Abstract
Adenoid hypertrophy is one of the most important causes of airway obstruction. Skull lateral soft tissues X ray are reliable diagnostic tools for detection adenoid enlargement with or without airway obstruction. Compared to nasoendoscopy that invasive and not available in all hospital. The aim of this study is to evaluate the diagnostic value of Skull lateral soft tissues X ray for assessment adenoid enlargement using Kurien, Cohen and Konak, Fujioka and McNamara methods compared with nasoendoscopy. Analytic observational with cross sectional study. 24 patients suspected adenoid enlargement was performed Skull lateral soft tissues X ray and measured the enlargement with Kurien, Cohen and Konak, Fujioka and McNamara methods. After performed X-ray these patients was been nasoendoscopy. Diagnostic value of Skull lateral soft tissues X ray Kurien methods show sensitivity was 73.6%, specificity 100%, positive predictive value 100%, negative predictive value 50% and accuracy 79.1%. Diagnostic value of Skull lateral soft tissues X ray Cohen and Konak methods show sensitivity was 94.7%, specificity 100%, positive predictive value 100%, negative predictive value 83.3% and accuracy 95.8%. Diagnostic value of Skull lateral soft tissues X ray Fujioka methods show sensitivity was 10.5%, specificity 100%, positive predictive value 100%, negative predictive value 22.7% and accuracy 29.1%. Diagnostic value of Skull lateral soft tissues X ray McNamara methods show sensitivity was 68.4%, specificity 100%, positive predictive value 100%, negative predictive value 45.4% and accuracy 75%. Adenoid enlargement can be measure with Skull lateral soft tissues X ray using Cohen and Konak method that has the highest sensitivity, specificity, and accuration compare another methods and using McNamara methods can predict the airway obstruction.
Keywords: Adenoid enlargement, Lateral soft tissues X-ray, Nasoendoscopy
Introduction
Adenoid is a triangular lymphoepithelial tissue located on superoposterior nasopharynx wall and is one of the tissues that forms Waldeyer’s ring. Adenoid grows faster after someone’s birth and reaches its maximum size when the bearer is at the age of 3–7 years old and that size remains the same until the person is at the age of 8–9 years old [1]. After 14 years, adenoid experiences an involusion. Adenoid hypertrophy, especially found on children, appears as the response on multiantigens such as virus, bacteria, allergens, food, and environmental irritation [2]. There are several ways that can be used to define the size of adenoid, namely palpation, posterior rhinoscopy, lateral skull image, endoscopy check-up, CT Scan, and MRI [3]. There was a previous study conducted to compare adenoid enlargement with air passage obstruction by using AN ratio method [4]. Besides, another study was also conducted to investigate the comparison between the results of nasoendoscopy with that of cephalometric lateral image in diagnosing nasopharynx obstruction [5]. Meanwhile, the result of the research by Michael et al. [6] says that the sensitivity of McNamara line is quite high in diagnosing the obstruction of air passage compared with post surgery. Lateral skull image examination is often used to measure the size of adenoid. There actually are several possible ways to conduct in order to measure adenoid. According to Murilo et al. the methods that have higher sensitivity compared to lateral orthodontic teleradiography are: (1) superior pharynx measurement to define the enlargement of adenoid based on Kurien, (2) superior pharynx measurement based on Cohen and Konak, (3) adenoid-nasopharynx ratio (A/N ratio) based on Fujioka, and a research, which was conducted a year later, by Murilo [7] that compared the measurement of adenoid using lateral skull image and nasopharyngoscopy video showed that the A/N ratio method by Fujioka was highly correlated with the result of nasopharyngoscopy video. As to now, there has not been any research conducted on defining the enlargement of adenoid with or without obstruction on the air passage using lateral skull image that is being compared with nasoendoscopy. Child patients with enlarged adenoid visiting ENT (ear, nose, and throat) clinic of dr. Saiful Anwar hospital Malang rarely got nasoendoscopy because this treatment is quite invasive by nature. As opposed to that, lateral skull image is feasible and has low dose of radiation so that it is often used to diagnose whether or not there is adenoid enlargement. Based on that background, the researchers would like to do a study on diagnostic experiment of soft tissue lateral skull image to measure the enlargement of adenoid based on Kurien, Cohen and Konak, and Fujioka’s methods, as well as that of McNamara which is used to see whether or not there is obstruction on the air passage which will be compared with the result of nasoendocopy examination. Diagnostic test on radiology examination is necessary as it can be used as one of the methods of diagnosing adenoid enlargement in the areas that do not have nasoendoscopy. This examination can also be applied to help diagnosing adenoid enlargement on child patients who refuse to have nasoendoscopy assessment as well as to see whether or not there is any obstruction in the air passage due to the adenoid enlargement.
Material and Method
This research is cross sectional observational by design. The research was conducted in Radiology Department of dr. Saiful Anwar Hospital Malang, and local operating room (OR) of ENT of the same hospital during the period of June 2015–December 2015. The inclusive criteria of this study are: patients with clinical adenoid enlargement, patients who are willing to join the research (by filling in the informed-consent form), and 5–14 years of age (the age when adenoid enlargement is likely to occur and the patients are cooperative to be examined using nasoendoscopy). Meanwhile, the exclusive criteria are: the patients have birth defects on the face, mouth and nose cavity such as choanal atresia, cleft lip and palate, patients with upper air passage infection, and patients with nose obstruction due to cavum nasi tumor.
Soft tissue lateral skull image is radiology examination by means of X-ray. The patient is positioned standing up and the focus of the film is 140 cm away with 70 kV and 12 mA and without grid. The light is focused on the nasopharynx. Patients are asked to close the mouth and inhale through the nose. Once the image is printed, some methods (by Kurien, Cohen and Konak, Fujioka, and McNamara) are employed to investigate the adenoid enlargement.
Kurien method measures the degree of pharynx tonsil’s (adenoid) thickness that narrows the air passage down. Then, the passage of air (PA) was also measured by drawing a line from the anterior adenoid to the palatum molle (1 cm away from the palatum durum). Adenoid is considered enlarged when the passage of air (PA) is <6 mm. Cohen and Konak method was employed to measure pharynx tonsil by comparing the passage of air (PA) influenced by adenoid enlargement with the thickness of palatum molle (soft palate = SfP). A pharynx tonsil is considered enlarged when AC/SfP < 1.1 [8].
Fujioka method is used to measure adenoid enlargement by comparing the ratio of adenoid enlargement with the nasopharynx. It is done by drawing a straight line toward basis spheno occipital line. The result of adenoid enlargement is then compared with the distance of nasopharynx. The distance of nasopharynx is measured from spheno-occipital synchondrosis to palatum durum posterior. The ratio of adenoid (A) is then compared with nasopharynx (N): it is normal if A/N ratio ≤ 0.8 and is enlarged when A/N ratio > 0.8 [8]. McNamara method is used to identify whether or not there is obstruction on the air passage by measuring the distance of air of column (AC). Air of column is a distance measured from palatum molle posterior to the side anterior of adenoid enlargement. ‘No air passage osbstruction’ is declared when air of column is >5 mm and it is considered obstructed when AC ≤ 5 mm [8]. The interpretation on the soft tissue skull lateral image was performed by 2 radiology specialists. Later on, patients were examined using nasoendoscopy. According to Parikh, degree of adenoid enlargement using nasoendoscopy is the degree shown by nasoendoscopy based on the relation of adenoid with the structures around it such as torus tubarius, vomer, and palatum molle. The degrees are:
Degree 1: adenoid does not make any contact with the structures around it → there is no air passage obstruction.
Degree 2: there is a contact between adenoid and torus tubarius.
Degree 3: there is a contact between adenoid with torus tubarius and vomer.
Degree 4: there is a contact between adenoid and palatum molle.
Degree 2, 3, 4 → trigger obstruction on the air passage [9].
Diagnostic test is performed to find out the diagnostic score on the lateral skull image using the methods by Kurien, Fujioka, Cohen and Konak, in diagnosing adenoid enlargement and the method by McNamara in defining whether or not there is air passage obstruction by comparing the gold standard in the form of nasoendoscopy examination. Nasoendoscopy was conducted by an ENT specialist in the ENT local OR of dr. Saiful Anwar Hospital, Malang.
Results
There were 24 patients who were suspected with adenoid enlargement. The data showed adenoid enlargement is mostly suffered by patients of 10–12 years old (45.8%), and it rarely happens to those of 13–15 years old (4.1%). The proportion of the research subjects based on gender shows that male patients (75%) have more chances of suffering from adenoid enlargement compared to female (25%). The following Table 1 shows the difference of sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of the methods by Kurien, Cohen and Konak, as well as that of Fujioka in defining adenoid enlargement.
Table 1.
Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of the methods by Kurien, Cohen and Konak, as well as that of Fujioka in defining adenoid enlargement
| Value | Kurien method | Cohen and Konak method | Fujioka method |
|---|---|---|---|
| Sensitivity | 73.6% | 94.7% | 10.5% |
| Specificity | 100% | 100% | 100% |
| Positive predictive Value | 100% | 100% | 100% |
| Negative predictive value | 50% | 83.3% | 22.7% |
| Accuracy | 79.1% | 95.8% | 29.1% |
The following is the Table 2, which shows the difference of sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of McNamara method in defining whether or not there is obstruction on the air passage.
Table 2.
Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of McNamara method in defining whether or not there is obstruction on the air passage
| Value | McNamara method |
|---|---|
| Sensitivity | 68.4% |
| Specificity | 100% |
| Positive predictive value | 100% |
| Negative predictive value | 45.4% |
| Accuracy | 75% |
The soft tissue lateral skull image from Kurien method and the result of nasoendoscopy on patient with adenoid enlargement is on Fig. 1.
Fig. 1.
a Soft tissue lateral skull image, measuring adenoid using Kurien method, which shows adenoid enlargement. b The result of nasoendoscopy which shows grading IV on the right side and grading III on the left side based on Parikh
The soft tissue lateral skull image resulted from Cohen and Konak method and the result of nasoendoscopy on patients with adenoid enlargement is on Fig. 2.
Fig. 2.
a Soft tissue lateral skull image, measuring adenoid in Cohen and Konak method, shows adenoid enlargement. b The result of nasoendoscopy which shows grading IV on the right side and grading III on the left side based on Parikh
Soft tissue lateral skull image in Fujioka method and the result of nasoendoscopy on patients with adenoid enlargement is on Fig. 3.
Fig. 3.
a Soft tissue lateral skull image, measuring adenoid using Fujioka method, which shows adenoid enlargement. b The result of nasoendoscopy examination that shows grading III both on the right and left side based on Parikh
Soft tissue lateral skull image in McNamara method and the result of nasoendoscopy on patients with air passage obstruction is on Fig. 4.
Fig. 4.
a Soft tissue lateral skull image, measuring adenoid using McNamara method, shows air passage obstruction. b The result of nasoendoscopy examination that shows grading II both on the right and left side based on Parikh
Discussion
Adenoid enlargement mostly occurs on 10–12 year old patients and rarely occurs at those who are 13–15 years old. It is in line with the theory stating that adenoid enlargement will experience regression on children of 14 years old, reaches its maximum size in those who are 3–7 years old and remains the same on children of 8–9 years old. Adenoid enlargement which occurs on 10–12 year old children tends to be caused by infection on upper respiratory system [10]. Soft tissue lateral skull image examination is performed by covering the mouth when the head is not positioned either upward or downward. The research shows that soft tissue lateral skull image by opening the mouth intrigues retraction and thinning on palatum molle. There is no regulation or limitation on how wide the mouth should be opened so that the decision taken was on letting the patients closed the mouth.
Grading II adenoid enlargement with nasoendoscopy was not detected enlarged when examined using soft tissue lateral skull image on Kurien method. It might be because the adenoid enlargement tended to be lateral so that it was detected by nasoendoscopy but not by soft tissue lateral skull image using Kurien method.
Cohen and Konak method measures air passage compared with the thickness of palatum molle. It is very advantageous in diagnosing adenoid enlargement because the contracting air passage can be compared with the thickness of palatum molle which remains the same in size and is not affected by muscle or other parts. The thickness of palatum molle which remains the same has been proven by the previous researchers both from adenoid pre-op and post-op patients [11]. The accuracy of soft tissue lateral skull image using Cohen and Konak method is 95.8%, so that its accuracy in detecting adenoid enlargement is high. Advantages this method are:
Easy to determine and measure air of column and soft palate.
Nasopharynx size are growth according to the age, so measure adenoid enlargement more accurately using the air way than adenoid size itself.
Disadvantages this method are the thickness of palatum mole will make false positive because if the palatum molle is thin, as though there are no adenoid enlargement.
Fujioka method used for measuring adenoid enlargement has the lowest sensitivity, specificity, and accuracy compared with the other methods. It is due to several reasons. They are: the limitation of synchondrosis is hard to define, adenoid size including the thickness of the muscles behind adenoid structures (superior pharynx constrictor muscle and fascia) are different, and the border of palatum durum posterior on molar tooth that has not or already erupted is sometimes hard to define [12]. Those aspects will affect the comparison of AN ratio. The research data shows that Fujioka method on soft tissue lateral skull image could detect Grading IV adenoid enlargement. The data also shows that Grading II adenoid enlargement detected from nasoendoscopy based on Parikh mostly shows more that 0.4 AN ratio. It contradicts the previous study which stated that adenoid enlargement could only occur when the AN ratio is more than 0.8.
Soft tissue lateral skull image resulted from McNamara method can be used to evaluate whether or not there is obstruction because this method could detect almost all Grading III adenoid enlargement (detecting 10 out of 11 patients) and all Grading IV adenoid enlargement.
The data shows that Grading II air passage obstruction on 4 out of 6 patients (66.6%) could not be detected by soft tissue lateral skull image. It might be because adenoid enlargement was likely to be on lateral side instead of its anterior. Meanwhile, Grading III and IV adenoid enlargement on 10 out of 11 patients (90.9%) could be detected by both nasoendoscopy and soft tissue lateral skull image. It is somewhat in line with the theory stating that Grading III adenoid makes a contact with torus tubarius and vomer while Grading IV adenoid has a contact with palatum molle.
Conclusion
Adenoid enlargement examination using soft tissue lateral skull image based on Cohen and Konak method has sensitivity value of 94.7%, specificity 100% and accuracy 95.8%. It can also be used to detect most Grading II adenoid enlargement with nasoendoscopy. Soft tissue lateral skull image based on McNamara method can be used to detect Grading III and IV air passage obstructions by using nasoendoscopy. Soft tissue lateral skull image examination is feasible, fast, and non-invasive. Therefore, soft tissue lateral skull image based on Cohen and Konak method can be used to help doctors to define adenoid enlargement and McNamara method can be used to detect air passage obstruction.
Funding
This work was supported by grants from Saiful Anwar Hospital Malang, Indonesia.
Compliance with Ethical Standards
Conflict of Interest
The authors declare that there is no conflict of interests regarding the publication of this paper.
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 all individual participants included in the study.
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