401

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

Mutsuhisa Adenoidal-nasopharyngeal ratios (AN ratios) obtained by simple linear measurements

Lionel W. Young from lateral skull radiographs are described. The AN ratio reliably expresses adenoidal
and Bertram R. Girdany 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 are the most common pediatric surgical

procedures in the United States [1 ]. Recent emphasis on careful selection of
patients for these procedures derives from concern for complications of surgery
[2], as well as the immunologic [3] and space-filling roles [4, 5] of tonsils and
adenoids. Adenoidectomy without tonsillectomy is indicated to relieve nasopha-
ryngeal airway obstruction caused by enlarged adenoids, especially if the airway
obstruction is complicated by heart failure [6] or is associated with recurrent or
chronic otitis media [7].
Radiographic evaluation of the nasopharynx is established as a simple method
for determination of the size, shape, and position of the adenoids [5, 8]. However,
we know of no reliable objective criteria for this evaluation reported in pediatric
age groups [9-14].
The absolute size of the adenoids and the size and shape of the nasopharyn-
geal space are major factors that determine nasopharyngeal obstruction [5, 10,
1 2]. The ratio of these two sizes can provide a simple arithmetic measure of
nasopharyngeal obstruction. We describe an adenoidal-nasopharyngeal ratio
(AN ratio) derived from linear measurements on lateral radiographs of the
nasopharynx. Statistically derived standards for this AN ratio were obtained from
measurements of infants and children of varying ages. These standards were
tested against the subjective evaluation of adenoidal size made by experienced
Received October 20. 1978: accepted after
observers using the same radiographs.
revision May 1 7. 1979.
Materials and Methods
All authors: Department of Radiology. Chil-
dren’s Hospital of Pittsburgh. University of Pitts- For more than 20 years, lateral radiographs of the nasopharynx have been routinely
burgh School of Medicine. Pittsburgh, PA 15213.
Address reprint requests to M. Fujioka. exposed during examinations of the chest and/or the paranasal sinuses in the radiology
department of Children’s Hospital of Pittsburgh. These radiographs have been obtained
AJR 133:401-404, September 1979
with the patients in the erect position at the tube-cassette distance of 180 cm. Radiographic
0361 -803X/79/ 1333-0401 $00.00
© American Roentgen Ray Society samples of i .398 children (812 boys and 586 girls) were randomly selected from outpa-
 402 FUJIOKA ET AL. AJR:133, September 1979

TABLE 1 : Adenoidal-Nasopharyngeal Ratios (AN Ratio) in

Infants and Children

Median Ages No Children

Mean SD
(years, months) (n = 1 .398)

0, i.5 33 0.329 0.ii54

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0, 4.5 Si .457 .1242

0, 9 74 .508 .1087
1, 3 56 .548 .i023
i, 9 45 .538 .0940
2, 6 78 .555 .0991
3, 6 82 .567 .1021
4, 6 85 .588 .ii29
5, 6 79 .586 .1046
6, 6 98 .575 .1182
7, 6 85 .555 .i174
8, 6 73 .568 .1108
B
9, 6 74 .536 .1372
10, 6 79 .Sii .i5iS
ii, 6 93 .532 .i4Oi
Fig. 1 -Adenoidal measurements. ‘ ‘A” represents distance from
12, 6 81 .518 .542
A , point of maximal convexity, along inferior margin of adenoid
shadow to line B, drawn along straight part of anterior margin of i3, 6 84 .458 .i52i
basiocciput. ‘ A’ ‘ is measured along line perpendicular from point A 14, 6 85 .435 .i436
to its intersection with B. is, 6 63 .380 .1533

basioccipital synchondrosis. When the synchondrosis is not clearly

visualized, point D’ is determined as the point of crossing of the
posteroinfenior margin of the lateral pterygoid plate (P) and the floor
of the bony nasopharynx. The AN ratio is obtained by dividing the
measurement for A by the value for N.
Lateral radiographs of the nasopharynx of i 398 children be-
tween ages i month and 1 6 years were reviewed and the AN ratios
were calculated, tabulated, and statistically analyzed (table 1 and
fig. 3). The 1 43 lateral nasopharyngeal radiographs of 92 patients
from the study by Paradise (unpublished data, National Institute of
Child Health and Human Development grant HO 07403) were also
evaluated. In these, the adenoidal size and nasopharyngeal airway
patency had been estimated visually by experienced observers (C.
0. Bluestone, S. Stool, J. C. Paradise, B. A. Girdany) and graded
for adenoidal size as well as patency of the nasopharyngeal airway
(table 2). Adenoidal size was classified incrementally as: (1 ) unus-
ually large and/or narrow nasopharyngeal air space, (2) normal, or

c:3 (3)
graphs
unusually
was
small.
plotted
The
against
AN
age
ratio
(fig.
from
4).
each
The
of these
statistical
1 43 radio-
distribution
of these values was compared with the distribution derived by the
visual classifications in the Paradise study.
Fig. 2.-Nasopharyngeal measurement. ‘ ‘N’ ‘ is distance between
C! , posterior superior edge of hard palate, and 0 . anteroinfenior
edge of sphenobasioccipital synchondrosis. When synchondrosis is
Results
not clearly visualized, point 0’ can be determined as site of crossing
posteroinfenior margin of lateral pterygoid plates P and floor of bony
nasopharynx.
The frequency distribution of the AN ratios for each gen-
der and in each age group followed expected curves for
normal distribution. There were no statistically significant
tients referred from private physicians’ offices during the 3 year differences on AN ratios for gender in any age group (p>
period, i 973-i 976. Patients with any radiographic abnormalities 0.1 0). The mean AN ratio increased from 0.33 at age 1.5
of the paranasal sinuses or lungs were excluded. No child had a
months to 0.55 at age 1 year 3 months, and reached its
history of adenoidectomy.
highest value, 0.59, at age 4 years 6 months. The AN ratio
The adenoidal measurement A (fig. 1 ) represents the distance
gradually decreased from this peak value to 0.52 at age 12
from A’, the point of maximal convexity along the inferior margin of
years 6 months and then diminished sharply to 0.38 at age
the adenoid shadow, to a line B, drawn along the straight part of
1 5 years 6 months (table 1 and fig. 3).
the anterior margin of the basiocciput. The distance A is measured
along a line dropped perpendicularly from point A’ to its point of The AN ratios on 1 43 radiographs of the 92 patients
intersection with line B. The nasopharyngeal space N (fig. 2) is referred to in the Paradise study were statistically evaluated
measured as the distance between C’, the posterior-superior edge and the results compared with visually estimated classifi-
of the hard palate, and D’, the anteroinfenior edge of the 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

S
0.90 5
S S
S S
55 5
S
55 5 s__!!._s___s.___S..
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0.80 .sS--X x

.-- x 5 x
Sxx xxx a “,,,,

070
. I, x X xxx5 x x x ‘+2SD

I X’X XX x:xx.xk
0 0.60 a

0.50 (//c’XXX XXa #{149} Si

z

< #{149}X #{149} #{149} #{149}#{149} S X\MEAN

0.40
‘--.- -------
, -.
,
I
0.30 / #{149}
S #{149}

0.20
i
i
I
I
I

, _‘__%__
#{149} .
-.

.%
,..
i 5.
I S
010 5.
. 5
-2SD

I 2 3 4 5 6 7 8 9 lOll 1213141516
AGE AGE
Fig. 3-AN ratio in 1 .398 infants and children in different ages. Fig. 4.-Visual classification vs. AN ratio in 143 radiographs of 92 patients
in the Paradise study. Square = unusually large adenoids and/or narrow
nasopharyngeal air space; X = normal adenoids; circle = unusually small
adenoids; solid line = mean for the 1 .398 patients: broken lines = + 2 SD
TABLE 2: AN Ratio in Each Visual Grade and -2 SD from mean in 1 .398 patients.

No. Radiographs
Classification Mean SD
(n = 143)
dren with large but not abnormally enlarged adenoids were
Unusually large adenoids 36 0.864 0.0652
thought to have narrowed air spaces.
and/or narrow airway
space
Normal adenoids 82 0.636 0.0908
0.409 0.0959 Discussion
Unusually small adenoids 25
Simple, accurate, and objective measurements for the
radiographic assessment of adenoidal size in children may
for each grade and demonstrates that the differences in have important clinical applications. Several methods of
mean values among the grades were statistically significant adenoidal measurement have been reported. However,
with p values of less than 0.01 . When these AN ratios were none has been widely accepted or implemented because
plotted against age (fig. 4), 34 of 36 adenoidal shadows the measurements have not expressed the maximal thick-
designated as ‘ ‘ unusually large adenoids’ ‘ and/or ‘ ‘ narrow ness of nasopharyngeal soft tissue [5, 9, 1 5, 1 6], have not
nasopharyngeal air space’ ‘ were more than 2 SD above the consistently shown landmarks [8, 1 1 ], and have been im-
mean of the AN ratios derived from our measurements in practical and too time consuming to be adapted for routine
1 .398 infants and children. However, only four of 25 ade- use[10-12, 16].
noidal shadows designated as ‘ ‘unusually small’ ‘ were 2 SD The straight part of the basiocciput is an easily identifiable
below the mean of the measured group. landmark. The maximal thickness of the anteroinferior con-
The designation ‘ ‘ narrow nasopharyngeal airway, ‘ ‘ as vexity of the nasopharyngeal soft tissue from the basiocciput
estimated by experienced observers, was an impression reflects the adenoidal size, even though it does include
that did not specifically take into account the anatomic other posterior nasopharyngeal soft tissues. The measure-
landmarks used to measure N in this study; the terms N and ment N represents the anteroposterior diameter of the na-
nasopharyngeal airway are not interchangeable. The visual sopharyngeal space.
estimates of nasopharyngeal airway space were impres- Capitanio and Kirkpatrick [1 5] stated that the adenoidal
sions of whether or not there was sufficient air space around shadow is usually visible in infants aged 6 months and older,
the adenoids to allow normal breathing without airway ob- and that absence of adenoids in infants older than 6 months
struction. No effective criteria were used or derived for this is consistent with immunodeficiency. From subjective Ion-
, ‘gestalt’ ‘ grading. Patients with average-size or small ade- gitudinal observation of serial lateral cephalometnic radio-
noids all had ample air passages. In some instances, chil- graphs, Subterny and Koepp-Baker [1 7] observed that the
 404 FUJIOKA ET AL. AJR: 133, September 1979

adenoids grew rapidly in infants up to age 2 years, at which morbidity. Trans Am Acad Ophthalmol Otolaryngol 74 : i i 46-
time they filled half of the nasopharyngeal cavity. Pruzansky ii54, i974
[1 3] reported that by visual evaluation, large adenoids most 3. Morag A, Ogura PL: Immunologic aspect of tonsils. Ann Otol
frequently occurred in children 4-6 years old. Our data are Rhino! Laryngol 84:37-43, i975
4. Ardran GM, Kemp FH: A function for adenoids and tonsils. AJR
consistent with all these observations.
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1i4:268-28i, i972
Our data are based on the measurements of a large
5, Steele CH, Fairchild RC, Aicketts AM: Forum on the tonsil and
number of infants and children whose paranasal sinuses
adenoid problem in orthodontics. Am J Orthod 54:485-Si 5,
and lungs were normal. However, since there were clinical
1968
indications for their radiographic examinations, these chil- 6. Cayler GG, Johnson EE, Lewis BE, Kortzeborn JO, Jordan JF,
dren are not a random sample of the normal population. Fnicker GA: Heart failure due to enlarged tonsils and adenoids.
When adenoidal-nasopharyngeal measurements were Am J Dis Child i i 8:708-71 7, i 969
compared with subjective assessments of adenoidal size in 7, Reid JM: The indication for tonsillectomy and adenoidectomy.
the 92 patients in theParadise study, there was good Otolaryngol Clin North Am 3:339-344, 1970
agreement except at small AN ratios (table 2). Also, 34 of 8. Weitz HL: Aoentgenography of adenoids. Radiology 47:66-

36 (94%) of the adenoidal shadows that were designated 70, 1946

9. Ellen JL, Roberts JF, Ziten FM Jn: Normal nasopharyngeal soft
, . unusually large’ ‘ and/or ‘ ‘ narrow air space’ ‘ had AN ratios
tissue in adults, a statistical study. AJR i i 2:537-541 , 1 97i
more than 2 SD above the mean value derived from the
1 0. Handelman CS, Osborne G: Growth of the nasopharynx and
large series of measurements for the appropriate age group
adenoid development from one to eighteen years. Angle Orthod
(fig. 4). For practical purposes, a value of the AN ratio 46:243-259, 1976
greater than 0.80 may be considered indicative of enlarged 1 1 . Johannesson 5: Aoentgenologic investigation of the nasopha-
adenoids. An abnormally small AN ratio (less than 2 SD ryngeal tonsil in children of different ages. Acta Radio! [DiagnJ
below mean) derived from the large series did not correlate (Stockh) 7:299-304, 1967
well with the visual assessment. The reason for this discrep- 1 2. Linden-Aronson 5: Adenoids: their effect on mode of breathing
ancy is not certain. and nasal air flow and their relationship to characteristics of
the facial skeleton and dentition. Acta Otolaryngol [Suppl]
(Stockh) 265: 1 -i 32, 1970
ACKNOWLEDGMENTS 1 3. Pruzansky 5: Roentgencephalometnic studies of tonsils and
adenoids in normal and pathologic states. Ann Otorhinolaryn-
We thank Dr. Paradise for suggestions and encouragement and
go184:55-62, i975
Sue Arlen for manuscript preparation.
i 4. Ricketts AM: The cranial base and soft structures in cleft palate
speech and breathing. Plast Reconstr Surg 1 4 : 47-61 , 19S4
i 5. Capitanio MA, Kirkpatrick JA: Nasophanyngeal lymphoid tis-
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