214 Fig. 5 Distribution of ﬁndings among a sample of the normal population (asymptomatic patients seeking non-nasal cosmetic sur- gery). Note that some exhibited abnormal valves at examination, and some exhibited positive Cottle test results. The nasal strip improved the airway for a signiﬁcant number of the asymptomatic patients The nasal strip test is a functional test. It is especially helpful in cases in which it is not obvious at the physical exam that the valve is collapsed. For example, the middle third of the nose may appear normal and show no abnor- mality at palpation although the nasal strip suggests otherwise. The nasal strip test also is helpful in those few cases that do not show improvement of an apparently collapsed or dysfunctional valve with use of the nasal strip. In these cases, the nasal strip test should be a warning to the surgeon that surgical correction of the valve may not produce the desired result and that he or she should be looking elsewhere for a solution to the airway problem. The normal population [10, 11], perhaps excepting the African-American population in one study [12], is known to be improved by nasal strips. The valvular function of most people is not necessarily abnormal, yet they subjectively experience improved airﬂow with the nasal strips. Athletes frequently use these strips to increase their nasal airﬂow. In some studies (including those with cadavers) [13], the nasal strip increased mean nasal cross-sectional area by 17 to 37% [14, 15] and airﬂow by 27% [15]. The results of experiment 2 conﬁrm studies showing that nasal airﬂow is improved in a signiﬁcant portion of the normal population. Some of the normal population may have unrecognized or asymptomatic valvular problems. More likely, much of the population may exhibit a beneﬁt from nasal strips by achieving a greater than normal nasal airﬂow. It could be argued therefore that much of the improved results with nasal strips seen in the patients of Experiment 1 are not reﬂecting abnormal valvular function but simply increasing airﬂow to aforementioned normal values. That may very well be, but this does not detract from the fact that as a functional test, it predicts which valve will beneﬁt from surgical correction. Interestingly, the subjective airﬂow of normal patients was increased more by the BR test than by the Cottle test, indicating that the nasal strip is a more powerful test than the examining ﬁngers. 123 Aesth Plast Surg (2011) 35:211–215 To prove conclusively that the BR classiﬁcation leads to a better diagnosis and outcome, it would have been nec- essary to exclude the BR classiﬁcation from the decision as to which valve should receive surgery. Ideally, a study should base the surgical decision on the physical ﬁndings and the Cottle test alone. Then the clinician would correlate the successful outcome with the BR classiﬁcation it was given. However, early in the study, it was readily apparent that the functional nasal strip test was so superior to the Cottle test and provided such vital information as to which valve should receive surgery that it was impossible to ignore it and subject the patient to surgery without using that information. Nasal airway obstruction can result from other causes (septal deformities, turbinate hypertrophy, drooping nasal tip) that cannot be evaluated by the BR test. It is reasonable to ask whether the BR test is useful when these other pathologies coexist, and they often do. The answer is yes, with few exceptions. Septal deformities and turbinate hypertrophy tend to obstruct expiratory ﬂow, which we test for separately. Unless the septal or turbinate deformity is almost com- pletely occluding the vestibule, the patient is almost always able to inspire to some degree. That amount of inspiration will be enhanced if in fact the damaged valve or valves are opened further by the nasal strip. One caveat is in order, however. When septal deviation is severe, a false-positive test can be expected. Under those circumstances, the valve on the obstructed side is closer to the septum, and (by Bernoulli’s principle) collapse of the valve is more likely to occur. Correction of the septal deviation alone without valvular correction then would be expected to reverse a positive BR. However, severe septal deviations of this kind are in the minority. The BR test will be helpful in the vast majority of cases. It is of interest that the BR test proved to be more speciﬁc than the Cottle test. That probably is because the force of the examining ﬁngers to open the nose is at the cheek level only. On the other hand, the nasal strip expands the actual side walls of the nose (Fig. 6). It is more speciﬁc because it is narrower than the ﬁngers and can be applied directly either to the middle third of the nose or along the alar rims. Dr. Cottle’s test is an ingenious, quick way to evaluate overall valvular function. The BR test is simply an improvement. Conclusions Inspiratory nasal function (related to ULC/LLC cartilages) is easily evaluated and classiﬁed by using nasal strips. The BR test is more speciﬁc and powerful than the Cottle test.