401

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Radiographic Evaluation of Adenoidal Size in Children: Adenoidal-Nasopharyngeal Ratio

Mutsuhisa Lionel and Bertram

W.

Young

R. Girdany

Adenoidal-nasopharyngeal ratios (AN ratios) obtained by simple linear measurements from lateral skull radiographs are described. The AN ratio reliably expresses adenoidal size and patency of the nasopharyngeal airway. The validity of the ratio as an indicator of adenoidal size was determined by evaluation of measurements of radiographs of 1 ,398 infants and children and comparison with a subjective visual assessment made by experienced observers in 92 patients. An AN ratio greater than 0.80 was present in 34 of 36 patients (94%) subjectively judged to have enlarged adenoids.

Tonsillectomy and adenoidectomy procedures in the United States

patients [2], as for well

[1
[3]

].

are the most common Recent emphasis on from concern

space-filling roles

pediatric surgical careful selection of of surgery

of tonsils and [4, 5]

these
as the

procedures
immunologic

derives without caused by heart of the

for complications

and

adenoids. Adenoidectomy ryngeal airway obstruction obstruction

chronic otitis

tonsillectomy by enlarged failure [6]

is indicated to relieve nasophaadenoids, especially if the airway or is associated is established

of the adenoids

is complicated
media [7].

with

recurrent method
However,

or

Radiographic
for we determination know

evaluation
of the size,

nasopharynx
and position

as a simple
[5, 8].

shape,

of no reliable

objective of the adenoids that sizes We

criteria and

for the

this size

evaluation and shape

reported of the

in pediatric nasopharyn-

age groups [9-14]. The absolute size

geal space are major factors 1 2]. The ratio of these two nasopharyngeal obstruction. (AN ratio) nasopharynx. measurements tested
Received
revision May

determine nasopharyngeal obstruction [5, 10, can provide a simple arithmetic measure of describe an adenoidal-nasopharyngeal ratio measurements standards on lateral for this AN ratio ages. size radiographs were obtained standards of the from were

derived from Statistically of infants

linear derived and

children

of varying of adenoidal

These made

against

October
1 7. 1979.

20.

1978:

accepted

after

observers

the subjective evaluation using the same radiographs. Methods 20 years,

examinations

by experienced

Materials For more

exposed

and than

All authors: Department of Radiology. Childrens Hospital of Pittsburgh. University of Pittsburgh School of Medicine. Pittsburgh, PA 15213. Address reprint requests to M. Fujioka.
AJR 133:401-404, September 1979 0361 -803X/79/ 1333-0401 $00.00 American Roentgen Ray Society

lateral
of the

radiographs
chest of and/or

of the nasopharynx
the paranasal

have
sinuses

been
in the

routinely
radiology

during

department of Childrens Hospital with the patients in the erect position samples of i .398 children

Pittsburgh. These at the tube-cassette

radiographs have been obtained distance of 180 cm. Radiographic randomly selected from outpa-

(812

boys

and 586

girls)

were

402

FUJIOKA

ET

AL.

AJR:133,

September

1979

TABLE Infants

1 : Adenoidal-Nasopharyngeal

Ratios

(AN Ratio)

in

and Children
No (n Children
=

Median Ages (years, months)

Mean

SD

1 .398)

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0, 0, 0,

i.5 4.5 9 1, 3 i, 9 2, 6 3, 6

33 Si 74 56 45 78 82

0.329 .457 .508 .548 .538 .555 .567

0.ii54 .1242 .1087 .i023 .0940 .0991 .1021

4, 6
5, 6, 7, 8, 9, 10, ii, i3, 14, 6 6 6 6 6 6 6 6 6

85
79 98 85 73 74 79 93

.588
.586 .575 .555 .568 .536 .Sii .532

.ii29
.1046 .1182 .i174 .1108 .1372 .i5iS .i4Oi

Fig. 1 -Adenoidal measurements. A represents distance from A , point of maximal convexity, along inferior margin of adenoid shadow to line B, drawn along straight part of anterior margin of basiocciput. A is measured along line perpendicular from point A
to its intersection with B.

12, 6

81
84 85

.518
.458 .435

.542
.i52i .i436 .1533

is,

63

.380

basioccipital visualized, posteroinfenior of the bony measurement

synchondrosis. point D margin nasopharynx. for A by the of the

When lateral AN for

the as ratio N.

synchondrosis the point plate

is not of crossing (P) and by

clearly of the the floor the

is determined The value 1 6 years nasopharyngeal

pterygoid

is obtained

dividing

Lateral
tween ages 3). The Health

radiographs
i month 1 43 and In these, lateral Human the and

of the nasopharynx
were

of i 398
reviewed radiographs and

children
the of 92

be1 and

AN ratios patients

were
fig. Child

calculated,

tabulated, by Paradise

and statistically (unpublished

Development size and

analyzed data, National

HO 07403) nasopharyngeal

(table

from the study

evaluated.

Institute
were airway

of
also

grant

adenoidal

patency
0.

had been
size and/or small. plotted was

estimated
as well narrow The against compared in the

visually
as patency nasopharyngeal AN ratio age (fig. with Paradise

by experienced
B. A. Girdany) of the

observers
and

(C.

Bluestone,

S. Stool,

J. C. Paradise,

graded airway

for adenoidal

nasopharyngeal air space,

(table
ually

2). Adenoidal
large

size was classified

from 4). the

incrementally
each The of these statistical

as: (1 ) unus(2) normal, 1 43 radioby the distribution derived or

c:3
Fig. 2.-Nasopharyngeal

(3)

unusually was values

graphs of these visual

distribution

classifications

study.

C! , posterior superior edge edge of sphenobasioccipital

not clearly visualized, point

N is distance between of hard palate, and 0 . anteroinfenior synchondrosis. When synchondrosis is 0 can be determined as site of crossing

measurement.

Results The
der normal and

posteroinfenior

margin

of lateral

pterygoid

plates

P and

floor

of bony

nasopharynx.

frequency
in each

distribution
age group

of the
followed

AN

ratios
expected

for

each
curves

genfor

tients

referred i 973-i paranasal adenoidal A, anterior the point

from 976.

private Patients or

physicians with lungs any were

offices radiographic excluded.

during No

the child the

3 year had a

distribution. differences on AN
0.1 0). months

There were no statistically ratios for gender in any age 0.33 and
to 0.52

significant group (p> at age reached The AN

at age

period,
of the history The from the the

abnormalities

sinuses

The mean AN ratio increased from to 0.55 at age 1 year 3 months, value, 0.59, at age
from

1.5 its ratio

12

of adenoidectomy. measurement of maximal to a line of the line and B. A (fig. convexity B, drawn basiocciput. The D, the 1 ) represents along along The the the distance inferior straight distance margin part of of

highest
gradually

4 years
this peak

6 months.
value

decreased

adenoid

shadow, margin with palate,

A is measured

years 6 months and then 1 5 years 6 months (table The referred

and the

diminished 1 and fig.

sharply 3).

to 0.38 92

at age

along

a line dropped

perpendicularly between

from

point

A to its point
space N (fig. of the 2)

of
is

intersection

nasopharyngeal anteroinfenior

AN ratios to in the
results

on 1 43 radiographs Paradise study were

compared with visually

of the statistically
estimated

patients evaluated
classifi-

measured
of the hard

as the distance

C, the posterior-superior
edge

edge
spheno-

cations

of adenoidal

size.

Table

2 shows

the

mean

values

AJR:133,

September

1979

ADENOIDAL

SIZE

IN

CHILDREN

403

1.00

S S S S 5 S 55 S 55 5 .sS--X .-5 s__!!._s___s.___S.. x S S S S

0.90

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0.80

x
Sxx xxx

x
a
,,,,

070 .

I,

x
XX

X
XX

xxx5
x:xx.xk

+2SD

0.60

0.50

(//cXXX

z
<

XXa

#{149} Si

0.40
, , --.-

#{149}X
-------

#{149}
-.

#{149}

#{149}#{149} S

X\MEAN

0.30
I I

I
/ #{149} S #{149}

0.20

I
i i i I

,
I 2 3 4 5 6 7 8 9 AGE

___%__

#{149}

. -. .% ,.. 5.

S 5. 5

010 .

-2SD

lOll

1213141516

AGE Fig. 3-AN ratio in 1 .398 infants and children in different ages.
in

Fig. 4.-Visual
the Paradise

classification
study. Square

nasopharyngeal

air space;

vs. AN ratio in 143 radiographs = unusually large adenoids normal adenoids; circle =
patients: broken

TABLE

2: AN

Ratio

in Each

Visual

Grade
Mean SD

adenoids; and -2

solid line = SD from mean

mean for the 1 .398 in 1 .398 patients.

of 92 patients and/or narrow unusually small lines = + 2 SD

Classification

No. Radiographs
(n
=

143)

Unusually large adenoids and/or narrow airway space Normal adenoids Unusually small adenoids

36

0.864

0.0652

dren with large thought to have

but not abnormally enlarged narrowed air spaces.

adenoids

were

82 25

0.636 0.409

0.0908 0.0959

Discussion Simple,
radiographic

accurate,
assessment

and

objective
of adenoidal

measurements
size in children

for methods
However,

the
may

for mean with

each

grade

and of less

demonstrates the than grades 0.01

.

that were When

the

differences significant AN ratios were

in

have
adenoidal

important has been

clinical widely
have

applications.
have been

Several
reported.

of

values p values

among

statistically these

measurement

none
the

accepted
not

or

implemented
the maximal

because
thick-

plotted against designated as nasopharyngeal mean

1 .398

age (fig. unusually air space ratios

4), 34 of 36 adenoidal shadows large adenoids and/or narrow were more than 2 SD above the derived from our measurements in However, only four as unusually small of 25 ade were 2 SD

measurements

expressed

ness
practical

of nasopharyngeal shown
and too time

soft landmarks
consuming

tissue [8,

[5,

9,

1 5, 1 6],

have

not

consistently

of

the

AN

1 1 ], and have been imto be adapted for routine is an easily of the identifiable coninclude
measurebasiocciput

noidal

infants shadows

and children. designated

use[10-12, 16]. The straight part landmark. The

of the vexity

of the basiocciput thickness

soft tissue

below the mean of the measured group. The designation narrow nasopharyngeal estimated by experienced observers, was that did not specifically to measure airway of nasopharyngeal
or not there was

maximal

anteroinferior
from the

airway, as an impression the the anatomic N and visual impresaround

nasopharyngeal

reflects
other

the
posterior

adenoidal

size,

even
soft

though
tissues.

it does
The

take are not

into

account study; space

air

nasopharyngeal

landmarks nasopharyngeal estimates

sions

used

N in this airway

terms The were

space

interchangeable.
sufficient

ment N represents the sopharyngeal space. Capitanio and shadow is usually and that absence is consistent with gitudinal observation graphs, Subterny

anteroposterior

diameter

of the

na-

of whether

the

adenoids

to allow No effective grading.

normal criteria with

breathing were used

without

airway or small

obadechil-

Kirkpatrick [1 5] stated visible in infants aged of adenoids in infants immunodeficiency. of serial lateral and Koepp-Baker

that the adenoidal 6 months and older, older than 6 months From subjective cephalometnic Ionradiothat the

struction.
,

or derived instances,

for this

gestalt all

Patients air

average-size In some

noids

had

ample

passages.

[1 7] observed

404

FUJIOKA

ET

AL.

AJR: 133,

September

1979

adenoids time they

[1 3] reported frequently consistent

grew filled

rapidly in infants up to age 2 years, at which half of the nasopharyngeal cavity. Pruzansky
that by visual in children all these evaluation, 4-6 years large old. adenoids Our data most are 4. 3.

morbidity. ii54, Morag Rhino! Ardran Steele adenoid i974

Trans A, Ogura Laryngol GM, CH, Kemp Fairchild

Am PL: FH:

Acad

Ophthalmol aspect

Otolaryngol of tonsils. and

74 : i i 46Ann tonsils. tonsil Otol AJR and

Immunologic i975 A function RC, Aicketts

occurred with

84:37-43, i972

observations.

for adenoids AM: Am Forum J Orthod

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Our
number and

data
of

are
infants were

based
and normal.

on

the

measurements
whose since paranasal there

of
were

a large
sinuses 5,

1i4:268-28i, problem

children However,

on the

lungs

indications dren are not When compared

the 92

for

their

radiographic sample

examinations, of the normal

clinical these chilwere size in good 34 of

in orthodontics.

54:485-Si

5,

1968
6. Cayler

a random

population.
7, 8. 9. 1 0.

Fnicker
Am Reid Weitz 70, Ellen tissue adenoid

GG, Johnson EE, Lewis BE, Kortzeborn JO, Jordan JF, GA: Heart failure due to enlarged tonsils and adenoids.
i i 8:708-71 indication Clin North Aoentgenography Roberts CS, development JF, Ziten FM G: one for Am 7, i 969 tonsillectomy and adenoidectomy. 47:66soft
, 1 97i

adenoidal-nasopharyngeal with subjective assessments

patients in the

measurements of adenoidal was Also,

J Dis Child JM: HL: 1946 JL, The

agreement
36
, .

except
of the

Paradise study, there at small AN ratios (table 2).

shadows that were

Otolaryngol

3:339-344,
of adenoids.

1970
Radiology nasopharyngeal i i 2:537-541 the nasopharynx Angle of the Acta on mode Otolaryngol studies of Radio! years.

(94%) than

adenoidal

designated

unusually series 4). For

than

more

large (fig.
greater

large and/or narrow air space had AN ratios 2 SD above the mean value derived from the of measurements for the appropriate age group practical
0.80 may

Jn: Normal study. Growth

in adults,

a statistical Osborne from

AJR
of

Handelman

and Orthod nasopha[DiagnJ

to eighteen investigation ages. effect Acta

purposes, a value of be considered indicative small the AN large The ratio series reason (less did from

the AN ratio of enlarged than not 2 SD correlate discrep-

46:243-259,
1 1 . Johannesson ryngeal (Stockh) 1 2. and nasal tonsil

1976
5: Aoentgenologic in children 5: Adenoids: air flow and their of different 1967 their of breathing of [Suppl] tonsils and relationship to characteristics 7:299-304,

adenoids.
below well ancy

An mean)
the

abnormally derived
visual

with

assessment.

for this

Linden-Aronson

is not

certain.

the facial skeleton and dentition. (Stockh) 265: 1 -i 32, 1970 ACKNOWLEDGMENTS
We Sue thank for Dr. Paradise for suggestions and encouragement and i 4. i 5. Operations
,

1 3.

Pruzansky

5:

Roentgencephalometnic

adenoids
go184:55-62, Ricketts speech Capitanio sue. in Short-Stay of and Health, Hospitals. No. Education, 1 974, p 4 mortality and United 1 000-Series and States13, Welfare i 7. 1 6. Hibbert Public U.S. Center LW: Health for Service Health Publication Statistics, Arlen manuscript preparation.

in normal
i975 AM: and MA, The

and pathologic
cranial base Plast JA: GH: The and

states.
soft

Ann

Otorhinolarynin cleft palate

,

structures Surg

breathing. Kirkpatrick

Reconstr 1970

1 4 : 47-61

19S4 tissize

REFERENCES
i

Nasophanyngeal assessment

lymphoid of adenoidal

Radiology96:389-39i, J, Whitehouse means. Clin Koepp-Baker

Surgical 1 971 no. National 1 8,

Department

by radiological Subtelny JO, tissue 235-250, in i956

Otolaryngol3:43-47, H: The significance function. Plast Reconstr

i978 of adenoid Surg 1 7:

velopharyngeal

2.

Pratt

Tonsillectomy

adenoidectomy: