From Physiology to Intervention: Endoscopic Adenoid-to-Choanae Ratio Thresholds for Symptomatic Adenoid Hypertrophy in Preschool Children

ImportanceAdenoid enlargement in preschool children is commonly cited as a cause of nasal obstruction and sleep-disordered breathing, yet age-related lymphoid development complicates differentiation between physiological growth and clinically significant hypertrophy. Existing endoscopic grading schemes lack consensus on age-specific normative limits and clear management thresholds.ObjectiveThis study aimed to determine endoscopic adenoid-to-choanae (A/C) ratio cut-offs that discriminate symptomatic from asymptomatic preschool children and to propose a practical, management-oriented grading scale.DesignSTROBE.ParticipantsWe performed a retrospective analysis of 225 preschool children (age 3-7). Standardized history-taking, flexible nasopharyngoscopy, MASNA (Mucus on Adenoid Scale by Nasopharyngoscopy Assessment) mucus scoring, and tympanometry were performed.InterventionChildren were classified as symptomatic (≥2 "yes" responses to core symptom items) or asymptomatic (no more than one "occasionally" response). Adenoid size was quantified from blinded video review as the A/C ratio.Main Outcome MeasuresReceiver operating characteristic (ROC) analysis identified an optimal A/C threshold for symptomatic status; multivariable logistic regression evaluated independent predictors.ResultsMedian A/C ratio was greater in symptomatic versus asymptomatic children. Symptomatic children also had higher MASNA mucus scores, greater reported rhinorrhea frequency, and less favorable tympanometric profiles. ROC analysis identified an A/C ratio of 60% as the optimal cut-off to discriminate symptomatic from asymptomatic children. An A/C ratio >60% emerged as the sole independent predictor of symptomatic status.ConclusionIn this cohort, the endoscopic A/C ratio strongly discriminated symptomatic from asymptomatic presentations. An A/C threshold of 60% reliably separated predominantly asymptomatic from symptomatic children.RelevanceThese findings, in conjunction with clinical experience and results from our previous studies, form the basis for a proposed three-tier, management-oriented endoscopic scale for preschool patients: Degree I (A/C ≤60%)-within age-appropriate norm; Degree II (A/C 65%-75%)-hypertrophy amenable to conservative management/observation; Degree III (A/C ≥80%)-hypertrophy for which we suggest that surgical intervention ought to be considered.