The handkerchief test is a simple diagnostic technique used to assess nasal airflow and detect nasal obstruction. It involves occluding one nostril at a time with a handkerchief and having the patient gently blow out of the open nostril. The test provides information about airflow through each nasal passage and can identify structural problems or mucosal congestion causing obstruction.
What is the purpose of the handkerchief test?
The main purposes of the handkerchief test are:
- Evaluate nasal patency (openness) of each nasal passage
- Screen for nasal obstruction or blockage
- Determine whether obstruction is unilateral or bilateral
- Distinguish between structural versus mucosal causes of obstruction
- Assess septal deviations or nasal polyps
- Monitor changes in nasal airflow over time or with treatments
By comparing airflow through each side, the handkerchief test can localize blockages and elucidate patterns of obstruction. This helps identify appropriate treatments to resolve the obstruction.
When is the handkerchief test performed?
The handkerchief test is commonly performed when patients present with:
- Nasal congestion or stuffiness
- Chronic nasal obstruction
- Snoring or sleep disordered breathing
- Unilateral nasal symptoms
- Post-nasal drip or rhinorrhea
- Recurrent sinus infections
- Facial pain or pressure
It may be used prior to imaging studies like CT scans or endoscopy to determine areas of interest. The test is simple, inexpensive, and can be repeated over time to follow responses to medical or surgical treatment.
How is the handkerchief test performed?
The handkerchief test involves the following basic steps:
- Have the patient sit upright in a chair
- Provide a handkerchief, tissue, or cotton ball to occlude the nostrils
- Ask the patient to breathe through the mouth with lips sealed for a few cycles
- Occlude one nostril completely by pressing the handkerchief against the lateral nasal wall
- Instruct the patient to gently blow out of the open nostril while keeping mouth closed
- Assess the airflow through the open passage subjectively on a scale of 0 to 2:
- 0 – no airflow
- 1 – reduced airflow
- 2 – normal airflow
- Repeat the procedure on the opposite nostril
- Compare airflow between right and left nasal passages
No special equipment is required. The clinician occlusion and assesses airflow based on resistance felt against the handkerchief. Airflow through each nasal passage is graded and documented.
Interpreting the results
The handkerchief test results are interpreted by comparing airflow grades between the two nasal passages:
- Equal airflow – Suggests normal nasal patency without obstruction
- Unilateral low airflow – Indicates obstruction primarily affecting one nasal passage, often due to septal deviation or nasal polyps
- Bilateral low airflow – Suggests diffuse mucosal congestion, chronic rhinitis, or turbinate hypertrophy
- Unilateral high, contralateral low airflow – Can occur with large septal spurs or deviations obstructing one side
- Alternating high/low airflow – May indicate dynamic nasal cycle with alternating congestion
The pattern of obstruction provides useful clinical information to target appropriate treatments.
Advantages of the handkerchief test
Key advantages of the handkerchief test:
- Simple and fast to perform
- Non-invasive and well tolerated
- No equipment or costs required
- Provides lateralizing information on location of obstruction
- Can differentiate structural versus mucosal causes
- Allows dynamic retesting after treatments
- Can be easily taught to patients for home monitoring
As a basic screening test, the handkerchief test offers valuable clinical data without requiring specialized resources. It can guide the need for additional workup or imaging.
Limitations of the handkerchief test
Limitations of the handkerchief test include:
- Subjective assessment of airflow
- Not quantitative like rhinomanometry
- Dependent on patient cooperation and effort
- Cannot identify specific anatomical problems
- Not helpful in young children or frail elderly
- Does not assess complex nasal physiology
While useful for basic screening, the handkerchief test has limited accuracy and reliability compared to formal objective measurements. Advanced tests may be required to fully evaluate nasal obstruction.
When should other tests be performed?
Other diagnostic tests may be warranted if the handkerchief test shows:
- Unclear or ambiguous results
- Persistent unilateral obstruction
- High suspicion of underlying pathology
- No improvement after medical therapy
- Being considered for surgery
Additional tests may include:
- Rhinomanometry – measures nasal airflow resistance
- Acoustic rhinometry – assesses nasal cavity dimensions
- Peak nasal inspiratory flow (PNIF) – quantifies inspiratory airflow
- Nasal endoscopy – visualizes nasal anatomy
- CT or MRI imaging – defines sinus or nasal structural abnormalities
These tests provide objective, anatomically detailed information to complement the handkerchief test. They are often required before planning surgery.
Conclusion
The handkerchief test is a simple and effective preliminary screening tool for evaluating nasal obstruction. By comparing airflow between nostrils, it can detect unilateral or bilateral blockages, differentiate mucosal versus structural causes, and monitor responses to treatment. While subjective, it provides valuable clinical information to guide management. More advanced testing is reserved for unclear or high-risk cases requiring surgery. Used appropriately, the handkerchief test is a fast diagnostic aid requiring only basic supplies and clinical skills.
| Purpose | Screen for nasal obstruction, compare airflow between nostrils |
|---|---|
| Indications | Nasal congestion, obstruction, snoring, recurrent sinusitis, unilateral symptoms |
| Procedure | Occlude each nostril separately, have patient blow out other side, assess airflow |
| Interpretation | Compare airflow grades between nostrils, unilateral vs bilateral reduction |
| Advantages | Simple, fast, non-invasive, no equipment needed, dynamic retesting |
| Limitations | Subjective, qualitiative data, low accuracy, limited information |
| Additional testing | Rhinomanometry, acoustic rhinometry, nasal endoscopy, imaging |