Aesth Plast Surg (2011) 35:211–215 DOI 10.1007/s00266-010-9589-4 O R I G I N A L A R T I C L E Nasal Strips for Evaluating and Classifying Valvular Nasal Obstruction Ronald P. Gruber • Alexander Y. Lin • Todd Richards Received: 31 December 2009 / Accepted: 2 July 2010 / Published online: 17 November 2010 The Author(s) 2010. This article is published with open access at Springerlink.com Abstract Background A normal-appearing upper lateral cartilage (ULC) or lower lateral cartilage (LLC) may be functionally abnormal. The Cottle sign estimates obstruction but not its exact location. A test is needed that evaluates the ULC and LLC separately. Methods The study included 30 patients with airway obstruction symptoms and signs referable only to the nasal valves. They received a Cottle test and a Breathe-Rite nasal strip to the middle third of the nose and again to the lower third (the rims). The patients were asked whether the strip made their inspiration better, worse, or no different and classiﬁed as BR 0 (no airway obstruction due to ULC/LLC dysfunction), BR I (improvement with the strip on the ULC), BR II (improvement with the strip on the LLC), or BR III (improvement with strips on both the ULC and the LLC, independently). All the patients underwent surgery involving spreader grafts, lateral crural struts, suture tech- niques, and the like. Correlations were sought between the BR classiﬁcation, Cottle sign, and physical integrity of the ULC/LLC. Results A total of 12 patients required internal valve correction, whereas 8 required external valve correction, and 10 required correction of both. The Cottle test was nonspeciﬁc because most patients in all the groups exhib- ited a positive Cottle. However, the BR classiﬁcation was speciﬁc, correlating with functional outcomes for 27 of the R. P. Gruber (&) T. Richards Division of Plastic and Reconstructive Surgery, Stanford University, Stanford, CA, USA e-mail: rgrubermd@hotmail.com R. P. Gruber A. Y. Lin Division of Plastic and Reconstructive Surgery, University of California (SF), San Francisco, CA, USA 30 patients. The McNemar test showed a signiﬁcant cor- relation (V2 = 9.09091; P = 0.00257) between physical ﬁnding and BR score. Conclusions Inspiratory nasal function (related to ULC/ LLC cartilages) is easily classiﬁed using nasal strips. The BR test is more speciﬁc and powerful than the Cottle test. Keywords Breathe-Rite Cottle test External valves Inspiratory obstruction Internal valves Nasal strips Nasal valves Valvular nasal airway obstruction is arguably as important a cause of nasal airway obstruction as septal and turbinate deformities if not more important [1]. This has prompted many surgeons [2–7] to devise a variety of procedures to treat the problem if it can be diagnosed. Preoperative evaluation of valvular dysfunction usu- ally is based on gross examination of the internal and external valves (narrowness or weakness of the middle third of the nose; deformity or weakness of the alar rims) in conjunction with a diminution of inspiratory air ﬂow. The Cottle test allows for an opening of these valves to see what improvement results by spreading the lateral nasal walls apart. In terms of predicting the beneﬁt of valvular reconstruction, it is a good test in that it provides a functional evaluation of the valves. This is particularly important when the valves are not obviously deformed as noted by inspection and palpation. However, it is inaccurate because it is not speciﬁc for any one valve. The examining thumb is as wide as the entire nasal wall. The modiﬁed Cottle test [8, 9], which involves insertion of a cotton applicator inside the nose to elevate the lateral nasal wall, is a much improved version of the original test 123