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International Journal of Otorhinolaryngology
2020; X(X): XX-XX
doi: 10.11648/j.XXXX.2020XXXX.XX
ISSN: 2472-2405 (Print); ISSN: 2472-2413 (Online)
Assessment of Nasal Breathing Using Lip Taping: A Simple and Effective Screening Tool.
Author List:
Soroush Zaghi1*; Cynthia Peterson1; Shayan Shamtoob1; Brigitte Fung2; Daniel Kwok-keung Ng3; Triin
Jagomagi4; Nicole Archambault5; Bridget O’Connor6; Kathy Winslow7; Zahra Peeran8; Miche’ Lano9;
Janine Murdock9; Sanda Valcu-Pinkerton1; Lenore Morrissey10.
Affiliations/ Institution:
1The Breathe Institute, Los Angeles, CA, USA
2Kwong Wah Hospital, Hong Kong SAR
3Hong Kong Sanatorium & Hospital, Hong Kong SAR
4University of Tartu, Unimed United Clinics, Estonia
5Minds in Motion, Santa Monica, CA, USA
6O’Connor Dental Health, Ireland
7Independent Researcher, Halfmoon Bay, USA
8Happy Kids Dental Planet, Agoura Hills, CA, USA
9South County Pediatric Speech, Mission Viejo, USA
10Be Well Collaborative Care, Huntington Beach, CA
*corresponding author and author to whom correspondence, reprint requests, and proofs will
be sent:
Soroush Zaghi, MD ENT-
Sleep Surgeon The
Breathe Institute
10921 Wilshire Blvd Suite 912 Los
Angeles, CA 90024
Email: soroush.zaghi@gmail.com Phone: 310-
579-9710
International Journal of Otorhinolaryngology
2020; X(X): XX-XX
doi: 10.11648/j.XXXX.2020XXXX.XX
ISSN: 2472-2405 (Print); ISSN: 2472-2413 (Online)
Abstract
Objectives: Subjective assessment of nasal obstruction with patient-reported outcome measures such
as visual analogue scale and NOSE score may be limited in chronic mouth breathing subjects who are
not consciously aware of nasal breathing difficulties. This study investigates a simple objective
screening tool to assess the capacity for comfortable nasal breathing that is based on sealing the lips
and mouth with tape and assessing whether the subject can breathe comfortably through the nose for
up to three minutes. Method: Cross-sectional, multi-center cohort study with 663 participants (ages: 3-
83 years, 50.5% female). Lips were gently sealed using MicroPore paper tape; timer was used to
assess how long the participants were able to breathe comfortably through the nose for up to 180
seconds. Other measures included subjective rating of perceived difficulty with nasal breathing (VAS,
0-100) as well as self-assessed reports of mouth breathing. Results: There were 9.3% of patients with
subjective reports of moderate to severe nasal obstruction (VAS> 50) and 17.2% of patients with
predominance of self-reported mouth breathing in this series. Overall, 93.4% of participants
successfully passed the nasal breathing test. Among patients with habitual mouth breathing, 83.5%
(91/109) were able to breathe comfortably through the nose when instructed to do so for the entire 3-
minute duration tested. Similarly, there were 67% (40/59) patients with VAS score >50 who could
breathe comfortably through the nose for >180 seconds despite subjective reports of moderate to
severe nasal obstruction. Participants unable to breathe exclusively through the nose for 180 seconds
had increased likelihood of mouth breathing while awake (O4 4.12, 95% confidence interval 2.14-7.89,
p<.0001) as well as increased odds of mouth breathing while asleep (OR 3.05, 95% confidence
interval 1.61-5.72, p=0.0003). Conclusion: Objectively testing whether a subject can breathe through
the nose with the lips and mouth taped for three minutes can identify patients at risk of mouth
breathing and is a simple and effecting screening tool to distinguish organic nasal obstruction from
functional mouth breathing habit and or nasal resistance.
International Journal of Otorhinolaryngology
2020; X(X): XX-XX
doi: 10.11648/j.XXXX.2020XXXX.XX
ISSN: 2472-2405 (Print); ISSN: 2472-2413 (Online)
Levels of Evidence: 2b –Cross sectional cohort study
Keywords: nasal breathing, assessment tool, nasal obstruction, mouth breathing, lip taping, lip seal
test.
1. Introduction:
Establishment of exclusive nasal breathing is now appreciated as the single most important
objective in securing adequate craniofacial and airway development in children [1]. Indeed, chronic
mouth breathing in growing children is associated with palatal growth restriction, alterations of
craniofacial development, altered head posture, sleep-disordered breathing, and increased risk for
obstructive-sleep apnea later in life [2] [3] [4]. Nasal breathing in adulthood has many advantages:
nasal ventilation filters, warms, and humidifies the air [5]; protects against exercise-induced
bronchospasm [8]; reduces snoring, improves daytime energy, and self-reported sleep quality [7] [8];
decreases vocal effort and laryngeal dryness [9]; and facilitates anxiety reduction and deep meditation
techniques [10].
Subjective assessment of nasal breathing ability with validated tools such as the Visual
Analogue Scale [11] and NOSE [12] [13] score may sometimes be inadequate in chronic mouth
breathing subjects who are not consciously aware of problems with nasal breathing.
Furthermore, these tools may prove ineffective in children who cannot accurately articulate difficulties
with nasal breathing. Objective tools available for assessment of nasal breathing include peak nasal
airflow, acoustic rhinomanometry, rhinomanometry, Odiosof Rhino [14], and computation flow dynamics
using CT- generated three-dimensional nasal models [15]. However, these techniques are often
cumbersome and time-consuming and may not serve well as a quick screening tool.
As such, there is a need for more easily accessible methods to objectively screen and assess
nasal breathing ability. Here we investigate the efficacy of a simple screening tool to assess the
individuals’ capacity for comfortable nasal breathing that is based on sealing the lips and mouth with
International Journal of Otorhinolaryngology
2020; X(X): XX-XX
doi: 10.11648/j.XXXX.2020XXXX.XX
ISSN: 2472-2405 (Print); ISSN: 2472-2413 (Online)
tape while simultaneously assessing whether the subjects can breathe comfortably through
the nose for a duration of up to three minutes.
2. Methods:
2.1 Study Design: Cross-sectional multi-center cohort study of subjects age three and up from the
general population surveyed in a standardized fashion by interdisciplinary professionals trained in the
evaluation of orofacial myofunctional disorders at 10 sites including researchers in the United States,
Hong Kong, Estonia, and Ireland as part of the Functional Airway Evaluation Screening Tool
(FAIREST) study. The study was approved by Solutions IRB on 3-16-18; IRB Protocol # 2018/03/4.
Data was collected between 3-22-18 and 8-5-18. Subjects recruited include friends, family, colleagues,
and private clients of the researchers who volunteered without financial compensation and provided
written-informed consent to participate. Exclusion criteria: syndromic craniofacial disorder (e.g. Downs,
Treacher Collins, Crouzon, Apert); history of tracheostomy dependence; prior history of laryngeal,
subglottic, or pulmonary airway stenosis or surgery; pregnant women; and
mentally/emotionally/developmentally disabled; impaired decision-making capacity; and prisoners.
There were 21 objective screening-tool items and an 8-item subjective screening tool questionnaire
completed by both subject and a FAIREST researcher (See Appendix A for FAIREST Questionnaire).
2.2 Lip Taping Nasal Breathing Assessment: Lips and mouth of the subject were sealed completely
with gentle MicroPore paper tape. A timer was used to assess how long the subject could comfortably
breathe through the nose for up to 180 seconds with the lips and mouth taped. Subjects were deemed
to pass the test if they could successfully breathe through the nose for three minutes. This test is also
known as “lip seal test” [16]. See Figure 1 (Photo of individual with lips taped as described).
International Journal of Otorhinolaryngology
2020; X(X): XX-XX
doi: 10.11648/j.XXXX.2020XXXX.XX
ISSN: 2472-2405 (Print); ISSN: 2472-2413 (Online)
Figure 1. Lip Taping Nasal Breathing Assessment: Lips are sealed with MicroPore tape. A timer is used to
assess how long the subject can comfortably breathe through the nose for up to 180 seconds with the lips taped.
2.3 Other Assessments: Other assessments included in the analysis for this manuscript from the
FAIREST dataset included: age, gender; subjective visual analogue scale rating of perceived difficulty
with nasal breathing (“Rate how difficult it is to breathe through the nose from 0-100, 0= no obstruction,
100= complete obstruction”) [11]; self-assessed reports of mouth breathing when awake and mouth
breathing when asleep were graded on 4 point Likert Scale: (Rarely to never, sometimes, often, almost
always). For the statistical analysis, reports of “often” and “almost always” were considered positive as
an assessment of chronic mouth breathing habit.
2.4 Statistical Analysis: Statistical analyses were performed using JMP Pro 14 (SAS Institute Inc.,
Cary, NC). Continuous variables are summarized as mean (M) ± standard deviation (SD), standard error
(SE) where applicable. Categorical variables are summarized as frequencies and percentages.
Univariate analysis with Pearson’s Chi Square or independent t-test (continuous variables) was
performed to assess for nominal or continuous covariates of lip taping test: pass vs. unable including
VAS nasal breathing difficulty score, mouth breathing while awake, mouth breathing while asleep,
International Journal of Otorhinolaryngology
2020; X(X): XX-XX
doi: 10.11648/j.XXXX.2020XXXX.XX
ISSN: 2472-2405 (Print); ISSN: 2472-2413 (Online)
age-cohort, and gender. Due to the testing of multiple variables for each outcome, a two-tailed p-value
<0.01 was selected as the cut-off for statistical significance.
3. Results: There were 633 subjects who participated in the lip taping nasal breathing test including
335 females and 298 males with average age: 21.4 +/- 18.7 years including
315 children (ages 3-11), 71 adolescents (age 12-17), 102 young adults (age 18-35), 126 adults (age
36-64), and 19 seniors (age >65). A total of 591 subjects (93.4%) passed the test as they were able to
breathe through the nose with lips taped for at least 180 seconds. There were 42 subjects (6.6%) who
were unable to complete the nasal breathing test. Among n=42 subjects unable to complete nasal
breathing for 180 seconds, average time to failure was 58.9 +/- 40 seconds (mean +/- SD), median 60
seconds, range 0-150 seconds (Figure 2). There was an increased rate of inability to pass the test
among the adolescent age-cohort (15.5%, 11/71) as compared to children (23/315, 7.3%), young
adults (4/102, 3.9%), adults (4/126, 3.2%), and seniors (0/19, 0%), Pearson Chi Square, p= 0.0066.
There were no significant gender differences.
International Journal of Otorhinolaryngology
2020; X(X): XX-XX
doi: 10.11648/j.XXXX.2020XXXX.XX
ISSN: 2472-2405 (Print); ISSN: 2472-2413 (Online)
Figure 2. Distribution of time to failure in seconds among subjects unable to pass the lip taping nasal breathing
test. “Pass” was defined as being able to breathe comfortably through the nose with lips taped for the entire 180
seconds tested.
Among subjects who passed the nasal breathing test, mean +/- SD report of nasal breathing difficulty
on the visual analogue scale (0-100) was 8.28 +/- 18.8. Among subjects who were unable to complete
the lip taping nasal breathing test, mean report of nasal breathing difficulty was 41.6 +/- 26.3
(p<0.0001) (Figure 3). Subjects who could not complete the nasal breathing tape test had increased
odds of mouth breathing while awake (OR 4.12, 95% confidence interval 2.14-7.89, p<0.0001) as well
as increased odds of mouth breathing while asleep (OR 3.04, 95% Confidence Interval 1.61- 5.72,
p=0.0003).
International Journal of Otorhinolaryngology
2020; X(X): XX-XX
doi: 10.11648/j.XXXX.2020XXXX.XX
ISSN: 2472-2405 (Print); ISSN: 2472-2413 (Online)
Figure 3. Box and whisker plot of perceived nasal obstruction (Visual Analogue Scale, 0-100) among patients able
and unable to pass the lip taping nasal breathing test.
There were 17.2% (109/633) patients with reports of a predominance of mouth breathing (“often” or
“almost always” mouth breathes) while awake in this series. Among these patients with habitual
mouth breathing, 83.5% (91/109) were able to successfully pass the lip taping nasal breathing test.
There were only 16.5% (18/109) of mouth breathers who physically could not tolerate breathing
through their nose for 3 minutes duration. Similarly, there were 67% (40/59) patients with moderate to
severe difficulty breathing through the nose (VAS score >50) who could still tolerate lip taping for
>180 seconds despite subjective reports of moderate to severe nasal obstruction.
4. Discussion: This study supports the use of the lip taping nasal breathing test as an effective
screening tool in the assessment of mouth breathing and nasal breathing difficulty. Subjects who
could not complete the nasal breathing tape test had a four-fold increased likelihood of mouth
breathing while awake and three-fold increased likelihood of mouth breathing during sleep. The lip
tape test for nasal breathing was found to be a safe, simple, inexpensive, and rationale tool that offers
excellent utility in bringing nasal obstruction and/or mouth breathing habit to the forefront of a
subject’s awareness.
Although physical examination of the nasal cavity can provide accurate information as to the cause of
nasal obstruction and potential treatment options, previous studies have shown that physical exam
findings (including septal deviation, turbinate hypertrophy, and internal nasal valve collapse) do not
accurately correlate with patients’ subjective awareness and report of nasal obstruction [17] [18]. This
highlights the controversy seen regarding the correlation between changes in objective and subjective
outcome measures of nasal obstruction [19]. Given the lack of correlation found between objective and
subjective nasal obstruction outcome measures, clinical consensus [20] has focused on assessing the
International Journal of Otorhinolaryngology
2020; X(X): XX-XX
doi: 10.11648/j.XXXX.2020XXXX.XX
ISSN: 2472-2405 (Print); ISSN: 2472-2413 (Online)
efficacy of nasal breathing interventions on patient-reported outcome measures such as the Visual
Analogue Scale [11], Nasal Surgical Questionnaire [21], Nasal Obstruction Septoplasty Effectiveness
[22], and Nasal Obstruction Symptom Evaluation [12], among others [19].
Whereas these tools are effective in helping those patients who proactively report problems with and
seek intervention for nasal obstruction, they do not address the needs of mouth breathing patients who
do not acknowledge, or may be unaware of a problem with nasal breathing. Other tools investigated for
the assessment of nasal patency in the clinical recognition of mouth breathing among this population of
patients include the Glatzel mirror test and water-retention test. [23] [16]. In the Glatzel mirror test, also
called nasographic mirror, a cold mirror is placed under the nostrils and the subject is asked to inhale
and exhale through the nose. If moisture condenses on the mirror, this demonstrates that the patient has
successfully exhaled through the nares. However, prior studies have shown that the Glatzel mirror test
lacks inter-trial reproducibility and does not correlate with other objective and subjective measures of
nasal patency [24]; moreover, it was deemed a poor assessment tool in detecting patient-reported
improvements in breathing following rhinoplasty [25]. The water retention test, on the other hand, is an
effective alternative to the lip taping test in which approximately 15 ml of water is placed in the mouth
and the subject is asked to hold it for three minutes. A prior study shows similar distribution of results
and efficacy between the water retention test and the lip taping test for assessment of nasal versus
mouth breathing [23].
The most interesting finding of this study is that the majority of patients with self-reported mouth
breathing and/or subjective reports of moderate to severe nasal breathing difficulty were still physically
able to breathe comfortably through the nose for at least three minutes duration when instructed to do so
in this study. This is consistent with prior studies on mouth breathing and nasal disuse which show that
oral breathing route may persist even after structural obstructions for nasal breathing have been removed
and that nasal breathing re-education plays an important role in the treatment of mouth breathing [26]
International Journal of Otorhinolaryngology
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doi: 10.11648/j.XXXX.2020XXXX.XX
ISSN: 2472-2405 (Print); ISSN: 2472-2413 (Online)
[27] [28]. According to the Proceedings of the Royal Academy of Medicine in 1957, it had been widely
appreciated that: “Nasal breathing depends on the patency of the nasal passages and on the orofacial
muscles closing and sealing off the oral cavity from the nasopharyngeal airway. Mouth breathing due
solely to gross nasal obstruction is comparatively rare… [whereas,] mouth breathing due to failure of
the orofacial muscles is relatively common” [29]. Since that time, models of oro-nasal rehabilitation
have been developed and incorporated into myofunctional therapy programs to address the functional
aspects of mouth breathing with a high degree of success [28] [30]. Therapeutic mouth and lip-taping
during the day as well as overnight while asleep has been shown to be helpful in re-educating nasal
breathing [31] as well as in improving symptoms of mouth breathing, snoring, and obstructive sleep
apnea [32]. Assessment of nasal breathing ability with the lip tape test can help identify patients with
organic structural obstructions who would benefit from interventions for nasal obstructions, as well as to
distinguish patients with functional deficits who may benefit from re-education of nasal breathing with
myofunctional therapy, oro-nasal rehabilitation programs, or simple lip taping to encourage and
reinforce nasal breathing as a long-term habit.
5. Conclusion: Proper breathing, specifically exclusive nasal breathing, is essential to the health
and development of children. Children who are unable to breathe well through the nose compensate by
breathing more through the mouth. This not only negatively impacts their current health but may also
lead to detrimental issues in adulthood. Early detection of improper breathing is therefore vital. Current
methods for assessing nasal breathing capacity such as visual analogue scale and NOSE score are
subjective and may be limited in chronic mouth breathing subjects who are not consciously aware of
nasal breathing difficulties. This paper advances the field of research by introducing a novel method for
assessing nasal breathing. Specifically, objectively testing whether a subject can breathe through the
nose with the lips and mouth taped for three minutes is a safe and effective screening tool for the
assessment of nasal obstruction and mouth breathing habit.
International Journal of Otorhinolaryngology
2020; X(X): XX-XX
doi: 10.11648/j.XXXX.2020XXXX.XX
ISSN: 2472-2405 (Print); ISSN: 2472-2413 (Online)
Compliance with Ethical Standards
Conflict of Interest: Soroush Zaghi declares that he has no conflict of interest. Cynthia Peterson
declares that she has no conflict of interest. Shayan Shamtoob declares that he has no conflict of
interest. Brigitte Fung declares that she has no conflict of interest. Daniel K. Ng declares that he has
no conflict of interest. Triin Jagomagi declares that she has no conflict of interest. Nicole Archambault
declares that she has no conflict of interest. Bridget O’Connor declares that she has no conflict of
interest. Kathy Winslow declares that she has no conflict of interest. Zahra Peeran declares that she
has no conflict of interest. Miche’ Lano declares that she has no conflict of interest. Janine Murdock
declares that she has no conflict of interest. Sanda Valcu-Pinkerton declares that she has no conflict
of interest. Lenore Morrissey declares that she has no conflict of interest.
Ethical approval: All procedures performed in studies involving human participants were in
accordance with the ethical standards of the institutional and/or national research committee and with
the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
Informed consent: Informed consent was obtained from all individual participants included in the
study. The subjects who are portrayed in the photos provided consent to have these photos submitted
and published by the journal.
Acknowledgement: This study was sponsored by the Academy of Applied Myofunctional Sciences
with financial support for funding of the IRB application. We acknowledge The Breathe Institute for
financial support for the open access publication fees and research assistant support. We also
acknowledge Hoang Anh Dao, Judith Dember-Paige, Jennifer Hobson, and Barry Raphael for their
data collection contributions, Marc Moeller for help in the IRB application, as well as Bruce Peterson
for his efforts with tool creation, design, photography and technical support. The data that support the
findings of this study are available from the corresponding author, Soroush Zaghi, upon reasonable
request.
International Journal of Otorhinolaryngology
2020; X(X): XX-XX
doi: 10.11648/j.XXXX.2020XXXX.XX
ISSN: 2472-2405 (Print); ISSN: 2472-2413 (Online)
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List of Titles/Captions For Each Figure:
1. Figure 1. Lip Taping Nasal Breathing Assessment: Lips are sealed with MicroPore tape. A
timer is used to assess how long the subject can comfortably breathe through the nose for up
to 180 seconds with the lips taped.
2. Figure 2. Distribution of time to failure in seconds among subjects unable to pass the lip
taping nasal breathing test. “Pass” was defined as being able to breathe comfortably through
the nose with lips taped for the entire 180 seconds tested.
3. Figure 3. Box and whisker plot of perceived nasal obstruction (Visual Analogue Scale, 0-
100) among patients able and unable to pass the lip taping nasal breathing test.
