AC Portal
Variant: 1   Oropharyngeal dysphagia with an attributable cause. Initial imaging.
Procedure Appropriateness Category Relative Radiation Level
Fluoroscopy barium swallow modified Usually Appropriate ☢☢☢
Fluoroscopy biphasic esophagram May Be Appropriate ☢☢☢
Fluoroscopy pharynx dynamic and static imaging May Be Appropriate ☢☢☢
Fluoroscopy single contrast esophagram May Be Appropriate ☢☢☢
Esophageal transit nuclear medicine scan Usually Not Appropriate ☢☢☢
CT neck and chest with IV contrast Usually Not Appropriate ☢☢☢☢
CT neck and chest without and with IV contrast Usually Not Appropriate ☢☢☢☢
CT neck and chest without IV contrast Usually Not Appropriate ☢☢☢☢

Variant: 2   Unexplained oropharyngeal dysphagia. Initial imaging.
Procedure Appropriateness Category Relative Radiation Level
Fluoroscopy biphasic esophagram Usually Appropriate ☢☢☢
Fluoroscopy barium swallow modified May Be Appropriate ☢☢☢
Fluoroscopy pharynx dynamic and static imaging May Be Appropriate (Disagreement) ☢☢☢
Fluoroscopy single contrast esophagram May Be Appropriate ☢☢☢
Esophageal transit nuclear medicine scan May Be Appropriate ☢☢☢
CT neck and chest with IV contrast Usually Not Appropriate ☢☢☢☢
CT neck and chest without and with IV contrast Usually Not Appropriate ☢☢☢☢
CT neck and chest without IV contrast Usually Not Appropriate ☢☢☢☢

Variant: 3   Retrosternal dysphagia in immunocompetent patients. Initial imaging.
Procedure Appropriateness Category Relative Radiation Level
Fluoroscopy biphasic esophagram Usually Appropriate ☢☢☢
Fluoroscopy barium swallow modified May Be Appropriate ☢☢☢
Fluoroscopy single contrast esophagram May Be Appropriate ☢☢☢
Esophageal transit nuclear medicine scan May Be Appropriate ☢☢☢
Fluoroscopy pharynx dynamic and static imaging Usually Not Appropriate ☢☢☢
CT neck and chest with IV contrast Usually Not Appropriate ☢☢☢☢
CT neck and chest without and with IV contrast Usually Not Appropriate ☢☢☢☢
CT neck and chest without IV contrast Usually Not Appropriate ☢☢☢☢

Variant: 4   Retrosternal dysphagia in immunocompromised patients. Initial imaging.
Procedure Appropriateness Category Relative Radiation Level
Fluoroscopy biphasic esophagram Usually Appropriate ☢☢☢
Fluoroscopy barium swallow modified May Be Appropriate ☢☢☢
Fluoroscopy single contrast esophagram May Be Appropriate ☢☢☢
Fluoroscopy pharynx dynamic and static imaging Usually Not Appropriate ☢☢☢
Esophageal transit nuclear medicine scan Usually Not Appropriate ☢☢☢
CT neck and chest with IV contrast Usually Not Appropriate ☢☢☢☢
CT neck and chest without and with IV contrast Usually Not Appropriate ☢☢☢☢
CT neck and chest without IV contrast Usually Not Appropriate ☢☢☢☢

Variant: 5   Early postoperative dysphagia. Oropharyngeal or retrosternal. Initial imaging.
Procedure Appropriateness Category Relative Radiation Level
Fluoroscopy single contrast esophagram Usually Appropriate ☢☢☢
CT neck and chest with IV contrast Usually Appropriate ☢☢☢☢
CT neck and chest without IV contrast May Be Appropriate ☢☢☢☢
Fluoroscopy barium swallow modified Usually Not Appropriate ☢☢☢
Fluoroscopy biphasic esophagram Usually Not Appropriate ☢☢☢
Fluoroscopy pharynx dynamic and static imaging Usually Not Appropriate ☢☢☢
Esophageal transit nuclear medicine scan Usually Not Appropriate ☢☢☢
CT neck and chest without and with IV contrast Usually Not Appropriate ☢☢☢☢

Variant: 6   Delayed (greater than 1 month) postoperative development of dysphagia. Oropharyngeal or retrosternal. Initial imaging.
Procedure Appropriateness Category Relative Radiation Level
Fluoroscopy single contrast esophagram Usually Appropriate ☢☢☢
CT neck and chest with IV contrast Usually Appropriate ☢☢☢☢
Fluoroscopy barium swallow modified May Be Appropriate ☢☢☢
Fluoroscopy biphasic esophagram May Be Appropriate ☢☢☢
Esophageal transit nuclear medicine scan May Be Appropriate ☢☢☢
Fluoroscopy pharynx dynamic and static imaging Usually Not Appropriate ☢☢☢
CT neck and chest without and with IV contrast Usually Not Appropriate ☢☢☢☢
CT neck and chest without IV contrast Usually Not Appropriate ☢☢☢☢

Panel Members
Summary of Literature Review
Introduction/Background
Special Imaging Considerations
Discussion of Procedures by Variant
Variant 1: Oropharyngeal dysphagia with an attributable cause. Initial imaging.
Variant 1: Oropharyngeal dysphagia with an attributable cause. Initial imaging.
A. Fluoroscopy Barium Swallow Modified
Variant 1: Oropharyngeal dysphagia with an attributable cause. Initial imaging.
B. Fluoroscopy Pharynx Dynamic and Static Imaging
Variant 1: Oropharyngeal dysphagia with an attributable cause. Initial imaging.
C. Fluoroscopy Single-Contrast Esophagram
Variant 1: Oropharyngeal dysphagia with an attributable cause. Initial imaging.
D. Fluoroscopy Biphasic Esophagram
Variant 1: Oropharyngeal dysphagia with an attributable cause. Initial imaging.
E. CT Neck and Chest
Variant 1: Oropharyngeal dysphagia with an attributable cause. Initial imaging.
F. Esophageal Transit Nuclear Medicine Scan
Variant 2: Unexplained oropharyngeal dysphagia. Initial imaging.
Variant 2: Unexplained oropharyngeal dysphagia. Initial imaging.
A. Fluoroscopy Biphasic Esophagram
Variant 2: Unexplained oropharyngeal dysphagia. Initial imaging.
B. Fluoroscopy Single-Contrast Esophagram
Variant 2: Unexplained oropharyngeal dysphagia. Initial imaging.
C. Fluoroscopy Pharynx Dynamic and Static Imaging
Variant 2: Unexplained oropharyngeal dysphagia. Initial imaging.
D. Fluoroscopy Barium Swallow Modified
Variant 2: Unexplained oropharyngeal dysphagia. Initial imaging.
E. CT Neck and Chest
Variant 2: Unexplained oropharyngeal dysphagia. Initial imaging.
F. Esophageal Transit Nuclear Medicine Scan
Variant 3: Retrosternal dysphagia in immunocompetent patients. Initial imaging.
Variant 3: Retrosternal dysphagia in immunocompetent patients. Initial imaging.
A. Fluoroscopy Biphasic Esophagram
Variant 3: Retrosternal dysphagia in immunocompetent patients. Initial imaging.
B. Fluoroscopy Single-Contrast Esophagram
Variant 3: Retrosternal dysphagia in immunocompetent patients. Initial imaging.
C. Fluoroscopy Barium Swallow Modified
Variant 3: Retrosternal dysphagia in immunocompetent patients. Initial imaging.
D. Fluoroscopy Pharynx Dynamic and Static Imaging
Variant 3: Retrosternal dysphagia in immunocompetent patients. Initial imaging.
E. CT Neck and Chest
Variant 3: Retrosternal dysphagia in immunocompetent patients. Initial imaging.
F. Esophageal Transit Nuclear Medicine Scan
Variant 4: Retrosternal dysphagia in immunocompromised patients. Initial imaging.
Variant 4: Retrosternal dysphagia in immunocompromised patients. Initial imaging.
A. Fluoroscopy Biphasic Esophagram
Variant 4: Retrosternal dysphagia in immunocompromised patients. Initial imaging.
B. Fluoroscopy Single-Contrast Esophagram
Variant 4: Retrosternal dysphagia in immunocompromised patients. Initial imaging.
C. Fluoroscopy Barium Swallow Modified
Variant 4: Retrosternal dysphagia in immunocompromised patients. Initial imaging.
D. Fluoroscopy Pharynx Dynamic and Static Imaging
Variant 4: Retrosternal dysphagia in immunocompromised patients. Initial imaging.
E. CT Neck and Chest
Variant 4: Retrosternal dysphagia in immunocompromised patients. Initial imaging.
F. Esophageal Transit Nuclear Medicine Scan
Variant 5: Early postoperative dysphagia. Oropharyngeal or retrosternal. Initial imaging.
Variant 5: Early postoperative dysphagia. Oropharyngeal or retrosternal. Initial imaging.
A. Fluoroscopy Single-Contrast Esophagram
Variant 5: Early postoperative dysphagia. Oropharyngeal or retrosternal. Initial imaging.
B. Fluoroscopy Biphasic Esophagram
Variant 5: Early postoperative dysphagia. Oropharyngeal or retrosternal. Initial imaging.
C. Fluoroscopy Barium Swallow Modified
Variant 5: Early postoperative dysphagia. Oropharyngeal or retrosternal. Initial imaging.
D. Fluoroscopy Pharynx Dynamic and Static Imaging
Variant 5: Early postoperative dysphagia. Oropharyngeal or retrosternal. Initial imaging.
E. CT Neck and Chest
Variant 5: Early postoperative dysphagia. Oropharyngeal or retrosternal. Initial imaging.
F. Esophageal Transit Nuclear Medicine Scan
Variant 6: Delayed (greater than 1 month) postoperative development of dysphagia. Oropharyngeal or retrosternal. Initial imaging.
Variant 6: Delayed (greater than 1 month) postoperative development of dysphagia. Oropharyngeal or retrosternal. Initial imaging.
A. Fluoroscopy Single-Contrast Esophagram
Variant 6: Delayed (greater than 1 month) postoperative development of dysphagia. Oropharyngeal or retrosternal. Initial imaging.
B. Fluoroscopy Biphasic Esophagram
Variant 6: Delayed (greater than 1 month) postoperative development of dysphagia. Oropharyngeal or retrosternal. Initial imaging.
C. Fluoroscopy Barium Swallow Modified
Variant 6: Delayed (greater than 1 month) postoperative development of dysphagia. Oropharyngeal or retrosternal. Initial imaging.
D. Fluoroscopy Pharynx Dynamic and Static Imaging
Variant 6: Delayed (greater than 1 month) postoperative development of dysphagia. Oropharyngeal or retrosternal. Initial imaging.
E. CT Neck and Chest
Variant 6: Delayed (greater than 1 month) postoperative development of dysphagia. Oropharyngeal or retrosternal. Initial imaging.
F. Esophageal Transit Nuclear Medicine Scan
Summary of Recommendations
Supporting Documents

The evidence table, literature search, and appendix for this topic are available at https://acsearch.acr.org/list. The appendix includes the strength of evidence assessment and the final rating round tabulations for each recommendation.

For additional information on the Appropriateness Criteria methodology and other supporting documents, please go to the ACR website at https://www.acr.org/Clinical-Resources/Clinical-Tools-and-Reference/Appropriateness-Criteria.

Appropriateness Category Names and Definitions

Appropriateness Category Name

Appropriateness Rating

Appropriateness Category Definition

Usually Appropriate

7, 8, or 9

The imaging procedure or treatment is indicated in the specified clinical scenarios at a favorable risk-benefit ratio for patients.

May Be Appropriate

4, 5, or 6

The imaging procedure or treatment may be indicated in the specified clinical scenarios as an alternative to imaging procedures or treatments with a more favorable risk-benefit ratio, or the risk-benefit ratio for patients is equivocal.

May Be Appropriate (Disagreement)

5

The individual ratings are too dispersed from the panel median. The different label provides transparency regarding the panel’s recommendation. “May be appropriate” is the rating category and a rating of 5 is assigned.

Usually Not Appropriate

1, 2, or 3

The imaging procedure or treatment is unlikely to be indicated in the specified clinical scenarios, or the risk-benefit ratio for patients is likely to be unfavorable.
Relative Radiation Level Information
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Disclaimer
The ACR Committee on Appropriateness Criteria and its expert panels have developed criteria for determining appropriate imaging examinations for diagnosis and treatment of specified medical condition(s). These criteria are intended to guide radiologists, radiation oncologists and referring physicians in making decisions regarding radiologic imaging and treatment. Generally, the complexity and severity of a patient’s clinical condition should dictate the selection of appropriate imaging procedures or treatments. Only those examinations generally used for evaluation of the patient’s condition are ranked.  Other imaging studies necessary to evaluate other co-existent diseases or other medical consequences of this condition are not considered in this document.  The availability of equipment or personnel may influence the selection of appropriate imaging procedures or treatments. Imaging techniques classified as investigational by the FDA have not been considered in developing these criteria; however, study of new equipment and applications should be encouraged.  The ultimate decision regarding the appropriateness of any specific radiologic examination or treatment must be made by the referring physician and radiologist in light of all the circumstances presented in an individual examination