (17 to 70 years old) with rhinoconjunc-       not included in the evaluation (Fig. 1).
tivitis 11. RQLQ covers the following seven domains: ac-         These two patient groups were very homogeneous in
tivity limitations; sleep problems; nose symptoms; eye           terms of age, gender and clinical findings. Demographic
symptoms; non-nose/eye symptoms; practical problems;             data are shown in Table II. Both groups had significant
and emotional function. Each item is graded on a seven-          improvements from baseline total RQLQ and NOSE
point scale (0 = not impaired at all; 6 = severely impaired)     scores after treatment. At the same time, the treatment by
and the score is the average of 28 responses. The Nasal          time interaction was found to be significant, which sug-
Obstruction Symptom Evaluation (NOSE) scale is a fre-            gests that the patterns of change in total RQLQ and NOSE
quently used quality of life questionnaire 12 which specifi-
cally focuses on nasal congestion before and after treat-
ment 13. The NOSE scale is composed of five questions
concerning the severity of nasal obstruction. Each item
is evaluated using a Likert scale (0 = not a problem to
4 = severe problem); these answers are summed and then
multiplied by five, for a total final NOSE score within a
range of 0 to 100.
Nasal airflow and nasal airway resistance were measured
objectively with active anterior rhinomanometry. In this
study, measurements were made with an SRE 2000 Rhi-
nometer (RhinoMetrics, Lynge, Denmark) device. All
measurements were performed without decongestion un-
der the same standard conditions. Airway resistances were
measured with right, left and total airflows in all patients.
The evaluation was carried out at a fixed 150 Pascal pres-
sure agreed upon by the European Rhinomanometry Stand-
ardization Committee in 1984. Left (RL) and right (RR)
unilateral nasal resistance values were calculated according     Figure 1. The Consolidated Standards of Reporting Trials (CONSORT) flow-
to Ohm’s law 14. Total nasal resistance was calculated using     chart.
the formula RL × RR / RL × + RR.                                 Group 1, intranasal beclomethasone dipropionate therapy Group 2, Rhinopho-
                                                                 totherapy with intranasal beclomethasone dipropionate therapy.
Statistical analysis
Data are presented as means ± SD. Repeated-measures              Table II. Demographic data for treatment groups.
ANOVA was used to assess treatment effects and chang-
                                                                                           Treatment group
es at the end of the treatment, as well as the variation of
                                                                                           Group 1              Group 2                  p
mean values before and after treatment within the treatment                                (n = 33)             (n = 31)
groups. The differences between treatment groups at differ-
                                                                  Age                  32.45 ± 12.27        28.84 ± 10.68             0.215a
ent stages were further evaluated Student’s t-tests. Holm-
                                                                  Gender                                                              0.479b
Bonferroni correction was employed to adjust for multiple
                                                                    Female               23 (69.7%)           19 (1.3%)
testing. The results were assessed at a level of p < 0.05. The
                                                                    Male                 10 (30.3%)           12 (37.5%)
analyses were performed using the Statistical Package for
                                                                 Mean ± SD, or n (%); a Independent samples t-test; b Pearson’s chi-square test.
Social Sciences 25.0 for Windows (SPSS Inc., Chicago,            Group 1: Intranasal beclomethasone dipropionate therapy. Group 2: Rhinophototherapy
Illinois, USA). Figures were generated using the ggplot2         with intranasal beclomethasone dipropionate therapy.




                                                                                                                                               153
E. Karali et al.




Figure 2. Changes in nasal symptoms, eye symptoms, total RQLQ and NOSE scores after treatment, compared to before treatment (figures represent mean ±
SEM. p-values obtained from two-way repeated measures ANOVA).


scores were different in Group 1 and Group 2 (p < 0.001)                    these RQLQ domain scores implies that the changes in
(Fig. 2).                                                                   scores over time were different depending on the treat-
When total RQLQ scores were considered, no significant                      ment group. Further comparisons of treatment groups
differences were observed between groups before treat-                      for nasal and eye symptoms scores showed significant
ment (p = 0.102). However, the differences between groups                   differences after treatment (p = 0.001, p = 0.009), while
after treatment were significant (p = 0.011). Although total                there was no difference between groups before treatment
RQLQ scores decreased after treatment in both groups, the                   (p = 0.753, p = 0.224).
reduction in total RQLQ scores after treatment was larger                   When RQLQ domains were compared within groups, both
in Group 2 compared to Group 1 [mean differences: -1.16                     treatment groups showed significant improvements from
(95%CI: -1.45, -0.87) vs -0.48 (95%CI: -0.69, -0.26)].                      baseline RQLQ domain scores after treatment (p < 0.01),
When the effect of treatments was assessed for the RQLQ                     except for the eye symptoms score in Group 1 (p = 0.625)
domain scores, the overall group effect was significant for                 (Tab. III). When the change in eye symptoms scores were
nasal (p = 0.002) and eye (p < 0.001) symptoms (Fig. 2).                    examined, no significant improvements in eye symptoms
In addition, a significant group by time interaction for                    were observed in Group 1 after treatment (Fig. 2).



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Table III. Comparison of RQLQ (Rhinoconjunctivitis Quality of Life Questionnaire) domains before and after treatment.
 RQLQ Domain                             Treatment Group                       Before treatment                   After treatment                                        pa
                                                                                  (mean ± SD)                       (mean ± SD)
 Sleep                                                 Group 1                               2.06 ± 1.14                             1.55 ± 0.94                       0.001
                                                       Group 2                               2.59 ± 0.95                             1.25 ± 0.67                      < 0.001
                                                          pb                                    0.045                                   0.149
 Non-nose/eye symptoms                                 Group 1                               2.06 ± 1.30                             1.73 ± 1.21                       0.006
                                                       Group 2                               1.88 ± 1.13                             1.22 ± 0.91                      < 0.001
                                                          pb                                    0.541                                   0.060
 Practical problems                                    Group 1                               2.09 ± 1.16                             1.61 ± 1.09                       0.001
                                                       Group 2                               2.22 ± 0.75                             1.19 ± 0.78                      < 0.001
                                                          pb                                    0.600                                   0.080
 Nasal symptoms                                        Group 1                               2.88 ± 0.86                             1.91 ± 0.88                      < 0.001
                                                       Group 2                               2.94 ± 0.62                             1.25 ± 0.67                      < 0.001
                                                          pb                                    0.753                                   0.001
 Eye symptoms                                          Group 1                               1.73 ± 1.13                             1.79 ± 1.02                       0.625
                                                       Group 2                               2.06 ± 1.08                             1.19 ± 0.74                      < 0.001
                                                          pb                                    0.224                                   0.009
 Limited activity                                      Group 1                               1.67 ± 0.99                             1.18 ± 0.95                       0.007
                                                       Group 2                               2.31 ± 0.97                             1.13 ± 0.75                      < 0.001
                                                          pb                                    0.010                                   0.790
 Emotional functions                                   Group 1                               1.73 ± 1.07                             1.12 ± 0.93                       0.002
                                                       Group 2                               2.31 ± 0.86                             1.00 ± 0.80                      < 0.001
                                                          pb                                    0.018                                   0.576
 Total RQLQ score                                      Group 1                               2.03 ± 0.76                             1.55 ± 0.78                      < 0.001
                                                       Group 2                               2.33 ± 0.69                             1.17 ± 0.59                      < 0.001
                                                          pb                                    0.102                                   0.011
Mean ± SD; a Paired samples t-test; b Independent samples t-test; bold p-values indicate statistical significance based on Holm-Bonferonni adjustment for multiple testing.
Group 1: Intranasal beclomethasone dipropionate therapy. Group 2: Rhinophototherapy with intranasal beclomethasone dipropionate therapy.



When total NOSE scores were considered, no significant                                       the group and time interaction was not (Fig. 3). In Group
differences between groups were observed before treat-                                       2, significant differences were observed between results
ment (p = 0.268). However, the differences between groups                                    taken before and after treatment for inspiratory total na-
after treatment were significant (p = 0.001) (Tab. IV). The                                  sal resistances (p = 0.004) and inspiratory total nasal flow
improvement in the total NOSE scores after treatment was                                     (p = 0.001) (Tab. V). However, in Group 1, no significant
larger in Group 2 as compared to Group 1 [mean differ-                                       differences were observed in results taken before and after
ences: -38.9 (95%CI: -46.62, -30.16) vs -15.91 (95%CI:                                       treatment in terms of rhinomanometry parameters.
-21.40, -10.42)].                                                                            Rhinophototherapy was generally well-tolerated. There
When rhinomanometry parameters were considered, al-                                          were no side effects other than mild dryness in the nasal
though the overall group effect was statistically significant,                               mucosa, which was not severe enough to stop the treatment.


Table IV. Comparison of NOSE (Nasal Obstruction Symptom Evaluation) scores before and after treatment.
                                        Treatment group                   Before treatment                                         After treatment                       pa
                                                                            (mean ± SD)                                             (mean ± SD)
 Total NOSE score (%)                                  Group 1                             61.67 ± 22.00                            45.76 ± 22.32                     < 0.001
                                                       Group 2                             67.10 ± 16.27                            28.71 ± 14.72                     < 0.001
                                                          pb                                   0.268                                    0.001
Mean ± SD; a Paired samples t-test; b Independent samples t-test; bold p-values indicate statistical significance based on Holm-Bonferonni adjustment for multiple testing.
Group 1: Intranasal beclomethasone dipropionate therapy. Group 2: Rhinophototherapy with intranasal beclomethasone dipropionate therapy.




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E. Karali et al.




Table V. Comparison of rhinomanometric parameters before and after treatment.
                                        Treatment group             Before treatment (mean ± SD)                           After treatment (mean ± SD)                   pa
 İnspiratory total nasal                               Group 1                               0.33 ± 0.12                             0.28 ± 0.08                       0.018
 resistances
                                                       Group 2                               0.35 ± 0.16                            0.24 ± 0.08                        0.004
                                                          pb                                    0.578                                  0.074
 İnspiratory total nasal flow                          Group 1                             516.35 ± 144.8                         579.59 ± 177.73                      0.042
                                                       Group 2                            516.57 ± 158.75                         671.12 ± 170.60                      0.001
                                                          pb                                    0.994                                  0.040
Mean ± SD; a Paired samples t-test; b Independent samples t-test; bold p-values indicate statistical significance based on Holm-Bonferonni adjustment for multiple testing.
Group 1: Intranasal beclomethasone dipropionate therapy. Group 2: Rhinophototherapy with intranasal beclomethasone dipropionate therapy.




Figure 3. Changes in Rhinomanometry parameters after treatment, compared to before treatment (figures represent mean ± SEM. p-values obtained from two-
way repeated measures ANOVA).



156
                                                                                                 Rhinophototherapy for nasal congestion




Discussion                                                          light therapy is an effective therapeutic procedure to treat
                                                                    AR. In their clinical study, Kennedy et al. 23 demonstrated
SAR has a significant negative affect on the quality of
                                                                    that intranasal phototherapy is effective in reducing nasal
life 16. The symptom of AR that most severely impacts               symptoms – but not eye symptoms – in patients with AR
quality of life is nasal congestion. INCS are given as the          susceptibility to a single allergen or a combination of mul-
first treatment option in international guidelines due to           tiple allergens. Our study showed that nasal beclometha-
their effectiveness in relieving the nasal symptoms of AR.          sone dipropionate alone did not significantly decrease eye
In a meta-analysis, INCS were reported to be superior to            symptoms, but, when combined with rhinophototherapy,
OA in improving nasal symptoms and quality of life in               eye symptoms were significantly decreased.
patients with AR 17. However, many patients report that              A recent meta-analysis has revealed that rhinophotothera-
these pharmacotherapies are insufficient to control their           py is more effective in reducing symptoms and improving
allergic symptoms 18. Therefore, alternative treatment mo-          quality of life in AR patients compared to those with per-
dalities are needed. In this prospective controlled study, we       ennial AR 24. The authors reported that studies evaluating
showed that the addition of rhinophototherapy to intranasal         objective airflow parameters were required to confirm the
beclomethasone dipropionate therapy improves quality of             effectiveness of phototherapy in AR 24.
life and objectively improves nasal patency in patients with        Albu and Baschir showed that rhinophototherapy had similar
SAR. To our knowledge, our study is the first to demon-             efficacy as intranasal azelastine in reducing symptoms in pa-
strate that rhinophototherapy objectively improves nasal            tients with SAR 10. In their study, TNSS scores, RQLQ scores
patency.                                                            and active anterior rhinomanometry were used before and
Based on the results of their randomised double-blind               after treatment in the evaluation of patients. However, the
controlled study, Koreck et al. 7 proposed intranasal photo-        decrease in nasal resistance was not significant after treat-
therapy with a combination of UVA, UVB and visible light            ment in either group. In contrast, in our study, when nasal
as treatment for patients with AR who did not respond to            beclomethasone dipropionate treatment was applied alone,
pharmacotherapy. Various studies have shown that rhino-             no significant decrease was observed in nasal resistance after
phototherapy reduces AR symptoms and improves quality               treatment; however, when combined with rhinophotothera-
of life 19-21. In these studies, the effectiveness of rhinopho-     py, a significant reduction in nasal resistance was observed.
totherapy was evaluated with visual analog scores (VAS),            The strength of our study is that the results are based on
Total Nasal Symptom Scores (TNSS) and RQLQ scores.                  subjective and objective measurements that are strongly
However, in our study, two other measurements were used             recommended in the literature. There are several limita-
in addition to the RQLQ questionnaire: the NOSE ques-               tions to this study. First of all, the physicians who applied
tionnaire (which measures the effect of nasal obstruction           the treatments as well as patients could not be blinded to
on quality of life) and rhinomanometry (which provides an           the study design. The results were evaluated by a different
objective measurement of nasal congestion).                         researcher in order to minimise the negative consequences
In their pilot study, Garaczi et al. 19 compared the clini-         of this study design. Secondly, nasal resistance was meas-
cal effectiveness of rhinophototherapy with fexofenadine            ured without the use of a decongestant. Type of nasal ob-
hydrochloride. The results were evaluated by changes in             struction should be determined by rhinomanometry before
the TNSS scores and the authors reported that intranasal            and after topical decongestant administration. Thirdly, en-
phototherapy was more effective than fexofenadine HCl in            vironmental pollen load was not taken into consideration.
patients with SAR 19.                                               The possible difference in pollen counts may have affected
Tatar et al. 20 reported that the addition of rhinophotothera-      the results as well. Another limitation of this study is that
py to medical therapy (topical mometasone furoate and oral          the satisfaction index of patients was not evaluated.
levocetirizine) had a better effect on quality of life in persis-
tent AR than medical treatment. In a randomised, prospec-
tive, placebo-controlled study, Cingi et al. 21 used TNSS
                                                                    Conclusions
scores to evaluate the efficacy of rhinophototherapy (UV-A,         Adding intranasal phototherapy with a combination of
UV-B, visible light) in patients whose symptoms could not           UVA, UVB, and visible light therapy to nasal beclometha-
be controlled with pharmacotherapy; it was concluded that           sone dipropionate treatment positively affects the quality of
it was an effective method to improve disease symptoms              life and objectively improves nasal patency in patients with
and quality of life. The randomised, single blind, placebo-         SAR. Our study suggests that the addition of rhinophoto-
controlled study by Alyasin et al. 22 showed that intranasal        therapy to other medical treatments can be implemented on
phototherapy with a combination of UVA, UVB and visible             a large scale in the standard treatment of SAR.



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Acknowledgements                                                                    septal deviation. Auris Nasus Larynx 2012;39:275-279. https://doi.
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