Endoscopy versus Lateral X-Ray for Assessing Adenoid Hypertrophy in Children and Adolescents: A Prospective Comparative Study

Background: Adenoid hypertrophy is a frequent cause of nasal obstruction, mouth breathing, snoring, and otologic symptoms in children. Lateral nasopharyngeal radiography is commonly used, while nasal endoscopy allows direct visualization. Objective: To compare grading and diagnostic performance of lateral nasopharyngeal X-ray with rigid nasal endoscopy for adenoid hypertrophy in children and adolescents. Methods: This prospective observational comparative study included symptomatic patients aged 4–16 years attending a tertiary ENT center. Each participant underwent lateral nasopharyngeal X-ray (Fujioka adenoidnasopharyngeal [A/N] ratio grading) and rigid nasal endoscopy (Clemens grading) within 48 hours. Agreement between modalities was assessed using weighted Cohen’s kappa. Diagnostic accuracy of X-ray was calculated using endoscopy as the reference standard for clinically significant adenoid hypertrophy (grade ≥2). Results: A total of 97 participants were analyzed (mean age 8.4 ± 3.1 years; 59.8% male). Nasal obstruction was present in all patients (100%), followed by mouth breathing (93.8%) and snoring (87.6%). Exact grade concordance between X-ray and endoscopy was 74.2%, with excellent agreement (weighted kappa = 0.812; p < 0.001). For clinically significant hypertrophy (grade ≥2), X-ray showed sensitivity 91.9%, specificity 82.6%, PPV 96.3%, NPV 67.9%, and overall accuracy 90.7%. Conclusion: Lateral nasopharyngeal X-ray demonstrates high sensitivity and accuracy with excellent agreement compared with nasal endoscopy for clinically significant adenoid hypertrophy. Endoscopy remains preferable when detailed anatomical assessment is required, while X-ray is a useful alternative when endoscopy is unavailable or not feasible.