ADVANCED IMAGING CLINICAL APPROPRIATENESS GUIDELINES. Appropriate Use Criteria: Imaging of the Head and Neck. EFFECTIVE JANUARY 1, 2019 Proprietary

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1 CLINICAL APPROPRIATENESS GUIDELINES ADVANCED IMAGING Apprpriate Use Criteria: Imaging f the Head and Neck EFFECTIVE JANUARY 1, 2019 Prprietary 8600 West Bryn Mawr Avenue Suth Twer Suite 800 Chicag, IL Apprpriate.Safe.Affrdable AIM Specialty Health

2 Table f Cntents Descriptin and Applicatin f the Guidelines... 4 Administrative Guidelines... 5 Ordering f Multiple Studies... 5 Simultaneus Ordering f Multiple Studies... 5 Repeated Imaging... 5 Pre-Test Requirements... 6 Histry... 6 Head and Neck Imaging... 7 General Infrmatin/Overview... 7 Scpe... 7 Technlgy Cnsideratins... 7 Definitins... 7 Clinical Indicatins... 9 Cngenital and Develpmental Cnditins... 9 Infectin and Inflammatry Cnditins... 9 Sinusitis/rhinsinusitis... 9 Infectius disease nt therwise specified Inflammatry cnditins nt therwise specified Trauma Trauma Tumr/Sft Tissue Mass Chlesteatma Neck mass Parathyrid adenma Thyrid ndule r thyrmegaly (giter) Tumr nt therwise specified Nasal Indicatins Ansmia Cerebrspinal fluid leak Freign bdy Muccele f the paranasal sinus Nasal airway bstructin refractry t medical therapy Nasal r sinus plypsis Recurrent epistaxis Orbital Indicatins Absence f red reflex (pediatric nly) Dyscnjugate gaze Exphthalms r prptsis Extracular muscle weakness Nystagmus Cpyright AIM Specialty Health. All Rights Reserved. 2

3 Optic neuritis Orbital pseudtumr Papilledema Strabismus Thyrid phthalmpathy Temprmandibular Jint Pathlgy Arthrpathy f the temprmandibular jints Frzen jaw Juvenile idipathic arthritis (Pediatric nly) Temprmandibular disease Temprmandibular jint dysfunctin Miscellaneus Cnditins Cchlear implant Freign bdy evaluatin Laryngeal edema Osseus lesins Ostenecrsis f the jaw Salivary gland ductal calculi Trticllis (Pediatric nly) Tracheal stensis r upper airway bstructin Signs and Symptms Dizziness r vertig Hearing lss Harseness, dysphnia, and vcal crd weakness/paralysis Hrner s syndrme Lcalized facial pain Lymphadenpathy Stridr Tinnitus Pulsatile tinnitus (Pediatric nly) Visual disturbance r visual field defect References Cdes Histry Cpyright AIM Specialty Health. All Rights Reserved. 3

4 Descriptin and Applicatin f the Guidelines The AIM Clinical Apprpriateness Guidelines (hereinafter the AIM Clinical Apprpriateness Guidelines r the Guidelines ) are designed t assist prviders in making the mst apprpriate treatment decisin fr a specific clinical cnditin fr an individual. As used by AIM, the Guidelines establish bjective and evidence-based criteria fr medical necessity determinatins where pssible. In the prcess, multiple functins are accmplished: T establish criteria fr when services are medically necessary T assist the practitiner as an educatinal tl T encurage standardizatin f medical practice patterns T curtail the perfrmance f inapprpriate and/r duplicate services T advcate fr patient safety cncerns T enhance the quality f health care T prmte the mst efficient and cst-effective use f services The AIM guideline develpment prcess cmplies with applicable accreditatin standards, including the requirement that the Guidelines be develped with invlvement frm apprpriate prviders with current clinical expertise relevant t the Guidelines under review and be based n the mst up-t-date clinical principles and best practices. Relevant citatins are included in the References sectin attached t each Guideline. AIM reviews all f its Guidelines at least annually. AIM makes its Guidelines publicly available n its website twenty-fur hurs a day, seven days a week. Cpies f the AIM Clinical Apprpriateness Guidelines are als available upn ral r written request. Althugh the Guidelines are publicly-available, AIM cnsiders the Guidelines t be imprtant, prprietary infrmatin f AIM, which cannt be sld, assigned, leased, licensed, reprduced r distributed withut the written cnsent f AIM. AIM applies bjective and evidence-based criteria, and takes individual circumstances and the lcal delivery system int accunt when determining the medical apprpriateness f health care services. The AIM Guidelines are just guidelines fr the prvisin f specialty health services. These criteria are designed t guide bth prviders and reviewers t the mst apprpriate services based n a patient s unique circumstances. In all cases, clinical judgment cnsistent with the standards f gd medical practice shuld be used when applying the Guidelines. Guideline determinatins are made based n the infrmatin prvided at the time f the request. It is expected that medical necessity decisins may change as new infrmatin is prvided r based n unique aspects f the patient s cnditin. The treating clinician has final authrity and respnsibility fr treatment decisins regarding the care f the patient and fr justifying and demnstrating the existence f medical necessity fr the requested service. The Guidelines are nt a substitute fr the experience and judgment f a physician r ther health care prfessinals. Any clinician seeking t apply r cnsult the Guidelines is expected t use independent medical judgment in the cntext f individual clinical circumstances t determine any patient s care r treatment. The Guidelines d nt address cverage, benefit r ther plan specific issues. If requested by a health plan, AIM will review requests based n health plan medical plicy/guidelines in lieu f the AIM Guidelines. The Guidelines may als be used by the health plan r by AIM fr purpses f prvider educatin, r t review the medical necessity f services by any prvider wh has been ntified f the need fr medical necessity review, due t billing practices r claims that are nt cnsistent with ther prviders in terms f frequency r sme ther manner. Cpyright AIM Specialty Health. All Rights Reserved. 4

5 Administrative Guidelines Ordering f Multiple Studies Requests fr multiple imaging studies t evaluate a suspected r identified cnditin and requests fr repeated imaging f the same anatmic area are subject t additinal review t avid unnecessary r inapprpriate imaging. Simultaneus Ordering f Multiple Studies In many situatins, rdering multiple imaging studies at the same time is nt clinically apprpriate because: Current literature and/r standards f medical practice supprt that ne f the requested imaging studies is mre apprpriate in the clinical situatin presented; r One f the imaging studies requested is mre likely t imprve patient utcmes based n current literature and/r standards f medical practice; r Apprpriateness f additinal imaging is dependent n the results f the lead study. When multiple imaging studies are rdered, the request will ften require a peer-t-peer cnversatin t understand the individual circumstances that supprt the medically necessity f perfrming all imaging studies simultaneusly. Examples f multiple imaging studies that may require a peer-t-peer cnversatin include: CT brain and CT sinus fr headache MRI brain and MRA brain fr headache MRI cervical spine and MRI shulder fr pain indicatins MRI lumbar spine and MRI hip fr pain indicatins MRI r CT f multiple spine levels fr pain r radicular indicatins MRI ft and MRI ankle fr pain indicatins Bilateral exams, particularly cmparisn studies There are certain clinical scenaris where simultaneus rdering f multiple imaging studies is cnsistent with current literature and/r standards f medical practice. These include: Onclgic imaging Cnsideratins include the type f malignancy and the pint alng the care cntinuum at which imaging is requested Cnditins which span multiple anatmic regins Examples include certain gastrintestinal indicatins r cngenital spinal anmalies Repeated Imaging In general, repeated imaging f the same anatmic area shuld be limited t evaluatin fllwing an interventin, r when there is a change in clinical status such that imaging is required t determine next steps in management. At times, repeated imaging dne with different techniques r cntrast regimens may be necessary t clarify a finding seen n the riginal study. Repeated imaging f the same anatmic area (with same r similar technlgy) may be subject t additinal review in the fllwing scenaris: Repeated imaging at the same facility due t mtin artifact r ther technical issues Repeated imaging requested at a different facility due t prvider preference r quality cncerns Repeated imaging f the same anatmic area (MRI r CT) based n persistent symptms with n clinical change, treatment, r interventin since the previus study Repeated imaging f the same anatmical area by different prviders fr the same member ver a shrt perid f time Cpyright AIM Specialty Health. All Rights Reserved. 5

6 Pre-Test Requirements Critical t any finding f clinical apprpriateness under the guidelines fr specific imaging exams is a determinatin that the fllwing are true with respect t the imaging request: A clinical evaluatin has been perfrmed prir t the imaging request (which shuld include a cmplete histry and physical exam and review f results frm relevant labratry studies, prir imaging and supplementary testing) t identify suspected r established diseases r cnditins. Fr suspected diseases r cnditins: Based n the clinical evaluatin, there is a reasnable likelihd f disease prir t imaging; and Current literature and standards f medical practice supprt that the requested imaging study is the mst apprpriate methd f narrwing the differential diagnsis generated thrugh the clinical evaluatin and can be reasnably expected t lead t a change in management f the patient; and The imaging requested is reasnably expected t imprve patient utcmes based n current literature and standards f medical practice. Fr established diseases r cnditins: Advanced imaging is needed t determine whether the extent r nature f the disease r cnditin has changed; and Current literature and standards f medical practice supprt that the requested imaging study is the mst apprpriate methd f determining this and can be reasnably expected t lead t a change in management f the patient; and The imaging requested is reasnably expected t imprve patient utcmes based n current literature and standards f medical practice. If these elements are nt established with respect t a given request, the determinatin f apprpriateness will mst likely require a peer-t-peer cnversatin t understand the individual and unique facts that wuld supersede the pre-test requirements set frth abve. During the peert-peer cnversatin, factrs such as patient acuity and setting f service may als be taken int accunt. Histry Status Date Actin Reviewed and revised 07/26/2016 Independent Multispecialty Physician Panel review and revisin Created 03/30/2005 Original effective date Cpyright AIM Specialty Health. All Rights Reserved. 6

7 Head and Neck Imaging General Infrmatin/Overview Scpe These guidelines address advanced imaging f the head and neck in bth adult and pediatric ppulatins. Fr interpretatin f the Guidelines, and where nt therwise nted, adult refers t persns age 19 and lder, and pediatric refers t persns age 18 and yunger. Where separate indicatins exist, they are specified as Adult r Pediatric. Where nt specified, indicatins and prerequisite infrmatin apply t persns f all ages. See the Cding sectin fr a list f mdalities included in these guidelines. Technlgy Cnsideratins There are a number f advanced imaging mdalities available t visualize structures f the head and neck. Chice f imaging in this area is determined primarily by anatmic lcatin. CT rbit/sella/psterir fssa utilizes specific prtcls depending n the clinical indicatin. Cverage may include the internal auditry canals, psterir fssa, sella turcica, rbits and tempral bne, and mastid air cells. With capability fr high-reslutin sseus imaging, CT can prvide detailed anatmic depictin f the tempral bne anatmy, including the middle and inner ear structures. CT is usually effective at demnstrating bny changes frm a sellar, parasellar, r rbital mass. CT f the paranasal sinuses and maxillfacial area is used t evaluate the sinuses, facial structures, and maxillary regins. Individual scan cverage depends n the specific clinical request, but generally includes images thrugh the entire frntal, ethmid, maxillary and sphenid sinuses. Cverage may be extended t include the mandible and temprmandibular jint in select cases and depending n the clinical indicatin. CT sectins may be btained in 1 r 2 (usually crnal and axial) planes. CT sft tissue neck prvides axial images frm the skull base t the clavicles. Cverage includes the submandibular area and salivary glands as well as the pharynx, larynx, and prximal trachea. Thyrid and parathyrid glands are als included. Disadvantages f CT include expsure t inizing radiatin and risks assciated with infusin f idinated cntrast media, including allergic reactins r renal cmprmise. MRI rbit/face/neck utilizes prtcls tailred t the clinical indicatin. Cverage may include facial structures; larynx and subglttic regins; naspharynx, rpharynx and hyppharynx; neck sft tissues, surrunding the airway and glands; ptic nerve; rbit; salivary glands; sinuses; thyrid and parathyrid gland. MRI is usually preferred ver CT fr evaluatin f the sella turcica and visual pathways. Fr imaging f the internal auditry canals, MRI brain is the apprpriate study (see Brain Imaging guidelines). MRI temprmandibular jint (TMJ) is a bilateral study including pen and clsed muth views, ften perfrmed with surface cils. Images may be btained in axial, (blique) sagittal, and (blique) crnal planes. The presence f implantable devices such as pacemakers r defibrillatrs, a ptential need fr sedatin in pediatric patients, and claustrphbia are the main limitatins f MRI. Infusin f gadlinium may als cnfer an unacceptable risk in persns with advanced renal disease. Definitins Phases f the care cntinuum are bradly defined as fllws: Screening testing in the absence f signs r symptms f disease Cpyright AIM Specialty Health. All Rights Reserved. 7

8 Diagnsis testing based n a reasnable suspicin f a particular cnditin r disrder, usually due t the presence f signs r symptms Management testing t direct therapy f an established cnditin, which may include preperative r pstperative imaging, r imaging perfrmed t evaluate the respnse t nnsurgical interventin Surveillance peridic assessment fllwing cmpletin f therapy, r fr mnitring knwn disease that is stable r asymptmatic Statistical terminlgy 1 Cnfidence interval (CI) range f values which is likely t cntain the cited statistic. Fr example, 92% sensitivity (95% CI, 89%-95%) means that, while the sensitivity was calculated at 92% n the current study, there is a 95% chance that, if a study were t be repeated, the sensitivity n the repeat study wuld be in the range f 89%-95%. Diagnstic accuracy ability f a test t discriminate between the target cnditin and health. Diagnstic accuracy is quantified using sensitivity and specificity, predictive values, and likelihd ratis. Hazard rati dds that an individual in the grup with the higher hazard reaches the utcme first. Hazard rati is analgus t dds rati and is reprted mst cmmnly in time-t-event analysis r survival analysis. A hazard rati f 1 means that the hazard rates f the 2 grups are equivalent. A hazard rati f greater than 1 r less than 1 means that there are differences in the hazard rates between the 2 grups. Likelihd rati rati f an expected test result (psitive r negative) in patients with the disease t an expected test result (psitive r negative) in patients withut the disease. Psitive likelihd ratis, especially thse greater than 10, help rule in a disease (i.e., they substantially raise the pst-test prbability f the disease, and hence make it very likely and the test very useful in identifying the disease). Negative likelihd ratis, especially thse less than 0.1, help rule ut a disease (i.e., they substantially decrease the pst-test prbability f disease, and hence make it very unlikely and the test very useful in excluding the disease). Odds rati dds that an utcme will ccur given a particular expsure, cmpared t the dds f the utcme ccurring in the absence f that expsure. An dds rati f 1 means that the expsure des nt affect the dds f the utcme. An dds rati greater than 1 means that the expsure is assciated with higher dds f the utcme. An dds rati less than 1 means that the expsure is assciated with lwer dds f the utcme. Predictive value likelihd that a given test result crrelates with the presence r absence f disease. Psitive predictive value is defined as the number f true psitives divided by the number f test psitives. Negative predictive value is defined as the number f true negatives divided by the number f test negative patients. Predictive value is dependent n the prevalence f the cnditin. Pretest prbability prbability that a given patient has a disease prir t testing. May be divided int very lw (less than 5%), lw (less than 20%), mderate (20%-75%), and high (greater than 75%) althugh these numbers may vary by cnditin. Relative risk prbability f an utcme when an expsure is present relative t the prbability f the utcme ccurring when the expsure is absent. Relative risk is analgus t dds rati; hwever, relative risk is calculated by using percentages instead f dds. A relative risk f 1 means that there is n difference in risk between the 2 grups. A relative risk f greater than 1 means that the utcme is mre likely t happen in the expsed grup cmpared t the cntrl Cpyright AIM Specialty Health. All Rights Reserved. 8

9 grup. A relative risk less than 1 means that the utcme is less likely t happen in the expsed grup cmpared t the cntrl grup. Sensitivity cnditinal prbability that the test is psitive, given that the patient has the disease. Defined as the true psitive rate (number f true psitives divided by the number f patients with disease). Excellent r high sensitivity is usually greater than 90%. Specificity cnditinal prbability that the test is negative, given that the patient des nt have the disease. Defined as the true negative rate (number f true negatives divided by the number f patients withut the disease). Excellent r high specificity is usually greater than 90%. Clinical Indicatins The fllwing sectin includes indicatins fr which advanced imaging f the head and neck is cnsidered medically necessary, alng with prerequisite infrmatin and supprting evidence where available. Indicatins, diagnses, r imaging mdalities nt specifically addressed are cnsidered nt medically necessary. It is recgnized that imaging ften detects abnrmalities unrelated t the cnditin being evaluated. Such findings must be cnsidered within the cntext f the clinical situatin when determining whether additinal imaging is required. Cngenital and Develpmental Cnditins Advanced imaging is cnsidered medically necessary fr diagnsis and management f cngenital and develpmental cnditins in the head and neck regin when the results f imaging will impact treatment. - CT rbit, sella, r psterir fssa and uter, middle r inner ear - MRI rbit, face and neck (sft tissue) - CT paranasal sinuses and maxillfacial area - CT sft tissue neck Infectin and Inflammatry Cnditins Sinusitis/rhinsinusitis ADULT Advanced imaging is cnsidered medically necessary fr diagnsis and/r management (including preperative and pstperative evaluatin) f ANY f the fllwing cnditins: Acute uncmplicated sinusitis/rhinsinusitis Evaluatin f symptms persisting beynd 3 t 4 weeks f adequate treatment, which may include antibitics, nasal sterids and/r decngestants. Nte: Under these circumstances, a cmplicatin f acute sinusitis/rhinsinusitis r an alternative diagnsis may warrant imaging. Cpyright AIM Specialty Health. All Rights Reserved. 9

10 Acute recurrent sinusitis/rhinsinusitis Chrnic sinusitis/rhinsinusitis Perirbital swelling assciated with sinus infectin Head and Neck Imaging Barsinusitis/headache refractry t antibitics and respnding nly t decngestants/ral sterids PEDIATRIC Acute and subacute sinusitis in EITHER f the fllwing scenaris: Screening f a patient wh is immuncmprmised r likely t becme immuncmprmised by therapy, such as prir t chemtherapy r transplant Management f ANY f the fllwing cmplicatins f acute sinusitis Abscess, intracranial r rbital Encephalitis r cerebritis Meningitis Sinus thrmbsis Invasive fungal sinusitis in immuncmprmised individuals Chrnic r recurrent sinusitis in ANY f the fllwing scenaris: Cnfirmatin f chrnic sinusitis prir t a prlnged curse f antibitics Evaluatin in immuncmprmised individuals Evaluatin f unilateral sinusitis T assist in diagnsing ANY f the fllwing underlying medical cnditins: Chrnic allergies r asthma Ciliary mtility disrder Cranifacial abnrmality Cystic fibrsis Preperative evaluatin t determine whether the patient is a surgical candidate Preperative image guidance study Management f pstperative cmplicatins Nte: Radigraphic imaging is nt indicated fr immuncmpetent patients with acute rhinsinusitis unless a cmplicatin r alternative diagnsis is suspected. - CT paranasal sinuses and maxillfacial area Ratinale ADULT SINUSITIS Rhinsinusitis is defined as symptmatic inflammatin f the paranasal sinuses and nasal cavity. The term rhinsinusitis is preferred because sinusitis is almst always accmpanied by inflammatin f the cntiguus nasal mucsa. Twelve percent f the U.S. ppulatin (nearly 1 in 8 adults) reprted being diagnsed with rhinsinusitis. 2 Acute uncmplicated rhinsinusitis is defined as rhinsinusitis lasting less than 4 weeks, withut clinically evident extensin f the inflammatin utside the paranasal sinuses and nasal cavity at the time f diagnsis, e.g., n neurlgic, phthalmlgic, r sft tissue invlvement. 3 There is strng, cnsistent specialty sciety cnsensus that imaging shuld nt be perfrmed fr acute uncmplicated sinusitis. The American Academy f Otlarynglgy Head and Neck Surgery states that, as lng as the clinical diagnstic criteria are met fr patients with acute uncmplicated rhinsinusitis, imaging f the paranasal sinuses is unnecessary. 4 Clinicians shuld ffer either watchful waiting (withut antibitics) r prescribe initial antibitic therapy fr adults with uncmplicated acute bacterial rhinsinusitis and that clinicians shuld nt btain radigraphic imaging fr acute bacterial rhinsinusitis unless a cmplicatin r alternative diagnsis is suspected. 3 In a prspective study f 174 patients suspected f having acute maxillary sinusitis, the authrs Cpyright AIM Specialty Health. All Rights Reserved. 10

11 fund that CT scans cntributed little t the final diagnsis, while clinical findings such as elevated C-reactive prtein r erythrcyte sedimentatin rate were mre reliable indicatrs. 5 Cmplicatins f sinusitis may be intrarbital (such as rbital cellulitis, cavernus sinus thrmbsis, r subperisteal r rbital abscess) r intracranial (such as encephalitis, cerebritis, meningitis, abscess, r venus sinus thrmbsis). Ostemyelitis and sinnasal muccele r mucpycele are als ptential cmplicatins f sinusitis. Suggestive findings n physical examinatin include prptsis, visual changes, severe headache, abnrmal extracular mvements, changes in mental status, and perirbital inflammatin, edema, r erythema. 3 The American Cllege f Radilgy states that either MRI with and withut cntrast r CT sinus with and/r withut cntrast is usually apprpriate. MRI prvides superir visualizatin f the rbits and intracranial sft tissues, and CT is useful when stemyelitis is suspected. 6 The primary rle f advanced imaging in chrnic rhinsinusitis and recurrent acute rhinsinusitis (defined as 3 r mre separate episdes f acute sinusitis within a year) is t evaluate the anatmy f the paranasal sinuses prir t surgery. Status f the paranasal sinus drainage pathways including cclusin f the stimeatal units, frntethmidal r sphenethmidal drainage pathways help determine whether functinal endscpic sinus surgery will be beneficial. In additin, anatmic variants are imprtant t knw in advance f endscpic surgery t reduce pstperative cmplicatin risk. Fr instance, an anatmically depressed r asymmetric cribrifrm plate increases the risk f intracranial penetratin, while bny dehiscence f the cartid canal r pneumatizatin f the sphenid and clinids increases the risk f vascular r ptic nerve injury. CT withut cntrast is ptimal fr visualizatin f paranasal sinus bny anatmy and is the imaging methd f chice. 6 Clinicians shuld recmmend saline nasal irrigatin, tpical intranasal crticsterids, r bth fr symptm relief f chrnic rhinsinusitis. 3 The presence f nnspecific inflammatin f the paranasal sinuses wuld likely lead t repeat imaging requests, due t bscuratin f the underlying anatmy. Therefre, even thugh a patient has been symptmatic fr 12 weeks, the accurate diagnsis f chrnic sinusitis will require a trial f medicatin t reduce inflammatin in the paranasal sinuses prir t imaging. The American Academy f Otlarynglgy Head and Neck Surgery states that nly ne CT is needed and anther shuld nt be rdered within 90 days t evaluate patients with uncmplicated chrnic rhinsinusitis as lng as the CT btained is f adequate quality and reslutin t be interpreted by the clinician and used fr clinical decisin-making and/r surgical planning. 4 PEDIATRIC SINUSITIS The American Academy f Pediatrics states that imaging t differentiate acute bacterial sinusitis frm viral upper respiratry infectin shuld nt be perfrmed as it des nt cntribute t the diagnsis. 7 Fr suspected rbital r central nervus system cmplicatins, a cntrast-enhanced CT f the paranasal sinuses shuld be perfrmed. 7 Chrnic sinusitis is cmmnly due t nnstructural causes including asthma, gastresphageal reflux disease, r allergic rhinitis. 8 The American Cllege f Radilgy indicates that CT is usually apprpriate in pediatric patients with chrnic sinusitis that des nt respnd t treatment r that is recurrent. 8 Infectius disease nt therwise specified Applies t cnditins nt therwise referenced in Head and Neck Imaging Advanced imaging is cnsidered medically necessary fr infectin in the head and neck regin when the results f imaging are essential t establish a diagnsis and/r direct management. - CT rbit, sella, r psterir fssa and uter, middle r inner ear - MRI rbit, face, and neck (sft tissue) - CT paranasal sinuses and maxillfacial area - CT sft tissue neck Inflammatry cnditins nt therwise specified Includes Wegener s granulmatsis (granulmatsis with plyangiitis). Advanced imaging is cnsidered medically necessary fr diagnsis and management f inflammatry disease in the head and neck regin when the results f imaging will impact treatment. - CT rbit, sella, r psterir fssa and uter, middle r inner ear Cpyright AIM Specialty Health. All Rights Reserved. 11

12 Trauma Trauma - MRI rbit, face, and neck (sft tissue) - CT paranasal sinuses and maxillfacial area - CT sft tissue neck Advanced imaging is cnsidered medically necessary fr traumatic injury t the head and neck regin when the results f imaging are essential t establish a diagnsis and/r direct management. - CT rbit, sella, r psterir fssa and uter, middle r inner ear - MRI rbit, face, and neck (sft tissue) - CT paranasal sinuses and maxillfacial area - CT sft tissue neck - MRI temprmandibular jint Nte: Cnventinal radigraphs, Panrex views, r CT f the temprmandibular jint are preferred fr initial evaluatin f temprmandibular jint trauma. Tumr/Sft Tissue Mass Fr management f dcumented malignancy, see Onclgic Imaging guidelines. Chlesteatma Advanced imaging is cnsidered medically necessary when the results f imaging are essential t establish a diagnsis and/r direct management. Neck mass ADULT - CT rbit, sella, r psterir fssa and uter, middle, r inner ear Advanced imaging is cnsidered medically necessary in ANY f the fllwing scenaris: Evaluatin f a palpable neck mass Fllw up f a nnpalpable neck mass identified n a prir imaging study Management (including periperative evaluatin) f knwn cystic neck mass r ther benign tumr PEDIATRIC Advanced imaging is cnsidered medically necessary in ANY f the fllwing scenaris: Cpyright AIM Specialty Health. All Rights Reserved. 12

13 Initial evaluatin f a palpable neck mass when ultrasund demnstrates a slid mass ther than a lymph nde Management f a knwn cystic neck mass r ther benign tumr when ultrasund is nt sufficient t guide treatment Evaluatin f a retrpharyngeal neck mass - MRI rbit, face, and neck (sft tissue) - CT sft tissue neck Ratinale ADULT NECK MASS The American Academy f Otrhinlarynglgy Head and Neck Surgery recmmends a neck CT r MRI with cntrast fr patients with a neck mass fund t be at increased risk fr malignancy; 9 this apprach is als endrsed by best practice guidelines. 9 A variety f factrs increase the clinical pretest prbability fr a malignant neck mass, including age ver 40, persistence fr greater than 2 weeks, and absence f infectius symptms. 10 PEDIATRIC NECK MASS Unlike neck masses in adults, the majrity f pediatric neck masses are benign. Ultrasund is usually the first-line imaging mdality fr pediatric neck masses, especially given the risk f radiatin, inaccessibility f MRI and ptential need fr sedatin. 11 Ultrasund has lwer but cmparable diagnstic accuracy t CT in the diagnsis f lateral neck masses in children 12 and helps t select patients with midline neck masses wh require surgery. 13 CT r MRI may be indicated fr a negative ultrasund with high clinical suspicin r t further evaluate anatmic extent and/r cmpsitin f incmpletely characterized ultrasund findings. 11 CT r MRI may be apprpriate as an initial imaging test when deep neck space r retrpharyngeal masses are suspected; in the setting f acute infectin, the psitive predictive value fr CT is 100%. 14 Parathyrid adenma Advanced imaging is cnsidered medically necessary in ANY f the fllwing scenaris: Evaluatin f suspected adenma fllwing abnrmal parathyrid ultrasund r scintigraphy Preperative planning in patients with aberrant anatmy Lcalizatin f residual parathyrid tissue fllwing failed parathyridectmy - MRI rbit, face, and neck (sft tissue) - CT sft tissue neck Ratinale Ultrasund and sestamibi scintigraphy are the mst cmmn initial imaging tests used t evaluate suspected parathyrid adenma and have a diagnstic accuracy f apprximately 82%. 15 When ultrasund and sestamibi exams are nt diagnstic, 4 dimensinal CT, including dynamic cntrast enhancement, has high sensitivity (94%) and specificity (96%). 16 Thyrid ndule r thyrmegaly (giter) Advanced imaging is cnsidered medically necessary in EITHER f the fllwing scenaris: Mass effect n the upper airway r esphagus Preperative evaluatin - Thyrid ultrasund r scintigraphy recmmended fr initial evaluatin - MRI rbit, face, and neck (sft tissue) r CT neck (sft tissue) when further imaging is required t direct treatment Cpyright AIM Specialty Health. All Rights Reserved. 13

14 Tumr nt therwise specified Advanced imaging is cnsidered medically necessary when the results f imaging are essential t establish a diagnsis and/r direct management. - CT rbit, sella, r psterir fssa and uter, middle r inner ear - MRI rbit, face, and neck (sft tissue) - CT paranasal sinuses and maxillfacial area - CT sft tissue neck Nasal Indicatins Advanced imaging is cnsidered medically necessary fr evaluatin f ANY f the fllwing indicatins: Ansmia Cerebrspinal fluid leak Freign bdy Muccele f the paranasal sinus Nasal airway bstructin refractry t medical therapy Nasal r sinus plypsis Recurrent epistaxis - CT paranasal sinuses and maxillfacial area Orbital Indicatins Advanced imaging is cnsidered medically necessary fr evaluatin f ANY f the fllwing cnditins: Cpyright AIM Specialty Health. All Rights Reserved. 14

15 Absence f red reflex (pediatric nly) Dyscnjugate gaze Exphthalms r prptsis Extracular muscle weakness Nystagmus Optic neuritis Orbital pseudtumr Papilledema Strabismus Thyrid phthalmpathy - MRI rbit, face, and neck (sft tissue) - CT rbit, sella, r psterir fssa and uter, middle r inner ear Temprmandibular Jint Pathlgy Arthrpathy f the temprmandibular jints Includes traumatic, inflammatry r infectius arthritis. Advanced imaging is cnsidered medically necessary when the results f imaging are essential t establish a diagnsis and/r direct management. Frzen jaw - Radigraphs required fr initial evaluatin in pediatric patients - MRI temprmandibular jint Advanced imaging is cnsidered medically necessary when the results f imaging are essential t establish a diagnsis and/r direct management (including periperative evaluatin). - MRI f temprmandibular jint Juvenile idipathic arthritis (Pediatric nly) Advanced imaging f the head and neck is cnsidered medically necessary fr management f established juvenile idipathic arthritis when radigraphs are nt sufficient t guide treatment. - MRI f temprmandibular jint Cpyright AIM Specialty Health. All Rights Reserved. 15

16 Ratinale Juvenile idipathic arthritis (JIA) is an umbrella term that encmpasses all frms f arthritis that begin befre age 16, persist fr mre than 6 weeks, and are f unknwn etilgy. Specific examples f JIA include ligarthritis, plyarthritis, systemic arthritis, psriatic and enthesis-related arthritis. JIA is the mst cmmn childhd rheumatic disease, with a prevalence f 0.6 t 1.9 in 1000 children. 17 JIA is primarily a clinical diagnsis. General practitiners shuld base diagnsis f JIA n histry and clinical examinatin, with strng suspicin f JIA indicated by pain and swelling f single r multiple jints, persistent r wrsening lss f functin, fever f at least 10 days with unknwn cause, ften assciated with transient erythematus rash, decreased range f mtin, and jint warmth r effusin. 18 Labratry assessment with apprpriate tests can assist in increasing diagnstic certainty, excluding differential diagnses, and predicting patients likely t prgress t ersive disease. Base investigatins usually include erythrcyte sedimentatin rate r C-reactive prtein, full bld cunt, and rheumatid factr, antinuclear antigen, r human leukcyte antigen B27 as clinically indicated. 18 When there is dubt, cnventinal radigraphs, ultrasund r MRI can be used t imprve the certainty f a diagnsis f JIA. 19 MRI is the mst sensitive nninvasive imaging mdality t evaluate fr inflammatin f the jints, tendns, and entheses and is the nly mdality that can depict bne marrw edema. Currently, MRI with cntrast is the mst sensitive tl fr determining active synvitis. 20 When the imaging mdalities are directly cmpared, MRI and ultrasund detected mre jint damage than cnventinal radigraphs, particularly at the hip and the wrist. 19 Imaging studies can help identify children with a high likelihd f early ersive jint damage, prviding an pprtunity t implement aggressive therapy at an early stage in an attempt t reduce mrbidity. 20 Temprmandibular disease Includes disrders f the masticatry muscles and the temprmandibular jint. Advanced imaging is cnsidered medically necessary in ANY f the fllwing scenaris: Panrex is incnclusive r nt available Panrex findings require further characterizatin Panrex is nrmal but high clinical suspicin fr temprmandibular jint pathlgy remains, and the results will change management (including periperative evaluatin) - CT paranasal sinuses and maxillfacial area Temprmandibular jint dysfunctin Advanced imaging is cnsidered medically necessary when ALL f the fllwing requirements are met: Symptms have nt imprved with cnservative treatment, including nnsteridal anti-inflammatry drugs r acetaminphen, a shrt-term trial f sft diet and prper chewing techniques, and an ral appliance (such as a bite blck) Radigraphs r Panrex have nt prvided sufficient infrmatin t guide treatment Interventin is being cnsidered - MRI f temprmandibular jint Miscellaneus Cnditins Cchlear implant Advanced imaging is cnsidered medically necessary fr periperative evaluatin related t cchlear implant placement when the results f imaging will impact management. - CT rbit, sella, r psterir fssa and uter, middle r inner ear Cpyright AIM Specialty Health. All Rights Reserved. 16

17 Freign bdy evaluatin Advanced imaging is cnsidered medically necessary when radigraphs are nndiagnstic. - CT rbit, sella, r psterir fssa fr freign bdy in ear canal r rbit - CT sft tissue neck fr freign bdy in aerdigestive tract Laryngeal edema Advanced imaging is cnsidered medically necessary when the results f imaging are essential t establish a diagnsis and/r direct management (including periperative evaluatin). - CT sft tissue neck - MRI rbit, face, and neck (sft tissue) Osseus lesins Include fibrus dysplasia, Paget s disease, and tsclersis Advanced imaging is cnsidered medically necessary fr diagnsis and management (including periperative evaluatin) f lesins in the tempral bnes, sella turcica, rbit r psterir fssa when the results f imaging will impact treatment. - CT rbit, sella, r psterir fssa and uter, middle r inner ear Ostenecrsis f the jaw Advanced imaging is cnsidered medically necessary when radigraphs r Panrex have been perfrmed and further imaging is needed t direct management. - MRI rbit, face, and neck (sft tissue) - CT paranasal sinuses and maxillfacial area - CT sft tissue neck Salivary gland ductal calculi Advanced imaging is cnsidered medically necessary when the results f imaging are essential t establish a diagnsis and/r direct management. - CT sft tissue neck Trticllis (Pediatric nly) Cngenital muscular trticllis in infants age 8 mnths r yunger When ultrasund f the neck and cervical spine radigraphs are nndiagnstic, and there is n imprvement fllwing 4 weeks f cnservative treatment Childhd (acquired) trticllis Evaluatin fr secndary causes (such as infectin, neplasm, trauma) when clinically indicated Cpyright AIM Specialty Health. All Rights Reserved. 17

18 - CT sft tissue neck - MRI rbit, face, and neck (sft tissue) Tracheal stensis r upper airway bstructin Advanced imaging is cnsidered medically necessary when the results f imaging are essential t establish a diagnsis and/r direct management (including periperative evaluatin). - CT sft tissue neck - MRI rbit, face, and neck (sft tissue) Signs and Symptms Dizziness r vertig Als see Brain Imaging guidelines. Advanced imaging is cnsidered medically necessary in EITHER f the fllwing scenaris: Evaluatin f signs r symptms suggestive f a central nervus system lesin Symptms assciated with abnrmal audigram r auditry brainstem respnse Nte: Vertig r dizziness that is clearly related t psitinal change des nt require advanced imaging. - CT rbit/sella/psterir fssa Ratinale Fr islated vertig withut additinal neurlgical signs r symptms, the diagnstic yield f imaging fr a structural cause is lw. In a large single institutin retrspective study (N = 1028), CT fund structural causes fr dizziness r vertig in nly 6.17% f patients and nly 0.74% f these findings were clinically significant. 21 In a retrspective study cmparing different imaging mdalities fr the wrk-up f dizziness, the likelihd f CT angigraphy and MRI affecting management has been reprted in the range f 1.1%-1.3%. 22 The diagnstic yield fr imaging f benign parxysmal psitinal vertig n clinical exam is als lw and rutine imaging is nt warranted. The American Academy f Otlarynglgy Head and Neck Surgery recmmends that initial imaging shuld nt be perfrmed fr patients wh meet the diagnstic criteria fr benign parxysmal psitinal vertig and that patients shuld be reassessed after 1 mnth f bservatin r treatment fr the reslutin r persistence f symptms. 23 When central vertig is suspected, prmpt use f advanced imaging is generally apprpriate t rule ut acute ptentially life-threatening causes. One study fund that the dds ratis fr identifying strke in patients presenting with gait instability, neurlgic findings, and fcal neurlgic deficits were 9.3, 8.7, and > 20 respectively. 24 In 2 single-center retrspective studies, MRI changed management in 16%-22% f patients with central vertig. 25,26 The American Cllege f Radilgy recmmends MRI brain with and withut cntrast fr patients with central vertig. 27 CT brain may als be perfrmed althugh MRI is mre sensitive than CT fr detectin f psterir fssa strkes. 24,26 Hearing lss Als see Brain Imaging guidelines fr sensrineural hearing lss. ADULT Advanced imaging is cnsidered medically necessary fr detecting a structural cause f hearing lss in EITHER f the fllwing scenaris: Cpyright AIM Specialty Health. All Rights Reserved. 18

19 Cnductive hearing lss Sensrineural hearing lss characterized by EITHER f the fllwing features: Head and Neck Imaging Gradual nset f unilateral r asymmetric hearing lss demnstrated by audimetric testing (15 db r greater at 2 cnsecutive frequencies between 0.5 and 3 khz) Hearing lss assciated with at least 1 neurlgic sign r symptm knwn t increase the pretest prbability f a retrcchlear lesin PEDIATRIC - MRI brain fr evaluatin f sensrineural hearing lss - CT brain fr evaluatin f sensrineural hearing lss when MRI cntraindicated - CT rbit/sella/psterir fssa fr evaluatin f cnductive hearing lss Advanced imaging is cnsidered medically necessary t evaluate fr a structural cause f sensrineural, cnductive, r mixed hearing lss. - MRI brain preferred fr evaluatin f sensrineural hearing lss - CT rbit/sella/psterir fssa preferred fr evaluatin f cnductive r mixed hearing lss Ratinale The primary purpse f imaging sensrineural hearing lss is t detect retrcchlear pathlgy, typically a tumr f the vestibular nerve (cranial nerve 8) r cerebellpntine angle (CPA). Mre than 85% f these tumrs are acustic neurmas (als called vestibular schwannmas). Hwever, vestibular schwannmas are rare, with an verall prevalence f 1 per 100,000, and they are fund nly in 2% t 8% f patients with autimmune sensrineural hearing lss. A 15 db r greater difference at 2 cnsecutive frequencies has a sensitivity f 97% and a specificity f 49% fr the diagnsis f vestibular schwannma. Fr ptimum specificity (~67%) with high sensitivity (~90%) the American Academy f Otlarynglgy Head and Neck Surgery prtcl is recmmended, which prpses 15 db between ears, averaging 0.5 t 3 khz. 122 MRI f the head and the internal auditry canal, cmmnly knwn as an IAC prtcl, is mst effective in screening fr CPA tumrs. Clinicians shuld nt rder CT f the head/brain in the initial evaluatin f a patient with presumptive sudden sensrineural hearing lss. 123 Harseness, dysphnia, and vcal crd weakness/paralysis ADULT Advanced imaging is cnsidered medically necessary in ANY f the fllwing scenaris: Fllwing laryngscpy, when findings suggest recurrent laryngeal nerve dysfunctin r identify a suspicius lesin Evaluatin f symptms persisting lnger than 1 mnth which are unexplained by laryngscpy Presence f at least ONE f the fllwing high-risk features: PEDIATRIC Tbacc use Alchl abuse Hemptysis Histry f radiatin therapy Knwn head and neck malignancy Advanced imaging is cnsidered medically necessary in EITHER f the fllwing scenaris: Cpyright AIM Specialty Health. All Rights Reserved. 19

20 Fllwing abnrmal r nndiagnstic laryngscpy Evaluatin f symptms persisting lnger than 1 mnth - CT sft tissue neck - MRI rbit, face, and neck (sft tissue) Ratinale Mst harseness is self-limited r caused by a pathlgy that can be identified by laryngscpy. Clinicians shuld visualize the patient s larynx, r refer the patient t a clinician wh can visualize the larynx, when harseness fails t reslve by a maximum f 3 mnths after nset, r irrespective f duratin if a serius underlying cause is suspected. 28,29 Benign lesins f the vcal crds such as cysts, ndules, plyps, and gastresphageal reflux are frequently diagnsed and managed with laryngscpy alne. Accuracy f histry and physical exam in harseness is lw (5%) and laryngscpy increases the accuracy f diagnsis by apprximately 68%. 30 Harseness is cmmn in yung children (15%-24%) and usually due t benign lesins that can be seen n laryngscpy. Vcal crd ndules are the mst cmmn type f these benign lesins, accunting fr apprximately 77% f cases. 28 American Academy f Otlarynglgy Head and Neck Surgery Fundatin states that advanced imaging (CT r MRI) shuld nt be perfrmed in patients with a primary cmplaint f harseness prir t examining the larynx. 31 Hrner s syndrme Advanced imaging is cnsidered medically necessary fr evaluatin when the results f imaging will impact management. - CT sft tissue neck - MRI rbit, face, and neck (sft tissue) Ratinale Hrner s syndrme is a cnditin that results frm disruptin f the sympathetic nervus supply t the eye and is characterized by the triad f misis, ptsis and anhidrsis. 32 Evaluatin f Hrner s syndrme begins with a cmplete neurlgical and phthalmlgical examinatin which may reveal an etilgy fr the cnditin such as surgical trauma. Additinal neurlgical features such as additinal cranial nerve deficits may lcalize the pathlgy t the brain in which case a sequential diagnstic testing strategy starting with brain MRI may be pssible. In nnlcalized cases, the entire curse f the culsympathetic pathway may need t be visualized including an MRI f the brain and an MRI, CT, r MRA/CTA f the neck if there is cncern fr cartid dissectin as a cause. The yield f diagnstic imaging in islated Hrner s syndrme is apprximately 15%-20%, 33,34 and the mst cmmn etilgies identified by neurimaging are cartid artery dissectins and cavernus sinus masses. Fr pediatric patients, ne study fund that neurimaging (MRI head, neck, and chest if indicated) identified a cause in up t 33% f cases. 35 Unlike in adults, neplasms such as neurblastma and Ewing sarcma are the mst cmmn etilgies fr Hrner s syndrme identified by neurimaging in pediatric patients. Lcalized facial pain Advanced imaging is cnsidered medically necessary fr evaluatin when lcalized facial pain is persistent and unexplained, and when the results f imaging will impact management. - CT rbit, sella, r psterir fssa and uter, middle r inner ear Lymphadenpathy ADULT Advanced imaging is cnsidered medically necessary fr evaluatin when persistent and unexplained, and when the results f imaging will impact management. Cpyright AIM Specialty Health. All Rights Reserved. 20

21 PEDIATRIC Advanced imaging is cnsidered medically necessary in ANY f the fllwing scenaris: Ultrasund findings suggestive f ndal malignancy Nndiagnstic ultrasund and failure t reslve fllwing a 6-week curse f empiric therapy Nndiagnstic ultrasund and presence f at least ONE f the fllwing features: Absence f pain r tenderness Cnstitutinal symptms Firm/immbile and size greater than 3 cm in diameter Persistent enlargement n exam fr lnger than 2 weeks Presence f ulceratin Supraclavicular r psterir triangle lcatin Nte: Bipsy may be mre apprpriate than imaging when any f these features are present. - CT sft tissue neck - MRI rbit, face, and neck (sft tissue) Ratinale Persistent unexplained neck masses in adults, especially ver age 40, are ften malignant whereas thse in children are typically benign. 10 Advanced imaging is mst useful t evaluate the extent f lymphadenpathy and t evaluate ndal lcatins that are nt palpable r accessible t ultrasund (such as the lateral retrpharyngeal ndes). Ultrasund is the primary mdality fr evaluating and fllwing lymph ndes in children. 36,37 Sngraphic characteristics such as size, lss f fatty hilar mrphlgy, and shape increase the likelihd f malignancy but d nt replace bipsy. 38 Additinal high-risk features f adenpathy such as supraclavicular lcatin r firmness increase the likelihd f malignancy. Advanced imaging may be indicated as an adjuvant t bipsy t lk fr adenpathy in ther lcatins, particularly in places where ultrasund assessment is limited. Stridr Advanced imaging is cnsidered medically necessary in EITHER f the fllwing scenaris: Evaluatin f acute stridr Evaluatin f subacute r chrnic stridr, fllwing nndiagnstic radigraph and tlarynglgy (ENT) evaluatin Tinnitus - CT sft tissue neck - MRI rbit, face, and neck (sft tissue) See Brain Imaging guidelines. Pulsatile tinnitus (Pediatric nly) Als see Vascular Imaging guidelines. Advanced imaging is cnsidered medically necessary when the results f imaging will impact management. - CT rbit/sella turcica/psterir fssa Cpyright AIM Specialty Health. All Rights Reserved. 21

22 Visual disturbance r visual field defect Advanced imaging is cnsidered medically necessary t evaluate fr rbital r ptic nerve pathlgy when suggested by the phthalmlgic exam. - MRI rbit, face, and neck (sft tissue) - CT rbit, sella, r psterir fssa and uter, middle r inner ear Ratinale Advanced imaging is usually nt apprpriate in patients whse visual disturbance is explained by the phthalmlgic exam. 39 MRI f the rbits, typically with and withut cntrast, is apprpriate t further characterize abnrmalities n the phthalmlgic exam. 39 References 1. Simundic AM. Measures f Diagnstic Accuracy: Basic Definitins. Ejifcc. 2009;19(4): Epub 2009/01/01. PMID: Rsenfeld RM, Piccirill JF, Chandrasekhar SS, et al. Clinical practice guideline (update): adult sinusitis. Otlaryngl Head Neck Surg. 2015;152(2 Suppl):S1-s39. Epub 2015/04/04. PMID: Rsenfeld RM, Piccirill JF, Chandrasekhar SS, et al. Clinical practice guideline (update): adult sinusitis. Otlaryngl Head Neck Surg. 2015;152(2 Suppl):S1-S39. PMID: Fundatin AAOHaNS. Chsing Wisely: Ten Things Physicians and Patients Shuld Questin: ABIM Fundatin; 2018 [updated April 3, 2018; cited 2018 June 7, 2018]. Available frm: 5. Hansen JG, Lund E. The assciatin between paranasal cmputerized tmgraphy scans and symptms and signs in a general practice ppulatin with acute maxillary sinusitis. Apmis. 2011;119(1):44-8. PMID: Kirsch CFE, Bykwski J, Aulin JM, et al. ACR Apprpriateness Criteria((R)) Sinnasal Disease. Jurnal f the American Cllege f Radilgy : JACR. 2017;14(11s):S550-s9. Epub 2017/11/06. PMID: Wald ER, Applegate KE, Brdley C, et al. Clinical practice guideline fr the diagnsis and management f acute bacterial sinusitis in children aged 1 t 18 years. Pediatrics. 2013;132(1):e PMID: McAlister WH, Parker BR, Kushner DC, et al. Sinusitis in the pediatric ppulatin. American Cllege f Radilgy. ACR Apprpriateness Criteria. Radilgy. 2000;215 Suppl: Epub 2000/10/19. PMID: Haynes J, Arnld KR, Aguirre-Oskins C, et al. Evaluatin f neck masses in adults. Am Fam Physician. 2015;91(10): Epub 2015/05/16. PMID: Pynnnen MA, Gillespie MB, Rman B, et al. Clinical Practice Guideline: Evaluatin f the Neck Mass in Adults. Otlaryngl Head Neck Surg. 2017;157(2_suppl):S1-s30. Epub 2017/09/12. PMID: Stern JS, Ginat DT, Nichlas JL, et al. Imaging f pediatric head and neck masses. Otlaryngl Clin Nrth Am. 2015;48(1): Epub 2014/12/03. PMID: Cllins B, Stner JA, Digy GP. Benefits f ultrasund vs. cmputed tmgraphy in the diagnsis f pediatric lateral neck abscesses. Int J Pediatr Otrhinlaryngl. 2014;78(3): Epub 2014/02/04. PMID: Tanphaichitr A, Bhushan B, Maddalzz J, et al. Ultrasngraphy in the treatment f a pediatric midline neck mass. Arch Otlaryngl Head Neck Surg. 2012;138(9): Epub 2012/09/19. PMID: Lee DY, Sek J, Kim YJ, et al. Neck cmputed tmgraphy in pediatric neck mass as initial evaluatin in ED: is it malpractice? Am J Emerg Med. 2014;32(10): Epub 2014/08/31. PMID: Smith RB, Evasvich M, Gird DA, et al. Ultrasund fr lcalizatin in primary hyperparathyridism. Otlaryngl Head Neck Surg. 2013;149(3): Epub 2013/06/12. PMID: Kutler DI, Mquete R, Kazam E, et al. Parathyrid lcalizatin with mdified 4D-cmputed tmgraphy and ultrasngraphy fr patients with primary hyperparathyridism. Laryngscpe. 2011;121(6): Epub 2011/05/11. PMID: Cpyright AIM Specialty Health. All Rights Reserved. 22