REVIEW ARTICLE

Assessment of lateral cephalometric diagnosis

of adenoid hypertrophy and posterior upper
airway obstruction: A systematic review
Michael P. Major,a Carlos Flores-Mir,b and Paul W. Majorc
Boston, Mass, and Edmonton, Alberta, Canada

Introduction: Our objective was to evaluate the capability of lateral cephalograms in diagnosing hypertro-
phied adenoids and obstructed posterior nasopharyngeal airways. Methods: A systematic review of the
literature by using several electronic databases (Cochrane Library, Medline, Medline in progress, PubMed,
Web of Science, Embase, and Lilacs) was performed with the help of a senior health-sciences librarian. The
electronic search was followed up with hand searches. After applying our inclusion-exclusion criteria, the
search yielded 11 articles that were then scored based on their methodological validity. Results: Lateral
cephalograms performed reasonably well in evaluating adenoid size; both quantitative measures of adenoid
area and subjective grading of adenoid size on lateral cephalograms had reasonable correlations to actual
adenoid size (range of r, 0.60 to 0.88). However, evidence suggested that cephalograms were less ideal for
evaluating the size of the posterior nasopharyngeal airway. The diagnostic difference is likely because the
adenoid is a simpler 3-dimensional structure than the nasopharynx; therefore, it loses less information when
compressed into 2 dimensions by the radiograph. Conclusions: Being used as a screening tool to determine
the need for more rigorous ENT follow-up appears to be the greatest utility of lateral cephalograms. Because
no consensus could be reached on what are the most useful landmarks, we recommend that clinicians look
for multiple deviant measures of adenoid size rather than one definitive quantification. (Am J Orthod
Dentofacial Orthop 2006;130:700-8)

T
he adenoid is a conglomerate of lymphatic
tissue in the posterior nasopharyngeal airway.
Constriction of the posterior airway, whether by
genetic factors or repeated adenoidal infection and
inflammation, has been a suggested cause of altered
craniofacial development1-3 and has been associated
with the “adenoid face” morphology of a narrow
maxillary arch, a posterior crossbite, a large face
height, and a retrognathic mandible.2,4,5 Many of these
same facial dimensions are often found in adults with
obstructive sleep apnea.6-9
If an obstructed posterior upper airway causes
problematic facial growth, which is still a topic of
controversy,1,3,4,10-13 then it would be beneficial to
a
DMD student, Goldman School of Dental Medicine, Boston University,
Boston, Mass; member, Cranio-facial & Oral-health Evidence-based Practice
Group, Edmonton, Alberta, Canada.
b
Postdoctoral fellow, Orthodontic Graduate Program, Faculty of Medicine and
Dentistry, University of Alberta; Clinical Associate Professor, Cranio-facial &
Oral-health Evidence-based Practice Group, Edmonton, Alberta, Canada.
c
Professor, Director of the Orthodontic Graduate Program, Faculty of Medicine
and Dentistry, University of Alberta, Edmonton, Alberta, Canada.
Reprint requests to: Paul W. Major, Faculty of Medicine and Dentistry, Room
4051B, Dentistry/Pharmacy Centre, University of Alberta, Edmonton, Alberta,
Canada T6G 2N8; e-mail, major@ualberta.ca.
Submitted, March 2005; revised and accepted, May 2005.
0889-5406/$32.00
Copyright © 2006 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2005.05.050
700
have a reliable diagnostic test to evaluate the need for
treatment. However, diagnosing an obstructed posterior
airway is not always a simple task because its location
normally prevents direct observation. Several tools
have been used for diagnosis including nasal resistance
and airflow tests, nasoendoscopy, lateral cephalometry,
and 3-dimensional imaging; each posseses positive and
negative qualities. Of these tests, there is no consensus
on the gold standard procedure for diagnosing posterior
airway obstruction.
The lateral cephalogram, a standardized sagittal
X-ray of the head and neck, is perhaps the most
commonly used of the above tests, especially by den-
tists. It is a simple, economical, readily available, and
reproducible way to diagnose upper airway obstruction.
Many studies have advocated the use of lateral cepha-
lograms,14-17 and a number of adenoid and nasopha-
ryngeal measurements have been proposed. Of these,
some of the most notable are McNamara’s line17 and
Fujioka’s adenoid-nasopharyngeal ratio,18 although
various other linear and area measurements have also
been advocated.
No previous study has systematically evaluated the
evidence regarding the use of lateral cephalograms
for diagnosing enlarged adenoids and obstructed
posterior upper airways. A systematic review exam-
American Journal of Orthodontics and Dentofacial Orthopedics Major, Flores-Mir, and Major 701
Volume 130, Number 6

Table I. Search terms and number of articles processed in each selection phase
Database Key words Results Phase 1 articles Selected articles

Cochrane Library (1) Nasophary* 3 1 0

(2) Cephalogram* OR Cephalometr*
(3) 1 AND 2
Medline (1) Nasophary$ 200 57 8
(2) Cephalogram$ OR Cephalometr$
(3) 1 AND 2
PubMed (1) Nasophary* 192 57 8
(2) Cephalogram* OR Cephalometr*
(3) 1 AND 2
Embase (1) Nasophary$ 47 25 1
(2) Cephalogram$ OR Cephalometr$
(3) 1 AND 2
Web of Science (1) Nasophary* 93 33 4
(2) Cephalogram* OR Cephalometr*
(3) 1 AND 2
Lilacs (1) Nasophary$ 9 0 0
(2) Cephalo$
(3) 1 AND 2
Hand search 19 19 3
Total 221 85 11

Total number of articles is less than sum of respective columns because of overlap between databases.

ines the literature about a specific topic by using a
highly reproducible methodology determined a priori to
minimize bias and random error.19 The purpose of this
study was to systematically examine the literature to
determine the validity of lateral cephalograms in diag-
nosing enlarged adenoids and obstructed posterior na-
sopharyngeal airways in children and adolescents. Sec-
ondarily, we hoped to find consensus on the most useful
landmarks for posterior airway diagnosis.
MATERIAL AND METHODS
To ensure that the search was sensitive to all articles
pertaining to our question, we used a truncation of the
word “nasopharynx” rather than only “adenoid” to help
improve the probability of including any study that
focused on the anatomical location in question. We
then combined “nasopharynx” with truncated forms of
“cephalogram” and “cephalometric” to find articles
pertaining to the diagnostic procedure in question. The
truncated forms of these terms are listed in Table I.
Both the selection of search terms and the actual
searches were made with the help of a senior health-
sciences librarian. A search of the electronic databases
was then conducted during week 2 of May 2005. The
earliest entries to the most current articles available by
the second week of May 2005 were examined. The
databases searched were the Cochrane Library (includ-
ing Cochrane Database of Systematic Reviews, Data-
base of Abstracts of Reviews of Effects [DARE],
Cochrane Central Register of Controlled Trials, Co-
chrane Database of Methodology Reviews, Cochrane
Methodology Register, Health Technology Assessment
Database, NHS Economic Evaluation Database), Med-
line (including In-Progress & Other Non-Indexed Cita-
tions), PubMed, Embase, Web of Science, and Lilacs.
Electronic searches were followed up with biblio-
graphic hand searches.
The initial selection process was completed inde-
pendently by 2 researchers. Eligibility of potential
articles was determined by applying the following
inclusion criteria to the article abstracts: studies had to
be on humans, lateral cephalograms had to be taken,
and alternative methods of diagnosis must have been
used. Initially, we allowed any alternative diagnostic
method to be accepted. This could include clinical
questionnaire, clinical examination, evaluation dur-
ing surgery, type of nasal air resistance measure-
ment, polysomnography, rhinometry, nasopharyn-
gealendoscopy, alternative X-ray type, computerized
tomography (CT) imaging, or magnetic resonance
imaging (MRI). During the preliminary selection
process, no attempts were made to exclude studies
that examined other upper airway syndromes. Con-
sequently, initial article topics included cleft palates,
speech impediments, obstructive sleep apnea, cho-
anal atresia, and various maxillofacial surgical pro-
cedures. All articles in languages other than English
were included. An article had only to be justified by
1 researcher to be included for the second selection
phase.
702 Major, Flores-Mir, and Major
Table II. Article selection inclusion/exclusion criteria
summary
Inclusion criteria Exclusion criteria
Phase 1
Only human studies Nonhuman studies
Lateral cephalogram taken Alternative radiographs
Alternative diagnostic method
used
All languages included
Other upper airway syndromes
permitted
Phase 2
Only adenoid and nasopharyngeal Alternative anatomical
airway regions
Must make cephalometric
measurements
Useful statistical comparisons
The entire article of each study that passed the first
selection phase was retrieved and critically examined in
a second, more rigorous and specific selection phase.
This subsequent selection was used to identify only
articles that dealt specifically with adenoids or obstruc-
tion of the posterior nasopharyngeal airway for system-
atic review selection. Only studies that made cephalo-
metric measurements of the adenoids or the immediate
surrounding area in the nasopharyngeal lumen and
useful statistical comparisons were included. Any dis-
agreements were resolved by discussion until both
researchers were satisfied with the choices. A summary
of the inclusion-exclusion criteria is outlined in Ta-
ble II.
Knowing that more methodologically sound studies
provide more reliable conclusions, we developed a
methodological scoring process to identify which se-
lected studies would be most valuable (Table III). Our
scoring process was a modified version of one previ-
ously used in a systematic review by Lagravère et al.20
No attempt was made to support this methodological
evaluation as it has been previously validated.21-23
The 2 most ambiguous rankings were what defines
a “well-described” population, and what defines “ade-
quate” selection criteria. A study population was con-
sidered well described when information was provided
in 3 of the following 4 categories: age, sex, ethnicity,
and brief medical history. Furthermore, a study’s selec-
tion criteria was considered adequate if the subjects’
ages were between 5 and 17, it included a group with
posterior nasopharyngeal obstructions, and it excluded
patients who had surgery or other procedures that
would alter the upper airway morphology.
Two experienced orthodontists (C.F.M. and P.M.)
evaluated the types of lateral radiograph used in all
American Journal of Orthodontics and Dentofacial Orthopedics
December 2006
Table III.Methodological scoring protocol for accepted
studies (total ✓ ⫽ 20)
1. Study design (8✓)
a. Population: described (✓), random group (✓)
b. Selection criteria: described (✓), adequate (✓)
c. Sample Size: ⬎30/group (✓)
d. Control: includes subjects without adenoid problems (✓)
e. Timing: prospective (✓)
f. Radiograph: conventional lateral cephalograph taken (✓)
2. Study measurements (7✓)
g. Gold standard
(1) Cephalometric comparisons; nasal resistance; clinical
examination (✓)
(2) Postsurgery adenoid measurement; nasoendoscopy (✓✓)
(3) 3D-imaging (✓✓✓)
h. Cephalometric measurements: linear (✓), area (✓✓)
i. Blinding: examiner (✓), statistician (✓)
3. Data analysis (5✓)
j. Reliability: described (✓), kappa ⬎0.75 (✓)
k. Test type: appropriate for data (✓)
l. Confounders: age effects taken into account (✓)
m. Significance: P value, r value or sensitivity/specificity stated
(✓)
studies. Studies were included if there was a reasonable
expectation that the lateral radiograph could be consid-
ered comparable to a standardized, conventional lateral
cephalogram. However, studies that reported and ad-
hered to the strict definition of a lateral cephalogram—
midsagittal plane vertical and parallel to film cassette,
teeth in centric occlusal position, focus film distance of
5 feet (152.4 cm), and left side of head facing film
cassette24—were given an extra methodological point.
RESULTS
Our search yielded 11 articles (Table IV) that met the
inclusion criteria (Table II).15,18,25-33 The numbers of
articles found in each database during our initial search,
first phase selection, and final selection meeting the
inclusion criteria are given in Table I. Articles that were
nearly accepted but in the end rejected are listed in Table V.
Once the articles were selected, we systematically
assigned a methodological score to each study to order
them in their usefulness for evaluating lateral cephalo-
metric diagnosis of obstructed posterior nasopharyn-
geal airways (Table IV). Based on this criterion, we
found that 5 studies were particularly useful.25-28,32 All
pertinent cephalometric landmarks used in the selected
studies are shown in Figures 1 and 2 and defined in
Table VI, and the results displayed in Table VII. Based
on these findings, the remaining results section is
organized into 2 parts: the deficiencies found in the
literature are discussed, and the usable evidence from
the literature is presented.
American Journal of Orthodontics and Dentofacial Orthopedics Major, Flores-Mir, and Major 703
Volume 130, Number 6

Table IV. Methodological scores of selected studies

Study authors a b c d e f g h i j k l m Total %

Maw et al27 ✓ ✓✓ ✓ ✓ ✓ ✓✓ ✓✓ ✓ ✓ ✓ ✓ 14 70
Holmberg and Linder-Aronson26 ✓ ✓✓ ✓ ✓ ✓✓ ✓✓ ✓ ✓ ✓ 12 60
Hibbert and Whitehouse25 ✓ ✓✓ ✓ ✓ ✓✓ ✓✓ ✓ ✓ 11 55
Jeans et al28 ✓ ✓ ✓ ✓ ✓✓ ✓✓ ✓ ✓ ✓ 11 55
Wormald and Prescott32 ✓✓ ✓ ✓ ✓✓ ✓ ✓ ✓ ✓ ✓ 11 55
Vig et al30 ✓ ✓ ✓ ✓ ✓ ✓ ✓✓ ✓ ✓ 10 50
Kemaloglu et al33 ✓✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ 9 45
Poole et al15 ✓ ✓✓ ✓ ✓ ✓ ✓ ✓✓ 9 45
Wang et al31 ✓ ✓✓ ✓ ✓✓ ✓ ✓ 8 40
Fujioka et al18 ✓ ✓ ✓ ✓ ✓ ✓ 6 30
Kohli-Dang and Crysdale29 ✓ ✓ ✓ ✓✓ ✓ 6 30

Table V. Articles short-listed for inclusion but ulti-
mately rejected
Author Reason for exclusion
Aboudara et al36 Qualitative numerical comparisons rather
than rigorous statistical analysis
Cohen and Konak16 Lacked standardized lateral cephalograms;
no statistical analysis preformed
Oulis et al49 Study focused on posterior crossbite
rather than cephalometric validity
Thuer et al50 Lacked useful statistical comparisons to
adjudicate cephalometric diagnosis
Although none of the studies was perfect, the 6
lower-ranked studies were particularly problem-
atic.15,18,29-31,33 Of these 6, all except Wang et al31
used weak, unverified, or questionable gold standards.
In addition, many of these studies had serious sampling
problems. Kemaloglu et al,33 Kohli-Dang and Crys-
dale,29 and Poole et al15 lacked adequate sample sizes
(30 per group) or were unclear about the number of
subjects per group. Fujioka et al18 made a questionable
claim about having a “randomized group” for normal
control measurements by only using ear-nose-throat
outpatients and then made double measurements in
some subjects, yet evaluated them as independent
measures.
In our sample of 11 articles, we encountered 2
recurring problems that were rarely addressed. First,
only Kemaloglu et al33 considered age effects in their
diagnoses. Yet studies by Jeans et al34 and Linder-
Aronson and Leighton35 established that the growth of
the adenoids and the nasopharynx are not in sync;
therefore, the nasopharyngeal airway space can be
relatively smaller during childhood compared with later
adolescence. The second problem with our article
sample was that only Maw et al27 and Wormald and
Prescott32 attempted to reduce experimenter bias by
using blinding methods.
All problems aside, we uncovered some useful
findings. Maw et al27 tested the validity of a number of
cephalometric measurements by correlating them to the
volume of adenoid tissue removed during adenoidecto-
mies. Using this method, they found that the following
measurements possessed some value: subjective mea-
sure of the adenoid (r ⫽ 0.66), McNamara’s line (r ⫽
⫺0.67), and adenoid area (r ⫽ 0.71). Conversely, they
found little value in linear measurements of the superior
nasopharynx (r ⫽ ⫺0.28).
Also using postoperative adenoid weight as a gold
standard, Hibbert and Whitehouse25 found very strong
correlations to Log10 transformed cephalometric mea-
sures of adenoid area (r ⫽ 0.88) and Log10 transformed
linear measures of the superior nasopharynx (r ⫽ 0.78).
Strangely, this finding stood in strong contrast to the
results of the same measure by Maw et al27 (r ⫽
⫺0.28). Furthermore, it was not fully understood why
the authors transformed their data, when no other
authors found it necessary.
Holmberg and Linder-Aronson26 evaluated a num-
ber of measures to various gold standards. The 3 most
useful comparisons were correlating subjectively graded
adenoid size during rhinoscopy with lateral cephalo-
metric measures of subjectively graded adenoid size
(r ⫽ 0.71), a linear measure of the adenoid (r ⫽ 0.57),
and an area measure of the adenoid (r ⫽ 0.60).
Jeans et al28 also correlated cephalometric measure-
ments of adenoid size to the volume of lymphoid tissue
removed during adenoidectomy. Their most important
measure was correlating nasopharyngeal soft-tissue
area on a lateral cephalogram to adenoid volume. Using
2 observers, they found r values of 0.70 and 0.74
(Spearman interobserver correlation of 0.90). Further-
more, they found correlations of ⫺0.66 and ⫺0.67
(Spearman interobserver agreement ⫽ 0.83) between
McNamara’s line and adenoid size.
Adjudicating cephalometric measures against na-
704 Major, Flores-Mir, and Major American Journal of Orthodontics and Dentofacial Orthopedics
December 2006

Table VI. Definitions of landmarks and lines in Figures

1 and 2
Symbol Landmark description

Points
Ad1 Point on adenoid between P and Ba
Ad2 Point on adenoid nearest P (most convex point)
Ad3 Point on adenoid 5 mm higher than line 4
Ad4 Point on adenoid between P and Sy2
Ad5 Point on adenoid between P and Sy1
Ad6 Point on adenoid between P and perpendicular to line 2
Ba Basion
Bc1 Point on basiocciput intersected by line from P to Ad2
Bc2 Point on basiocciput intersected by line perpendicular
to Pt-Ad2
P Posterior end of hard palate
Pt Intersection of forman rotundum’s inferior edge with
pterygomaxillary fissure’s posterior edge
S Sella turcica
Sp Point on anterior edge of sphenoid bone between Sy1
and P Fig 1. Cephalometric landmarks used by systematic
Sy1 Anterior edge of sphenobasioccipital synchondrosis review articles.
Sy2 (Ho) Posterior edge of sphenobasioccipital synchondrosis

Lines
1 Line parallel to anterior margin of basiocciput
2 Line between Ba and S
3 McNamara’s line: shortest distance between adenoid
and palate
4 Shortest line from anterior edge of soft palate 1 cm
below P to adenoid
5 Airway size measured from anteriormost margin of
adenoid
6 PTV line
7 Parallel to hard-palate axis
8 Passes against anterior arch of atlas and perpendicular
to 6
9 Through P and perpendicular to 6
10 Through Ba and sphenoid tangent
11 Parallel to 6 and 2 cm lower
12 Approximate vertical continuation of nasopharyngeal
wall
13 Line from Ba through anterior-inferior edge of adenoid,
Fig 2. Cephalometric area measurements used by sys-
marks bottom of nasopharynx
tematic review articles.

soendoscopy, Wormald and Prescott32 found that a

simple linear measure of adenoid size did not corre-
late well (r ⫽ 0.34) against degree of nasopharyngeal
obstruction, nor did Fujioka’s adenoid-nasopharynx
ratio (r ⫽ 0.11), or a different adenoid-nasopharynx
ratio (r ⫽ 0.22) that used the same superior nasophar-
ynx measure as tested by Maw et al27 and Hibbert and
Whitehouse.25 However, they found a fair association
between nasopharyngeal obstruction and airway–soft-
palate ratio (r ⫽ 0.66).
The study by Vig et al30 was the only one that tested
the sensitivity and specificity of cephalometric adenoid
diagnosis. Adjudicating airway obstruction using Mc-
Namara’s linear measure17 and Schulhof’s area mea-
sure,14 they found lateral cephalometric diagnosis had
sensitivities of 0.318 and 0.182, respectively, and
specificities of 0.833 and 0.666, respectively.
Also of interest were studies by Kemaloglu et al33
and Poole et al.15 By comparing cephalograms of
normal and diagnosed subjects, Poole et al15 demon-
strated that a lateral cephalogram’s diagnostic capabil-
ity greatly increased if the clinician looked for several
deviant measurements indicating airway obstruction
rather than just 1 decisive measure; he also identified 4
potentially useful diagnostic measurements (Table
VII). Kemaloglu et al33 found some cephalometric
differences between adenoid size (r ⫽ 0.54-0.68) in
American Journal of Orthodontics and Dentofacial Orthopedics Major, Flores-Mir, and Major 705
Volume 130, Number 6

Table VII. Summary of cephalometric measurements used and their usefulness

Sensitivity/
Type Cephalometric measure Author R value P value specificity Gold standard

Subjective measure Holmberg26 0.71 — — endoscopy

Maw27 0.66 — — postsurgery
Wang31 — ⬍.001 — endoscopy
Linear adenoid size Ad1-Ba Holmberg26 0.57 — — endoscopy
Ad2-Bc2 Wormald32 0.34 — — endoscopy
ave size* Kemaloglu33 0.36 — — cln qstn
Adenoid area Ad1-Ad4-Sy2-Ba-Ad1 Holmberg26 0.60 — — endoscopy
Ad area Jeans28 0.70, 0.74 — — postsurgery
Ad area Maw27 0.71 — — postsurgery
Log10 Ad area inside 12 Hibbert25 0.88 — — postsurgery
Linear nasopharynx size Ad1-P Poole15 — ⬍.001 — ceph comp
Ad6-P Poole15 — ⬍.001 — ceph comp
Ad3-:6 Poole15 — ⬍.001 — ceph comp
ave nsphr size† Kemaloglu33 r⬇0 ⬎.5 — cln qstn
Log10 line 5 Hibbert25 0.78 — — postsurgery
Line 5 Maw27 ⫺0.28 — — postsurgery
McNamara line (3) Maw27 ⫺0.67 — — postsurgery
McNamara line (3) Jeans28 ⫺0.66, ⫺0.67 — — postsurgery
McNamara line (3) Vig30 — — 0.32/0.83 nsl rst
Nasopharynx area Na area Kohli-Dang29 ⫺0.387 — — nsl rst
Nasopharynx ratios (:1-Ad2)/(Sy2-Pl)‡ Fujioka18 — ⬍.01 — ceph comp
“ Jeans28 0.51, 0.48 — — postsurgery
“ Wormald32 0.11 — — endoscopy
Ad2-Bc2/line 5 Wormald32 0.22 — — endoscopy
(Sp-Ad5)/(Sp-P) Kemaloglu33 0.68 — — cln qstn
(Bc1-Ad2)/(Bc-P) Kemaloglu33 0.67 — — cln qstn
(Ba-Ad1)/(Ba-P) Kemaloglu33 0.54 — — cln qstn
4a/4b Wormald32 0.66 — — endoscopy
A:N area Airway % (in 7-8-9-10) Poole15 — ⬍.001 — ceph comp
“ Vig30 — — 0.18/0.67 nsl rst

*Average of 3 measurements Ad1-Ba, Ad2-2, Ad5-Sp.

†
Average of 3 measurements Ad1-P, Ad2-P, Ad5-P.
‡
Fujioka adenoid-nasopharynx ratio.
All landmarks, lines, and areas are shown in Figures 1 and 2.
:, Perpendicular to; nsl rst, nasal resistance; cln qstn, clinical questionnaire; ceph comp, cephalometric comparison.

children with upper airway problems but no difference
in airway size (r ⬇ 0, P ⬎.5).
In general, we found that a subjective evaluation of
the X-ray had a fair correlation with the actual diagno-
sis (r ⫽ 0.66-0.71), as did various cephalometric area
measures of the adenoid (r ⫽ 0.60-0.88). Unfortu-
nately, no consensus could be reached in determining
what would be the most important cephalometric land-
marks to use. Virtually every study used different
landmarks, so we organized the cephalometric mea-
surements into similar groups based on the method of
cephalometric nasopharyngeal evaluation and dis-
played the results of the 11 studies according to this
classification (Table VII).
DISCUSSION
Because of the relatively high frequency and poten-
tial orthodontic consequences of nasopharyngeal ob-
struction, it is important to have a simple, economical,
readily available, and reproducible way to diagnose
upper airway obstruction. We performed a systematic
review of the literature to determine the capabilities of
lateral cephalograms in diagnosing enlarged adenoids
and obstructed upper airways. We found 11 studies that
met the criteria. In general, the conclusions of these
studies depended on what feature was measured and to
what gold standard it was compared.
First, it was found that the capacity of lateral
cephalograms for diagnosing posterior upper airway
obstructions depended on the feature on the radiograph
that was evaluated. When diagnosing posterior upper
airway obstruction, there were 2 main features to
consider—size of the adenoid and size of the nasophar-
ynx. Both features can be evaluated by linear size
measurements, area measurements, and subjective clas-
sification.
706 Major, Flores-Mir, and Major
Adenoid size in lateral cephalograms was found to
have clinically useful correlations when area measure-
ments were used, whereas linear measurements were
virtually useless (Table VII). For example, both Jeans
et al28 and Maw et al27 found that nasopharyngeal
soft-tissue areas in radiographs had good correlations
with actual tissue volumes removed during adenoidec-
tomy (r ⫽ 0.7-0.74). Similarly, Holmberg and Linder-
Aronson26 and Linder-Aronson et al11 found fair cor-
relations of radiographic adenoid areas to subjectively
graded adenoid sizes during endoscopy (r ⫽ 0.60).
Although this r value might be slightly lower, the
difference can be accounted for in their use of different
cephalometric measures defining the posterior margin
of the adenoid much deeper than what occurs anatom-
ically. If a more accurate measure of adenoid area could
be determined, it would increase this correlation.
On the other hand, the ability of lateral cephalo-
grams to diagnose a small posterior nasopharynx was
less conclusive. The most reputable and trustworthy
studies regularly found poor correlation values for
nasopharynx measurements (r ⫽ ⫺0.2827) and naso-
pharyngeal ratios (r ⫽ 0.11-0.6632). Only the Mc-
Namara line was consistently useful (r ⫽ ⫺0.66 to
⫺0.67) and largely because of its dependency on
adenoid size.27,28 Although Poole et al15 found signif-
icant differences between clinically diagnosed patients
and normal controls for 3 different nasopharyngeal
airway measures, Kemaloglu et al33 found no differ-
ence in children’s nasopharyngeal airway sizes (r ⬇ 0,
P ⬎.5). But results from Poole et al15 must be inter-
preted with caution. Small test sample sizes and use of
less than ideal statistics made the results less certain.
Furthermore, Poole’s comparison of 1 cephalogram to
another might tell us about the facial morphology of
“diseased” subjects, but does little to validate its diag-
nostic accuracy.
However, the greater caution about cephalometric
imaging of the nasopharyngeal space comes from a
pilot study by Aboudara et al.36 They found that the
variability of nasopharyngeal airway area in lateral
cephalograms was drastically less than the variability of
airway volume in 3-dimensional NewTom images.
Their results provide the strongest documented evi-
dence that lateral cephalograms are missing much of
the structural information in the nasopharynx. This
finding supports and begins to quantify the long-known
drawback of compressing a 3-dimensional structure
into a 2-dimensional image and reaffirms the word of
caution already offered by Vig and Hall10 25 years ago.
It is this 2-dimensional compression that likely causes
the difference between the cephalogram’s diagnostic
capacity of enlarged adenoids vs a small nasopharynx.
American Journal of Orthodontics and Dentofacial Orthopedics
December 2006
The adenoid is a simpler 3D structure than the naso-
pharynx and, therefore, loses less information when
compressed into 2 dimensions.
Even though correlation statistics have some value
in evaluating the capacity for cephalometric diagnosis,
they are appreciably deficient compared with sensitivity
and specificity analysis in adjudicating clinical useful-
ness.37 Unfortunately, only 1 of our included studies—
Vig et al30— used sensitivity-specificity evaluation of
lateral cephalograms. Yet, even this study had a serious
shortcoming by using nasal resistance as the gold-
standard comparison, a technique with many problems
identified in the literature discrediting its use as a gold
standard for diagnosing posterior nasopharyngeal ob-
struction.29,38 Most importantly, nasal resistance is
influenced by many factors, such as rhinosinusitis,
nasal septum morphology, turbinate size, and small
naries and not just adenoid and posterior nasopharyn-
geal size.29,39,40 These problems produce a predictable
bias that was found in the study of Vig et al.30 Their
analysis suggested that lateral cephalograms have low
sensitivity and high specificity. The low sensitivity
found by Vig et al30 is likely because many patients
could be diagnosed as having adenoid problems when
they have rhinosinusitis or simply small naries. How-
ever, if a person has no problems with nose breathing,
the likelihood of having enlarged adenoids is also low,
leading to a high specificity. Furthermore, this study
lacked a receiver-operator characteristic analysis that
would predict more accurately the adequate cutoff
points for the best sensitivity-specificity balance.
Theoretically, nasoendoscopy should be a far supe-
rior test for gold-standard diagnosis and stands as the
current gold standard. Nasoendoscopy improves on
nasal resistance by allowing direct observation of the
nasopharyngeal space and, therefore, should allow
more accurate diagnosis in far less severe cases. But
nasoendoscopy has drawbacks as well; mainly, it al-
lows little opportunity for objective measurement but
instead relies on professional opinion, often causing
low interobserver agreement.41,42
Unfortunately, we found no literature testing the
sensitivity or specificity of lateral cephalometric diag-
nosis of the adenoids against nasoendoscopic diagnosis.
However, we found a study that examined enlarged
turbinates in the sinus cavity. In this comparison, Filho
et al42 found cephalometric sensitivity high and speci-
ficity low. In the context of the available evidence, this
result makes intuitive sense. Cephalograms are good at
properly identifying hypertrophied soft tissues (high
sensitivity). However, they are poor at imaging open
spaces, thus leading to a number of false positive
diagnoses (low specificity) when the turbinates are
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 130, Number 6
large but the airway space is still large enough to allow
normal breathing. Although there is no definitive evi-
dence that this trend would hold true when diagnosing
hypertrophied adenoids, it seems reasonable to expect
similar results.
Although nasoendoscopy holds the position of gold
standard diagnosis for upper airway obstruction at
present, we expect that 3D imaging will become the
gold standard of the future. New generation cone-beam
computed tomography (CBCT) produces less radiation
than traditional spiral CT (a CBCT can be as low as
about 50 ␮Sv in absorbed dose to a dental periapical
full-mouth series, or approximately a fifth of the ab-
sorbed dose of traditional CT43). Compared with tradi-
tional cephalometric radiographs, CBCT produces im-
ages that are anatomically true, and 3D representations
with 1-to-1 correlation from which slices can be dis-
played at any angle. It allows secondary reconstruc-
tions, such as sagittal, coronal, and par-axial cuts and
3D reconstructions of the airway which are not magni-
fied or distorted in size and shape.43-46 Although it
might never be financially feasible for everyday diag-
nostic use, 3D imaging in general has already become
invaluable in research and gained wide acceptance for
airway imaging.36,40,47,48 For this reason, we suggest
that future studies should use 3D imaging as the
diagnostic gold standard.
The literature regarding cephalometric diagnosis of
obstructed posterior nasopharyngeal airways still has
serious deficiencies in sample sizes, absence of blind-
ing, age factors, and use of a rigorous gold standard.
Cephalograms appear useful in diagnosing adenoid size
but poor at diagnosing nasopharynx size. Current evi-
dence suggests that the greatest use of lateral cephalo-
grams is as a screening tool for diagnosing obstructed
upper airways before more rigorous ear-nose-throat
follow-up.
CONCLUSIONS
● No conclusive evidence was found. All selected
studies had some methodological deficiency. Better
designed studies with adequate sensitivity-specificity
analysis, including receiver-operating characteristic
curves should be performed and 3D imaging used as
the diagnostic gold standard.
● Cephalograms seem to reliably image the adenoid
but are less dependable for diagnosing nasopharyn-
geal size.
● No consensus for landmarking procedures was
found; NcNamara’s line was the only specific mea-
surement with limited validation from multiple stud-
ies. When measurements were assessed according to
Major, Flores-Mir, and Major 707
similar types, a measure of adenoid area that re-
flected its true anatomical size appeared to be the best
quantitative cephalometric analysis. However, clini-
cians should look for several abnormalities in ade-
noid and nasopharyngeal size rather than 1 definitive
measure. The subjective ranking of a professional
also appears to hold some reliability.
● Current evidence suggests that the greatest use of
lateral cephalograms is as a screening tool for deter-
mining whether more intensive followup is needed.
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