Indian J Otolaryngol Head Neck Surg
https://doi.org/10.1007/s12070-018-1359-7
ORIGINAL ARTICLE
Role of Adenoid-Nasopharyngeal Ratio in Assessing Adenoid
Hypertrophy
Sanu P. Moideen1 • Regina Mytheenkunju2 • Arun Govindan Nair3
Mohan Mogarnad4 • M. Khizer Hussain Afroze5
Received: 12 May 2017 / Accepted: 10 April 2018
Ó Association of Otolaryngologists of India 2018
Abstract Most of the time, pediatrician is the first to see
children with adenotonsillar hypertrophy (AH) and they
mostly rely on clinical assessment with or without some
investigation to refer these children to otorhinolaryngologist.
Numerous methods have been described for evaluation of
AH, but many of these methods are not possible to follow in
busy pediatric outpatient unit either because of lack of
cooperation from child or due to limited availability of test or
due to cost constraints. This study has been conducted to
determine the diagnostic accuracy of lateral neck X-ray
(LNX) for assessing AH and to assess the correlation
between adenoid size in LNX and clinical symptoms in a
pediatric unit. Prospective study conducted in Department of
ENT, Pathmavathy Medical Foundation, Kollam, Kerala,
India from January 2015 to March 2016. 60 consecutive
children of both genders, between the age group of 5 to
14 years, attending Department of Pediatrics with a provi-
sional diagnosis of AH were included in the study. The
symptom scores, radiographic ratio of adenoid to
nasopharynx and endoscopic scorings were calculated.
Lateral neck X-ray with calculation of adenoid-to-
& Sanu P. Moideen
drsanu85@gmail.com
1
Department of Pediatric ENT, Christian Medical College &
Hospital, Vellore, Tamilnadu 632004, India
2
Department of Pediatrics, Academy of Medical Sciences,
Pariyaram, Kannur, Kerala, India
3
Department of Otorhinolaryngology, Padmavathy Medical
Foundation, Kollam, Kerala, India
4
Department of Otorhinolaryngology, Sri Siddhartha Medical
College, Tumakuru, Karnataka, India
5
Department of Anatomy, Sri Siddhartha Medical College,
Tumakuru, Karnataka, India
•
nasopharynx ratio is found to have significant correlation
with patient reported symptoms and findings in nasal endo-
scopic examination (NE). LNX can be considered as a useful
objective tool in evaluation of children with adenoid
hypertrophy. Primary care physicians or pediatricians can
confidently use lateral neck X-ray for making clinical deci-
sions and can consider nasopharyngoscopy when clinical
picture remains unclear or more evaluation is needed.
Keywords Adenoids
Adenotonsillectomy

Adenotonsillar hypertrophy
Adenotonsillectomy

Neck X-ray
Introduction
Adenoids, also known as nasopharyngeal tonsils are nor-
mal lymphoid tissues present on posterior wall of
nasopharynx, forming a part of Waldeyer’s ring at the entry
of upper respiratory tract. Adenoids are the first site of
immunological contact for inhaled antigens in early
childhood. They produce B cells, which give rise to IgG
and IgA plasma cells, provides natural acquired immunity
in early childhood and appears to have an important role in
development of an ‘immunological memory’ in younger
children [1]. Adenoids become evident by 6 months to 1
year of life, increases rapidly in size during first 6–8 years
of life and generally atrophies by 15 years of age in most
children [2]. The growth of adenoid tissues is not in
agreement with the growth of the bony nasopharynx,
leading to nasal obstructive symptoms of adenoid hyper-
trophy (AH), which is described as the most common cause
of nasal obstruction in pediatric populations [3, 4].
Most well-known clinical symptoms of AH are upper air
way obstruction, reccurent otitis media, obstructive sleep
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apnoea, pediatric chronic rhinosinusitis, failure to thrive
and craniofacial developmental anomalies. Other symp-
toms of AH are mouth breathing, snoring, cough, speech
disturbance, lethargy and poor academic or scholastic
performances. Recently children with AH are found to
have increased association with nocturnal enuresis, atten-
tion deficit hyperactivity disorder, pulmonary hypertension
and right heart failure. These clinical symptoms are more
common in young pediatric population because of rela-
tively small volume of nasopharynx and increased fre-
quency of upper respiratory tract infections [3–6].
Most of the time, pediatrician is the first to see these
children and they mostly rely on clinical assessment with
or without some investigations to refer these children to
otorhinolaryngologist. Numerous methods have been
described for evaluation of AH, like history, physical
examination, palpation, posterior rhinoscopic mirror
examination (PR), nasal endoscopic examination (NE),
lateral neck X-ray, magnetic resonance imaging (MRI) and
acoustic rhinometry (AR). But most of these methods are
not possible to follow in busy pediatric outpatient unit
either because of lack of cooperation from child (palpation,
PR, NPL) or due to limited availability of test or due to cost
constraints (NE, MRI, AR) etc. [4, 7, 8].
Lateral neck X-rays (LNX) have long been used as a
diagnostic tool in AH. They are simple, cost effective,
readily available and reproducible [8]. This study has been
conducted to determine the diagnostic accuracy of LNX for
assessing AH and to assess the correlation between adenoid
size in LNX and clinical symptoms in a pediatric unit.
Materials and Methods
Study Setting
This prospective study was conducted by Department of
Otolaryngology in association with Department of Pedi-
atrics at Padmavathy Medical Foundation, Kerala during
the period January 2015 to March 2016. The study was
approved by institutional ethics committee and informed
consents were obtained from the parents.
Study Population
60 consecutive children of both genders, between the age
group of 5 to 14 years, attending Department of Pediatrics
with a provisional diagnosis of AH for the first time were
included in the study.
Children with history of previous adenotonsillectomy,
having acute respiratory tract infections, septal deviations,
nasal polyps, anatomic abnormalities like cleft palate,
syndromic children or those with mental retardation were
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Indian J Otolaryngol Head Neck Surg
excluded from the study. Parents of children who were not
willing to enroll for study or those children presenting
directly to department of otorhinolaryngology were also
excluded from the study.
Symptom Scores
Structured questionnaires were administered to parents or
caregivers to collect the demographic data and clinical
information about presence or absence of symptoms of AH
as described by Contencin P [9]—explained in Table 1.
The original questionnaire was modified by the authors,
so that, instead of ‘‘Yes’’ or ‘‘No’’ answers, a score of ‘‘1’’
or ‘‘0’’ was given. The total score was then calculated
which ranges between 0 (minimum) to 10 (maximum).
Based on the final symptom score (SS), the children were
categorized into four different groups – Groups S1/Mild
symptoms (score ranging between 0 and 2), Group S2/
Moderate symptoms (score between 3 and 5), Group S3/
Moderate to severe (score of 6 or 7) and Group S4/Severe
symptoms (score between 8 and 10).
Radiogarphic Grading
Enrolled children were advised to have a digital X-ray of
neck lateral view, in standing position, such that Frankfurt
plane is parallel to floor and the X-ray beams are centered to
external auditory meatus. The children were instructed to
breathe through the nose, keeping the mouth closed and teeth
occluded [10]. All images were acquired with the same
machine, with identical settings and by same radiologist.
Those children with significant rotation of head or elevated
soft palate were later excluded from the study group.
The LNX were interpreted as per guidelines provided by
Fujioka et al. [11], which is the most accepted and com-
monly followed method of interpreting LNX for assessing
the AH. To avoid inter-observer variations, all LNX were
Table 1 Contents of medical questionnaire for parents
Day time symptoms
Failure to thrive Yes No
Thinness (general aspect) Yes No
Rhinolalia clausa Yes No
Permanent mouth breathing Yes No
Reccurent rhinitis/rhinopharyngitis Yes No
Sleepiness Yes No
Night time symptoms
Observed apneas (respiratory obstructions) Yes No
Snoring: in case of URTI Yes No
Intermittent (even with no infection) Yes No
Habitual, permanent Yes No
Indian J Otolaryngol Head Neck Surg
Fig. 1 Plain radiograph of nasopharynx lateral view (LNX) showing
how adenoidal—nasopharyngeal ratio was calculated. BB: Line
drawn along straight part of anterior margin of basiocciput; AD:
Adenoid depth (perpendicular line from BB to most convex part of
adenoid pad); ND: Nasopharyngeal depth (line between spheno-
occipital synchondrosis to posterior edge of hard palate); ANR
calculated by dividing AD with ND
evaluated by the same pediatrician. Adenoid depth (AD)
thickness was measured by drawing a perpendicular line
from a line drawn along the straight part of anterior margin
of basi-occiput to the most convex part of adenoid pad.
Nasopharyngeal depth (ND) was calculated by drawing
another line between the spheno-occipital synchondrosis to
posterosuperior edge of hard palate—Fig. 1.
The adenoid-to-nasopharyngeal ratio (ANR) was then
calculated from all images by dividing AD with ND. The
value was then documented in percentage by multiplying
with 100. Based on the ANR, the subjects were then cat-
egorized into 4 groups; Group X0—0–25%, Group X1—
25–50%, Group X2—50–75% and Group X3—75–100%.
Endoscopic Grading
All children were then referred to department of otorhi-
nolaryngology for a nasal endoscopic (NE) examination
the same day. All children were examined by a single
senior otorhinolaryngologist who was blinded to the clin-
ical data and X-ray findings. The nasal endoscopy was
performed with a 2.7 mm rigid pediatric nasal endoscope
by Karl Storz (Germany) after achieving topical decon-
gestion and anesthesia with 4% xylocaine with 1:10,000
adrenaline solutions. Choanal images were obtained with
help of a Storz HD camera unit.
The images were analyzed using Adobe photoshop CS5
version 12 software (Adobe, USA). Based on the degree of
AH, patients were categorized into 4 grades (I–IV) as
described by Ysunza [12] et al. Grade I (None) consists less
than 25% of scarce tissue at choanal opening, Grade II
(Mild) with more than 25% but less than 50% of obstruc-
tion confined to upper half of nasopharynx cavity and with
a patent choanae. Grade III (Moderate) with more than
50% but less than 75% obstruction, with free airway only
in inferior area. Grade IV (Severe) was more than 75% or
practically complete choanal obstruction.
Correlation of Data
Statistical analysis was done among different groups to find
the correlation between SS and ANR, ANR and NE, SS and
NE. Considering NE Scores as the gold standard, the
sensitivity, specificity, positive predictive value (PPV),
negative predictive value (NPV) and diagnostic accuracy
(DA) of ANR in LNX was assessed.
Statistical Analysis
Statistical analysis was performed with SPSS software
(SPPS 16.0, SPSS Inc, Chicago, IL). Correlation between
symptoms scores, LNX grades and NE grades were cal-
culated with Pearson correlation. A value of p \ 0.05 was
considered statistically significant.
Results
After applying the exclusion criteria, a total of 48 patients
were evaluated. They aged between 5 and 14 years with a
mean age of 5.2 and standard deviation of 2.3 years. There
were 26 (54.16%) males and 22 (45.83%) females.
Nasal obstruction followed by snoring was the most
common symptoms in the study population. Many children
had more than one symptom. These details are summarized
in Table 2.
Table 2 Presenting symptoms
Symptoms Present in
n %
Nasal obstruction 44 91.66
Mouth breathing 42 87.50
Snoring 38 79.16
Reccurent rhinitis 37 77.08
Sleepiness 22 45.83
Failure to thrive 4 8.33
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Table 3 Summarization of symptom score groups, ANR groups and NPL groups
SS groups n % ANR groups
Group S1 2 4.16 Group X1
Group S2 6 12.5 Group X2
Group S3 18 37.5 Group X3
Group S4 22 45.83 Group X4
When the symptom scores were calculated, majority
were of Group S4 (n = 22, 45.83%) and Group S3 (n = 18,
37.5%). 6 (12.5%) were of Group S2 and 2 (4.16%) were
from Group S1.
When ANR was calculated majority of subjects were of
Group X3 (n = 24, 50.00%) and X4 (n = 21, 43.75%). 3
(6.25%) subjects belonged to Group X2. No subjects were
registered in Group X1.
During NE, 2 (4.16%) subjects were having Grade I
hypertrophy, 3 (6.25%) had Grade II, 21 (43.75%) having
Grade III and 22 (45.83%) were having Grade IV adenoid
hypertrophy. These results are summarized in Table 3.
When statistical analysis was done, there was a highly
significant correlation between SS and ANR groups
(p \ 0.005). When ANR results were compared with NE
groups, the result was statistically significant (p = 0.027).
We also did a correlation analysis between SS and NE
groups, which was also found to be statistically significant
(p \ 0.001).
We got a sensitivity of 88.37%, specificity of 80.00%,
positive predictive value of 97.43% (86.81–99.54% at 95%
confidence interval), negative predictive value of 44.44%
(18.87–73.33% at 95% confidence interval) for ANR in
LNX. The overall diagnostic accuracy of the ANR in LNX
for detecting AH was 87.50%.
Discussion
LNX are generally used by pediatricians to estimate AH in
clinics, based on which they may decide to choose the
treatment, which can be follow-up or operation [13].
Fourteen studies were done previously between the period
1992-2016, to assess AH by using ANR in LNX. They all
reported conflicting results [3, 13–24]. All these studies
used NE as the reference standard to which LNX data were
compared. Results of ten of these studies [3, 13–21] were
similar to that of ours, showing a significant correlation
between ANR in LNX and AH in NE. Four authors
[12, 22–24] reported that there exist no correlation between
ANR in LNX and AH in NE.
Only four authors [12, 15, 17, 24] calculated sensitivity,
specificity, positive predictive value, negative predictive
value of AH to LNX. There values were ranging between
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Indian J Otolaryngol Head Neck Surg
n % NPL groups n %
0 0 Grade I 2 4.16
9 18.75 Grade II 3 6.25
19 39.58 Grade III 21 43.75
20 41.66 Grade IV 22 45.83
41 and 100%, 55 and 95%, 66.7 and 94%, 41 and 75%. Our
values for these indices were 88.37, 80.00, 97.43 and
44.44% respectively.
Only Kurien et al. [17] and Barbosa et al. [21] calculated
the diagnostic accuracy of AH to LNX in literature. They
estimated 65 and 83.3% respectively. Our value 87.5%
calculated was very close to that of Barbosa et al.
The variations in results of our study with the previous
studies may be due to differences in standardization of
clinical symptoms or usage of different methods (objective
[16, 19, 20] or subjective [12, 15]) for radiological and
endoscopic classification of AH. The main strength of our
study is that we used an objective measure for both index
test (LNX) and reference test (NE).
Although nasopharyngoscopy examination (flexible or
rigid) is the gold standard for diagnosis of AH, this is not
easily available in many centers. When it is available, it is
an invasive procedure and many children mayn’t cooperate
for an endoscopic examination. The cost of undergoing an
endoscopic examination also is higher. These factors limit
the use of nasopharyngoscopy examination in diagnosis of
AH [3].
In contrast to nasal endoscopy, lateral neck Xrays are
cheap, readily available, non-invasive option for evaluation
of AH. Different methods are available for estimation of
adenoid size in LNX [3, 8]. In our study and various other
studies [3, 13– 21], ANR measurement is found to be a
very reliable and valid diagnostic test for AH.
The limitations of LNX are risk of exposure to radia-
tions, the adenoid shadow obtained is a two-dimensional
image of a three-dimensional structure which may not
correctly represent the adenoid hypertrophy in all planes.
There may be superimposition of anatomic structures and
inter-observer variations in interpreting the X-rays [3].
Positional changes and respiratory movements may also
affect the X-ray images [13].
Conclusions
Adenoid hypertrophy is the most common cause of nasal
obstruction in pediatric population having a negative
impact on quality of life of children and caregivers. Vari-
ous diagnostic modalities are available for determination of
Indian J Otolaryngol Head Neck Surg
adenoid hypertrophy. But the limited availability, increased
cost, lack of cooperation from child etc. limits the use of
these in routine practive. LNX with calculation of adenoid-
to-nasopharynx ratio is found to have significant correla-
tion with endoscopic examination and can be considered as
a useful objective tool in evaluation of children with ade-
noid hypertrophy. Pediatricians can confidently rely on
LNX for making clinical decisions and can consider
nasopharyngoscopy when clinical picture remains unclear
or more evaluation is needed.
Compliance with Ethical Standards
Conflict of interest The authors declare that they have 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 parents of
all individual participants included in the study.
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