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CT Neck Soft Tissue

CPT: 70490, 70491, 70492

Note

CT examinations of the neck are tailored to the particular clinical situation being evaluated. Examinations that may include intrathoracic pathology, e.g. hoarseness, are continued to avout the level of the carina.. Thus is is often inappropriate to order both neck and chest CT exams at the same time. Such requests should be sent for physician review.

1 Major Symptom or Complaint presented as primary indication

1.1 Epistaxis, uncontrolled by usual methods time sensitive, treat as expedited case.

References

  • Schlosser, Rodney J. Epistaxis N Engl J Med 2009 360: 784-789

1.2 Hoarseness due to vocal cord paralysis

  • 1.2.1 Prior laryngoscopy not diagnostic
  • 1.2.2 CT Chest should not be approved at the same time as CT of the neck for hoarseness. CT neck should be performed before a CT of the chest is approved for hoarseness. According to the ACR Guidelines the CT of the neck will include structures in the upper chest, to about the level of the carina, that might contribute to hoarseness

References

  • Chin, Shy-Chyi, Edelstein, Simon, Chen, Cheng-Yu, Som, Peter M. Using CT to Localize Side and Level of Vocal Cord Paralysis Am. J. Roentgenol. 2003 180: 1165-1170
  • Glazer, HS, Aronberg, DJ, Lee, JK, Sagel, SS Extralaryngeal causes of vocal cord paralysis: CT evaluation Am. J. Roentgenol. 1983 141: 527-531
  • ACR Practice Guideline for the Performance of Computed Tomography of the Extracranial Head and Neck Accessed at www.acr.org/ secondaryMainMenuCategories/quality_safety/guidelines/dx/head-neck/ct_head_neck.aspx 7/7/11
  • Johns MM 3rd et al. Shortfalls of the American Academy of Otolaryngology-Head and Neck Surgery’s Clinical practice guideline: Hoarseness (Dysphonia). Otolaryngol Head Neck Surg. 2010 Aug;143(2):175–7. [PMID: 20647114]
  • Lustig Lawrence R, Schindler Joshua, “Chapter 8. Ear, Nose, & Throat Disorders” (Chapter). McPhee SJ, Papadakis MA: CURRENT Medical Diagnosis & Treatment 2012: http://www.accessmedicine.com/content.aspx?aID=2356.

1.3 Stridor after trauma a harsh vibrating sound heard during respiration in cases of obstruction of the air passages

References:

2 Working Diagnosis or Rule Out presented as primary indication

2.1 Parathyroid pathology

  • 2.1.1 Nondiagnostic nuclear or ultrasound examinations

2.2 Parathyroid tumor suspected (no mass detected) based on elevated serum Calcium or PTH

2.3 Vocal cord paralysis

3 Abnormal Physical Exam Finding presented as primary indication

3.1 Airway Compromise by neck mass time sensitive, treat as expedited case

3.2 Cranial nerve findings ONE

3.2.1 1st Olfactory Abnormal or absent sense of smell.

3.2.2 2nd Optic Visual disturbances of various kinds

3.2.3 3rd Oculomotor Ptosis (drooping) of eyelid, lateral deviation of eye, dilatation of the pupil, diplopia

3.2.4 4th Trochlear Upward and outward deviation of the eye, diplopia

3.2.5 5th Trigeminal

  • 3.2.5.1 Motor root: Deviation of the jaw to the affected side.
  • 3.2.5.2 Sensory root: Abnormal or absent sensation in face, forehead, temple, or eye.

3.2.6 6th Abducens Deviation of the eye outward, diplopia.

3.2.7 7th Facial Paralysis on one side of face

3.2.8 8th Vestibulocochlear Decreased hearing, dizziness, nausea and vomiting, tinnitus.

3.2.9 9th Glossopharyngeal Abnormal sense of taste. dysphagia.

3.2.10 10th Vagus Hoarseness and dysphagia, dysarthria

3.2.11 11th Spinal accessory Drooping of the shoulder. Inability to rotate the head away from the affected side.

3.2.12 12th Hypoglossal Unilateral tongue paralysis or weakness with deviation to the affected side.

References:

  • Dhillon Nripendra, “Chapter 1. Anatomy” (Chapter). Lalwani AK: CURRENT Diagnosis & Treatment in Otolaryngology-Head & Neck Surgery, 2nd Edition: http://www.accessmedicine.com/content.aspx?aID=2823000. 3/31/09
  • Saremi, F et al; MRI of cranial Nerve Enhancement; AJR 2005 185:1487-1497

3.3 Crepitus after laryngeal trauma

3.4 Flattening of thyroid cartillage after trauma

3.5 Hoarseness due to vocal cord paralysis

  • 3.5.1 CT Chest should not be approved at the same time as CT of the neck for hoarseness. CT neck should be performed before a CT of the chest is approved for hoarseness. According to the ACR Guidelines the CT of the neck will include structures in the upper chest, to about the level of the carina, that might contribute to hoarseness

References:

  • Chin, Shy-Chyi, Edelstein, Simon, Chen, Cheng-Yu, Som, Peter M. Using CT to Localize Side and Level of Vocal Cord Paralysis Am. J. Roentgenol. 2003 180: 1165-1170
  • Glazer, HS, Aronberg, DJ, Lee, JK, Sagel, SS Extralaryngeal causes of vocal cord paralysis: CT evaluation Am. J. Roentgenol. 1983 141: 527-531
  • ACR PRACTICE GUIDELINE FOR THE PERFORMANCE OF COMPUTED TOMOGRAPHY (CT) OF THE EXTRACRANIAL HEAD AND NECK IN ADULTS AND CHILDREN accessed at www.acr.org/ secondaryMainMenuCategories/quality_safety/guidelines/dx/head-neck/ct_head_neck.aspx 5/11/11

3.6 Neck mass new, discovered by physical examination or other imaging, or recurrent

3.7 Positive endoscopy

NOTE

CT may be appropriate and necessary to further evaluate findings on nasal endoscopy especially if surgical intervention is under consideration.

References:

3.8 Salivary gland mass suspected by physical examination or other testing.

3.9 Thyroid Mass

  • 3.9.1 Compromising airway time sensitive, treat as expedited case.
  • 3.9.2 Extending substernally

4 Abnormal Lab or Imaging presented as primary indication

  • 4.1 Neck mass new, discovered by physical examination or other imaging, or recurrent

5 Significant Prior Medical History presented as primary indication

5.1 Head or Neck Cancer

  • 5.1.1 Interval evaluation during or after treatment
  • 5.1.2 Intial staging
  • 5.1.3 Restaging
  • 5.1.4 Worsening clinical situation

5.2 Lymphoma

  • 5.2.1 Initial staging
  • 5.2.2 Interval follow up
  • 5.2.3 Worsening clinical status

References:

  • NCCN Clinical Practice Guidelines in OncologyHodkin Disease/LymphomaCancers V.2.2009 accessed 1/22/09

5.3 Neck abscess

5.4 Parathyroid mass or tumor, recurrent after surgery

  • 5.4.1 Nondiagnostic nuclear or ultrasound examinations

5.5 Recurrence, or new mass, at site of previously treated tumor

5.6 Trauma to the neck

5.6.1 Suspect Laryngeal fracture

  • 5.6.1.1 Difficulty breathing
  • 5.6.1.2 Difficulty speaking
  • 5.6.1.3 Difficulty swallowing
  • 5.6.1.4 Subcutaneous air

References:

5.7 Vocal cord paralysis