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2.4Function Tests
2.4.1Breathing Tests
Nasal breathing can be investigated by simple
observational tests that can be carried out in the office as
part of a rhinologic examination, and by more sophisticated
quantitative tests such as rhinomanometry, acoustic
rhinometry (not a real breathing test), measurement of
inspiratory peak flow, and anemometry, which require
special instruments.
Observational Tests
Observational tests are carried out as part of our standard
rhinological examination since they are not time-consuming
and do not require special instruments. They are not
quantitative, however, and their outcome cannot be
recorded. Some of them were suggested over a century
ago, such as the observation of alar movement and of
breathings sounds.
Breathing Sounds
Normal respiration: The patient is asked to breathe
quietly through the nose while the examiner listens to
the inspiratory and expiratory breathing sounds. At the
same time, the examiner observes the movements of
the lateral nasal wall. This is first performed with both
nostrils open, then with the right and left nostril closed
alternately. This may be done by gently sealing the
nostril with the inside of the thumb in such a way that
the lobule is not distorted.
Forced inspiration: The sequence is repeated during
forced inspiration. The examiner carefully watches the
movements of the alae and looks for any retraction of
the lateral nasal wall (▶ Fig. 2.141a, b).
Fig. 2.141a, b The nostrils and alae are observed during normal and forced
inspiration for inspiratory insufficiency of the lateral nasal wall (“alar collapse”).
This simple test must be performed in all patients who
complain of inspiratory breathing obstruction. It is the
only way to determine the level of functional stenosis of
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the anterior nasal segment (area 1, nostril and
vestibule, and area 2, valve area).
OO Phenomenon
In a tension nose (see ▶ Prominent-Narrow Pyramid Syndrome
(Tension Nose)), the tip is narrow and may be pulled down
slightly by the tension of the stretched alae and columella
(positive “OO phenomenon”). By puckering the lips, as
when pronouncing the vowel sound “OO,” the tip is drawn
down and backward due to the tension (overstretch) of the
columella and the upper lip (▶ Fig. 2.142).
Fig. 2.142Positive “OO phenomenon.” When the lips are puckered, as by pronouncing
the vowel sound “OO,” the tip is drawn down and backward.
Columella Narrowing Test (Nostril Test)
The lower half of the columella is narrowed by means of a
forceps to examine the effect of widening the nostril and
vestibule on inspiration. The patient is asked whether this
influences breathing, while the observer studies how
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narrowing the columella affects alar movement (▶ Fig.
2.143).
Fig. 2.143Columella narrowing test. The lower half of the columella is narrowed with a
forceps to test alar insufficiency.
Valve Opening Test (Cottle Test)
The skin over the upper margin of the piriform aperture is
pulled laterally and slightly upward in order to widen the
valve area (▶ Fig. 2.144). The patient is asked if this affects
inspiratory breathing, while the examiner observes the
effect on the valve area. This simple test may corroborate
the existence of a valve problem. Most patients suffering
from valvular stenosis have already discovered the positive
effect of this maneuver. They sometimes apply it to help in
falling asleep, using tape or a finger. It is important to use
the thumb or one finger. Otherwise, the whole nasal
entrance will be opened, whereby the test loses its
specificity.
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Fig. 2.144Cottle test. The lateral lobular wall is pulled laterally and slightly upward to
examine inspiratory valvular insufficiency.
Cotton Ball Test/Breathe-Right Nasal Strip
The effect of artificially widening the valve area can also be
determined by the “cotton ball test” or by applying a
Breathe-Right nasal strip.
A small ball of cotton wool is positioned with a bayonet
forceps at the valve angle to study the effect of widening
the valve area (▶ Fig. 2.145). Alternatively, a Breathe-Right
nasal strip may be used. A positive outcome of this test
suggests that widening the valve by septal pyramid surgery,
valve surgery, or a spreader graft will very likely improve
nasal breathing.
Fig. 2.145Cotton ball test. A cotton ball is positioned at the valve angle to examine the
effect of widening the valve area.
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Quantitative Tests
History
The importance of nasal breathing was not fully recognized
until the 1870s. The first measurements of nasal breathing
date from the last decades of the 19th century. In 1889,
Zwaardemaker introduced the first clinical breathing test
using a calibrated cold mirror to measure and compare the
amount of air exhaled through the right and left nostrils.
In the first half of the 20th century, various manometric
techniques were developed. The development of the
pneumotachograph made dynamic recording of respiration
possible, which led to the development of modern
rhinomanometry in the 1960s. Thanks to the work of
several pioneers in different countries (e.g., Cottle, Spoor,
Masing, Bachmann, Broms, Kern, and Cole),
rhinomanometry gradually became a standardized
technique. This method allows the recording of nasal
pressure in relation to inspiratory and expiratory flow in an
XY diagram. Following various improvements, the
technique was finally standardized by the “International
Standardization Committee on Objective Assessment of the
Nasal Airway” (ISCOANA) in 1984 and 2005 ([29], [28]).
Acoustic rhinometry was devised as a method to measure
the cross-sectional area and volume of the nasal cavity by
[113]. It is thus not a breathing test per se, but informs us
about the geometry of the nasal cavity. It was further
developed by [185] and [304]. A report on its use and
standardization can be found in the 2005 ISCOANA report.
In more recent years, measurement of nasal peak
inspiratory flow (NPIF) has been added as a simple,
although less reliable, method that may be used for clinical
screening purposes.
Finally, anemometry is a method that measures air velocity
over time, but is not directly proportional to resistance or
flow.
Objective Breathing Tests
Rhinomanometry
Rhinomanometry has become a standardized technique and
the most commonly used quantitative breathing test. It
measures the relationship between flow and pressure for
each nasal cavity separately. Different methods have been
suggested: anterior versus posterior rhinomanometry and
active versus passive rhinometry. Active anterior
rhinomanometry has become the method of choice.
Active Anterior Rhinometry (AAR)
In active anterior rhinomanometry, the pressure difference
(Δp) between the nostril and the nasopharynx is measured
as a function of airflow for each nasal cavity separately.
An airtight transparent mask is placed over the nose of the
test subject. The mask is connected to a
pneumotachograph, which measures airflow through the
tested side. The pressure difference between the nostril
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