Pediatric airway study: Endoscopic grading system for quantifying tonsillar size in comparison to standard adenotonsillar grading systems

Neha A. Patel, Kristen Carlin, Joseph M. Bernstein

Research output: Contribution to journalArticlepeer-review

8 Scopus citations


Significance Current grading systems may not allow clinicians to reliably document and communicate adenotonsillar size in the clinical setting. A validated endoscopic grading system may be useful for reporting tonsillar size in future clinical outcome studies. This is especially important as tonsillar enlargement is the cause of a substantial health care burden on children. Objective To propose and validate an easy-to-use flexible fiberoptic endoscopic grading system that provides physicians with a more accurate sense of the three-dimensional relationship of the tonsillar fossa to the upper-airway. Methods 50 consecutive pediatric patients were prospectively recruited between February 2015 and February 2016 at a pediatric otolaryngology outpatient clinic. The patients had no major craniofacial abnormalities and were aged 1 to 16 years. Each patient had data regarding BMI, Friedman palate position, OSA-18 survey results collected. For each child, digital video clips of fiberoptic nasopharyngeal, oropharyngeal and laryngeal exams were presented to 2 examiners. Examiners were asked to independently use the proposed Endoscopic tonsillar grading system, the Brodsky tonsillar grading scale, the Modified Brodsky tonsillar grading scale with a tongue depressor, and the Parikh adenoid grading system to rate adenotonsillar hypertrophy. Cohen's Kappa and weighted Kappa scores were used to assess interrater reliability for each of the four grading scales. The Spearman correlation was used to test the associations between each scale and OSA-18 scores, as well as Body Mass Index (BMI). Results 50 pediatric patients were included in this study (mean age 6.1 years, range of 1 year to 16 years). The average BMI was 20. The average OSA-18 score was 61.7. The average Friedman palate position score was 1.34. Twelve percent of the patients had a Friedman palate position score ≥ 3, which made traditional Brodsky grading of their tonsils impossible without a tongue depressor. All four scales showed strong agreement between the two raters. The weighted Kappa was 0.83 for the Modified Brodsky scale, 0.89 for the Brodsky scale, 0.94 for the Parikh scale to 0.98 for the Endoscopic scale (almost perfect agreement). The Endoscopic scale showed the most consistent agreement between the raters during the study. There was a moderate association between the Parikh adenoid grading system with OSA-18 scores (Spearman's ρ = 0.58, p < 0.001) compared to a low association of the tonsillar grading systems with OSA- 18 scores. None of the scales correlated with patient BMI. Conclusions The proposed Endoscopic tonsillar grading system is as reliable of a method of grading tonsillar size as conventional grading systems. It offers the advantage of allowing for critical evaluation of the tonsils without any anatomic distortion which may occur with the use of a tongue blade. This new validated endoscopic grading system provides a tool for communicating the degree of airway obstruction at the level of the oropharynx regardless of Friedman palate position and may be used in future outcomes projects.

Original languageEnglish
Pages (from-to)56-64
Number of pages9
JournalAmerican Journal of Otolaryngology - Head and Neck Medicine and Surgery
Issue number1
StatePublished - Jan 2018


  • Adenoid hypertrophy
  • Endoscopy
  • Fiberoptic exam
  • Grading system
  • Sleep apnea
  • Tonsillar hypertrophy
  • Upper-airway obstruction


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