ADVANCED IMAGING CLINICAL APPROPRIATENESS GUIDELINES. Appropriate Use Criteria: Imaging of the Head and Neck. EFFECTIVE JUNE 29, 2019 Proprietary

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1 CLINICAL APPROPRIATENESS GUIDELINES ADVANCED IMAGING Apprpriate Use Criteria: Imaging f the Head and Neck EFFECTIVE JUNE 29, 2019 Prprietary 8600 West Bryn Mawr Avenue Suth Twer Suite 800 Chicag, IL Apprpriate.Safe.Affrdable AIM Specialty Health

2 Table f Cntents Apprpriate Use Criteria: Imaging f the Head and Neck... 1 Descriptin and Applicatin f the Guidelines... 4 General Clinical Guideline... 5 Clinical Apprpriateness Framewrk... 5 Simultaneus Ordering f Multiple Diagnstic r Therapeutic Interventins... 5 Repeat Diagnstic Interventin... 5 Repeat Therapeutic Interventin... 6 Histry General Infrmatin/Overview... 7 Scpe... 7 Technlgy Cnsideratins... 7 Definitins... 7 Clinical Indicatins... 9 Cngenital and Develpmental Cnditins... 9 Infectius 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 (including lymphadenpathy) Parathyrid adenma Thyrid ndule r thyrmegaly (giter) Tumr nt therwise specified Nasal Indicatins Orbital Indicatins Temprmandibular Jint Pathlgy Temprmandibular jint dysfunctin Miscellaneus Cnditins Cerebrspinal fluid (CSF) leak f the skull base Cchlear implant Freign bdy evaluatin Laryngeal edema Osseus lesins Ostenecrsis f the jaw Salivary gland ductal calculi Trticllis (Pediatric nly) Cpyright AIM Specialty Health. All Rights Reserved. 2

3 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 (including trigeminal neuralgia) Lymphadenpathy Stridr Tinnitus 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. Applicable federal and state cverage mandates take precedence ver these clinical guidelines. 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 General Clinical Guideline Clinical Apprpriateness Framewrk Critical t any finding f clinical apprpriateness under the guidelines fr a specific diagnstic r therapeutic interventin are the fllwing elements: Prir t any interventin, it is essential that the clinician cnfirm the diagnsis r establish its pretest likelihd based n a cmplete evaluatin f the patient. This includes a histry and physical examinatin and, where applicable, a review f relevant labratry studies, diagnstic testing, and respnse t prir therapeutic interventin. The anticipated benefit f the recmmended interventin shuld utweigh any ptential harms that may result (net benefit). Current literature and/r standards f medical practice shuld supprt that the recmmended interventin ffers the greatest net benefit amng cmpeting alternatives. Based n the clinical evaluatin, current literature, and standards f medical practice, there exists a reasnable likelihd that the interventin will change management and/r lead t an imprved utcme fr the patient. 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 requirements set frth abve. During the peer-t-peer cnversatin, factrs such as patient acuity and setting f service may als be taken int accunt. Simultaneus Ordering f Multiple Diagnstic r Therapeutic Interventins Requests fr multiple diagnstic r therapeutic interventins at the same time will ften require a peer-tpeer cnversatin t understand the individual circumstances that supprt the medical necessity f perfrming all interventins simultaneusly. This is based n the fact that apprpriateness f additinal interventin is ften dependent n the utcme f the initial interventin. Additinally, either f the fllwing may apply: Current literature and/r standards f medical practice supprt that ne f the requested diagnstic r therapeutic interventins is mre apprpriate in the clinical situatin presented; r One f the diagnstic r therapeutic interventins requested is mre likely t imprve patient utcmes based n current literature and/r standards f medical practice. Repeat Diagnstic Interventin In general, repeated testing f the same anatmic lcatin fr the same indicatin shuld be limited t evaluatin fllwing an interventin, r when there is a change in clinical status such that additinal testing is required t determine next steps in management. At times, it may be necessary t repeat a test using different techniques r prtcls t clarify a finding r result f the riginal study. Repeated testing fr the same indicatin using the same r similar technlgy may be subject t additinal review r require peer-t-peer cnversatin in the fllwing scenaris: Repeated diagnstic testing at the same facility due t technical issues Repeated diagnstic testing requested at a different facility due t prvider preference r quality cncerns Repeated diagnstic testing f the same anatmic area based n persistent symptms with n clinical change, treatment, r interventin since the previus study Cpyright AIM Specialty Health. All Rights Reserved. 5

6 Repeated diagnstic testing f the same anatmic area by different prviders fr the same member ver a shrt perid f time Repeat Therapeutic Interventin In general, repeated therapeutic interventin in the same anatmic area is cnsidered apprpriate when the prir interventin prved effective r beneficial and the expected duratin f relief has lapsed. A repeat interventin requested prir t the expected duratin f relief is nt apprpriate unless it can be cnfirmed that the prir interventin was never administered. Histry Status Date Actin Revised 03/09/2019 Retitled Pretest Requirements t Clinical Apprpriateness Framewrk t summarize the cmpnents f a decisin t pursue diagnstic testing. T expand applicability beynd diagnstic imaging, retitled Ordering f Multiple Studies t Ordering f Multiple Diagnstic r Therapeutic Interventins and replaced imagingspecific terms with diagnstic r therapeutic interventin. Repeated Imaging split int tw subsectins, repeat diagnstic testing and repeat therapeutic interventin. Reviewed 07/11/2018 Last Independent Multispecialty Physician Panel review Revised 07/26/2016 Independent Multispecialty Physician Panel revised Created 03/30/2005 Original effective date Cpyright AIM Specialty Health. All Rights Reserved. 6

7 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 - CT paranasal sinuses and maxillfacial area Infectius and Inflammatry Cnditins Sinusitis/rhinsinusitis Diagnsis Cmplicatins f sinusitis Orbital Intracranial Vascular Related t invasive fungal sinusitis Initial evaluatin f acute recurrent rhinsinusitis, chrnic rhinsinusitis, r barsinusitis nt respnsive t at least 3 weeks f acceptable medical therapy including at least 1 trial f nasal saline irrigatin and intranasal sterids Management Cpyright AIM Specialty Health. All Rights Reserved. 9

10 Repeat imaging fr acute recurrent r chrnic sinusitis when prir imaging is insufficient t direct management r when signs r symptms wrsen Preperative planning fr functinal endscpic sinus surgery (e.g., InstaTrak) in ANY f the fllwing scenaris: Revisin sinus surgery Sin-nasal plypsis Cmplex r distrted sin-nasal anatmy Disease abutting the skull base Sinus disease predminant in the frntal, psterir ethmid, r sphenid sinuses Evaluatin f pstperative cmplicatins Ntes: Acute sinusitis is defined as symptms f sinusitis lasting less than 4 weeks. Recurrent acute rhinsinusitis is defined as 4 r mre episdes per year f acute bacterial rhinsinusitis withut signs r symptms f rhinsinusitis between episdes. Subacute sinusitis is defined as symptms f sinusitis lasting mre than 4 but less than 12 weeks. Fr the purpses f this guideline, subacute sinusitis shuld be treated as either acute r chrnic depending n the clinical presentatin. Chrnic sinusitis is defined as 12 weeks r lnger f 2 r mre f the fllwing signs and symptms: mucpurulent drainage, nasal bstructin, facial pain-pressure-fullness, r decreased sense f smell. Immunsuppressed patients are mre predispsed t cmplicatins f acute sinusitis, s a lwer threshld fr CT imaging may apply. - 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. 2 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. 3 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. 2 In a prspective study f 174 patients suspected f having acute maxillary sinusitis, the authrs 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. 4 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. 2 Cpyright AIM Specialty Health. All Rights Reserved. 10

11 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. 5 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. 5 Clinicians shuld recmmend saline nasal irrigatin, tpical intranasal crticsterids, r bth fr symptm relief f chrnic rhinsinusitis. 2 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. 3 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. 6 Fr suspected rbital r central nervus system cmplicatins, a cntrast-enhanced CT f the paranasal sinuses shuld be perfrmed. 6 Chrnic sinusitis is cmmnly due t nnstructural causes including asthma, gastresphageal reflux disease, r allergic rhinitis. 7 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. 7 Infectius disease nt therwise specified Applies t cnditins nt therwise referenced in. 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 - CT paranasal sinuses and maxillfacial area - MRI temprmandibular jint 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 - CT paranasal sinuses and maxillfacial area Cpyright AIM Specialty Health. All Rights Reserved. 11

12 Trauma Trauma - MRI temprmandibular jint fr suspected inflammatry arthritis, including juvenile idipathic arthritis (JIA) fllwing initial radigraphs 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. - Radigraphs required fr initial evaluatin f suspected mandibular fracture - CT rbit, sella, r psterir fssa and uter, middle, r inner ear - CT paranasal sinuses and maxillfacial area - MRI temprmandibular jint fr suspected internal derangement when surgery is being cnsidered Ratinale While CT is the gld standard fr maxillfacial trauma, radigraphs have mderate t high accuracy fr the detectin f mandibular fractures with sensitivities up t 92% 8 at lwer radiatin dses. CT is mre accurate fr nndisplaced fractures and cndylar fractures 8. MRI is generally reserved as an add-n test fllwing radigraphy r CT when trauma t the sft tissues f the temprmandibular jint/internal derangement is suspected in a surgical candidate. 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. - CT rbit, sella, r psterir fssa and uter, middle, r inner ear Neck mass (including lymphadenpathy) ADULT Advanced imaging is cnsidered medically necessary in EITHER f the fllwing scenaris: Diagnsis when ANY f the fllwing features are present: Firm mass greater than 1.5 cm in diameter Fixed mass f any size Ulceratin Persistent fr greater than 2 weeks r increasing in size Suspicius findings n histry and/r physical exam Ultrasund r laryngscpy findings suspicius fr malignancy Cpyright AIM Specialty Health. All Rights Reserved. 12

13 Management: T direct management f a knwn benign r benign-appearing mass incmpletely characterized n ultrasund r laryngscpy Nte: Fr management f a malignant mass, see Onclgic Imaging guidelines. PEDIATRIC Advanced imaging is cnsidered medically necessary in EITHER f the fllwing scenaris: Diagnsis: When incmpletely characterized by ultrasund r laryngscpy Management: T direct management f a knwn benign r benign-appearing mass incmpletely characterized n ultrasund r laryngscpy Nte: Fr management f a malignant mass, see Onclgic Imaging guidelines. Ratinale ADULT NECK MASS The American Academy f Otlarynglgy 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 EITHER f the fllwing scenaris: T identify an adenma fr surgical planning in patients with primary hyperparathyridism Lcalizatin f residual parathyrid tissue in patients with recurrent r persistent disease fllwing parathyridectmy when ultrasund and parathyrid scintigraphy are nndiagnstic r nrmal in patients with high clinical suspicin f a parathyrid adenma Ratinale Ultrasund and sestamibi scintigraphy are the mst cmmn initial imaging tests used t evaluate suspected parathyrid adenma and have a diagnstic accuracy f abve 80%. 15 When ultrasund and sestamibi exams are nt diagnstic, 4-dimensinal CT, including dynamic cntrast enhancement, has high sensitivity (94%) and specificity (96%). 16 Fur-dimensinal MRI remains an experimental technique. 17 Cpyright AIM Specialty Health. All Rights Reserved. 13

14 Thyrid ndule r thyrmegaly (giter) Advanced imaging is cnsidered medically necessary in EITHER f the fllwing scenaris: Diagnsis T cnfirm the diagnsis f retrsternal giter when suspected by ultrasund Management in EITHER f the fllwing scenaris: Mass effect n the upper airway r esphagus Preperative evaluatin Ratinale Multiple high quality evidence-based guidelines recmmend ultrasund in the initial characterizatin f thyrid ndules. 18, 19 Ultrasund has gd spatial reslutin, is widely available, and nn inizing. Ndule characteristics n ultrasund help t establish the pre test prbability f malignancy and determine the need fr bipsy. CT and MRI have a limited rle in the diagnsis f thyrid ndules but prvide a wider field f view and better anatmic delineatin f retrsternal giter and ther large thyrid masses as needed fr preperative planning. CT and MRI are als useful in staging bipsy-prven thyrid carcinma (see Onclgic Imaging) (recmmendatin based n mderate quality evidence). 18, 19 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 - CT paranasal sinuses and maxillfacial area Nasal Indicatins Advanced imaging is cnsidered medically necessary fr evaluatin f ANY f the fllwing indicatins: Ansmia 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 Cpyright AIM Specialty Health. All Rights Reserved. 14

15 fr ansmia, recurrent epistaxis, r nasal airway bstructin r plypsis refractry t medical therapy Orbital Indicatins Advanced imaging is cnsidered medically necessary fr evaluatin f ANY f the fllwing cnditins: Absence f red reflex (pediatric nly) Dyscnjugate gaze Exphthalms r prptsis Extracular muscle weakness Nystagmus Optic neuritis Orbital pseudtumr Papilledema Strabismus Thyrid phthalmpathy - CT rbit, sella, r psterir fssa and uter, middle, r inner ear Temprmandibular Jint Pathlgy Temprmandibular jint dysfunctin Advanced imaging is cnsidered medically necessary fr diagnsis r management when ALL f the fllwing requirements are met: Mechanical symptms (such as lcking, ppping, r clicking) which have nt imprved with cnservative treatment, including nnsteridal anti-inflammatry drugs r acetaminphen, a shrtterm trial f sft diet and prper chewing techniques, and an ral appliance (such as a bite blck) Surgical interventin is being cnsidered Radigraphs r ultrasund have nt prvided sufficient infrmatin t guide treatment. (This requirement is waived when mechanical signs r symptms are present and internal derangement is suspected). - CT paranasal sinuses and maxillfacial area preferred fr intraarticular lse bdies and temprmandibular jint stearthritis - MRI temprmandibular jint preferred fr evaluatin f internal derangement r disc displacement Ratinale The diagnsis f temprmandibular disease is primarily clinical with histry and physical exam features having mderate (~5) psitive likelihd ratis and mderate-t-high (~.3) negative likelihd ratis. 20, 21 While Cpyright AIM Specialty Health. All Rights Reserved. 15

16 radigraphs are less accurate than CT r MRI, they are ften a useful initial test t exclude ther etilgies fr temprmandibular jint pain such as fracture and have high (greater than 90%) specificity fr stearthritis. 22 While nt cmmnly perfrmed, ultrasund can als be used in the initial imaging evaluatin f temprmandibular jint dysfunctin. 23 Existing evidence-based guidelines strngly recmmend that, unless there are specific and justifiable indicatins t the cntrary, treatment f patients with temprmandibular disease (TMD) shuld initially be based n the use f cnservative, reversible, and evidence-based therapeutic mdalities. While n specific therapies have been prven t be universally effective, many f the cnservative mdalities have prven t be at least as effective in prviding symptmatic relief as mst frms f invasive treatment. Because thse mdalities d nt prduce irreversible changes, they present much less risk f prducing harm. Prfessinal treatment shuld be augmented with a hme care prgram, in which patients are taught abut their disrder and hw t manage their symptms. Due t high rates f asymptmatic disc pathlgy n MRI, imaging shuld generally be reserved until after initial attempts at nnperative management have failed. The evidence-based Diagnstic Criteria fr Temprmandibular Disrders (DC/TMD) includes criteria fr the assessment f Axis I (physical) diagnses fr the mst cmmn temprmandibular disrders. Amng the mechanical signs and symptms suggestive f disc displacement are temprmandibular jint clicking, ppping, r snapping nises which may be assciated with pening r clsing f the muth r with lateral r prtrusive mvements. Temprmandibular jint lcking, ften with limited pening, may als ccur. These criteria may be used fr screening purpses but definitive diagnses require advanced imaging. When disc displacement is suspected, MRI has the highest accuracy; hwever, CT prvides superir sseus detail and a higher diagnstic accuracy fr stearthritis and lse bdies. 21 Miscellaneus Cnditins Cerebrspinal fluid (CSF) leak f the skull base Imaging is cnsidered medically necessary fr diagnsis and management when CSF leak is suspected and EITHER f the fllwing is present: CSF rhinrrhea when fluid is psitive fr beta-2 transferrin Histry f skull base trauma r surgery - CT paranasal sinuses and maxillfacial area (CT cisterngraphy) 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 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 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). Cpyright AIM Specialty Health. All Rights Reserved. 16

17 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. - CT paranasal sinuses and maxillfacial area 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. 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 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). Cpyright AIM Specialty Health. All Rights Reserved. 17

18 Signs and Symptms Dizziness r vertig Als see Brain Imaging guidelines. Advanced imaging is cnsidered medically necessary in ANY f the fllwing scenaris: Evaluatin f signs r symptms suggestive f a central nervus system lesin Tulli s phenmenn (nise-induced dizziness) Symptms assciated with abnrmal audigram r vestibular functin testing suggestive f an intracranial r vestibulcchlear mass lesin 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. 24 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%. 25 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. 26 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. 27 In tw single-center retrspective studies, MRI changed management in 16%-22% f patients with central vertig. 28,29 The American Cllege f Radilgy recmmends MRI brain with and withut cntrast fr patients with central vertig. 30 CT brain may als be perfrmed althugh MRI is mre sensitive than CT fr detectin f psterir fssa strkes. 27, 29 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: Cnductive hearing lss Sensrineural hearing lss characterized by ANY f the fllwing features: Idipathic sudden nset hearing lss 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) PEDIATRIC Hearing lss assciated with at least 1 neurlgic sign r symptm knwn t increase the pretest prbability f a retrcchlear lesin Advanced imaging is cnsidered medically necessary t evaluate fr a structural cause f sensrineural, cnductive, r mixed hearing lss. Cpyright AIM Specialty Health. All Rights Reserved. 18

19 - 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 - MRI brain, CT rbit/sella/psterir fssa, r CT brain (when MRI is cntraindicated) fr evaluatin f mixed hearing lss, based n clinical scenari 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. 31 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. 32 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 ANY 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: Fllwing abnrmal r nndiagnstic laryngscpy Evaluatin f symptms persisting lnger than 1 mnth 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. 33, 34 Benign lesins f the vcal crds such as cysts, ndules, plyps, and Cpyright AIM Specialty Health. All Rights Reserved. 19

20 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%. 35 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. 33 The 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. 36 Hrner s syndrme Advanced imaging is cnsidered medically necessary fr evaluatin when the results f imaging will impact management. 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. 37 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%, 38, 39 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. 40 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 (including trigeminal neuralgia) 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. 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 ANY f the fllwing features: Absence f pain r tenderness Cnstitutinal symptms Cpyright AIM Specialty Health. All Rights Reserved. 20

21 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. 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. 41, 42 Sngraphic characteristics such as size, lss f fatty hilar mrphlgy, and shape increase the likelihd f malignancy but d nt replace bipsy. 43 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 laryngscpy Tinnitus See Brain Imaging guidelines. Visual disturbance r visual field defect Als see Brain Imaging guidelines. Advanced imaging is cnsidered medically necessary t evaluate fr rbital r ptic nerve pathlgy when suggested by the phthalmlgic exam. - 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. 44 MRI f the rbits, typically with and withut cntrast, is apprpriate t further characterize abnrmalities n the phthalmlgic exam. 44 Cpyright AIM Specialty Health. All Rights Reserved. 21

22 References 1. Simundic AM. Measures f diagnstic accuracy: basic definitins. Ejifcc. 2009;19(4): Rsenfeld RM, Piccirill JF, Chandrasekhar SS, et al. Clinical practice guideline (update): adult sinusitis. Otlaryngl Head Neck Surg. 2015;152(2 Suppl):S1-s 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: 4. 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): Kirsch CFE, Bykwski J, Aulin JM, et al. ACR Apprpriateness Criteria((R)) sinnasal disease. J Am Cll Radil. 2017;14(11s):S550-s9. 6. 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 McAlister WH, Parker BR, Kushner DC, et al. Sinusitis in the pediatric ppulatin. American Cllege f Radilgy. ACR Apprpriateness Criteria. Radilgy. 2000;215 Suppl: Naeem A, Gemal H, Reed D. Imaging in traumatic mandibular fractures. Quant Imaging Med Surg. 2017;7(4): Haynes J, Arnld KR, Aguirre-Oskins C, et al. Evaluatin f neck masses in adults. Am Fam Physician. 2015;91(10): 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-s Stern JS, Ginat DT, Nichlas JL, et al. Imaging f pediatric head and neck masses. Otlaryngl Clin Nrth Am. 2015;48(1): 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): 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): 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): Smith RB, Evasvich M, Gird DA, et al. Ultrasund fr lcalizatin in primary hyperparathyridism. Otlaryngl Head Neck Surg. 2013;149(3): 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): Merchavy S, Luckman J, Guindy M, et al. 4D MRI fr the lcalizatin f parathyrid adenma: a nvel methd in evlutin. Otlaryngl Head Neck Surg. 2016;154(3): Gharib H, Papini E, Garber JR, et al. American Assciatin f Clinical Endcrinlgists (AACE), American Cllege f Endcrinlgy (ACE) and Assciazine Medici Endcrinlgi (AME) medical guidelines fr clinical practice fr the diagnsis and management f thyrid ndules update. Endcr Pract. 2016;22(5): Haugen BR, Alexander EK, Bible KC, et al American Thyrid Assciatin management guidelines fr adult patients with thyrid ndules and differentiated thyrid cancer: The American Thyrid Assciatin Guidelines Task Frce n thyrid ndules and differentiated thyrid cancer. Thyrid. 2016;26(1): Chaput E, Grss A, Stewart R, et al. The diagnstic validity f clinical tests in temprmandibular internal derangement: a systematic review and meta-analysis. Physither Can. 2012;64(2): Schiffman E, Ohrbach R. Executive summary f the Diagnstic Criteria fr Temprmandibular Disrders fr clinical and research applicatins. J Am Dent Assc. 2016;147(6): Kaimal S, Ahmad M, Kang W, et al. Diagnstic accuracy f panramic radigraphy and MRI fr detecting signs f TMJ degenerative jint disease. Gen Dent. 2018;66(4): Li C, Su N, Yang X, et al. Ultrasngraphy fr detectin f disc displacement f temprmandibular jint: a systematic review and meta-analysis. J Oral Maxillfac Surg. 2012;70(6): Cpyright AIM Specialty Health. All Rights Reserved. 22