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Cranial Neuropathy

Variant: 1   Anosmia or other abnormalities of the sense of smell (olfactory nerve, CN I). Initial imaging.
Procedure Appropriateness Category Relative Radiation Level
MRI orbits face neck without and with IV contrast Usually Appropriate O
MRI head without and with IV contrast May Be Appropriate (Disagreement) O
MRI orbits face neck without IV contrast May Be Appropriate O
CT maxillofacial with IV contrast May Be Appropriate ☢☢
CT maxillofacial without IV contrast May Be Appropriate ☢☢
US neck Usually Not Appropriate O
MRA head with IV contrast Usually Not Appropriate O
MRA head without and with IV contrast Usually Not Appropriate O
MRA head without IV contrast Usually Not Appropriate O
MRI head with IV contrast Usually Not Appropriate O
MRI head without IV contrast Usually Not Appropriate O
MRI orbits face neck with IV contrast Usually Not Appropriate O
CT head with IV contrast Usually Not Appropriate ☢☢☢
CT head without and with IV contrast Usually Not Appropriate ☢☢☢
CT head without IV contrast Usually Not Appropriate ☢☢☢
CT maxillofacial without and with IV contrast Usually Not Appropriate ☢☢☢
CTA head with IV contrast Usually Not Appropriate ☢☢☢
FDG-PET/CT skull base to mid-thigh Usually Not Appropriate ☢☢☢☢

Variant: 2   Unilateral isolated weakness of the mastication muscles, paralysis of the mastication muscles, sensory abnormalities of the face and head, facial numbness, or trigeminal neuralgia (trigeminal nerve, CN V). Initial imaging.
Procedure Appropriateness Category Relative Radiation Level
MRI head without and with IV contrast Usually Appropriate O
MRI orbits face neck without and with IV contrast Usually Appropriate O
MRA head with IV contrast May Be Appropriate O
MRA head without and with IV contrast May Be Appropriate O
MRA head without IV contrast May Be Appropriate O
MRI head without IV contrast May Be Appropriate (Disagreement) O
MRI orbits face neck without IV contrast May Be Appropriate O
CT maxillofacial with IV contrast May Be Appropriate ☢☢
CT maxillofacial without IV contrast May Be Appropriate ☢☢
US neck Usually Not Appropriate O
MRI head with IV contrast Usually Not Appropriate O
MRI orbits face neck with IV contrast Usually Not Appropriate O
CT head with IV contrast Usually Not Appropriate ☢☢☢
CT head without and with IV contrast Usually Not Appropriate ☢☢☢
CT head without IV contrast Usually Not Appropriate ☢☢☢
CT maxillofacial without and with IV contrast Usually Not Appropriate ☢☢☢
CTA head with IV contrast Usually Not Appropriate ☢☢☢
FDG-PET/CT skull base to mid-thigh Usually Not Appropriate ☢☢☢☢

Variant: 3   Unilateral isolated weakness of the facial expression, paralysis of the facial expression, hemifacial spasm, or Bell palsy (facial nerve, CN VII). Initial imaging.
Procedure Appropriateness Category Relative Radiation Level
MRI head without and with IV contrast Usually Appropriate O
MRI orbits face neck without and with IV contrast Usually Appropriate O
MRA head with IV contrast May Be Appropriate O
MRA head without and with IV contrast May Be Appropriate O
MRA head without IV contrast May Be Appropriate (Disagreement) O
MRI head without IV contrast May Be Appropriate O
MRI orbits face neck without IV contrast May Be Appropriate (Disagreement) O
CT maxillofacial with IV contrast May Be Appropriate ☢☢
CT maxillofacial without IV contrast May Be Appropriate ☢☢
CT temporal bone with IV contrast May Be Appropriate ☢☢☢
CT temporal bone without IV contrast May Be Appropriate ☢☢☢
US neck Usually Not Appropriate O
MRI head with IV contrast Usually Not Appropriate O
MRI orbits face neck with IV contrast Usually Not Appropriate O
CT head with IV contrast Usually Not Appropriate ☢☢☢
CT head without and with IV contrast Usually Not Appropriate ☢☢☢
CT head without IV contrast Usually Not Appropriate ☢☢☢
CT maxillofacial without and with IV contrast Usually Not Appropriate ☢☢☢
CT temporal bone without and with IV contrast Usually Not Appropriate ☢☢☢
CTA head with IV contrast Usually Not Appropriate ☢☢☢
FDG-PET/CT skull base to mid-thigh Usually Not Appropriate ☢☢☢☢

Variant: 4   Multiple different middle cranial nerve palsies (CN V-VII). Initial imaging.
Procedure Appropriateness Category Relative Radiation Level
MRI head without and with IV contrast Usually Appropriate O
MRI orbits face neck without and with IV contrast Usually Appropriate O
MRI head without IV contrast May Be Appropriate O
MRI orbits face neck without IV contrast May Be Appropriate O
CT head without IV contrast May Be Appropriate ☢☢☢
US neck Usually Not Appropriate O
MRA head with IV contrast Usually Not Appropriate O
MRA head without and with IV contrast Usually Not Appropriate O
MRA head without IV contrast Usually Not Appropriate O
MRI head with IV contrast Usually Not Appropriate O
MRI orbits face neck with IV contrast Usually Not Appropriate O
CT maxillofacial with IV contrast Usually Not Appropriate ☢☢
CT maxillofacial without IV contrast Usually Not Appropriate ☢☢
CT head with IV contrast Usually Not Appropriate ☢☢☢
CT head without and with IV contrast Usually Not Appropriate ☢☢☢
CT maxillofacial without and with IV contrast Usually Not Appropriate ☢☢☢
CT neck with IV contrast Usually Not Appropriate ☢☢☢
CT neck without and with IV contrast Usually Not Appropriate ☢☢☢
CT neck without IV contrast Usually Not Appropriate ☢☢☢
CT temporal bone with IV contrast Usually Not Appropriate ☢☢☢
CT temporal bone without and with IV contrast Usually Not Appropriate ☢☢☢
CT temporal bone without IV contrast Usually Not Appropriate ☢☢☢
CTA head with IV contrast Usually Not Appropriate ☢☢☢
FDG-PET/CT skull base to mid-thigh Usually Not Appropriate ☢☢☢☢

Variant: 5   Oropharyngeal neurogenic dysphagia or oropharyngeal pain (glossopharyngeal nerve, CN IX). Initial imaging.
Procedure Appropriateness Category Relative Radiation Level
MRI head without and with IV contrast Usually Appropriate O
MRI orbits face neck without and with IV contrast Usually Appropriate O
MRI head without IV contrast May Be Appropriate O
MRI orbits face neck without IV contrast May Be Appropriate O
CT neck with IV contrast May Be Appropriate ☢☢☢
US neck Usually Not Appropriate O
MRA head and neck with IV contrast Usually Not Appropriate O
MRA head and neck without and with IV contrast Usually Not Appropriate O
MRA head and neck without IV contrast Usually Not Appropriate O
MRI head with IV contrast Usually Not Appropriate O
MRI orbits face neck with IV contrast Usually Not Appropriate O
CT maxillofacial with IV contrast Usually Not Appropriate ☢☢
CT maxillofacial without IV contrast Usually Not Appropriate ☢☢
CT head with IV contrast Usually Not Appropriate ☢☢☢
CT head without and with IV contrast Usually Not Appropriate ☢☢☢
CT head without IV contrast Usually Not Appropriate ☢☢☢
CT maxillofacial without and with IV contrast Usually Not Appropriate ☢☢☢
CT neck without and with IV contrast Usually Not Appropriate ☢☢☢
CT neck without IV contrast Usually Not Appropriate ☢☢☢
CT temporal bone with IV contrast Usually Not Appropriate ☢☢☢
CT temporal bone without and with IV contrast Usually Not Appropriate ☢☢☢
CT temporal bone without IV contrast Usually Not Appropriate ☢☢☢
CTA head and neck with IV contrast Usually Not Appropriate ☢☢☢
FDG-PET/CT skull base to mid-thigh Usually Not Appropriate ☢☢☢☢

Variant: 6   Unilateral isolated palatal or vocal cord paralysis or both (vagal nerve, CN X). Initial imaging.
Procedure Appropriateness Category Relative Radiation Level
MRI head without and with IV contrast Usually Appropriate O
MRI orbits face neck without and with IV contrast Usually Appropriate O
CT neck with IV contrast Usually Appropriate ☢☢☢
MRI head without IV contrast May Be Appropriate O
MRI orbits face neck without IV contrast May Be Appropriate O
CT chest with IV contrast May Be Appropriate ☢☢☢
CT chest without IV contrast May Be Appropriate ☢☢☢
CT neck without IV contrast May Be Appropriate ☢☢☢
US neck Usually Not Appropriate O
Radiography chest Usually Not Appropriate ☢
MRA head and neck with IV contrast Usually Not Appropriate O
MRA head and neck without and with IV contrast Usually Not Appropriate O
MRA head and neck without IV contrast Usually Not Appropriate O
MRI head with IV contrast Usually Not Appropriate O
MRI orbits face neck with IV contrast Usually Not Appropriate O
CT maxillofacial with IV contrast Usually Not Appropriate ☢☢
CT maxillofacial without IV contrast Usually Not Appropriate ☢☢
CT chest without and with IV contrast Usually Not Appropriate ☢☢☢
CT head with IV contrast Usually Not Appropriate ☢☢☢
CT head without and with IV contrast Usually Not Appropriate ☢☢☢
CT head without IV contrast Usually Not Appropriate ☢☢☢
CT maxillofacial without and with IV contrast Usually Not Appropriate ☢☢☢
CT neck without and with IV contrast Usually Not Appropriate ☢☢☢
CT temporal bone with IV contrast Usually Not Appropriate ☢☢☢
CT temporal bone without and with IV contrast Usually Not Appropriate ☢☢☢
CT temporal bone without IV contrast Usually Not Appropriate ☢☢☢
CTA head and neck with IV contrast Usually Not Appropriate ☢☢☢
FDG-PET/CT skull base to mid-thigh Usually Not Appropriate ☢☢☢☢

Variant: 7   Unilateral isolated weakness or paralysis of the sternocleidomastoid and trapezius muscles (accessory nerve, CN XI). Initial imaging.
Procedure Appropriateness Category Relative Radiation Level
MRI head without and with IV contrast Usually Appropriate O
MRI orbits face neck without and with IV contrast Usually Appropriate O
CT neck with IV contrast Usually Appropriate ☢☢☢
MRI head without IV contrast May Be Appropriate O
MRI orbits face neck without IV contrast May Be Appropriate O
CT neck without IV contrast May Be Appropriate ☢☢☢
US neck Usually Not Appropriate O
MRA head and neck with IV contrast Usually Not Appropriate O
MRA head and neck without and with IV contrast Usually Not Appropriate O
MRA head and neck without IV contrast Usually Not Appropriate O
MRI head with IV contrast Usually Not Appropriate O
MRI orbits face neck with IV contrast Usually Not Appropriate O
CT maxillofacial with IV contrast Usually Not Appropriate ☢☢
CT maxillofacial without IV contrast Usually Not Appropriate ☢☢
CT head with IV contrast Usually Not Appropriate ☢☢☢
CT head without and with IV contrast Usually Not Appropriate ☢☢☢
CT head without IV contrast Usually Not Appropriate ☢☢☢
CT maxillofacial without and with IV contrast Usually Not Appropriate ☢☢☢
CT neck without and with IV contrast Usually Not Appropriate ☢☢☢
CT temporal bone with IV contrast Usually Not Appropriate ☢☢☢
CT temporal bone without and with IV contrast Usually Not Appropriate ☢☢☢
CT temporal bone without IV contrast Usually Not Appropriate ☢☢☢
CTA head and neck with IV contrast Usually Not Appropriate ☢☢☢

Variant: 8   Unilateral isolated weakness or paralysis of the tongue (hypoglossal nerve, CN XII). Initial imaging.
Procedure Appropriateness Category Relative Radiation Level
MRI head without and with IV contrast Usually Appropriate O
MRI orbits face neck without and with IV contrast Usually Appropriate O
CT neck with IV contrast Usually Appropriate ☢☢☢
MRA head and neck with IV contrast May Be Appropriate O
MRA head and neck without and with IV contrast May Be Appropriate O
MRA head and neck without IV contrast May Be Appropriate O
MRI head without IV contrast May Be Appropriate O
MRI orbits face neck without IV contrast May Be Appropriate O
CT neck without IV contrast May Be Appropriate ☢☢☢
CTA head and neck with IV contrast May Be Appropriate ☢☢☢
US neck Usually Not Appropriate O
MRI head with IV contrast Usually Not Appropriate O
MRI orbits face neck with IV contrast Usually Not Appropriate O
CT maxillofacial with IV contrast Usually Not Appropriate ☢☢
CT maxillofacial without IV contrast Usually Not Appropriate ☢☢
CT head with IV contrast Usually Not Appropriate ☢☢☢
CT head without and with IV contrast Usually Not Appropriate ☢☢☢
CT head without IV contrast Usually Not Appropriate ☢☢☢
CT maxillofacial without and with IV contrast Usually Not Appropriate ☢☢☢
CT neck without and with IV contrast Usually Not Appropriate ☢☢☢
CT temporal bone with IV contrast Usually Not Appropriate ☢☢☢
CT temporal bone without and with IV contrast Usually Not Appropriate ☢☢☢
CT temporal bone without IV contrast Usually Not Appropriate ☢☢☢
FDG-PET/CT skull base to mid-thigh Usually Not Appropriate ☢☢☢☢

Variant: 9   Multiple different lower cranial nerve palsies or combined lower cranial nerve syndromes (CN IX-XII). Initial imaging.
Procedure Appropriateness Category Relative Radiation Level
MRI head without and with IV contrast Usually Appropriate O
MRI orbits face neck without and with IV contrast Usually Appropriate O
CT neck with IV contrast Usually Appropriate ☢☢☢
MRA head and neck with IV contrast May Be Appropriate O
MRA head and neck without and with IV contrast May Be Appropriate O
MRA head and neck without IV contrast May Be Appropriate O
MRI head without IV contrast May Be Appropriate O
MRI orbits face neck without IV contrast May Be Appropriate O
CT neck without IV contrast May Be Appropriate ☢☢☢
CTA head and neck with IV contrast May Be Appropriate ☢☢☢
US neck Usually Not Appropriate O
MRI head with IV contrast Usually Not Appropriate O
MRI orbits face neck with IV contrast Usually Not Appropriate O
CT maxillofacial with IV contrast Usually Not Appropriate ☢☢
CT maxillofacial without IV contrast Usually Not Appropriate ☢☢
CT head with IV contrast Usually Not Appropriate ☢☢☢
CT head without and with IV contrast Usually Not Appropriate ☢☢☢
CT head without IV contrast Usually Not Appropriate ☢☢☢
CT maxillofacial without and with IV contrast Usually Not Appropriate ☢☢☢
CT neck without and with IV contrast Usually Not Appropriate ☢☢☢
CT temporal bone with IV contrast Usually Not Appropriate ☢☢☢
CT temporal bone without and with IV contrast Usually Not Appropriate ☢☢☢
CT temporal bone without IV contrast Usually Not Appropriate ☢☢☢
FDG-PET/CT skull base to mid-thigh Usually Not Appropriate ☢☢☢☢

Variant: 10   Head and neck cancer. Suspected or known perineural spread of tumor. Initial imaging.
Procedure Appropriateness Category Relative Radiation Level
MRI head without and with IV contrast Usually Appropriate O
MRI orbits face neck without and with IV contrast Usually Appropriate O
MRI head without IV contrast May Be Appropriate O
MRI orbits face neck without IV contrast May Be Appropriate O
CT maxillofacial with IV contrast May Be Appropriate ☢☢
CT neck with IV contrast May Be Appropriate ☢☢☢
US neck Usually Not Appropriate O
MRA head and neck with IV contrast Usually Not Appropriate O
MRA head and neck without and with IV contrast Usually Not Appropriate O
MRA head and neck without IV contrast Usually Not Appropriate O
MRI head with IV contrast Usually Not Appropriate O
MRI orbits face neck with IV contrast Usually Not Appropriate O
CT maxillofacial without IV contrast Usually Not Appropriate ☢☢
CT head with IV contrast Usually Not Appropriate ☢☢☢
CT head without and with IV contrast Usually Not Appropriate ☢☢☢
CT head without IV contrast Usually Not Appropriate ☢☢☢
CT maxillofacial without and with IV contrast Usually Not Appropriate ☢☢☢
CT neck without and with IV contrast Usually Not Appropriate ☢☢☢
CT neck without IV contrast Usually Not Appropriate ☢☢☢
CT temporal bone with IV contrast Usually Not Appropriate ☢☢☢
CT temporal bone without and with IV contrast Usually Not Appropriate ☢☢☢
CT temporal bone without IV contrast Usually Not Appropriate ☢☢☢
CTA head and neck with IV contrast Usually Not Appropriate ☢☢☢
FDG-PET/CT skull base to mid-thigh Usually Not Appropriate ☢☢☢☢

Panel Members
Tanya J. Rath, MDa; Bruno Policeni, MD, MBAb; Amy F. Juliano, MDc; Mohit Agarwal, MDd; Alec M. Block, MDe; Judah Burns, MDf; David B. Conley, MDg; R. Webster Crowley, MDh; Prachi Dubey, MBBS, MPHi; Elliott R. Friedman, MDj; Maria K. Gule-Monroe, MDk; Mari Hagiwara, MDl; Kate DuChene Hanrahan, MD, MMEm; Christopher H. Hunt, MDn; Vikas Jain, MDo; William J. Powers, MDp; Joshua M. Rosenow, MDq; M. Reza Taheri, MD, PhDr; David Zander, MDs; Amanda S. Corey, MDt.
Summary of Literature Review
Introduction/Background
Special Imaging Considerations
Initial Imaging Definition

Initial imaging is defined as imaging at the beginning of the care episode for the medical condition defined by the variant. More than one procedure can be considered usually appropriate in the initial imaging evaluation when:

  • There are procedures that are equivalent alternatives (i.e., only one procedure will be ordered to provide the clinical information to effectively manage the patient’s care)

OR

  • There are complementary procedures (i.e., more than one procedure is ordered as a set or simultaneously wherein each procedure provides unique clinical information to effectively manage the patient’s care).
Discussion of Procedures by Variant
Variant 1: Anosmia or other abnormalities of the sense of smell (olfactory nerve, CN I). Initial imaging.
Variant 1: Anosmia or other abnormalities of the sense of smell (olfactory nerve, CN I). Initial imaging.
A. CT head
Variant 1: Anosmia or other abnormalities of the sense of smell (olfactory nerve, CN I). Initial imaging.
B. CT maxillofacial
Variant 1: Anosmia or other abnormalities of the sense of smell (olfactory nerve, CN I). Initial imaging.
C. CTA head
Variant 1: Anosmia or other abnormalities of the sense of smell (olfactory nerve, CN I). Initial imaging.
D. FDG-PET/CT
Variant 1: Anosmia or other abnormalities of the sense of smell (olfactory nerve, CN I). Initial imaging.
E. MRA head
Variant 1: Anosmia or other abnormalities of the sense of smell (olfactory nerve, CN I). Initial imaging.
F. MRI head
Variant 1: Anosmia or other abnormalities of the sense of smell (olfactory nerve, CN I). Initial imaging.
G. MRI orbits face neck
Variant 1: Anosmia or other abnormalities of the sense of smell (olfactory nerve, CN I). Initial imaging.
H. US neck
Variant 2: Unilateral isolated weakness of the mastication muscles, paralysis of the mastication muscles, sensory abnormalities of the face and head, facial numbness, or trigeminal neuralgia (trigeminal nerve, CN V). Initial imaging.
Variant 2: Unilateral isolated weakness of the mastication muscles, paralysis of the mastication muscles, sensory abnormalities of the face and head, facial numbness, or trigeminal neuralgia (trigeminal nerve, CN V). Initial imaging.
A. CT head
Variant 2: Unilateral isolated weakness of the mastication muscles, paralysis of the mastication muscles, sensory abnormalities of the face and head, facial numbness, or trigeminal neuralgia (trigeminal nerve, CN V). Initial imaging.
B. CT maxillofacial
Variant 2: Unilateral isolated weakness of the mastication muscles, paralysis of the mastication muscles, sensory abnormalities of the face and head, facial numbness, or trigeminal neuralgia (trigeminal nerve, CN V). Initial imaging.
C. CTA head
Variant 2: Unilateral isolated weakness of the mastication muscles, paralysis of the mastication muscles, sensory abnormalities of the face and head, facial numbness, or trigeminal neuralgia (trigeminal nerve, CN V). Initial imaging.
D. FDG-PET/CT skull base to mid-thigh
Variant 2: Unilateral isolated weakness of the mastication muscles, paralysis of the mastication muscles, sensory abnormalities of the face and head, facial numbness, or trigeminal neuralgia (trigeminal nerve, CN V). Initial imaging.
E. MRA head
Variant 2: Unilateral isolated weakness of the mastication muscles, paralysis of the mastication muscles, sensory abnormalities of the face and head, facial numbness, or trigeminal neuralgia (trigeminal nerve, CN V). Initial imaging.
F. MRI head
Variant 2: Unilateral isolated weakness of the mastication muscles, paralysis of the mastication muscles, sensory abnormalities of the face and head, facial numbness, or trigeminal neuralgia (trigeminal nerve, CN V). Initial imaging.
G. MRI orbits face neck
Variant 2: Unilateral isolated weakness of the mastication muscles, paralysis of the mastication muscles, sensory abnormalities of the face and head, facial numbness, or trigeminal neuralgia (trigeminal nerve, CN V). Initial imaging.
H. US neck
Variant 3: Unilateral isolated weakness of the facial expression, paralysis of the facial expression, hemifacial spasm, or Bell palsy (facial nerve, CN VII). Initial imaging.
Variant 3: Unilateral isolated weakness of the facial expression, paralysis of the facial expression, hemifacial spasm, or Bell palsy (facial nerve, CN VII). Initial imaging.
A. CT head
Variant 3: Unilateral isolated weakness of the facial expression, paralysis of the facial expression, hemifacial spasm, or Bell palsy (facial nerve, CN VII). Initial imaging.
B. CT maxillofacial
Variant 3: Unilateral isolated weakness of the facial expression, paralysis of the facial expression, hemifacial spasm, or Bell palsy (facial nerve, CN VII). Initial imaging.
C. CT temporal bone
Variant 3: Unilateral isolated weakness of the facial expression, paralysis of the facial expression, hemifacial spasm, or Bell palsy (facial nerve, CN VII). Initial imaging.
D. CTA head
Variant 3: Unilateral isolated weakness of the facial expression, paralysis of the facial expression, hemifacial spasm, or Bell palsy (facial nerve, CN VII). Initial imaging.
E. FDG-PET/CT skull base to mid-thigh
Variant 3: Unilateral isolated weakness of the facial expression, paralysis of the facial expression, hemifacial spasm, or Bell palsy (facial nerve, CN VII). Initial imaging.
F. MRA head
Variant 3: Unilateral isolated weakness of the facial expression, paralysis of the facial expression, hemifacial spasm, or Bell palsy (facial nerve, CN VII). Initial imaging.
G. MRI head
Variant 3: Unilateral isolated weakness of the facial expression, paralysis of the facial expression, hemifacial spasm, or Bell palsy (facial nerve, CN VII). Initial imaging.
H. MRI orbits face neck
Variant 3: Unilateral isolated weakness of the facial expression, paralysis of the facial expression, hemifacial spasm, or Bell palsy (facial nerve, CN VII). Initial imaging.
I. US neck
Variant 4: Multiple different middle cranial nerve palsies (CN V-VII). Initial imaging.
Variant 4: Multiple different middle cranial nerve palsies (CN V-VII). Initial imaging.
A. CT head
Variant 4: Multiple different middle cranial nerve palsies (CN V-VII). Initial imaging.
B. CT maxillofacial
Variant 4: Multiple different middle cranial nerve palsies (CN V-VII). Initial imaging.
C. CT neck
Variant 4: Multiple different middle cranial nerve palsies (CN V-VII). Initial imaging.
D. CT temporal bone
Variant 4: Multiple different middle cranial nerve palsies (CN V-VII). Initial imaging.
E. CTA head
Variant 4: Multiple different middle cranial nerve palsies (CN V-VII). Initial imaging.
F. FDG-PET/CT skull base to mid-thigh
Variant 4: Multiple different middle cranial nerve palsies (CN V-VII). Initial imaging.
G. MRA head
Variant 4: Multiple different middle cranial nerve palsies (CN V-VII). Initial imaging.
H. MRI head
Variant 4: Multiple different middle cranial nerve palsies (CN V-VII). Initial imaging.
I. MRI orbits face neck
Variant 4: Multiple different middle cranial nerve palsies (CN V-VII). Initial imaging.
J. US neck
Variant 5: Oropharyngeal neurogenic dysphagia or oropharyngeal pain (glossopharyngeal nerve, CN IX). Initial imaging.
Variant 5: Oropharyngeal neurogenic dysphagia or oropharyngeal pain (glossopharyngeal nerve, CN IX). Initial imaging.
A. CT head
Variant 5: Oropharyngeal neurogenic dysphagia or oropharyngeal pain (glossopharyngeal nerve, CN IX). Initial imaging.
B. CT maxillofacial
Variant 5: Oropharyngeal neurogenic dysphagia or oropharyngeal pain (glossopharyngeal nerve, CN IX). Initial imaging.
C. CT neck
Variant 5: Oropharyngeal neurogenic dysphagia or oropharyngeal pain (glossopharyngeal nerve, CN IX). Initial imaging.
D. CT temporal bone
Variant 5: Oropharyngeal neurogenic dysphagia or oropharyngeal pain (glossopharyngeal nerve, CN IX). Initial imaging.
E. CTA head and neck
Variant 5: Oropharyngeal neurogenic dysphagia or oropharyngeal pain (glossopharyngeal nerve, CN IX). Initial imaging.
F. FDG-PET/CT skull base to mid-thigh
Variant 5: Oropharyngeal neurogenic dysphagia or oropharyngeal pain (glossopharyngeal nerve, CN IX). Initial imaging.
G. MRA head and neck
Variant 5: Oropharyngeal neurogenic dysphagia or oropharyngeal pain (glossopharyngeal nerve, CN IX). Initial imaging.
H. MRI head
Variant 5: Oropharyngeal neurogenic dysphagia or oropharyngeal pain (glossopharyngeal nerve, CN IX). Initial imaging.
I. MRI orbits face neck
Variant 5: Oropharyngeal neurogenic dysphagia or oropharyngeal pain (glossopharyngeal nerve, CN IX). Initial imaging.
J. US neck
Variant 6: Unilateral isolated palatal or vocal cord paralysis or both (vagal nerve, CN X). Initial imaging.
Variant 6: Unilateral isolated palatal or vocal cord paralysis or both (vagal nerve, CN X). Initial imaging.
A. CT chest
Variant 6: Unilateral isolated palatal or vocal cord paralysis or both (vagal nerve, CN X). Initial imaging.
B. CT head
Variant 6: Unilateral isolated palatal or vocal cord paralysis or both (vagal nerve, CN X). Initial imaging.
C. CT maxillofacial
Variant 6: Unilateral isolated palatal or vocal cord paralysis or both (vagal nerve, CN X). Initial imaging.
D. CT neck
Variant 6: Unilateral isolated palatal or vocal cord paralysis or both (vagal nerve, CN X). Initial imaging.
E. CT temporal bone
Variant 6: Unilateral isolated palatal or vocal cord paralysis or both (vagal nerve, CN X). Initial imaging.
F. CTA head and neck
Variant 6: Unilateral isolated palatal or vocal cord paralysis or both (vagal nerve, CN X). Initial imaging.
G. FDG-PET/CT skull base to mid-thigh
Variant 6: Unilateral isolated palatal or vocal cord paralysis or both (vagal nerve, CN X). Initial imaging.
H. MRA head and neck
Variant 6: Unilateral isolated palatal or vocal cord paralysis or both (vagal nerve, CN X). Initial imaging.
I. MRA head and neck
Variant 6: Unilateral isolated palatal or vocal cord paralysis or both (vagal nerve, CN X). Initial imaging.
J. MRI head
Variant 6: Unilateral isolated palatal or vocal cord paralysis or both (vagal nerve, CN X). Initial imaging.
K. MRI orbits face neck
Variant 6: Unilateral isolated palatal or vocal cord paralysis or both (vagal nerve, CN X). Initial imaging.
L. Radiography chest
Variant 6: Unilateral isolated palatal or vocal cord paralysis or both (vagal nerve, CN X). Initial imaging.
M. US neck
Variant 7: Unilateral isolated weakness or paralysis of the sternocleidomastoid and trapezius muscles (accessory nerve, CN XI). Initial imaging.
Variant 7: Unilateral isolated weakness or paralysis of the sternocleidomastoid and trapezius muscles (accessory nerve, CN XI). Initial imaging.
A. CT head
Variant 7: Unilateral isolated weakness or paralysis of the sternocleidomastoid and trapezius muscles (accessory nerve, CN XI). Initial imaging.
B. CT maxillofacial
Variant 7: Unilateral isolated weakness or paralysis of the sternocleidomastoid and trapezius muscles (accessory nerve, CN XI). Initial imaging.
C. CT neck
Variant 7: Unilateral isolated weakness or paralysis of the sternocleidomastoid and trapezius muscles (accessory nerve, CN XI). Initial imaging.
D. CT temporal bone
Variant 7: Unilateral isolated weakness or paralysis of the sternocleidomastoid and trapezius muscles (accessory nerve, CN XI). Initial imaging.
E. CTA head and neck
Variant 7: Unilateral isolated weakness or paralysis of the sternocleidomastoid and trapezius muscles (accessory nerve, CN XI). Initial imaging.
F. MRA head and neck
Variant 7: Unilateral isolated weakness or paralysis of the sternocleidomastoid and trapezius muscles (accessory nerve, CN XI). Initial imaging.
G. MRI head
Variant 7: Unilateral isolated weakness or paralysis of the sternocleidomastoid and trapezius muscles (accessory nerve, CN XI). Initial imaging.
H. MRI orbits face neck
Variant 7: Unilateral isolated weakness or paralysis of the sternocleidomastoid and trapezius muscles (accessory nerve, CN XI). Initial imaging.
I. US neck
Variant 8: Unilateral isolated weakness or paralysis of the tongue (hypoglossal nerve, CN XII). Initial imaging.
Variant 8: Unilateral isolated weakness or paralysis of the tongue (hypoglossal nerve, CN XII). Initial imaging.
A. CT head
Variant 8: Unilateral isolated weakness or paralysis of the tongue (hypoglossal nerve, CN XII). Initial imaging.
B. CT maxillofacial
Variant 8: Unilateral isolated weakness or paralysis of the tongue (hypoglossal nerve, CN XII). Initial imaging.
C. CT neck
Variant 8: Unilateral isolated weakness or paralysis of the tongue (hypoglossal nerve, CN XII). Initial imaging.
D. CT temporal bone
Variant 8: Unilateral isolated weakness or paralysis of the tongue (hypoglossal nerve, CN XII). Initial imaging.
E. CTA head and neck
Variant 8: Unilateral isolated weakness or paralysis of the tongue (hypoglossal nerve, CN XII). Initial imaging.
F. FDG-PET/CT skull base to mid-thigh
Variant 8: Unilateral isolated weakness or paralysis of the tongue (hypoglossal nerve, CN XII). Initial imaging.
G. MRA head and neck
Variant 8: Unilateral isolated weakness or paralysis of the tongue (hypoglossal nerve, CN XII). Initial imaging.
H. MRI head
Variant 8: Unilateral isolated weakness or paralysis of the tongue (hypoglossal nerve, CN XII). Initial imaging.
I. MRI orbits, face, and neck
Variant 8: Unilateral isolated weakness or paralysis of the tongue (hypoglossal nerve, CN XII). Initial imaging.
J. US neck
Variant 9: Multiple different lower cranial nerve palsies or combined lower cranial nerve syndromes (CN IX-XII). Initial imaging.
Variant 9: Multiple different lower cranial nerve palsies or combined lower cranial nerve syndromes (CN IX-XII). Initial imaging.
A. CT head
Variant 9: Multiple different lower cranial nerve palsies or combined lower cranial nerve syndromes (CN IX-XII). Initial imaging.
B. CT maxillofacial
Variant 9: Multiple different lower cranial nerve palsies or combined lower cranial nerve syndromes (CN IX-XII). Initial imaging.
C. CT neck
Variant 9: Multiple different lower cranial nerve palsies or combined lower cranial nerve syndromes (CN IX-XII). Initial imaging.
D. CT temporal bone
Variant 9: Multiple different lower cranial nerve palsies or combined lower cranial nerve syndromes (CN IX-XII). Initial imaging.
E. CTA head and neck
Variant 9: Multiple different lower cranial nerve palsies or combined lower cranial nerve syndromes (CN IX-XII). Initial imaging.
F. FDG-PET/CT skull base to mid-thigh
Variant 9: Multiple different lower cranial nerve palsies or combined lower cranial nerve syndromes (CN IX-XII). Initial imaging.
G. MRA head and neck
Variant 9: Multiple different lower cranial nerve palsies or combined lower cranial nerve syndromes (CN IX-XII). Initial imaging.
H. MRI head
Variant 9: Multiple different lower cranial nerve palsies or combined lower cranial nerve syndromes (CN IX-XII). Initial imaging.
I. MRI orbits face neck
Variant 9: Multiple different lower cranial nerve palsies or combined lower cranial nerve syndromes (CN IX-XII). Initial imaging.
J. US neck
Variant 10: Head and neck cancer. Suspected or known perineural spread of tumor. Initial imaging.
Variant 10: Head and neck cancer. Suspected or known perineural spread of tumor. Initial imaging.
A. CT head
Variant 10: Head and neck cancer. Suspected or known perineural spread of tumor. Initial imaging.
B. CT maxillofacial
Variant 10: Head and neck cancer. Suspected or known perineural spread of tumor. Initial imaging.
C. CT neck
Variant 10: Head and neck cancer. Suspected or known perineural spread of tumor. Initial imaging.
D. CT temporal bone
Variant 10: Head and neck cancer. Suspected or known perineural spread of tumor. Initial imaging.
E. CTA head and neck
Variant 10: Head and neck cancer. Suspected or known perineural spread of tumor. Initial imaging.
F. FDG-PET/CT skull base to mid-thigh
Variant 10: Head and neck cancer. Suspected or known perineural spread of tumor. Initial imaging.
G. MRA head and neck
Variant 10: Head and neck cancer. Suspected or known perineural spread of tumor. Initial imaging.
H. MRI head
Variant 10: Head and neck cancer. Suspected or known perineural spread of tumor. Initial imaging.
I. MRI orbits face neck
Variant 10: Head and neck cancer. Suspected or known perineural spread of tumor. Initial imaging.
J. 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.

Gender Equality and Inclusivity Clause
The ACR acknowledges the limitations in applying inclusive language when citing research studies that predates the use of the current understanding of language inclusive of diversity in sex, intersex, gender, and gender-diverse people. The data variables regarding sex and gender used in the cited literature will not be changed. However, this guideline will use the terminology and definitions as proposed by the National Institutes of Health.
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.”
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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.