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.⁵

GENERAL INFORMATION

It is an expectation that all patients receive care/services from a licensed clinician. All appropriate supporting documentation, including recent pertinent office visit notes, laboratory data, and results of any special testing must be provided. If applicable: All prior relevant imaging results and the reason that alternative imaging cannot be performed must be included in the documentation submitted.

Where a specific clinical indication is not directly addressed in this guideline, medical necessity determination will be made based on widely accepted standard of care criteria. These criteria are supported by evidence-based or peer-reviewed sources such as medical literature, societal guidelines and state/national recommendations.

Policy

INDICATIONS
Suspected Tumor or Cancer

• Suspicious lesions in mouth or throat ⁽¹⁾
• Suspicious tumor or cancer mass/tumor found on another imaging study and needing clarification ⁽²⁾

Neck Mass or Lymphadenopathy (not parotid or thyroid region)

• Present on physical exam and remains non-diagnostic after ultrasound is completed (1)

• Mass or abnormality found on other imaging study and needing further evaluation
• Increased risk for malignancy ⁽²⁾ with one or more of the following findings ⁽³⁾:
  • Fixation to adjacent tissues
  • Firm consistency
  • Size > 1.5 cm
  • Ulceration of overlying skin

• • Mass present 2: 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 adenopathy ^(3,4)
• Pediatric (:5 18 years old) considerations ⁽⁵⁾
  • Ultrasound should be inconclusive or suspicious unless there is a history of malignancy ⁽⁶⁾

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)

• 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 (2,7)

Neck Mass (thyroid region)

• Staging and monitoring for recurrence of known thyroid cancer⁽⁸⁾
• To assess extent of thyroid tissue when other imaging suggests extension through the thoracic inlet into the mediastinum or concern for airway compression ⁽⁹⁾

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.

Follow-up of Known Tumor or Cancer (10)
For malignancies not listed, Neck CT is only indicated when there are signs or symptoms of neck involvement (such as palpable masses/lymph nodes or dysphagia)

Initial Staging

• Neck CT is indicated for initial diagnostic workup for the following cancer types:
  • Head and neck cancers
  • Thyroid cancer

• • B cell lymphomas (follicular lymphoma, diffuse large B cell lymphoma, Burkitt lymphoma, B-lymphoblastic lymphoma, post-transplant lymphoproliferative disorders)
  • ALL
  • AML
  • Hodgkin lymphoma (pediatric and adult)
  • Pediatric aggressive mature B cell lymphomas (Burkitt lymphoma, Diffuse large B cell lymphoma, primary mediastinal large B cell lymphoma)
  • Occult primary

Restaging

• Neck CT is indicated during active treatment (every 2-3 cycles of chemotherapy or immunotherapy, following radiation and/or after surgery) for the following malignancies:
  • Head and neck cancers (and after radiation treatment)
  • Thyroid cancer (and after surgery and/or if any concern for recurrence or progression)
  • ALL
  • AML
  • B Cell lymphomas (follicular lymphoma, diffuse large B cell lymphoma, Burkitt lymphoma, B-lymphoblastic lymphoma, post-transplant lymphoproliferative disorders)
  • Hodgkin lymphoma (pediatric and adult)
  • Pediatric aggressive mature B cell lymphomas (Burkitt lymphoma, Diffuse large B cell lymphoma, primary mediastinal large B cell lymphoma)
  • Occult primary

Surveillance

• Neck CT is appropriate during surveillance for the following malignancies at the intervals defined below:
  • ALL if lymphomatous features present, every 3-6 months for 2 years
  • AML if extramedullary disease present, every 3-6 months for 2 years
  • B Cell lymphomas (pediatric and adult) every 6 months for 2 years then annually as clinically indicated

• • Head and Neck cancer annually when specified that the area of original disease is difficult to follow on direct visualization (surveillance is typically with exam/scope rather than imaging)
  • Hodgkin lymphoma (pediatric and adult) every 3-6 months for 2 years
  • Occult primary every 3-6 months for 2 years, every 6-12 months for 3 years then annually

Note: There would need to be a sign or symptom of recurrence to consider Neck CT when the timeframe above for routine surveillance has elapsed OR when a cancer is not listed above because neck CT is not routinely a part of surveillance for that cancer in an asymptomatic patient.

Other Indications

• Known or suspected deep space infection or abscesses of the pharynx or neck with signs or symptoms of infection ⁽¹¹⁾
• Sialadenitis (infection and inflammation of the salivary glands) with indeterminate ultrasound, bilateral symptoms or concern for abscess ⁽¹²⁾
• Suspected or known salivary gland stones ^(12,13)
• To assess for foreign body when radiograph is inconclusive or negative ⁽¹⁴⁾
• Vocal cord lesions or vocal cord paralysis ⁽¹⁵⁾
• For evaluation of tracheal stenosis ⁽¹⁶⁾
• Dysphagia after appropriate work up including endoscopy and fluoroscopic studies (modified barium swallow, or biphasic Esophogram) ⁽¹⁷⁾
• Unexplained throat pain for more than 2 weeks when ordered by a specialist with all of the following: ^(18,19)
  • 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 following: ⁽²⁰⁾
  • 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 ⁽²¹⁾
  • Previous nondiagnostic ultrasound or nuclear medicine scan

• 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 onset ⁽²²⁾
• Objective cranial nerve palsy (CN IX-XII) if MRI is contraindicated or cannot be performed (for evaluation of the extracranial nerve course) ⁽²²⁾

Preoperative/Procedural Evaluation

• Pre-operative evaluation for a planned surgery or procedure

Postoperative/Procedural Evaluation

• 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.

Combination Studies
Neck/Chest CT

• Vocal cord paralysis on endoscopic exam and concern for recurrent laryngeal nerve lesion
• Phrenic nerve paralysis on diaphragm fluoroscopy (fluoroscopic sniff test)

Neck/Face CT or MRI and PET

• Neck/Face CT or MRI is indicated in addition to PET for Head and Neck Cancer
  • For surgical or radiation planning
  • 3-4 months after end of treatment in patients with locoregionally advanced disease or with altered anatomy

Combination Studies for Malignancy for Initial Staging or Restaging
Unless otherwise specified in this guideline, indication for combination studies for malignancy for initial staging or restaging:

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

Further Evaluation of Indeterminate Findings on Prior Imaging
Unless follow-up is specified elsewhere in the guideline:

• For initial evaluation of an inconclusive finding on a prior imaging report that requires further clarification
• One follow-up exam of a prior indeterminate MR/CT finding to ensure no suspicious interval change has occurred. (No further surveillance unless specified as highly suspicious or change was found on last follow-up exam)

Contraindications and Preferred Studies

• Contraindications and reasons why a CT/CTA cannot be performed may include: impaired renal function, significant allergy to IV contrast, pregnancy (depending on trimester).
• Contraindications and reasons why an MRI/MRA cannot be performed may include: impaired renal function, claustrophobia, non-MRI compatible devices (such as non- compatible defibrillator or pacemaker), metallic fragments in a high-risk location, patient exceeds limit/dimensions of MRI machine.

Rationale
CT can define the extent of the primary neck tumor and identify lymph node spread. 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. ⁽³⁾

References 

1. Kuno H, Sakamaki K, Fujii S, Sekiya K, Otani K et al. Comparison of MR Imaging and Dual-Energy CT for the Evaluation of Cartilage Invasion by Laryngeal and Hypopharyngeal Squamous Cell Carcinoma. American Journal of Neuroradiology. 2018; 39: true. 10.3174/ajnr.A5530.
2. American College of Radiology. ACR Appropriateness Criteria® Neck Mass/Adenopathy. 2018; 2023:
3. Pynnonen M, Gillespie M, Roman B, Rosenfeld R, Tunkel D et al. Clinical Practice Guideline: Evaluation of the Neck Mass in Adults. Otolaryngol Head Neck Surg. Sep 2017; 157: S1-s30. 10.1177/0194599817722550.
4. Haynes J, Arnold K, Aguirre-Oskins C, Chandra S. Evaluation of neck masses in adults. Am Fam Physician. May 15, 2015; 91: 698-706.
5. Wai K, Wang T, Lee E, Rosbe K. Management of Persistent Pediatric Cervical Lymphadenopathy. Archives of Otorhinolaryngology-Head & Neck Surgery (AOHNS). 2020; 4: 1. 10.24983/scitemed.aohns.2020.00121.
6. Brown R, Harave S. Diagnostic imaging of benign and malignant neck masses in children-a pictorial review. Quant Imaging Med Surg. Oct 2016; 6: 591-604. 10.21037/qims.2016.10.10.
7. Cicero G, D'Angelo T, Racchiusa S, Salamone I, Visalli C et al. Cross-sectional Imaging of Parotid Gland Nodules: A Brief Practical Guide. J Clin Imaging Sci. 2018; 8: 14. 10.4103/jcis.JCIS_8_18.
8. American College of Radiology. ACR Appropriateness Criteria® Thyroid Disease. 2018; 2023:
9. Gharib H, Papini E, Garber J, Duick D, Harrell R 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. May 2016; 22: 622-39. 10.4158/ep161208.Gl.
10. NCCN. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines): Head and Neck Cancers Version 3.2024. 2024.
11. Kauffmann P, Cordesmeyer R, Tröltzsch M, Sömmer C, Laskawi R. Deep neck infections: A single-center analysis of 63 cases. Med Oral Patol Oral Cir Bucal. Sep 1, 2017; 22: e536-e541. 10.4317/medoral.21799.
12. Abdel Razek A, Mukherji S. Imaging of sialadenitis. Neuroradiol J. Jun 2017; 30: 205-215. 10.1177/1971400916682752.
13. Kalia V, Kalra G, Kaur S, Kapoor R. CT Scan as an Essential Tool in Diagnosis of Non- radiopaque Sialoliths. J Maxillofac Oral Surg. Mar 2015; 14: 240-4. 10.1007/s12663-012-0461-8.
14. Pham S, Sakai O, Andreu-Arasa V. Imaging approach to ingested foreign bodies in the neck. Neuroradiology. 2024; 10.1007/s00234-024-03348-5.
15. Jain V. The role of imaging in the evaluation of hoarseness: A review. Journal of Neuroimaging. 2021; 31: 665 - 685. https://doi.org/10.1111/jon.12866.
16. Shepard J, Flores E, Abbott G. Imaging of the trachea. Annals of cardiothoracic surgery. 2018; 7: 197-209.
17. American College of Radiology. ACR Appropriateness Criteria® Dysphagia. 2018; 2023:
18. Jones D, Prowse S. Globus pharyngeus: an update for general practice. Br J Gen Pract. Oct 2015; 65: 554-5. 10.3399/bjgp15X687193.

19. Shephard E, Parkinson M, Hamilton W. Recognising laryngeal cancer in primary care: a large case-control study using electronic records. Br J Gen Pract. Feb 2019; 69: e127-e133. 10.3399/bjgp19X700997.
20. Earwood J, Rogers T, Rathjen N. Ear Pain: Diagnosing Common and Uncommon Causes. Am Fam Physician. Jan 1, 2018; 97: 20-27.
21. Zander D, Bunch P, Policeni B, Juliano A, Carneiro-Pla D et al. ACR Appropriateness Criteria: Parathyroid Adenoma. Journal of the American College of Radiology. 2021; 18: S406 - S422. 10.1016/j.jacr.2021.08.013.
22. American College of Radiology. ACR Appropriateness Criteria® Cranial Neuropathy. 2022; 2023:

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 nonaffiliated technology evaluation centers, reference to federal regulations, other plan medical policies, and accredited national guidelines.

"Current Procedural Terminology © American Medical Association. All Rights Reserved" 

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