Background:  Rhinoplasty patients frequently require functional correction of airway obstruction due to valvular obstruction.  The etiology of that obstruction is often unclear on physical examination.  A normal appearing LLC or ULC may be functionally abnormal.  The Cottle sign does provide an estimate of functional obstruction but not its exact location.  The modified Cottle is uncomfortable for the patient and varies depending on how much outward pressure the examiner places on the valve.  A test is needed that evaluates the functional capacity of the ULC and LLC (& rims) separately, one that is replicable, and best predicts which region is in need of cartilaginous reconstruction. 

Methods:Twenty five patients who had airway obstruction symptoms and signs referable only to the ULC and/or LLC (rims) were studied. They exhibited either weak or narrow middle 1/3 of the nose and weak and/or collapsing alar rims. They were tested for airway improvement by the standard Cottle test but also by applying a BreatheRight nasal strip to the middle 1/3 of the nose and again to the lower 1/3 of the nose (along the alar rims from one side to the other) – Fig. 1.  Patients were asked if the strip made their inspiratory airway better, worse, or no different.  They were given a functional classification:

BR 0 - no airway obstruction due to ULC/LLC malfunction.

BR I -  improvement with strip ULC

BR II - improvement with strip on LLC (& rims)

BR III -improvement with strips on both ULC and LLC (& rims)

All underwent surgical correction involving grafts (spreader, lateral crural strut, rim, etc.). Correlations were sought between 1) the new BR classification, 2) the Cottle sign, 3) the physical integrity of the ULC /LLC and 4) surgical outcomes.

Results: Of the 25 patients, on physical examination, 7 had an abnormal ULC by palpation 8 had abnormal LLC  by palpation. In10 patients both regions were abnormal. The Cottle test was non-specifically positive in all but one.  The preop physical findings (valve palpation) correlated with the intraop and postop results in only 19 patients.  However, the BR rating correlated with intraop and postop results in 24 of the 25 patients. Statistical correlation was done with McNemar's test.

Conclusions: Valvular nasal function (related to the ULC /LLC cartilages) is easily classified by using nasal strips. The BR test is a more specific test than the Cottle test.  It is more comfortable for the patient, and more replicable than the modified Cotttle test.  It is also one of the best means of predicting surgical outcome.

Fig. 1. BreatheRight Strip applied to the external nasal valve region to assess airway obstruction.