Description
High resolution CT can visualize both normal and pathologic anatomy of the neck. It is used in the evaluation of neck soft tissue masses, abscesses, and lymphadenopathy. For neck tumors, it defines the extent of the primary tumor and identifies lymph node spread. CT provides details about the larynx and cervical trachea and its pathology. Additional information regarding airway pathology is provided by three-dimensional images created from the CT dataset. Neck CT can also accurately depict and characterize tracheal stenoses.

With the rise of human papillomavirus-related oral, pharyngeal, and laryngeal cancers in adults, contrast-enhanced neck CT has become more important for the evaluation of a neck mass, deemed at risk for malignancy, surpassing ultrasound for the initial evaluation in many cases. The American Academy of Otolaryngology-Head and Neck Surgery recently issued strong recommendations for neck CT or MRI, emphasizing the importance of a timely diagnosis (Pynnonen, 2017).

Policy
INDICATIONS FOR NECK CT^1,2

Suspected tumor or cancer

• Suspicious lesions in mouth or throat³
• Suspicious mass/tumor found on another imaging study and needing clarification¹
• Neck mass or lymphadenopathy (not parotid region and not thyroid region):
  • Present on physical exam and remains non-diagnostic after ultrasound is completed³
  • Mass or abnormality found on other imaging study and needing further evaluation
  • Increased risk for malignancy⁴ with one or more of the following findings:⁵
    • Fixation to adjacent tissues
    • Firm consistency
    • Size > 1.5 cm
    • Ulceration of overlying skin
    • Mass present ≥ two weeks (or uncertain duration) without significant fluctuation and not considered of infectious cause
    • History of cancer
  • Failed 2 weeks of treatment for suspected infectious adenopathy⁶
  • Pediatric ( ≤ 18 years old) considerations⁷
    • Ultrasound should be inconclusive or suspicious unless there is a history of malignancy⁸

Note: For discrete cystic lesions of the neck, an ultrasound should be performed as initial imaging unless there is a high suspicion of malignancy

Neck Mass (parotid region)¹

• Parotid mass found on other imaging study and needing further evaluation

Note: US is the initial imaging study of a parotid region mass to determine if the location is inside or outside the gland^1,9,10

Neck Mass (thyroid region)²

• Staging and monitoring for recurrence of known thyroid cancer²
• To assess extent of thyroid tissue when other imaging suggests extension through the thoracic inlet into the mediastinum or concern for airway compression^11,12

Note: US is the initial imaging study of a thyroid region mass. Biopsy is usually the next step. In the evaluation of known thyroid malignancy, CT is preferred over MRI since there is less respiratory motion artifact. Chest CT may be included for preoperative assessment in some cases.

Known or suspected deep space infections or abscesses of the pharynx or neck with signs or symptoms of infection¹³

Known tumor or cancer of skull base, tongue, larynx, nasopharynx, pharynx, or salivary glands

• Initial staging³
• Restaging during treatment
• Areas difficult to visualize on follow-up examination
• Suspected recurrence or metastases based on symptoms or examination findings¹⁴
  • New mass
  • Change in lymph nodes

Indication for combination studies for the initial pre-therapy staging of cancer, OR active monitoring for recurrence as clinically indicated OR evaluation of suspected metastases

• < 5 concurrent studies to include CT or MRI of any of the following areas as appropriate depending on the cancer: Neck, Abdomen, Pelvis, Chest, Brain, Cervical Spine, Thoracic Spine or Lumbar Spine

Pre-operative/procedural evaluation

• Pre-operative evaluation for a planned surgery or procedure

Post-operative/procedural evaluation (e.g., post neck dissection)

• A follow-up study may be needed to help evaluate a patient’s progress after treatment, procedure, intervention, or surgery. Documentation requires a medical reason that clearly indicates why additional imaging is needed for the type and area(s) requested.

Other indications for a Neck CT

• Sialadenitis (infection and inflammation of the salivary glands) with indeterminate ultrasound, bilateral symptoms or concern for abscess¹⁵
• Suspected or known salivary gland stones ^{10, 15-18}
• To assess for foreign body when radiograph is inconclusive or negative¹⁹
• Vocal cord lesions or vocal cord paralysis²⁰
• For evaluation of tracheal stenosis^{21, 22}
• Dysphagia after appropriate work up including endoscopy and fluoroscopic studies (modified barium swallow, or biphasic esophogram)^{23, 24}
• Unexplained throat pain for more than 2 weeks when ordered by a specialist with all of the following^25-27
  • Complete otolaryngologic exam and laryngoscopy
  • No signs of infection
  • Evaluation for and failed treatment of laryngopharyngeal reflux
  • Risk factor for malignancy, i.e., tobacco use, alcohol use, dysphagia, weight loss OR age older than 50 years
• Unexplained ear pain when ordered by a specialist and MRI is contraindicated with all of the following²⁸
  • Otoscopic exam, nasolaryngoscopy, lab evaluation (ESR, CBC) AND
  • Risk factor for malignancy, i.e., tobacco use, alcohol use, dysphagia, weight loss OR age older than 50 years
• Diagnosed primary hyperparathyroidism when surgery is planned
  • Previous nondiagnostic ultrasound or nuclear medicine scan²⁹
• Bell’s palsy/hemifacial spasm, if MRI is contraindicated or cannot be performed (for evaluation of the extracranial nerve course)
  • If atypical signs, slow resolution beyond three weeks, no improvement at four months, or facial twitching/spasms prior to onset³⁰
• Objective cranial nerve palsy (CN IX-XII) if MRI is contraindicated or cannot be performed (for evaluation of the extracranial nerve course)^{31, 32}

References 

1. Kirsch CFE, Burns J, et al. ACR Appropriateness Criteria Neck Mass-Adenopathy Journal of the American College of Radiology, Volume 16, Issue 5, Supplement, May 2019, Pages S150-S160.
2. American College of Radiology (ACR). Appropriateness Criteria® - Cranial Neuropathy. 2017. https://acsearch.acr.org/docs/69509/Narrative.
3. American College of Radiology (ACR). ACR Appropriateness Criteria®. Dysphagia. Revised 2018a. 
4. American College of Radiology (ACR). ACR Appropriateness Criteria - Neck Mass/Adenopathy. 2018b. https://acsearch.acr.org/docs/69504/Narrative/.
5. American College of Radiology (ACR). ACR Appropriateness Criteria - Thyroid Disease. 2018c. https://acsearch.acr.org/docs/3102386/Narrative/.
6. Brown RE, Harave S. Diagnostic imaging of benign and malignant neck masses in children – A pictorial review. Quant Imaging Med Surg. 2016 Oct; 6(5):591-604.
7. Burke CJ, Thomas RH, Howlett D. Imaging the major salivary glands. Br J Oral Maxillofac Surg. 2011; 49(4):261.
8. Chung JH, Kanne JP, Gilman MD. CT of diffuse tracheal diseases. AJR Am J Roentgenol. 2011 Mar; 196(3):W240-246.  
9. Cicero G, D’angelo T, Racchiusa S, et al. Cross-sectional imaging of parotid gland nodules: A brief practical guide. J Clin Imaging Sci. 2018; 8:14.
10. Dankbaar JW, Pameijer FA. Vocal cord paralysis: Anatomy, imaging and pathology. Insights Imagings. 2014 Dec; 5(6):743-751. 8— Neck CT Copyright © 2019-2020 National Imaging Associates, Inc., All Rights Reserved
11. Gharib H, Papini E, Garber JR, et al. American Association of Clinical Endocrinologists, American College of Endocrinology, and Associazione Medici Endocrinologi Medical Guidelines for Clinical Practice for the Diagnosis and Management of Thyroid Nodules – 2016 Update. Endocr Pract. 2016 May: 22(5):622-39.
12. Guelfguat M, Kaplinsky V, Reddy SH, et al. Clinical guidelines for imaging and reporting ingested foreign bodies. AJR Am J Roentgenol. 2014 Jul; 203(1):37-53.  
13. Haynes J, Arnold K, Aguirre-Oskins C, et al. Evaluation of neck masses in adults. Am Fam Physician. May 2015; 91(10):698-706. https://www.aafp.org/afp/2015/0515/p698.html.
14. Harari A, Zarnegar R, Lee J, et al. Computed tomography can guide focused exploration in select patients with primary hyperparathyroidism and negative sestamibi scanning. Surgery. 2008; 144(6):970-976. doi: 10.1016/j.surg.2008.08.029.
15. Heidinger BH, Occhipinti M, Eisenberg RL, et al. Imaging of large airways disorders. AJR Am J Roentgenol. 2015 Jul; 205(1):41-56.  
16. Kirsch CFE, Bykowski J, et al. ACR Appropriateness Criteria Sinonasal Disease. J Am Coll Radiol. 2017 Nov; 14(11S):S550-S559.
17. Kirsch CFE, Burns J, et al. ACR Appropriateness Criteria Neck Mass-Adenopathy. 2019 May, 16(5suppl): S150-S160. 
18. Kuno H, Onaya H, Fujii S, et al. Primary staging of laryngeal and hypopharyngeal cancer: CT, MR imaging and dual-energy CT. (Published online ahead of print October 27, 2013). Eur J Radiol. January 2014; 83(1):e23-35.  
19. Lin YS, Wu HY, Lee CW, et al. Surgical management of substernal goiters at a tertiary referral centre: A retrospective cohort study of 2,104 patients. Int J Surg. 2016 Mar; 27:46-52.
20. Meyer AC, Kimbrough TG, Finkelstein M, et al. Symptom duration and CT findings in pediatric deep neck infection. Otolaryngol Head Neck Surg. 2009; 140(2):183-186. doi: 10.1016/j.otohns.2008.11.005.  
21. Mumtaz S, Jensen MB. Facial neuropathy with imaging enhancement of the facial nerve: A case report. Future Neurol. 2014; 9(6):571-576. doi:10.2217/fnl.14.55
22. Pfister DG, Ang KK, Brizel DM, et al. Head and Neck Cancers. J Natl Compr Canc Netw. 2013; 11(8):917-923.  
23. Policeni B, Corey AS, Burns J, et al. American College of Radiology (ACR) Appropriateness Criteria. Expert Panel on Neurologic Imaging: Cranial Neuropathy. https://acsearch.acr.org/docs/69509/Narrative/. 2017.  
24. Pynnonen MA, Gillespie MB, Roman B, et al. Clinical practice guideline: Evaluation of the neck mass in adults. Otolaryngol Head Neck Surg. 2017; 157(2 Suppl):S1  
25. Quesnel AM, Lindsay RW, Hadlock TA. When the bell tolls on Bell's palsy: Finding occult malignancy in acute-onset facial paralysis. Am J Otolaryngol. 2010 Sep-Oct; 31(5):339-42. Epub 2009 Jun 24.
26. Rosenberg T, Brown J, Jefferson G. Evaluating the adult patient with a neck mass. Med Clin North Am. 2010; 94(5):1017-1029. doi.org/10.1016/j.mcna.2010.05.007.  
27. Tharin BD, Kini JA, York GE, et al. Brachial plexopathy: A review of traumatic and nontraumatic causes. AJR Am J Roentgenol. 2014; 202(1):W67.
28. Talukdar R, Yalawar RS, Kumar A. CT evaluation of neck masses. IOSR Journal of Dental and Medical Science. 2014; 14(12):39-49. 
29. Tian Y, Tanny ST, Einsiedel P, et al. Four-dimensional computed tomography: Clinical impact for patients with primary hyperparathyroidism. Ann Surg Oncol. 2018 Jan; 25(1):117-21.
30. Vogel DW, Theony HC. Cross-sectional imaging in cancers of the head and neck: How we review and report. Cancer Imaging. 2016; 16:20.
31. Wai K, Wang T, Lee E, et al. Management of persistent pediatric cervical lymphadenopathy. Arch Otorhinolaryngol Head Neck Surg. 2020; 4(1):1 DOI: 10.24983/scitemed.aohns.2020.00121.  

Coding Section 

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each Policy. They may not be all-inclusive. 

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, Blue Cross Blue Shield Association technology assessment program (TEC) and other non-affiliated technology evaluation centers, reference to federal regulations, other plan medical policies, and accredited national guidelines.

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