The Laryngoscope

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Assessing Adenoid Hypertrophy in Children: X-Ray or Nasal

Endoscopy?
Cristina M. Baldassari, MD; Sukgi Choi, MD

QUESTION
Assessing Adenoid Hypertrophy in Children: X-ray
or Nasal Endoscopy?

BACKGROUND
Upper airway obstruction is a common complaint in
children presenting to otolaryngology clinics. In such
children, adenoid hypertrophy is often suspected. There
are numerous ways to determine adenoid size, including
palpation, mirror examination, endoscopic examination,
lateral neck roentgenogram (X-ray), magnetic resonance
imaging (MRI), and acoustic rhinometry. Pediatric
patient cooperation limits the utilization of palpation
and mirror examination, while acoustic rhinometry and
MRI are not practical in the clinical setting. Thus, flexible fiberoptic nasal endoscopy (FNE) and lateral neck
X-ray are the two most common diagnostic tools used to
assess for adenoid hypertrophy. Cost-effective, age-specific guidelines on how best to evaluate adenoid size are
lacking. The aim of this review is to determine whether
X-ray or endoscopy is superior in assessing adenoid
hypertrophy in pediatric patients presenting with upper
airway obstruction.

LITERATURE REVIEW
Different measurements have been proposed for
assessing adenoid size on lateral neck X-ray, including:
1) the adenoid-nasopharynx ratio (A/N ratio), 2) the

From the Department of OtolaryngologyHead and Neck Surgery

(C.M.B.), Eastern Virginia Medical School, Childrens Hospital of the
Kings Daughters; Norfolk, Virginia; and the Department of OtolaryngologyHead and Neck Surgery (S.C.), Childrens National Medical Center,
Washington, DC, U.S.A.
Editors Note: This Manuscript was accepted for publication on
July 25, 2013.
The literature review and drafting of the manuscript occurred in
the Otolaryngology Departments at the Childrens Hospital of the Kings
Daughters and Childrens National Medical Center.
The authors have no funding, financial relationships, or conflicts
of interest to disclose.
Send correspondence to Cristina M. Baldassari MD, Childrens
Hospital of the Kings Daughters, Department of Otolaryngology, 601
Childrens Lane; 2nd Floor; Norfolk Virginia 23507.
E-mail: baldassc@gmail.com
DOI: 10.1002/lary.24366

Laryngoscope 124: July 2014

adenoid thickness (distance along a perpendicular line

from the basiocciput to the adenoid convexity), and
3) the linear distance between the antrum and adenoid
tissue.1 The A/N ratio, the most commonly used measurement, is defined as the ratio of the measurement of
the adenoid thickness and the nasopharyngeal aperture
(the distance between the basiocciput and the posterior
edge of the hard palate).1 There have been numerous
articles that have focused on the utility of the A/N ratio
in diagnosing adenoid hypertrophy. A recent systematic
review1 reported conflicting data on the accuracy of the
A/N ratio. Of the five studies identified in the analysis
that focused on the A/N ratio, three studies found no
relation between the A/N ratio and adenoid size, and
two studies demonstrated a significant correlation.
Thus, the authors concluded that the utility of lateral
neck X-ray to detect adenoid hypertrophy could not be
clearly substantiated. While lateral neck X-rays have
the advantage of being noninvasive and quickly accessible in the clinical setting, these films are static in nature
and are a two-dimensional representation of a threedimensional space. Other limitations include radiation
exposure and the impact of patient respiration and phonation on the interpretability of the results. For example, mouth breathing, crying, or swallowing during the
examination may cause soft palate elevation and thus
reduce the size of the nasopharyngeal cavity. To optimize
image quality, lateral neck X-rays should be performed
at the end of inspiration with the neck in slight
extension.
FNE examination of the adenoid is safe and reliable
in the pediatric population.25 The main advantage of
FNE is its dynamic nature. Wang et al.3 conducted a
prospective study of 180 children presenting with nasal
obstruction and suspected adenoid hypertrophy. All children underwent FNE, tympanogram, and a survey
regarding their obstructive symptoms. During FNE, the
adenoid size was objectively quantified by measuring the
distance from the vomer to the adenoid. Ninety-three
percent of participants less than 1 year of age and
greater than 6 years of age were able to tolerate the
FNE with topical anesthesia. Thirty-three percent of
children between 1 and 3 years of age could tolerate
FNE without premedication. The authors concluded that
Baldassari and Choi: Assessing Adenoid Hypertrophy in Children

1509

adenoid size as determined by FNE was significantly

(P < 0.0001) correlated with both nasal obstructive symptomatology and tympanogram type. In this study, children with a large adenoid on FNE had a higher
incidence of both nasal obstruction complaints and type
B tympanograms when compared to children with small
or moderate-size adenoids.
Several publications have compared lateral neck
X-ray and FNE for the evaluation of adenoid hypertrophy
in children.25 Thirty-nine children with suspected
adenoid hypertrophy were evaluated by both FNE and
lateral neck X-ray in a study by Mlynarek et al.4 Caregivers of the patients also completed a standardized questionnaire on upper airway obstructive symptoms. There
was a significant (P 5 0.039) correlation between the total
symptom score and the percentage of airway occlusion as
assessed by FNE. Lateral neck X-ray measurements such
as adenoid thickness and A/N ratio did not correlate with
obstructive symptom scores. Conversely, Caylakli2 et al.
published a blinded, prospective study demonstrating
that the A/N ratio significantly correlated with FNE findings in 85 children with probable adenoid hypertrophy.
FNE findings in this study were standardized by calculating the obstruction ratio of adenoid tissue to choanal
opening. Finally, Lertsburapa et al.5 retrospectively
reviewed the FNE and lateral neck X-ray findings of children who underwent adenoidectomy. Both FNE findings
and the A/N ratio on lateral neck X-ray significantly correlated with adenoid size on intraoperative nasopharyngeal mirror exam. However, the radiologists subjective
report of adenoid size as either mild, moderate, or severe
on lateral neck X-ray did not correlate. The authors also
noted that children that had a lateral neck X-ray to
assess for adenoid hypertrophy were younger than those
who underwent FNE. The costs of FNE and X-ray were
comparable in this study.

BEST PRACTICE
Flexible nasal endoscopy is well tolerated in most
children and has the advantage of allowing for direct

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visualization of the adenoid. Adenoid hypertrophy diagnosed on flexible nasal endoscopy correlates with airway
obstruction symptomatology. While A/N ratio on lateral
neck X-ray frequently correlates with adenoid size, lateral neck films can be impacted by patient positioning
and involve radiation exposure. Furthermore, the cost of
flexible nasal endoscopy and lateral neck X-ray are comparable. Thus, in children presenting with upper airway
obstruction and suspected adenoid hypertrophy, flexible
nasal endoscopy is the best initial choice for evaluation
of adenoid size. Clinicians may consider lateral neck Xray in those children who need an objective assessment
of their adenoid size and are unable to cooperate with
flexible nasal endoscopy. Future research is necessary to
determine whether initial adenoid size noted on FNE or
lateral neck X-ray correlates with improvement in airway obstruction symptoms following surgical removal of
the adenoid.

LEVEL OF EVIDENCE
MFN Feres et al.1 is a systematic review of mostly
level 3 and 4 studies. F. Caylakli et al.2 is a blinded, prospective level 3 study. Wang D. et al,3 A. Mlynarek
et al.,4 and K. Lertsburapa et al.5 are level 4 studies.

BIBLIOGRAPHY
1. Feres MFN, Hermann JS, Cappellette M, et al. Lateral X-ray view of the
skull for the diagnosis of adenoid hypertrophy: a systematic review. Int
J Pediatr Otorhinolaryngol 2011;75:111.
2. Caylakli F, Hizal E, Yilmazer C. Correlation between adenoid-nasopharynx
ratio and endoscopic examination of adenoid hypertrophy: a blind, prospective clinical study. Int J Pediatric Otorhinolaryngol 2009;73:
15321535.
3. Wang D, Clment P, Kaufaman L, et al. Fiberoptic examination of the nasal
cavity and nasopharynx in children. Int J Pediatri Otorhinolaryngol
1992;24:3544.
4. Mlynarek A, Tewfik M, Hagr A, et al. Lateral neck radiography versus
direct video rhinoscopy in assessing adenoid size. J Otolaryngol 2004;33:
360365.
5. Lertsburapa K, Schroeder J, Sullivan C. Assessment of adenoid size: a
comparison of lateral radiographic measurements, radiologist assessment, and nasal endoscopy. Int J Pediatr Otorhinolaryngol 2010;74:
12811285.

Baldassari and Choi: Assessing Adenoid Hypertrophy in Children