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The Adenoidal-Nasopharyngeal Ratio (A-N Ratio)—Its Validity in Selecting

Children for Adenoidectomy

Article  in  The Journal of Laryngology & Otology · July 1987

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The Journal of Laryngology and Otology
June 1987. Vol. 101. pp. 569-573

The adenoidal-nasopharyngeal ratio (AN ratio)

Its validity in selecting children for adenoidectomy
by
SAMY ELWANY, M.D. (Al Khobar, Saudi Arabia)

Many otolaryngologists and pediatricians maintain that the methods employed

clinically for estimating the size of adenoids are in many ways unsatisfactory.
Hibbert et al. (1980), in a well designed study, found that symptoms and signs are
very unreliable predictors of adenoid size, and that it is incorrect to base the
decision for adenoidectomy on clinical findings only. In another report, Maw et al.
(1981) found poor inter-observer agreement for the clinical assessment of the
condition, and attributed their findings to differences in the clinical experience of
the examiners.

The feeling that clinical assessment alone can
be misleading when a decision for adenoidec-
tomy has to be taken stimulated the quest for a
radiological means of confirming the diag-
nosis. Several radiological techniques have
been suggested (Weitz, 1946; Johannesson,
1968; Pruzansky, 1975; Hibbert and White-
house, 1978). However, their use in routine
daily practice has not been popular since the
interpretation of radiographs has varied from
author to author, and there has always been a
divergence of opinion as to what constitutes
abnormally large adenoids. Moreover, some
of these techniques are expensive and
unavailable in rtfany medical centers.
The adenoidal-nasopharyngeal ratio was
first described by Fujioka et al. (1979), who
measured it in a large series of normal chil-
dren. The present work set out to measure the
AN ratio in children selected for adenoidec-
tomy and to assess its reproductibility
between different observers and its predictive
reliability in determining candidacy for
adenoidectomy.
Material and methods
Subjects:
One hundred children scheduled for ade-
569
noidectomy were studied. There were 68 boys
and 32 girls in the age range 3-7 years. As a
control group, one hundred normal children,
matched for age and sex with the first group,
without known ENT abnormality were also
examined. The consent of the parents of all
children was obtained.
Clinical assessment:
Clinical assessment was made by three
observers. A history of snoring, from parents,
was recorded as absent (0) or present (I).
Each child was then assessed for mouth
breathing and hyponasality. Each observer
scored a sign when present as I and when
absent as 0. The scores of each child were
added together to give the clinical assessment
score (CAS).
Radiographic assessment:
Lateral radiographs of the nasopharynx
were exposed with the patient in the erect
position and the head fixed with a wall-
mounted cephalostat and oriented with the
Frankfort horizontal plane. The exposures
were made with 100 kv. and 50 raA. The
exposure time varied between 0.4-0.6 sec
570
depending on the age of the child. The tube-
cassette distance was 180 cm. With this
arrangement, the median plane is enlarged by
65 per cent.
The adenoidal measurement A represents
the distance from the point of maximal con-
vexity of the adenoid shadow to a line (B)
along the anterior margin of the basiocciput.
FIG. 1 Adenoid weight:
Measurements for calculation of the AN ratio on stan-
dard lateral skull radiograph. Line B is tangential to
the basiocciput. The adenoidal measurement (A) is
obtained by drawing a prependicular line to B at the
point of maximal adenoid tissue. The nasopharyngeal
measurement (N) is made between the posterior
border of the hard palate (P) and the antero-inferior
aspect (S) of the spheno-basioccipital synchondrosis
(white arrowheads). When the synchodrosis is not
visible the point (S) is determined as the point on the
anterior edge of the basiocciput which is closest to the
intersection of lines A and B. The black arrowheads
outline the adenoid shadow.
SAMY ELWANY
The nasopharyngeal measurement N is the
distance between the posterior border of the
hard palate (p) and the antero-inferior edge of
the sphenobasioccipital synchondrosis (S).
When the synchondrosis is not clearly visual-
ized, the point S is determined as the point on
the anterior edge of the basiocciput which is
closest to the intersection of lines A and B
(Fig. 1). This has been found to be an easier
landmark than Fujioka's original landmark of
the point of crossing of the posterior border of
the pterygoid plate and the basiocciput. The
AN ratio was obtained by dividing the
measurement for A by the value for N. All
measurements were made with a caliper to
within ± 0.1mm. Each' radiograph was
assessed by three observers and the mean
value of the AN ratio was determined for each
case. Agreement between observers was con-
sidered absolute when the AN ratio values of
the three observers were identical (within
0.1), relative when two were identical, and
lacking if the three were different.
An overall impression of the size of adenoid
and nasopharyngeal airway was scored by
assessing the radiographic adenoid shadow
incrementally as small or normal (0), moder-
ately enlarged (I), or markedly enlarged (2).
The nasopharyngeal airway was rated normal
(0), moderately narrowed (I) or markedly
narrowed (2). These scores were combined to
give the radiological assessment score (RAS).
The average score was calculated for each
case. The inter-observer agreement was con-
sidered absolute if the three observers were
identical (within 1 scale point), relative when
two observers were identical, and absent if the
three were different.
One surgeon performed all of the ade-
noidectomy operations by a standard
curettage technique. Immediately after
removal the tissue was washed, and weighed
using a chemical beam balance. The weights
were recorded.
Results
/—Measurement of the AN ratio:
The mean AN ratio for children selected for
THE ADENOIDAL-NASOPHARYNGEAL RATIO 571
TABLE I Ill—AN ratio versus clinical assessment of
AN RATIO VERSUS CLINICAL ASSESSMENT OF ADENOID SIZE
adenoid size:
AN ratio When the values of the AN ratio were com-
Adenoid size pared to subjective clinical grading of adenoid
Range Mean ± SD size (Table I), it was found that the AN ratios
Normal 0.499-0.621 0.593 + 0.0771 of children with moderately and markedly
Moderately enlarged 0.652-0.742 0.680 + 0.1028 enlarged adenoids did not differ significantly
Markedly enlarged 0.732-0.853 0.726 ± 0.1007 (t = 1.067, P>0.05). On the other hand, each
of the previous two groups was significantly
TABLE II
different from normal children (t = 2.492,
CORRELATIONS OF AN RATIO, CAS, RASi, AND ADENOID P<0.05; t = 2.519, P<0.05 respectively). It is
WEIGHT of note that none of the children with mark-
edly enlarged adenoids had AN ratio smaller
AN ratio than the suggested threshold value.
r t P
CAS 0.72 10 .52 <0.001 TV—Correlations of AN ratio, RAS, CAS,
RAS 0.21 2 .13 <0.05 and adenoid weight:
Adenoid weight 0.66 8.69 <0.001
These were calculated using Pearson cor-
relation coefficient (Table II). A highly
adenoidectomy was 0.713 (range 0.652-0.853,
significant correlation existed between the
SD ± 0.105). For normal children the mean
AN ratio, CAS and adenoid weight. On the
value was 0.583 (range 0.499-0.621, SD ±
other hand, the correlation between AN ratio
0.0741). The difference between the two
and RAS was considerably less significant.
groups was statistically significant (t = 3.493,
Likewise, the correlations between RAS and
P<0.01).
CAS (r = 0.26, t = 2.45, 0.05>P>0.01) or
adenoid weight (r = 0.25, t = 2.56,
0.05>P>0.01) were less significant.

V—Inter-observer agreement:
//—Threshold value of the AN ratio:
Review of Table III shows that there was
For determination of a threshold value of less variability between observers when they
the AN ratio above which the diagnosis of used objective criteria (AN ratio) than when
enlarged adenoids is confirmed the data for they depended upon overall or 'gestalt' eval-
normal children were used. Since this ratio uation of the radiographs (RAS).
was found to be dependent on age (Fujioka et
ai, 1979; Jeans et al, 1981), the mean ratio
was determined for two age groups, children Discussion
below the median age and children above the Since 1946 several radiological techniques
median age. The average of these two means of adenoidal assessment have been described.
was calculated, and the threshold value was
defined as the value of AN ratio which is two TABLE III
INTER-OBSERVER AGREEMENT FOR AN RATIO AND R A S
standard deviations above the mean. The
threshold value was 0.73. When this value was Agreement AN ratio RAS
applied to the series selected for adenoidec-
tomy it was found that 94 per cent of patients Absolute 66* 24
had AN ratio above the threshold. On the Relative 25 48
Lacking 9 28
other hand, only 2 per cent of normal children
exceeded it (false positive). ' Per cent
572
However, none of them has been widely
accepted or implemented because they have
not expressed the maximal thickness of
nasopharyngeal soft tissues (Capitanio and
Kirkpatrick, 1970; BWexetal., 1971); have not
consistently shown landmarks (Weitz, 1946;
Johnannesson, 1968); or have been impracti-
cal, expensive and too time consuming to be
adopted for routine use (Goldman and Bach-
man, 1958; Handleman and Osborne, 1976;
Hibbert and Whitehouse, 1978). Moreover,
the literature is indefinite as to the normal
limits of the size of adenoids and the objective
criteria for the diagnosis of pathological
enlargement (Johannesson, 1968; Steele et
al., 1968). A recent survey of ENT surgeons in
the United Kingdom has shown that only 2.5
per cent of them use radiology as a routine
(Hibbert, 1977).
The AN ratio was first described by Fujioka
et al. (1979) as a reliable method of expressing
the size of the adenoids and the patency of the
nasopharyngeal airway. The present study is
an attempt to quantitate the diagnosis of path-
ological enlargement of the adenoids using
the AN ratio, and to assess the reliability of
the technique and its reproducibility between
different observers (inter-observer agree-
ment).
From the measurements of the AN ratio it
would appear that, for practical purposes, a
value of AN ratio greater than 0.73 may be
considered indicative of pathological enlarge-
ment as long as the child is in the age range of 2
to 12 years. Fukioka et al. (1979) found that
the mean AN ratio in normal children
increased from 0.55 at age 1 year 3 months,
and reached its highest value, 0.59, at age 4
years 6 months, and then decreased to 0.52 at
age 12 years 6 months. The fact that all of
these values are well below the suggested
criteria explains the notably low incidence of
false positive results (2 per cent). On the other
hand, only 6 per cent of children selected for
adenoidectomy would have been missed
(false negative diagnosis) if we depended only
on the AN ratio. It is noteworthy that none of
the children selected for adenoidectomy had
AN ratio less than 0.65, which is well above
the results of Fujioka et al. (1979). Likewise,
all children with markedly enlarged adenoids
SAMY ELWANY
had AN ratios above the suggested threshold
value of 0.73.
The AN ratio correlated with the clinical
score and the weight of adenoids better than
did subjective overall evaluation of the radio-
graphs (RAS). These results highlight the
reliability and validity of AN ratio, and con-
firm the results of Fujioka et al. (1979), which
expressed the small value of subjective assess-
ment of the radiographs. However, the AN
ratio technique may not be enough for
accurate assessment of children with obstruc-
tive sleep apnea since it does not consider the
complex physiologic factors that may be
involved in the pathogenesis of this condition
(Frenback^a/., 1983). •
An advantage of the AN ratio is that it
considers both the adenoidal size and the
nasopharyngeal capacity. Linder-Aronson
(1970) mentioned that symptoms caused by
enlarged adenoids tend to occur more com-
monly in children with a relatively small
nasopharynx. Hibbert and Stell (1979), in a
more recent series, found that there was no
difference in the radiographic area of ade-
noids between normal children and those
selected for adenoidectomy.
Proper exposure of the film and positioning
of the patient are mandatory for correct
measurements. The measurements to pro-
duce the ratio may be cumbersome, or pre-
cluded if the technique is too light or if
overcollimation has excluded any of the
necessary landmarks. The position of the soft
palate is, on the other hand, unimportant.
In conclusion, adenoidectomy is a com-
monly performed pediatric surgical procedure
and one which can be frequently abused. It is
hoped that, by establishing solid objective
criteria for assessing the patients, we will be
able to cut down this misuse leaving only the
benefits of the operation to be gained by the
patients.
Summary
The present study disclosed that the AN
ratio measured on simple lateral skull radio-
graphs reliably expressed the adenoidal size
and patency of the nasopharyngeal airway,
and correlated well with the clinical assess-
THE ADENOIDAL-NASOPHARYNGEAL RATIO 573

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