A Comparative Study Of The Cold Spatula Test And The Glatzel Mirror For Nasal Obstruction Screening In Indonesian Primary Healthcare Settings

A Comparative Study Of The Cold Spatula Test And The Glatzel Mirror For Nasal Obstruction Screening In Indonesian Primary Healthcare Settings | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article A Comparative Study Of The Cold Spatula Test And The Glatzel Mirror For Nasal Obstruction Screening In Indonesian Primary Healthcare Settings Musdah Mulia Mukmin, Rini Dharmastiti, Agus Surono This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8109252/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: This study aimed to compare two simple tools, the metal spatula (cold spatula test) and the Glatzel mirror, in detecting nasal obstruction in a primary healthcare facility in Indonesia. The study provides a direct comparison between two non-invasive, low-cost screening tools whose effectiveness has not been widely evaluated in Indonesia. Methods: A cross-sectional study was conducted involving 34 healthy subjects aged 18–59 years. Each participant underwent nasal airflow assessment using both tools. Condensation patterns were visually assessed to evaluate symmetry and condensation area. Results: The Glatzel mirror yielded an average condensation area of 4.1 cm (SD 0.5), ranging from 3.1 to 5.1 cm, with a median left–right nostril difference of 0.2 cm. The maximum difference was 1.4 cm, below the clinical threshold of 2 cm for nasal obstruction. In contrast, the cold spatula test produced only qualitative results, with all participants categorized as having wide condensation. A Wilcoxon signed-rank test showed a statistically significant user preference for the Glatzel mirror (Z = –2.183, p = 0.029). Conclusion: The Glatzel mirror provided more objective and quantifiable results than the metal spatula and was more favorably rated by users. These findings support its potential as a practical and informative screening tool for nasal obstruction in resource limited primary care settings in Indonesia. Trial registration : Not applicable. Health sciences/Diseases Health sciences/Health care Health sciences/Medical research Nasal obstruction cold spatula test Glatzel mirror primary healthcare facilities Indonesia Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 1. Background Indonesia is an archipelagic country that spans 5,245 km from Sabang to Merauke, with a population of over 280 million. The vast geographical area and uneven population distribution pose significant challenges in delivering equitable national healthcare services. To address these challenges, a tiered healthcare system has been implemented. Within this system, primary healthcare facilities serve as the front line for promotion, preventive, and screening efforts. Due to limited public access to advanced healthcare services, screening at the primary level becomes essential. This situation requires the availability of simple, user-friendly, and informative screening tools to support effective health evaluations (Kemenkes, 2020). One of the most common diseases encountered in primary healthcare settings is upper respiratory tract infection (URTI). Among various URTI symptoms, nasal obstruction is the second most frequently reported complaint by patients (Keeler and Most, 2016 ). However, this symptom is often subjective, highlighting the need for tools that can provide objective evaluations of patient complaints (Paramyta et al, 2017 ; Kapadia et al., 2017 ). Therefore, a screening tool that is not only simple and practical but also capable of offering an objective assessment of nasal airway patency is needed. Two tools widely used in clinical practice in developed countries for this purpose are the cold spatula test and the Glatzel mirror (Bassi et al., 2009 ). Nevertheless, comparative studies between these two tools in primary healthcare settings, especially in Indonesia remain scarce, which makes this study relevant to address this gap (Paramyta et al, 2017 ). 2. Materials and Methods This study was an observational cross-sectional design conducted in a primary healthcare facility in Indonesia in June 2025. The sample was selected by consecutive sampling, including all subjects who met the inclusion criteria and did not meet any exclusion criteria during the study period. The inclusion criteria were healthy individuals aged between 18 and 59 years. Exclusion criteria included those currently experiencing upper respiratory tract infections (URTI), a history of nasal surgery or trauma, complaints of nasal congestion, or a history of nasal and sinus diseases. Out of 37 participants initially screened, three were excluded because they had a history of nasal trauma, nasal congestion, and sinusitis. The final sample consisted of 34 subjects, including 3 males and 31 females, aged between 24 and 45 years. Each subject was assessed for nasal airflow using two tools: a metal spatula and the Glatzel mirror. The airflow was evaluated based on visual observation of condensation area and symmetry. Observational outcomes, including condensation size and symmetry, were analyzed to compare the effectiveness of both tools. In addition, all participants completed a user impression questionnaire based on a Likert scale to assess their preference between the two tools. The independent variable in this study was the type of screening tool, while the dependent variables were the measurement results and the user impression scores based on the questionnaire. This study was approved by the Ethics Committee of the Faculty of Medicine, Public Health, and Nursing, Universitas Gadjah Mada (Approval No. KE/1463/09/2024). All methods were performed in accordance with the relevant guidelines and regulations. All participants were informed about the objectives and procedures of the study and provided written informed consent prior to participation. Statistical analysis was performed using IBM® SPSS® Statistics version 31.0 with a significance level set at p < 0.05. 3. Results 3.1. Assessment of Nasal Airflow Symmetry Using Two Tools All subjects (n = 34) underwent nasal obstruction screening using both the metal spatula and the Glatzel mirror. Examination with the metal spatula revealed that 100% of subjects exhibited symmetrical results, with no observable difference in condensation between the left and right nostrils. In contrast, the Glatzel mirror provided quantitative measurements of the condensation area, which while appearing largely symmetrical still revealed individual variations in nasal airflow between the two sides. These variations were visualized using a boxplot showing the difference in the condensation area between the left and right nostrils Fig. 1 . The data distribution appeared relatively symmetrical, with a median difference of 0.2 cm. The minimum and maximum differences were 0.8 cm and 1.4 cm, respectively, without outliers. Most of the data (50%) were distributed within the interquartile range of 0.2 to 0.6 cm, with a standard deviation of 0.487 and a skewness of 0.040. The Shapiro–Wilk normality test yielded a significance value of 0.200 ( p > 0.05 ), indicating a normal distribution. These findings suggest that the majority of subjects had relatively balanced nasal airflow between the left and right nostrils, although physiologically normal individual variations remained. This finding was further supported by a histogram Fig. 2 , which demonstrated a distribution resembling a normal curve, with a frequency peak around 0.2 to 0.6 cm, reflecting the majority of values clustering near the mean of 0.24 cm. The frequency distribution appeared relatively symmet- rical, with minor spread toward both negative and positive extremes. Clinically, a nasal airflow difference greater than 2 cm is considered indicative of nasal obstruction in one nostril. In this study, the maximum observed difference was 1.4 cm. 3.2. Comparison of Examination Results Between Metal Spatula and Glatzel Mirror The results of the cold spatula test were classified into three categories: NA (No condensation), N (Narrow, condensation area 2 cm). In this study, all subjects showed a wide (W) result on the cold spatula test. In contrast, the Glatzel mirror examination revealed notable variations, with condensation area values ranging from 3.1 to 5.1 cm. The average condensation area observed was 4.1 cm, with a standard deviation of 0.5 cm. These results indicate that the majority of subjects remained within clinically normal limits (reference range: 3–6 cm) (Pacheco et al., 2015). The fundamental difference between the two tools lies in their ability to quantify data. The metal spatula provides only a visual and descriptive assessment of the presence and distribution of condensation, without any specific numerical measurement. In contrast, the Glatzel mirror enables a more objective and measurable identification of nasal airflow differences by providing the length of the condensation area, thus supporting more advanced statistical analyses. The distribution of the average condensation area obtained from the Glatzel mirror is visualized using both a histogram and a boxplot. The histogram Fig. 3 shows that the highest frequency was observed in the 4.0–4.5 cm range, with a relatively even distribution and no extreme peaks. This pattern is reinforced by the boxplot Fig. 4 , which shows a median value around 4.1 cm and an interquartile range between 3.7 and 4.4 cm. This relatively symmetrical distribution supports the notion that most subjects had efficient nasal breathing function without significant obstruction. 3.3. User Preference Toward the Metal Spatula and Glatzel Mirror The comparison of subject perceptions toward the two screening tools (Metal Spatula and Glatzel Mirror) was analyzed using the Wilcoxon Signed- Rank Test. The results showed that 11 subjects rated the Glatzel mirror more favorably, 3 subjects preferred the metal spatula, and 20 subjects gave equal ratings to both tools Fig. 5 . The Wilcoxon test revealed a statistically sig nificant difference between the two tools (Z = − 2.183, p = 0.029), indicating that the Glatzel mirror was significantly preferred or considered superior by the subjects based on the Likert scale (1 = very poor to 5 = excellent). These findings further support the notion that the Glatzel mirror’s ability to provide quantitative and objective information contributed to a more favorable user perception of its use in nasal screening examinations. 4. Discussion The results of this study demonstrated that all participants exhibited symmetrical outcomes when assessed using the metal spatula, with no observable dominance between the nostrils. However, the Glatzel mirror examination revealed measurable quantitative variations between the left and right nasal passages (Nakahara et al., 2019 ), as visualized through boxplots and histograms. Although the majority of subjects remained within the clinically normal range (difference < 2 cm), such variations could only be detected using the Glatzel mirror. This highlights the Glatzel mirror’s ad- vantage in identifying subtle asymmetries in nasal airflow that are not de- tectable through the metal spatula examination. Furthermore, analysis of the average condensation length indicated that all participants fell within the normal clinical range (3 to 6 cm), with a mean of 4.1 cm. This supports the clinical relevance of the Glatzel mirror as an objective assessment tool, even among healthy individuals. The histogram of mean condensation area showed a normal distribution centered within the 4.0 to 4.5 cm range, reflecting consistent and stable device performance. User preference data collected through the Likert scale questionnaire further reinforced these findings. The Wilcoxon signed-rank test revealed a statistically significant difference (p = 0.029), indicating a preference for the Glatzel mirror over the metal spatula. This suggests that the Glatzel mirror’s capacity to deliver objective and quantifiable information positively influenced user perception and acceptance in the context of nasal screening. Observations during the use of the devices revealed ergonomic challenges, particularly with the Glatzel mirror. The mirror’s long and straight curvature appeared to be less compatible with the facial anthropometry of the Indonesian population, especially among individuals with fuller cheek contours. This condition caused discom- fort when the device was positioned near the face and potentially affected the stability of the device placement during the examination. Consequently, variability in device positioning may have contributed to inconsistencies in the measurement outcomes Fig. 6 . Previous studies have suggested that facial convexity (prominent cheeks) in Indonesians may be associated with posterior traction of the cheek area and nasal cartilage, maxillary protrusion, proclined roots of the upper incisors and canines, and a retrusive or flat chin profile (Elfiah et al., 2011 ). Another limitation of this study was the use of healthy subjects without a history of nasal pathology, which limits the generalizability of the findings to symptomatic populations. Additionally, user perception was inherently subjective and not assessed through blinded methods, which may have introduced response bias. Future research involving patients with varying degrees of nasal obstruction and comparison with gold standard diagnostic tools is highly recommended (Naito et al., 2023 ). 5. Conclusion The Glatzel mirror offers a simple yet more objective alternative to the metal spatula for use in primary healthcare settings. It enables quantitative assessment of nasal symmetry and patency. In addition, users were statistically favored, which strengthened its potential as an effective and clinically relevant screening tool. Integrating the Glatzel mirror into routine clinical practice in primary healthcare could contribute to the early detection and documentation of nasal obstruction, particularly in environments with limited access to advanced diagnostic equipment. Declarations Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not for profit sectors. Human Ethics and Consent to Participate This study was approved by the Ethics Committee of the Faculty of Medicine, Public Health, and Nursing, Universitas Gadjah Mada (Approval No. KE/1463/09/2024). Consent to Publish Written informed consent for publication of the clinical images was ob- tained from the participant included in this study Competing Interests The authors declare that they have no competing interests. Acknowledgment I extend my sincere gratitude to all participants for their participation in this study. Special appreciation is also directed to the Jakarta Provincial Health Office and the Central Jakarta Health Sub-Office, particularly the Public Information Officer and Data and Information Center teams, for their invaluable assistance in facilitating the research permit process and data collection. Data Availability Data will be provided upon request. References Kementerian Kesehatan Republik Indonesia (Kemenkes RI), Permenkes RI Nomor 21 Tahun 2020 tentang Rencana Strategis Kementerian Kesehatan Tahun 2020–2024 , Kementerian Kesehatan RI, vol. 9, no. May, p. 6, 2020. Keeler J and Most SP, Measuring Nasal Obstruction , Facial Plastic Surgery Clinics of North America, vol. 24, no. 3, pp. 315–322, 2016. doi: 10.1016/j.fsc.2016.03.008. 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Available: http://www.medicina.ufmg.br/fon/monografias/ 07-iara-bassi.pdf Pacheco MCT, Casagrande CF, Teixeira LP, Finck NS, and de Arau´jo MTM, “Guidelines proposal for clinical recognition of mouth breathing children,” Dental Press Journal of Orthodontics , vol. 20, no. 4, pp. 39–44, Jul. 2015, doi: 10.1590/2176-9451.20.4.039-044.oar. Nakahara K, Mishiba K, Doi R, and Kondo K, “Nasal Expiration Image Detection on Mirror Surface Using Alternating Optimization,” in Proceed- ings of the 7th IIAE International Conference on Industrial Application Engineering 2019 , Institute of Industrial Applications Engineers, 2019, pp. 233–238. doi: 10.12792/iciae2019.045. U. Elfiah, I. L. Putri, M. R. Hutagalung, D. S. Perdanakusuma, and T. Kosbandriati, “Variasi Antropometri Wajah Indonesia dan Sefalometri se- bagai Data Dasar pada Rekonstruksi Trauma Maksilofasial (Variables of Indonesian Facial Antropometry and Cephalometry as Database in Recon- struction of Maxillofacial Trauma),” vol. 1, no. 1, pp. 6–12, 2011. K. Naito, S. Horibe, Y. Tanabe, H. Kato, S. Yoshioka, and I. Tateya, “Ob- jective assessment of nasal obstruction,” Fujita Medical Society, 2023. doi: 10.20407/fmj.2021-029. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8109252","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":546789709,"identity":"8d9bfd58-fb02-4e24-bf3a-de599b4cdbce","order_by":0,"name":"Musdah Mulia 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11:36:47","extension":"html","order_by":22,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":45714,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8109252/v1/12921e116017aa516c2c03e1.html"},{"id":96453394,"identity":"45aad3b4-c8d3-4cfc-94b1-5e324fe272e1","added_by":"auto","created_at":"2025-11-21 09:59:36","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":8080,"visible":true,"origin":"","legend":"\u003cp\u003eDifference in Condensation Area Between Left and Right Nostrils\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8109252/v1/6674fe2b2e2999260586e5c2.png"},{"id":96377970,"identity":"fe04cbfe-af8c-4fc6-9f09-f83b0f56439d","added_by":"auto","created_at":"2025-11-20 11:36:47","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":23245,"visible":true,"origin":"","legend":"\u003cp\u003eDistribution of Measurement Differences Between Left and Right Nostrils\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-8109252/v1/6d34125b4670c86bccb620e5.png"},{"id":96377968,"identity":"edb78dbf-5d10-4e5c-a2b7-c814bbea0542","added_by":"auto","created_at":"2025-11-20 11:36:47","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":22882,"visible":true,"origin":"","legend":"\u003cp\u003eDistribution of Mean Condensation Area of Both Nostrils Measured with the Glatzel Mirror\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-8109252/v1/80614a005938444da4e59eb8.png"},{"id":96377974,"identity":"58fce4aa-5cdc-415e-8308-d0b3e59a88b8","added_by":"auto","created_at":"2025-11-20 11:36:47","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":8323,"visible":true,"origin":"","legend":"\u003cp\u003eMean Condensation Area of Both Nostrils Measured with the Glatzel Mirror\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-8109252/v1/ad5e844c757968f1ebb20ab9.png"},{"id":96452869,"identity":"761d5a8a-d09c-41c6-8c40-63799f34f15d","added_by":"auto","created_at":"2025-11-21 09:50:31","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":22652,"visible":true,"origin":"","legend":"\u003cp\u003eComparison of User Impressions Between the Metal Spatula and Glatzel Mirror\u003c/p\u003e","description":"","filename":"5.png","url":"https://assets-eu.researchsquare.com/files/rs-8109252/v1/91db4fd4471a3daa274a7715.png"},{"id":96377979,"identity":"fd3acc49-5304-4029-a707-4bb71f4b03f7","added_by":"auto","created_at":"2025-11-20 11:36:47","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":338295,"visible":true,"origin":"","legend":"\u003cp\u003eUse of the Metal Spatula (A) and Glatzel Mirror (B)\u003c/p\u003e","description":"","filename":"6.png","url":"https://assets-eu.researchsquare.com/files/rs-8109252/v1/776aeb7b58a7db476a122345.png"},{"id":104209380,"identity":"07377f6d-768c-46d9-8023-1b6af11d0141","added_by":"auto","created_at":"2026-03-09 07:28:51","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1051303,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8109252/v1/30b26bba-e444-4b8a-95fb-7ee5b2c1f4da.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"A Comparative Study Of The Cold Spatula Test And The Glatzel Mirror For Nasal Obstruction Screening In Indonesian Primary Healthcare Settings","fulltext":[{"header":"1. Background","content":"\u003cp\u003eIndonesia is an archipelagic country that spans 5,245 km from Sabang to Merauke, with a population of over 280\u0026nbsp;million. The vast geographical area and uneven population distribution pose significant challenges in delivering equitable national healthcare services. To address these challenges, a tiered healthcare system has been implemented. Within this system, primary healthcare facilities serve as the front line for promotion, preventive, and screening efforts. Due to limited public access to advanced healthcare services, screening at the primary level becomes essential. This situation requires the availability of simple, user-friendly, and informative screening tools to support effective health evaluations (Kemenkes, 2020). One of the most common diseases encountered in primary healthcare settings is upper respiratory tract infection (URTI). Among various URTI symptoms, nasal obstruction is the second most frequently reported complaint by patients (Keeler and Most, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2016\u003c/span\u003e). However, this symptom is often subjective, highlighting the need for tools that can provide objective evaluations of patient complaints (Paramyta et al, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Kapadia et al., \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). Therefore, a screening tool that is not only simple and practical but also capable of offering an objective assessment of nasal airway patency is needed. Two tools widely used in clinical practice in developed countries for this purpose are the cold spatula test and the Glatzel mirror (Bassi et al., \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2009\u003c/span\u003e). Nevertheless, comparative studies between these two tools in primary healthcare settings, especially in Indonesia remain scarce, which makes this study relevant to address this gap (Paramyta et al, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2017\u003c/span\u003e).\u003c/p\u003e"},{"header":"2. Materials and Methods","content":"\u003cp\u003eThis study was an observational cross-sectional design conducted in a primary healthcare facility in Indonesia in June 2025. The sample was selected by consecutive sampling, including all subjects who met the inclusion criteria and did not meet any exclusion criteria during the study period. The inclusion criteria were healthy individuals aged between 18 and 59 years. Exclusion criteria included those currently experiencing upper respiratory tract infections (URTI), a history of nasal surgery or trauma, complaints of nasal congestion, or a history of nasal and sinus diseases. Out of 37 participants initially screened, three were excluded because they had a history of nasal trauma, nasal congestion, and sinusitis. The final sample consisted of 34 subjects, including 3 males and 31 females, aged between 24 and 45 years. Each subject was assessed for nasal airflow using two tools: a metal spatula and the Glatzel mirror. The airflow was evaluated based on visual observation of condensation area and symmetry. Observational outcomes, including condensation size and symmetry, were analyzed to compare the effectiveness of both tools. In addition, all participants completed a user impression questionnaire based on a Likert scale to assess their preference between the two tools. The independent variable in this study was the type of screening tool, while the dependent variables were the measurement results and the user impression scores based on the questionnaire. This study was approved by the Ethics Committee of the Faculty of Medicine, Public Health, and Nursing, Universitas Gadjah Mada (Approval No. KE/1463/09/2024). All methods were performed in accordance with the relevant guidelines and regulations. All participants were informed about the objectives and procedures of the study and provided written informed consent prior to participation. Statistical analysis was performed using IBM\u0026reg; SPSS\u0026reg; Statistics version 31.0 with a significance level set at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e"},{"header":"3. Results","content":"\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\n \u003ch2\u003e3.1. Assessment of Nasal Airflow Symmetry Using Two Tools\u003c/h2\u003e\n \u003cp\u003eAll subjects (n\u0026thinsp;=\u0026thinsp;34) underwent nasal obstruction screening using both the metal spatula and the Glatzel mirror. Examination with the metal spatula revealed that 100% of subjects exhibited symmetrical results, with no observable difference in condensation between the left and right nostrils. In contrast, the Glatzel mirror provided quantitative measurements of the condensation area, which while appearing largely symmetrical still revealed individual variations in nasal airflow between the two sides. These variations were visualized using a boxplot showing the difference in the condensation area between the left and right nostrils Fig. \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e. The data distribution appeared relatively symmetrical, with a median difference of 0.2 cm. The minimum and maximum differences were 0.8 cm and 1.4 cm, respectively, without outliers. Most of the data (50%) were distributed within the interquartile range of 0.2 to 0.6 cm, with a standard deviation of 0.487 and a skewness of 0.040. The Shapiro\u0026ndash;Wilk normality test yielded a significance value of 0.200 ( p\u0026thinsp;\u003cem\u003e\u0026gt;\u003c/em\u003e\u0026thinsp;0.05 ), indicating a normal distribution. These findings suggest that the majority of subjects had relatively balanced nasal airflow between the left and right nostrils, although physiologically normal individual variations remained.\u003c/p\u003e\n \u003cp\u003eThis finding was further supported by a histogram Fig. \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e, which demonstrated a distribution resembling a normal curve, with a frequency peak around 0.2 to 0.6 cm, reflecting the majority of values clustering near the mean of 0.24 cm. The frequency distribution appeared relatively symmet- rical, with minor spread toward both negative and positive extremes. Clinically, a nasal airflow difference greater than 2 cm is considered indicative of nasal obstruction in one nostril. In this study, the maximum observed difference was 1.4 cm.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\n \u003ch2\u003e3.2. Comparison of Examination Results Between Metal Spatula and Glatzel Mirror\u003c/h2\u003e\n \u003cp\u003eThe results of the cold spatula test were classified into three categories: NA (No condensation), N (Narrow, condensation area\u0026thinsp;\u003cem\u003e\u0026lt;\u003c/em\u003e\u0026thinsp;2 cm), and W (Wide, condensation area\u0026thinsp;\u003cem\u003e\u0026gt;\u003c/em\u003e\u0026thinsp;2 cm). In this study, all subjects showed a wide (W) result on the cold spatula test. In contrast, the Glatzel mirror examination revealed notable variations, with condensation area values ranging from 3.1 to 5.1 cm. The average condensation area observed was 4.1 cm, with a standard deviation of 0.5 cm. These results indicate that the majority of subjects remained within clinically normal limits (reference range: 3\u0026ndash;6 cm) (Pacheco et al., 2015). The fundamental difference between the two tools lies in their ability to quantify data. The metal spatula provides only a visual and descriptive assessment of the presence and distribution of condensation, without any specific numerical measurement. In contrast, the Glatzel mirror enables a more objective and measurable identification of nasal airflow differences by providing the length of the condensation area, thus supporting more advanced statistical analyses. The distribution of the average condensation area obtained from the Glatzel mirror is visualized using both a histogram and a boxplot. The histogram Fig. \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e shows that the highest frequency was observed in the 4.0\u0026ndash;4.5 cm range, with a relatively even distribution and no extreme peaks. This pattern is reinforced by the boxplot Fig. \u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e, which shows a median value around 4.1 cm and an interquartile range between 3.7 and 4.4 cm. This relatively symmetrical distribution supports the notion that most subjects had efficient nasal breathing function without significant obstruction.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\n \u003ch2\u003e3.3. User Preference Toward the Metal Spatula and Glatzel Mirror\u003c/h2\u003e\n \u003cp\u003eThe comparison of subject perceptions toward the two screening tools (Metal Spatula and Glatzel Mirror) was analyzed using the Wilcoxon Signed- Rank Test. The results showed that 11 subjects rated the Glatzel mirror more favorably, 3 subjects preferred the metal spatula, and 20 subjects gave equal ratings to both tools Fig. \u003cspan class=\"InternalRef\"\u003e5\u003c/span\u003e. The Wilcoxon test revealed a statistically sig nificant difference between the two tools (Z = \u0026minus;\u0026thinsp;2.183, p\u0026thinsp;=\u0026thinsp;0.029), indicating that the Glatzel mirror was significantly preferred or considered superior by the subjects based on the Likert scale (1\u0026thinsp;=\u0026thinsp;very poor to 5\u0026thinsp;=\u0026thinsp;excellent). These findings further support the notion that the Glatzel mirror\u0026rsquo;s ability to provide quantitative and objective information contributed to a more favorable user perception of its use in nasal screening examinations.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eThe results of this study demonstrated that all participants exhibited symmetrical outcomes when assessed using the metal spatula, with no observable dominance between the nostrils. However, the Glatzel mirror examination revealed measurable quantitative variations between the left and right nasal passages (Nakahara et al., \u003cspan class=\"CitationRef\"\u003e2019\u003c/span\u003e), as visualized through boxplots and histograms. Although the majority of subjects remained within the clinically normal range (difference\u0026thinsp;\u003cem\u003e\u0026lt;\u003c/em\u003e\u0026thinsp;2 cm), such variations could only be detected using the Glatzel mirror. This highlights the Glatzel mirror\u0026rsquo;s ad- vantage in identifying subtle asymmetries in nasal airflow that are not de- tectable through the metal spatula examination. Furthermore, analysis of the average condensation length indicated that all participants fell within the normal clinical range (3 to 6 cm), with a mean of 4.1 cm. This supports the clinical relevance of the Glatzel mirror as an objective assessment tool, even among healthy individuals. The histogram of mean condensation area showed a normal distribution centered within the 4.0 to 4.5 cm range, reflecting consistent and stable device performance. User preference data collected through the Likert scale questionnaire further reinforced these findings. The Wilcoxon signed-rank test revealed a statistically significant difference (p\u0026thinsp;=\u0026thinsp;0.029), indicating a preference for the Glatzel mirror over the metal spatula. This suggests that the Glatzel mirror\u0026rsquo;s capacity to deliver objective and quantifiable information positively influenced user perception and acceptance in the context of nasal screening. Observations during the use of the devices revealed ergonomic challenges, particularly with the Glatzel mirror. The mirror\u0026rsquo;s long and straight curvature appeared to be less compatible with the facial anthropometry of the Indonesian population, especially among individuals with fuller cheek contours. This condition caused discom- fort when the device was positioned near the face and potentially affected the stability of the device placement during the examination. Consequently, variability in device positioning may have contributed to inconsistencies in the measurement outcomes Fig. \u003cspan class=\"InternalRef\"\u003e6\u003c/span\u003e. Previous studies have suggested that facial convexity (prominent cheeks) in Indonesians may be associated with posterior traction of the cheek area and nasal cartilage, maxillary protrusion, proclined roots of the upper incisors and canines, and a retrusive or flat chin profile (Elfiah et al., \u003cspan class=\"CitationRef\"\u003e2011\u003c/span\u003e). Another limitation of this study was the use of healthy subjects without a history of nasal pathology, which limits the generalizability of the findings to symptomatic populations. Additionally, user perception was inherently subjective and not assessed through blinded methods, which may have introduced response bias. Future research involving patients with varying degrees of nasal obstruction and comparison with gold standard diagnostic tools is highly recommended (Naito et al., \u003cspan class=\"CitationRef\"\u003e2023\u003c/span\u003e).\u003c/p\u003e"},{"header":"5. Conclusion","content":"\u003cp\u003eThe Glatzel mirror offers a simple yet more objective alternative to the metal spatula for use in primary healthcare settings. It enables quantitative assessment of nasal symmetry and patency. In addition, users were statistically favored, which strengthened its potential as an effective and clinically relevant screening tool. Integrating the Glatzel mirror into routine clinical practice in primary healthcare could contribute to the early detection and documentation of nasal obstruction, particularly in environments with limited access to advanced diagnostic equipment.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research did not receive any specific grant from funding agencies in\u0026nbsp;the\u0026nbsp;public,\u0026nbsp;commercial,\u0026nbsp;or\u0026nbsp;not\u0026nbsp;for\u0026nbsp;profit\u0026nbsp;sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHuman Ethics and Consent to Participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Ethics Committee of the Faculty of Medicine, Public Health, and Nursing, Universitas Gadjah Mada (Approval No.\u0026nbsp;KE/1463/09/2024).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to Publish\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent for publication of the clinical images was ob- tained from the participant included in this study\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgment\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eI extend my sincere gratitude to all participants for their participation in this study. Special appreciation is also directed to the Jakarta Provincial Health Office and the Central Jakarta Health Sub-Office, particularly the Public Information Officer and Data and Information Center teams, for their invaluable assistance in facilitating the research permit process and data collection.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData will be provided upon request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eKementerian Kesehatan Republik Indonesia (Kemenkes RI), \u003cem\u003ePermenkes RI \u003c/em\u003e\u003cem\u003eNomor 21 Tahun 2020 tentang Rencana Strategis Kementerian Kesehatan Tahun 2020\u0026ndash;2024\u003c/em\u003e, Kementerian Kesehatan RI, vol. 9, no. May, p. 6, 2020.\u003c/li\u003e\n\u003cli\u003eKeeler J and Most SP, \u003cem\u003eMeasuring Nasal Obstruction\u003c/em\u003e, Facial Plastic Surgery Clinics of North America, vol. 24, no. 3, pp. 315\u0026ndash;322, 2016. doi: 10.1016/j.fsc.2016.03.008.\u003c/li\u003e\n\u003cli\u003eParamyta WW, Widiarni D, Wardani RS, and Bachtiar A, \u0026ldquo;Validitas dan reliabilitas kuesioner Nasal Obstruction Symptom Evaluation (NOSE) dalam Bahasa Indonesia,\u0026rdquo; \u003cem\u003eOto Rhino Laryngologica Indonesiana\u003c/em\u003e, vol. 47, no. 1, p. 11, 2017, doi: 10.32637/orli.v47i1.190.\u003c/li\u003e\n\u003cli\u003eKapadia PB, Chaudhari AV, Contractor JA, R. Patel RB, Suratwala JN, and Patel JA, \u003cem\u003eA study of correlation between subjective sensation of nose block and objective assessment of nasal patency by cold spatula test in a patient with nose block\u003c/em\u003e, Clinical Rhinology, vol. 10, no. 1, pp. 1\u0026ndash;5, 2017, doi: 10.5005/jp-journals-10013-1293.\u003c/li\u003e\n\u003cli\u003eBassi IB, Franco LP, and Motta AR, \u003cem\u003eEfic\u003c/em\u003e\u003cem\u003e\u0026acute;\u003c/em\u003e\u003cem\u003ea\u003c/em\u003e\u003cem\u003ecia\u003c/em\u003e\u003cem\u003e \u003c/em\u003e\u003cem\u003edo em- \u003c/em\u003e\u003cem\u003eprego do espelho de Glatzel na avalia\u0026cedil;c\u0026tilde;ao da permeabilidade nasal (Efficacy of the use of the Glatzel mirror in nasal permeability evaluation)\u003c/em\u003e, 2009. [Online]. Available: http://www.medicina.ufmg.br/fon/monografias/ 07-iara-bassi.pdf\u003c/li\u003e\n\u003cli\u003ePacheco MCT, Casagrande CF, Teixeira LP, Finck NS, and de Arau\u0026acute;jo MTM, \u0026ldquo;Guidelines proposal for clinical recognition of mouth breathing children,\u0026rdquo; \u003cem\u003eDental Press Journal of Orthodontics\u003c/em\u003e, vol. 20, no. 4, pp. 39\u0026ndash;44, Jul. 2015, doi: 10.1590/2176-9451.20.4.039-044.oar.\u003c/li\u003e\n\u003cli\u003eNakahara K, Mishiba K, Doi R, and Kondo K, \u0026ldquo;Nasal Expiration Image Detection on Mirror Surface Using Alternating Optimization,\u0026rdquo; in \u003cem\u003eProceed- ings of the 7th IIAE International Conference on Industrial Application Engineering 2019\u003c/em\u003e, Institute of Industrial Applications Engineers, 2019, pp. 233\u0026ndash;238. doi: 10.12792/iciae2019.045.\u003c/li\u003e\n\u003cli\u003eU. Elfiah, I. L. Putri, M. R. Hutagalung, D. S. Perdanakusuma, and T. Kosbandriati, \u0026ldquo;Variasi Antropometri Wajah Indonesia dan Sefalometri se- bagai Data Dasar pada Rekonstruksi Trauma Maksilofasial (Variables of Indonesian Facial Antropometry and Cephalometry as Database in Recon- struction of Maxillofacial Trauma),\u0026rdquo; vol. 1, no. 1, pp. 6\u0026ndash;12, 2011.\u003c/li\u003e\n\u003cli\u003eK. Naito, S. Horibe, Y. Tanabe, H. Kato, S. Yoshioka, and I. Tateya, \u0026ldquo;Ob- jective assessment of nasal obstruction,\u0026rdquo; Fujita Medical Society, 2023. doi: 10.20407/fmj.2021-029.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Nasal obstruction, cold spatula test, Glatzel mirror, primary healthcare facilities, Indonesia","lastPublishedDoi":"10.21203/rs.3.rs-8109252/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8109252/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eThis study aimed to compare two simple tools, the metal spatula (cold spatula test) and the Glatzel mirror, in detecting nasal obstruction in a primary healthcare facility in Indonesia. The study provides a direct comparison between two non-invasive, low-cost screening tools whose effectiveness has not been widely evaluated in Indonesia.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eA cross-sectional study was conducted involving 34 healthy subjects aged 18–59 years. Each participant underwent nasal airflow assessment using both tools. Condensation patterns were visually assessed to evaluate symmetry and condensation area.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eThe Glatzel mirror yielded an average condensation area of 4.1 cm (SD 0.5), ranging from 3.1 to 5.1 cm, with a median left–right nostril difference of 0.2 cm. The maximum difference was 1.4 cm, below the clinical threshold of 2 cm for nasal obstruction. In contrast, the cold spatula test produced only qualitative results, with all participants categorized as having wide condensation. A Wilcoxon signed-rank test showed a statistically significant user preference for the Glatzel mirror (Z = –2.183, p = 0.029).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003eThe Glatzel mirror provided more objective and quantifiable results than the metal spatula and was more favorably rated by users. These findings support its potential as a practical and informative screening tool for nasal obstruction in resource limited primary care settings in Indonesia.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTrial registration :\u003c/strong\u003e Not applicable.\u003c/p\u003e","manuscriptTitle":"A Comparative Study Of The Cold Spatula Test And The Glatzel Mirror For Nasal Obstruction Screening In Indonesian Primary Healthcare Settings","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-20 11:36:42","doi":"10.21203/rs.3.rs-8109252/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"7402a260-cf74-42b6-841a-ce4ef770c75c","owner":[],"postedDate":"November 20th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":58167673,"name":"Health sciences/Diseases"},{"id":58167674,"name":"Health sciences/Health care"},{"id":58167675,"name":"Health sciences/Medical research"}],"tags":[],"updatedAt":"2026-03-09T07:28:33+00:00","versionOfRecord":[],"versionCreatedAt":"2025-11-20 11:36:42","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8109252","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8109252","identity":"rs-8109252","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}