Radiographic Evaluation of
Adenoidal Size in Children:
Adenoidal-Nasopharyngeal
Ratio
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..
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
0.20
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.
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-