Neck Mass/Adenopathy

Variant: 1 Nonpulsatile neck mass(es). Not parotid region or thyroid. Initial imaging.

Procedure	Appropriateness Category	Relative Radiation Level
MRI neck without and with IV contrast	Usually Appropriate	O
CT neck with IV contrast	Usually Appropriate	☢☢☢
US neck	May Be Appropriate	O
MRI neck without IV contrast	May Be Appropriate	O
CT neck without IV contrast	May Be Appropriate	☢☢☢
Arteriography cervicocerebral	Usually Not Appropriate	☢☢☢
MRA neck without and with IV contrast	Usually Not Appropriate	O
MRA neck without IV contrast	Usually Not Appropriate	O
CT neck without and with IV contrast	Usually Not Appropriate	☢☢☢
CTA neck with IV contrast	Usually Not Appropriate	☢☢☢
FDG-PET/MRI skull base to mid-thigh	Usually Not Appropriate	☢☢☢
FDG-PET/CT skull base to mid-thigh	Usually Not Appropriate	☢☢☢☢

Variant: 2 Pulsatile neck mass(es). Not parotid region or thyroid. Initial imaging.

Procedure	Appropriateness Category	Relative Radiation Level
MRA neck without and with IV contrast	Usually Appropriate	O
MRI neck without and with IV contrast	Usually Appropriate	O
CT neck with IV contrast	Usually Appropriate	☢☢☢
CTA neck with IV contrast	Usually Appropriate	☢☢☢
US neck	May Be Appropriate	O
MRA neck without IV contrast	May Be Appropriate	O
MRI neck without IV contrast	May Be Appropriate	O
CT neck without IV contrast	May Be Appropriate (Disagreement)	☢☢☢
Arteriography cervicocerebral	Usually Not Appropriate	☢☢☢
CT neck without and with IV contrast	Usually Not Appropriate	☢☢☢
FDG-PET/MRI skull base to mid-thigh	Usually Not Appropriate	☢☢☢
FDG-PET/CT skull base to mid-thigh	Usually Not Appropriate	☢☢☢☢

Variant: 3 Parotid region mass(es). Initial imaging.

Procedure	Appropriateness Category	Relative Radiation Level
US neck	Usually Appropriate	O
MRI neck without and with IV contrast	Usually Appropriate	O
CT neck with IV contrast	Usually Appropriate	☢☢☢
Fluoroscopy sialography parotid	May Be Appropriate (Disagreement)	Varies
MRI neck with parotid sialography without and with IV contrast	May Be Appropriate	O
MRI neck with parotid sialography without IV contrast	May Be Appropriate	O
MRI neck without IV contrast	May Be Appropriate	O
CT neck without IV contrast	May Be Appropriate	☢☢☢
Arteriography cervicocerebral	Usually Not Appropriate	☢☢☢
MRA neck without and with IV contrast	Usually Not Appropriate	O
MRA neck without IV contrast	Usually Not Appropriate	O
CT neck with parotid sialography	Usually Not Appropriate	☢☢☢
CT neck without and with IV contrast	Usually Not Appropriate	☢☢☢
CTA neck with IV contrast	Usually Not Appropriate	☢☢☢
FDG-PET/MRI skull base to mid-thigh	Usually Not Appropriate	☢☢☢
FDG-PET/CT skull base to mid-thigh	Usually Not Appropriate	☢☢☢☢

Variant: 4 Child. Neck mass(es). Not parotid region or thyroid. Initial imaging.

Procedure	Appropriateness Category	Relative Radiation Level
US neck	Usually Appropriate	O
MRI neck without and with IV contrast	Usually Appropriate	O
MRI neck without IV contrast	Usually Appropriate	O
CT neck with IV contrast	Usually Appropriate	☢☢☢
CT neck without IV contrast	May Be Appropriate (Disagreement)	☢☢☢
Arteriography cervicocerebral	Usually Not Appropriate	☢☢☢
MRA neck without and with IV contrast	Usually Not Appropriate	O
MRA neck without IV contrast	Usually Not Appropriate	O
CT neck without and with IV contrast	Usually Not Appropriate	☢☢☢
CTA neck with IV contrast	Usually Not Appropriate	☢☢☢
FDG-PET/MRI skull base to mid-thigh	Usually Not Appropriate	☢☢☢
FDG-PET/CT skull base to mid-thigh	Usually Not Appropriate	☢☢☢☢

Panel Members

Joseph M. Aulino, MD^a; Claudia F. E. Kirsch, MD^b; Judah Burns, MD^c; Paul M. Busse, MD, PhD^d; Santanu Chakraborty, MBBS, MSc^e; Asim F. Choudhri, MD^f; David B. Conley, MD^g; Christopher U. Jones, MD^h; Ryan K. Lee, ⁱ; Michael D. Luttrull, MD^j; Toshio Moritani, MD, PhD^k; Bruno Policeni, MD^l; Maura E. Ryan, MD^m; Lubdha M. Shah, MDⁿ; Aseem Sharma, MD^o; Robert Y. Shih, MD^p; Rathan M. Subramaniam, MD, PhD, MPH^q; Sophia C. Symko, MD, MS^r; Julie Bykowski, MD^s.

Summary of Literature Review

Introduction/Background

Discussion of Procedures by Variant

Variant 1: Nonpulsatile neck mass(es). Not parotid region or thyroid. Initial imaging.

Variant 1: Nonpulsatile neck mass(es). Not parotid region or thyroid. Initial imaging.
A. Arteriography cervicocerebral

Variant 1: Nonpulsatile neck mass(es). Not parotid region or thyroid. Initial imaging.
B. CT neck

Variant 1: Nonpulsatile neck mass(es). Not parotid region or thyroid. Initial imaging.
C. CTA neck

Variant 1: Nonpulsatile neck mass(es). Not parotid region or thyroid. Initial imaging.
D. FDG-PET/CT skull base to mid-thigh

Variant 1: Nonpulsatile neck mass(es). Not parotid region or thyroid. Initial imaging.
E. FDG-PET/MRI skull base to mid-thigh

Variant 1: Nonpulsatile neck mass(es). Not parotid region or thyroid. Initial imaging.
F. MRA neck

Variant 1: Nonpulsatile neck mass(es). Not parotid region or thyroid. Initial imaging.
G. MRI neck

Variant 1: Nonpulsatile neck mass(es). Not parotid region or thyroid. Initial imaging.
H. US neck

Variant 2: Pulsatile neck mass(es). Not parotid region or thyroid. Initial imaging.

Variant 2: Pulsatile neck mass(es). Not parotid region or thyroid. Initial imaging.
A. Arteriography cervicocerebral

Variant 2: Pulsatile neck mass(es). Not parotid region or thyroid. Initial imaging.
B. CT neck

Variant 2: Pulsatile neck mass(es). Not parotid region or thyroid. Initial imaging.
C. CTA neck

Variant 2: Pulsatile neck mass(es). Not parotid region or thyroid. Initial imaging.
D. FDG-PET/CT skull base to mid-thigh

Variant 2: Pulsatile neck mass(es). Not parotid region or thyroid. Initial imaging.
E. FDG-PET/MRI skull base to mid-thigh

Variant 2: Pulsatile neck mass(es). Not parotid region or thyroid. Initial imaging.
F. MRA neck

Variant 2: Pulsatile neck mass(es). Not parotid region or thyroid. Initial imaging.
G. MRI neck

Variant 2: Pulsatile neck mass(es). Not parotid region or thyroid. Initial imaging.
H. US neck

Variant 3: Parotid region mass(es). Initial imaging.

Variant 3: Parotid region mass(es). Initial imaging.
A. Arteriography cervicocerebral

Variant 3: Parotid region mass(es). Initial imaging.
B. CT neck parotid sialography

Variant 3: Parotid region mass(es). Initial imaging.
C. CTA neck

Variant 3: Parotid region mass(es). Initial imaging.
D. FDG-PET/CT skull base to mid-thigh

Variant 3: Parotid region mass(es). Initial imaging.
E. FDG-PET/MRI skull base to mid-thigh

Variant 3: Parotid region mass(es). Initial imaging.
F. Fluoroscopy sialography parotid

Variant 3: Parotid region mass(es). Initial imaging.
G. MRA neck

Variant 3: Parotid region mass(es). Initial imaging.
H. MRI neck with parotid sialography

Variant 3: Parotid region mass(es). Initial imaging.
I. MRI neck

Variant 3: Parotid region mass(es). Initial imaging.
J. US neck

Variant 4: Child. Neck mass(es). Not parotid region or thyroid. Initial imaging.

Variant 4: Child. Neck mass(es). Not parotid region or thyroid. Initial imaging.
A. Arteriography cervicocerebral

Variant 4: Child. Neck mass(es). Not parotid region or thyroid. Initial imaging.
B. CT neck

Variant 4: Child. Neck mass(es). Not parotid region or thyroid. Initial imaging.
C. CTA neck

Variant 4: Child. Neck mass(es). Not parotid region or thyroid. Initial imaging.
D. FDG-PET/CT skull base to mid-thigh

Variant 4: Child. Neck mass(es). Not parotid region or thyroid. Initial imaging.
E. FDG-PET/MRI skull base to mid-thigh

Variant 4: Child. Neck mass(es). Not parotid region or thyroid. Initial imaging.
F. MRA neck

Variant 4: Child. Neck mass(es). Not parotid region or thyroid. Initial imaging.
G. MRI neck

Variant 4: Child. Neck mass(es). Not parotid region or thyroid. Initial imaging.
H. US neck

Summary of Highlights

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

Potential adverse health effects associated with radiation exposure are an important factor to consider when selecting the appropriate imaging procedure. Because there is a wide range of radiation exposures associated with different diagnostic procedures, a relative radiation level (RRL) indication has been included for each imaging examination. The RRLs are based on effective dose, which is a radiation dose quantity that is used to estimate population total radiation risk associated with an imaging procedure. Patients in the pediatric age group are at inherently higher risk from exposure, because of both organ sensitivity and longer life expectancy (relevant to the long latency that appears to accompany radiation exposure). For these reasons, the RRL dose estimate ranges for pediatric examinations are lower as compared with those specified for adults (see Table below). Additional information regarding radiation dose assessment for imaging examinations can be found in the ACR Appropriateness Criteria^® Radiation Dose Assessment Introduction document.

Relative Radiation Level Designations
Relative Radiation Level*	Adult Effective Dose Estimate Range	Pediatric Effective Dose Estimate Range
O	0 mSv	0 mSv
☢	<0.1 mSv	<0.03 mSv
☢☢	0.1-1 mSv	0.03-0.3 mSv
☢☢☢	1-10 mSv	0.3-3 mSv
☢☢☢☢	10-30 mSv	3-10 mSv
☢☢☢☢☢	30-100 mSv	10-30 mSv
*RRL assignments for some of the examinations cannot be made, because the actual patient doses in these procedures vary as a function of a number of factors (e.g., region of the body exposed to ionizing radiation, the imaging guidance that is used). The RRLs for these examinations are designated as “Varies.”

References

1.	Choi JW, Kim SS, Kim EY, Heran M. Peripheral T-cell lymphoma in the neck: CT findings of lymph node involvement. AJNR Am J Neuroradiol. 2006;27(5):1079-1082.
2.	Kim HJ, Lee HK, Seo JJ, et al. MR imaging of solitary fibrous tumors in the head and neck. Korean J Radiol. 2005;6(3):136-142.
3.	Kim ST, Kim HJ, Park SW, Baek CH, Byun HS, Kim YM. Nodular fasciitis in the head and neck: CT and MR imaging findings. AJNR Am J Neuroradiol. 2005;26(10):2617-2623.
4.	Lanka B, Turner M, Orton C, Carrington BM. Cross-sectional imaging in non-melanoma skin cancer of the head and neck. Clinical Radiology. 60(8):869-77, 2005 Aug.
5.	Smith JL, 2nd, Hsu JM, Chang J. Predicting deep neck space abscess using computed tomography. Am J Otolaryngol. 2006;27(4):244-247.
6.	Tanaka T, Morimoto Y, Takano H, et al. Three-dimensional identification of hemangiomas and feeding arteries in the head and neck region using combined phase-contrast MR angiography and fast asymmetric spin-echo sequences. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2005;100(5):609-613.
7.	Giannitto C, Esposito AA, Casiraghi E, Biondetti PR. Epidemiological profile of non-traumatic emergencies of the neck in CT imaging: our experience. Radiologia Medica. 119(10):784-9, 2014 Oct.Radiol Med (Torino). 119(10):784-9, 2014 Oct.
8.	Haugen BR, Alexander EK, Bible KC, et al. 2015 American Thyroid Association Management Guidelines for Adult Patients with Thyroid Nodules and Differentiated Thyroid Cancer: The American Thyroid Association Guidelines Task Force on Thyroid Nodules and Differentiated Thyroid Cancer. [Review]. Thyroid. 26(1):1-133, 2016 Jan.
9.	Kataoka M, Ueda H, Koyama T, et al. Contrast-enhanced volumetric interpolated breath-hold examination compared with spin-echo T1-weighted imaging of head and neck tumors. AJR Am J Roentgenol. 2005;184(1):313-319.
10.	Padovani RP, Kasamatsu TS, Nakabashi CC, et al. One month is sufficient for urinary iodine to return to its baseline value after the use of water-soluble iodinated contrast agents in post-thyroidectomy patients requiring radioiodine therapy. Thyroid. 22(9):926-30, 2012 Sep.
11.	Kirsch C, Dellacerra G. Increasing Incidence and Imaging in Pediatric Head and Neck Cancer and Role of the Human Papilloma Virus and Epstein–Barr Virus. Journal of Pediatric Neuroradiology. 2016;05(03):221-228.
12.	Sidell D, Nabili V, Lai C, Cheung G, Kirsch C, Abemayor E. Pediatric squamous cell carcinoma: Case report and literature review. Laryngoscope. 2009;119(8):1538-1541.
13.	Chuang SY, Lin HT, Wen YS, Hsu FJ. Pitfalls of CT for deep neck abscess imaging assessment: a retrospective review of 162 cases. B-ENT. 2013;9(1):45-52.
14.	Pynnonen MA, Gillespie MB, Roman B, et al. Clinical Practice Guideline: Evaluation of the Neck Mass in Adults Executive Summary. Otolaryngol Head Neck Surg. 157(3):355-371, 2017 09.
15.	American College of Radiology. ACR Appropriateness Criteria®: Thyroid Disease. Available at: https://acsearch.acr.org/docs/3102386/Narrative/.
16.	Salmela MB, Mortazavi S, Jagadeesan BD, et al. ACR Appropriateness Criteria® Cerebrovascular Disease. J Am Coll Radiol 2017;14:S34-S61.
17.	Kessler MM, Moussa M, Bykowski J, et al. ACR Appropriateness Criteria R Tinnitus. Journal of the American College of Radiology. 14(11S):S584-S591, 2017 Nov.
18.	Expert Panel on Neurologic Imaging:, Bykowski J, Aulino JM, et al. ACR Appropriateness Criteria Plexopathy. [Review]. J. Am. Coll. Radiol.. 14(5S):S225-S233, 2017 May.
19.	NCCN Clinical Practice Guidelines in Oncology. Head and Neck Cancers. Version 2.2017. Available at: https://www.nccn.org/professionals/physician_gls/pdf/head-and-neck.pdf.
20.	Gamss C, Gupta A, Chazen JL, Phillips CD. Imaging evaluation of the suprahyoid neck. [Review]. Radiol Clin North Am. 53(1):133-44, 2015 Jan.
21.	Wang B, Gao BL, Xu GP, Xiang C. Images of deep neck space infection and the clinical significance. Acta Radiol. 2014;55(8):945-951.
22.	Bartz BH, Case IC, Srinivasan A, Mukherji SK. Delayed MDCT imaging results in increased enhancement in patients with head and neck neoplasms. J Comput Assist Tomogr. 2006;30(6):972-974.
23.	Fujita A, Buch K, Truong MT, et al. Imaging characteristics of metastatic nodes and outcomes by HPV status in head and neck cancers. Laryngoscope. 126(2):392-8, 2016 Feb.
24.	Goldenberg D, Begum S, Westra WH, et al. Cystic lymph node metastasis in patients with head and neck cancer: An HPV-associated phenomenon. Head Neck. 2008;30(7):898-903.
25.	Eisenmenger LB, Wiggins RH 3rd. Imaging of head and neck lymph nodes. Radiol Clin North Am. 53(1):115-32, 2015 Jan.
26.	Haynes J, Arnold KR, Aguirre-Oskins C, Chandra S. Evaluation of neck masses in adults. Am Fam Physician. 91(10):698-706, 2015 May 15.
27.	Pepper C, Pai I, Hay A, et al. Investigation strategy in the management of metastatic adenocarcinoma of unknown primary presenting as cervical lymphadenopathy. Acta Otolaryngol (Stockh). 134(8):838-42, 2014 Aug.
28.	Kale HA, Prabhu AV, Sinelnikov A, Branstetter B 4th. Fat: friend or foe? A review of fat-containing masses within the head and neck. [Review]. Br J Radiol. 89(1067):20150811, 2016 Nov.
29.	Baldassari CM, Howell R, Amorn M, Budacki R, Choi S, Pena M. Complications in pediatric deep neck space abscesses. Otolaryngol Head Neck Surg. 2011;144(4):592-595.
30.	Favaretto N, Fasanaro E, Staffieri A, et al. Deep neck infections originating from the major salivary glands. American Journal of Otolaryngology. 36(4):559-64, 2015 Jul-Aug.
31.	Nougue H, Le Maho AL, Boudiaf M, et al. Clinical and imaging factors associated with severe complications of cervical necrotizing fasciitis. Intensive Care Med. 41(7):1256-63, 2015 Jul.
32.	Ibrahim M, Parmar H, Christodoulou E, Mukherji S. Raise the bar and lower the dose: current and future strategies for radiation dose reduction in head and neck imaging. AJNR Am J Neuroradiol. 2014;35(4):619-624.
33.	American College of Radiology. ACR Practice Parameter for Performing and Interpreting Diagnostic Computed Tomography (CT). Available at: https://www.acr.org/~/media/ACR/Documents/PGTS/guidelines/CT_Performing_Interpreting.pdf
34.	Kito S, Morimoto Y, Tanaka T, et al. Utility of diffusion-weighted images using fast asymmetric spin-echo sequences for detection of abscess formation in the head and neck region. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2006;101(2):231-238.
35.	Holzapfel K, Duetsch S, Fauser C, Eiber M, Rummeny EJ, Gaa J. Value of diffusion-weighted MR imaging in the differentiation between benign and malignant cervical lymph nodes. Eur J Radiol. 2009;72(3):381-387.
36.	Sumi M, Sakihama N, Sumi T, et al. Discrimination of metastatic cervical lymph nodes with diffusion-weighted MR imaging in patients with head and neck cancer. AJNR Am J Neuroradiol. 2003;24(8):1627-1634.
37.	Noij DP, Martens RM, Marcus JT, et al. Intravoxel incoherent motion magnetic resonance imaging in head and neck cancer: A systematic review of the diagnostic and prognostic value. Oral Oncol. 2017;68:81-91.
38.	Ashraf M, Biswas J, Jha J, et al. Clinical utility and prospective comparison of ultrasonography and computed tomography imaging in staging of neck metastases in head and neck squamous cell cancer in an Indian setup. Int J Clin Oncol. 16(6):686-93, 2011 Dec.
39.	Jayachandran S, Sachdeva SK. Diagnostic accuracy of color doppler ultrasonography in evaluation of cervical lymph nodes in oral cancer patients. Indian J Dent Res. 2012;23(4):557-558.
40.	Khanna R, Sharma AD, Khanna S, Kumar M, Shukla RC. Usefulness of ultrasonography for the evaluation of cervical lymphadenopathy. World J Surg Oncol. 2011;9:29.
41.	Ahuja AT, Ying M, Ho SY, et al. Ultrasound of malignant cervical lymph nodes. Cancer Imaging. 2008;8:48-56.
42.	Gronkiewicz JJ, Vade A. Cervical lymph node fine needle aspiration in patients with no history of malignancy. ULTRASOUND Q.. 29(4):323-6, 2013 Dec.
43.	Gupta A, Rahman K, Shahid M, et al. Sonographic assessment of cervical lymphadenopathy: role of high-resolution and color Doppler imaging. Head Neck. 2011;33(3):297-302.
44.	Ryu KH, Lee KH, Ryu J, et al. Cervical Lymph Node Imaging Reporting and Data System for Ultrasound of Cervical Lymphadenopathy: A Pilot Study. AJR Am J Roentgenol. 2016;206(6):1286-1291.
45.	Ying M, Bhatia KS, Lee YP, Yuen HY, Ahuja AT. Review of ultrasonography of malignant neck nodes: greyscale, Doppler, contrast enhancement and elastography. Cancer Imaging. 2013;13(4):658-669.
46.	Ying M, Ahuja A, Brook F. Accuracy of sonographic vascular features in differentiating different causes of cervical lymphadenopathy. Ultrasound Med Biol. 2004;30(4):441-447.
47.	Zhang J, Wang Y, Yu B, Shi X, Zhang Y. Application of Computer-Aided Diagnosis to the Sonographic Evaluation of Cervical Lymph Nodes. Ultrason Imaging. 2016;38(2):159-171.
48.	Tillman BN, Glazer TA, Ray A, Brenner JC, Spector ME. A lean neck mass clinic model: Adding value to care. Laryngoscope. 2015;125(11):2509-2513.
49.	Fakhry C, Agrawal N, Califano J, et al. The use of ultrasound in the search for the primary site of unknown primary head and neck squamous cell cancers. Oral Oncol. 50(7):640-5, 2014 Jul.
50.	Bhatia KS, Cho CC, Yuen YH, Rasalkar DD, King AD, Ahuja AT. Real-time qualitative ultrasound elastography of cervical lymph nodes in routine clinical practice: interobserver agreement and correlation with malignancy. Ultrasound Med Biol. 2010;36(12):1990-1997.
51.	Che D, Zhou X, Sun ML, Wang X, Jiang Z, Changjun W. Differentiation of metastatic cervical lymph nodes with ultrasound elastography by virtual touch tissue imaging: preliminary study. J Ultrasound Med. 2015;34(1):37-42.
52.	Choi YJ, Lee JH, Lim HK, et al. Quantitative shear wave elastography in the evaluation of metastatic cervical lymph nodes. Ultrasound Med Biol. 2013;39(6):935-940.
53.	Desmots F, Fakhry N, Mancini J, et al. Shear Wave Elastography in Head and Neck Lymph Node Assessment: Image Quality and Diagnostic Impact Compared with B-Mode and Doppler Ultrasonography. Ultrasound Med Biol. 2016;42(2):387-398.
54.	Fujiwara T, Tomokuni J, Iwanaga K, Ooba S, Haji T. Acoustic radiation force impulse imaging for reactive and malignant/metastatic cervical lymph nodes. Ultrasound Med Biol. 2013;39(7):1178-1183.
55.	Jin ZQ, Lin MY, Hu WH, Li WY, Bai SJ. Gray-scale ultrasonography combined with elastography imaging for the evaluation of papillary thyroid microcarcinoma: as a prognostic clinicopathology factor. Ultrasound Med Biol. 2014;40(8):1769-1777.
56.	Lenghel LM, Bolboaca SD, Botar-Jid C, Baciut G, Dudea SM. The value of a new score for sonoelastographic differentiation between benign and malignant cervical lymph nodes. Med. ultrasonography. 14(4):271-7, 2012 Dec.
57.	Meng W, Xing P, Chen Q, Wu C. Initial experience of acoustic radiation force impulse ultrasound imaging of cervical lymph nodes. Eur J Radiol. 2013;82(10):1788-1792.
58.	Poanta L, Serban O, Pascu I, Pop S, Cosgarea M, Fodor D. The place of CEUS in distinguishing benign from malignant cervical lymph nodes: a prospective study. Med Ultrason. 2014;16(1):7-14.
59.	Griauzde J, Srinivasan A. Imaging of vascular lesions of the head and neck. [Review]. Radiol Clin North Am. 53(1):197-213, 2015 Jan.
60.	Neves F, Huwart L, Jourdan G, et al. Head and neck paragangliomas: value of contrast-enhanced 3D MR angiography. AJNR Am J Neuroradiol. 2008;29(5):883-889.
61.	Romano A, Tavanti F, Rossi Espagnet MC, et al. The role of time-resolved imaging of contrast kinetics (TRICKS) magnetic resonance angiography (MRA) in the evaluation of head-neck vascular anomalies: a preliminary experience. Dentomaxillofac Radiol. 44(3):20140302, 2015.
62.	Razek AA, Gaballa G, Megahed AS, Elmogy E. Time resolved imaging of contrast kinetics (TRICKS) MR angiography of arteriovenous malformations of head and neck. Eur J Radiol. 82(11):1885-91, 2013 Nov.
63.	Archier A, Varoquaux A, Garrigue P, et al. Prospective comparison of (68)Ga-DOTATATE and (18)F-FDOPA PET/CT in patients with various pheochromocytomas and paragangliomas with emphasis on sporadic cases. Eur J Nucl Med Mol Imaging. 43(7):1248-57, 2016 Jul.
64.	Heimburger C, Veillon F, Taieb D, et al. Head-to-head comparison between 18F-FDOPA PET/CT and MR/CT angiography in clinically recurrent head and neck paragangliomas. Eur J Nucl Med Mol Imaging. 44(6):979-987, 2017 Jun.
65.	Janssen I, Chen CC, Taieb D, et al. 68Ga-DOTATATE PET/CT in the Localization of Head and Neck Paragangliomas Compared with Other Functional Imaging Modalities and CT/MRI. J Nucl Med. 57(2):186-91, 2016 Feb.
66.	Inohara H, Akahani S, Yamamoto Y, et al. The role of fine-needle aspiration cytology and magnetic resonance imaging in the management of parotid mass lesions. Acta Otolaryngol. 2008;128(10):1152-1158.
67.	de Ru JA, van Leeuwen MS, van Benthem PP, Velthuis BK, Sie-Go DM, Hordijk GJ. Do magnetic resonance imaging and ultrasound add anything to the preoperative workup of parotid gland tumors? J Oral Maxillofac Surg. 2007;65(5):945-952.
68.	Eom HJ, Lee JH, Ko MS, et al. Comparison of fine-needle aspiration and core needle biopsy under ultrasonographic guidance for detecting malignancy and for the tissue-specific diagnosis of salivary gland tumors. AJNR Am J Neuroradiol. 2015;36(6):1188-1193.
69.	Huang YC, Wu CT, Lin G, Chuang WY, Yeow KM, Wan YL. Comparison of ultrasonographically guided fine-needle aspiration and core needle biopsy in the diagnosis of parotid masses. J Clin Ultrasound. 2012;40(4):189-194.
70.	Ishibashi M, Fujii S, Kawamoto K, et al. Capsule of parotid gland tumor: evaluation by 3.0 T magnetic resonance imaging using surface coils. Acta Radiol. 2010;51(10):1103-1110.
71.	Wierzbicka M, Kaluzny J, Szczepanek-Parulska E, et al. Is sonoelastography a helpful method for evaluation of parotid tumors? Eur Arch Otorhinolaryngol. 2013;270(7):2101-2107.
72.	Zaghi S, Hendizadeh L, Hung T, Farahvar S, Abemayor E, Sepahdari AR. MRI criteria for the diagnosis of pleomorphic adenoma: a validation study. Am J Otolaryngol. 35(6):713-8, 2014 Nov-Dec.
73.	Brucker JL, Gentry LR. Imaging of head and neck emergencies. Radiol Clin North Am. 2015;53(1):215-252.
74.	Lim CY, Chang HS, Nam KH, Chung WY, Park CS. Preoperative prediction of the location of parotid gland tumors using anatomical landmarks. World J Surg. 2008;32(10):2200-2203.
75.	Bisdas S, Baghi M, Wagenblast J, et al. Differentiation of benign and malignant parotid tumors using deconvolution-based perfusion CT imaging: feasibility of the method and initial results. Eur J Radiol. 2007;64(2):258-265.
76.	Yerli H, Aydin E, Coskun M, et al. Dynamic multislice computed tomography findings for parotid gland tumors. J Comput Assist Tomogr. 2007;31(2):309-316.
77.	Imaizumi A, Kuribayashi A, Okochi K, et al. Differentiation between superficial and deep lobe parotid tumors by magnetic resonance imaging: usefulness of the parotid duct criterion. Acta Radiol. 2009;50(7):806-811.
78.	Kontzialis M, Glastonbury CM, Aygun N. Evaluation: Imaging Studies. [Review]. Adv Otorhinolaryngol. 78:25-38, 2016.
79.	Christe A, Waldherr C, Hallett R, Zbaeren P, Thoeny H. MR imaging of parotid tumors: typical lesion characteristics in MR imaging improve discrimination between benign and malignant disease. AJNR Am J Neuroradiol. 2011;32(7):1202-1207.
80.	Kato H, Kanematsu M, Watanabe H, Mizuta K, Aoki M. Salivary gland tumors of the parotid gland: CT and MR imaging findings with emphasis on intratumoral cystic components. Neuroradiology. 2014;56(9):789-795.
81.	Kato H, Fujimoto K, Matsuo M, Mizuta K, Aoki M. Usefulness of diffusion-weighted MR imaging for differentiating between Warthin's tumor and oncocytoma of the parotid gland. Jpn J Radiol. 2017;35(2):78-85.
82.	Policeni B, Corey AS, Burns J, et al. ACR Appropriateness Criteria® Cranial Neuropathy. J Am Coll Radiol 2017;14:S406-S20.
83.	Alibek S, Zenk J, Bozzato A, et al. The value of dynamic MRI studies in parotid tumors. Acad Radiol. 2007;14(6):701-710.
84.	Eida S, Ohki M, Sumi M, Yamada T, Nakamura T. MR factor analysis: improved technology for the assessment of 2D dynamic structures of benign and malignant salivary gland tumors. J Magn Reson Imaging. 2008;27(6):1256-1262.
85.	Eida S, Sumi M, Sakihama N, Takahashi H, Nakamura T. Apparent diffusion coefficient mapping of salivary gland tumors: prediction of the benignancy and malignancy. AJNR Am J Neuroradiol. 2007;28(1):116-121.
86.	Fruehwald-Pallamar J, Czerny C, Holzer-Fruehwald L, et al. Texture-based and diffusion-weighted discrimination of parotid gland lesions on MR images at 3.0 Tesla. NMR Biomed. 2013;26(11):1372-1379.
87.	Habermann CR, Arndt C, Graessner J, et al. Diffusion-weighted echo-planar MR imaging of primary parotid gland tumors: is a prediction of different histologic subtypes possible? AJNR Am J Neuroradiol. 2009;30(3):591-596.
88.	Capaccio P, Cuccarini V, Ottaviani F, et al. Comparative ultrasonographic, magnetic resonance sialographic, and videoendoscopic assessment of salivary duct disorders. Ann Otol Rhinol Laryngol. 2008;117(4):245-252.
89.	Onkar PM, Ratnaparkhi C, Mitra K. High-frequency ultrasound in parotid gland disease. Ultrasound Q. 2013;29(4):313-321.
90.	Rzepakowska A, Osuch-Wojcikiewicz E, Sobol M, Cruz R, Sielska-Badurek E, Niemczyk K. The differential diagnosis of parotid gland tumors with high-resolution ultrasound in otolaryngological practice. Eur Arch Otorhinolaryngol. 2017;274(8):3231-3240.
91.	Fischer T, Paschen CF, Slowinski T, et al. Differentiation of parotid gland tumors with contrast-enhanced ultrasound. Rofo. 2010;182(2):155-162.
92.	Klotz LV, Ingrisch M, Eichhorn ME, et al. Monitoring parotid gland tumors with a new perfusion software for contrast-enhanced ultrasound. Clin Hemorheol Microcirc. 58(1):261-9, 2014.
93.	Matsuzuka T, Suzuki M, Saijo S, et al. Stiffness of salivary gland and tumor measured by new ultrasonic techniques: Virtual touch quantification and IQ. Auris Nasus Larynx. 42(2):128-33, 2015 Apr.
94.	Strieth S, Siedek V, Rytvina M, Gurkov R, Berghaus A, Clevert DA. Dynamic contrast-enhanced ultrasound for differential diagnosis of submandibular gland disease. Eur Arch Otorhinolaryngol. 2014;271(1):163-169.
95.	Brown RE, Harave S. Diagnostic imaging of benign and malignant neck masses in children-a pictorial review. Quant Imaging Med Surg. 2016;6(5):591-604.
96.	Lee DY, Seok J, Kim YJ, Kim MS, Sung MW, Hah JH. Neck computed tomography in pediatric neck mass as initial evaluation in ED: is it malpractice? Am J Emerg Med. 2014;32(10):1237-1240.
97.	Baker LL, Dillon WP, Hieshima GB, Dowd CF, Frieden IJ. Hemangiomas and vascular malformations of the head and neck: MR characterization. AJNR Am J Neuroradiol. 1993;14(2):307-314.
98.	Fordham LA, Chung CJ, Donnelly LF. Imaging of congenital vascular and lymphatic anomalies of the head and neck. Neuroimaging Clin N Am. 2000;10(1):117-136, viii.
99.	Kollipara R, Dinneen L, Rentas KE, et al. Current classification and terminology of pediatric vascular anomalies. [Review]. AJR Am J Roentgenol. 201(5):1124-35, 2013 Nov.
100.	Donnelly LF, Adams DM, Bisset GS, 3rd. Vascular malformations and hemangiomas: a practical approach in a multidisciplinary clinic. AJR Am J Roentgenol. 2000;174(3):597-608.
101.	LaPlante JK, Pierson NS, Hedlund GL. Common pediatric head and neck congenital/developmental anomalies. Radiol Clin North Am. 2015;53(1):181-196.
102.	Hohlweg-Majert B, Metzger MC, Voss PJ, Holzle F, Wolff KD, Schulze D. Preoperative cervical lymph node size evaluation in patients with malignant head/neck tumors: comparison between ultrasound and computer tomography. J Cancer Res Clin Oncol. 2009; 135(6):753-759.
103.	Wong KT, Lee YY, King AD, Ahuja AT. Imaging of cystic or cyst-like neck masses. Clin Radiol. 2008; 63(6):613-622.
104.	Scholbach T, Scholbach J, Krombach GA, Gagel B, Maneschi P, Di Martino E. New method of dynamic color doppler signal quantification in metastatic lymph nodes compared to direct polarographic measurements of tissue oxygenation. Int J Cancer. 2005; 114(6):957-962.
105.	Collins B, Stoner JA, Digoy GP. Benefits of ultrasound vs. computed tomography in the diagnosis of pediatric lateral neck abscesses. Int J Pediatr Otorhinolaryngol. 2014;78(3):423-426.
106.	American College of Radiology. ACR Appropriateness Criteria® Radiation Dose Assessment Introduction. Available at: https://edge.sitecorecloud.io/americancoldf5f-acrorgf92a-productioncb02-3650/media/ACR/Files/Clinical/Appropriateness-Criteria/ACR-Appropriateness-Criteria-Radiation-Dose-Assessment-Introduction.pdf.

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.