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While lateral neck X-rays have the advantage of being noninvasive and quickly accessible in the clinical setting, these films are static in nature and are a two-dimensional representation of a three-dimensional space. Thus, the authors concluded that the utility of lateral neck X-ray to detect adenoid hypertrophy could not be clearly substantiated. Of the five studies identified in the analysis that focused on the A/N ratio, three studies found no relation between the A/N ratio and adenoid size, and two studies demonstrated a significant correlation. A recent systematic review 1 reported conflicting data on the accuracy of the A/N ratio. 1 There have been numerous articles that have focused on the utility of the A/N ratio in diagnosing adenoid hypertrophy. 1 The A/N ratio, the most commonly used measurement, is defined as the ratio of the measurement of the adenoid thickness and the nasopharyngeal aperture (the distance between the basiocciput and the posterior edge of the hard palate). LITERATURE REVIEWÄifferent measurements have been proposed for assessing adenoid size on lateral neck X-ray, including: 1) the adenoid-nasopharynx ratio (A/N ratio), 2) the adenoid thickness (distance along a perpendicular line from the basiocciput to the adenoid convexity), and 3) the linear distance between the antrum and adenoid tissue. The aim of this review is to determine whether X-ray or endoscopy is superior in assessing adenoid hypertrophy in pediatric patients presenting with upper airway obstruction. Cost-effective, age-specific guidelines on how best to evaluate adenoid size are lacking. Thus, flexible fiberoptic nasal endoscopy (FNE) and lateral neck X-ray are the two most common diagnostic tools used to assess for adenoid hypertrophy. Pediatric patient cooperation limits the utilization of palpation and mirror examination, while acoustic rhinometry and MRI are not practical in the clinical setting. There are numerous ways to determine adenoid size, including palpation, mirror examination, endoscopic examination, lateral neck roentgenogram (X-ray), magnetic resonance imaging (MRI), and acoustic rhinometry. In such children, adenoid hypertrophy is often suspected. Upper airway obstruction is a common complaint in children presenting to otolaryngology clinics. Assessing Adenoid Hypertrophy in Children: X-ray or Nasal Endoscopy? BACKGROUND