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Appropriateness Criteria

Variant 1: Acquired conductive hearing loss in absence of clinically evident mass in the middle ear. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
CT temporal bone without IV contrast Usually appropriate Strong ☢☢☢ 1-10 mSv 9 9 0 0 0 1 0 0 0 2 12
References Study Quality
5 (27430449) 4
1 (26491893) 4
10 (24625612) 2
11 (24162764) 2
12 (21739095) 4
8 (12563123) 2
9 (16424241) 2
2 (19733309) 4
MRA head without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 11 1 3 0 0 0 0 0 0
MRA head without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 10 2 3 0 0 0 0 0 0
MRI head and internal auditory canal without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 8 2 4 0 0 0 0 1 0
MRI head and internal auditory canal without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 8 2 3 0 1 1 0 0 0
MRV head without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 11 2 2 0 0 0 0 0 0
CT head with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 1 1 10 3 1 1 0 0 0 0 0
CT head without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 10 4 0 1 0 0 0 0 0
CT head without IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 2 2 7 2 5 1 0 0 0 0 0
CT temporal bone with IV contrast Usually not appropriate Strong ☢☢☢ 1-10 mSv 3 3 6 1 4 2 0 1 1 0 0
References Study Quality
5 (27430449) 4
1 (26491893) 4
10 (24625612) 2
11 (24162764) 2
12 (21739095) 4
8 (12563123) 2
9 (16424241) 2
2 (19733309) 4
CT temporal bone without and with IV contrast Usually not appropriate Strong ☢☢☢ 1-10 mSv 2 2 7 1 3 0 2 2 0 0 0
References Study Quality
5 (27430449) 4
1 (26491893) 4
10 (24625612) 2
11 (24162764) 2
12 (21739095) 4
8 (12563123) 2
9 (16424241) 2
2 (19733309) 4
CTA head with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 10 1 3 0 1 0 0 0 0
Variant 2: Acquired conductive hearing loss secondary to cholesteatoma or neoplasm with suspected intracranial or inner ear extension. Surgical planning.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
MRI head and internal auditory canal without and with IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 9 9 0 1 0 0 1 0 2 3 8
References Study Quality
5 (27430449) 4
13 (23158050) 4
15 (22877955) 4
2 (19733309) 4
CT temporal bone without IV contrast Usually appropriate Limited ☢☢☢ 1-10 mSv 9 9 0 0 0 1 0 0 2 0 12
References Study Quality
14 (26351038) 2
1 (26491893) 4
13 (23158050) 4
2 (19733309) 4
MRI head and internal auditory canal without IV contrast May be appropriate Limited O 0 mSv O 0 mSv [ped] 6 6 0 0 1 1 1 10 1 0 1
References Study Quality
5 (27430449) 4
13 (23158050) 4
15 (22877955) 4
2 (19733309) 4
CT temporal bone with IV contrast May be appropriate Limited ☢☢☢ 1-10 mSv 5 5 1 0 0 6 6 2 0 0 0
References Study Quality
14 (26351038) 2
1 (26491893) 4
13 (23158050) 4
2 (19733309) 4
CTA head with IV contrast May be appropriate (Disagreement) Expert Opinion ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 2 2 4 3 2 0 2 0 0
MRA head without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 3 3 6 1 3 2 2 1 0 0 0
MRA head without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 3 3 3 2 8 1 0 0 1 0 0
MRV head with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 1 7 3 2 0 0 2 0 0
MRV head without IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 3 3 5 1 7 1 0 0 1 0 0
References Study Quality
5 (27430449) 4
13 (23158050) 4
15 (22877955) 4
2 (19733309) 4
CT head with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 2 2 6 2 3 2 0 1 0 0 1
CT head without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 8 3 1 0 1 2 0 0 0
CT head without IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 2 2 7 2 4 0 0 1 1 0 0
CT temporal bone without and with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv 3 3 6 1 3 1 2 1 1 0 0
References Study Quality
14 (26351038) 2
1 (26491893) 4
13 (23158050) 4
2 (19733309) 4
Variant 3: Acquired sensorineural hearing loss. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
MRI head and internal auditory canal without and with IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 0 2 2 11
References Study Quality
5 (27430449) 4
27 (24370138) 4
18 (23681028) 3
19 (22980677) 4
24 (306012) 4
20 (15454755) 1
25 (1636533) 4
26 (8279324) 3
22 (14967854) 3
30 (10817038) 2
21 (10512225) 3
2 (19733309) 4
28 (10733180) 4
23 (10782723) 4
29 (9227246) 3
MRI head and internal auditory canal without IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 8 8 0 0 0 0 0 2 4 4 5
References Study Quality
5 (27430449) 4
27 (24370138) 4
18 (23681028) 3
19 (22980677) 4
24 (306012) 4
20 (15454755) 1
25 (1636533) 4
26 (8279324) 3
22 (14967854) 3
30 (10817038) 2
21 (10512225) 3
2 (19733309) 4
28 (10733180) 4
23 (10782723) 4
29 (9227246) 3
CT temporal bone with IV contrast May be appropriate Limited ☢☢☢ 1-10 mSv 4 4 3 3 1 1 5 2 0 0 0
References Study Quality
16 (23713470) 3
13 (23158050) 4
2 (19733309) 4
CT temporal bone without IV contrast May be appropriate Limited ☢☢☢ 1-10 mSv 5 5 0 0 1 1 7 3 3 0 0
References Study Quality
16 (23713470) 3
13 (23158050) 4
2 (19733309) 4
MRA head without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 11 1 2 1 0 0 0 0 0
MRA head without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 10 2 2 1 0 0 0 0 0
MRV head with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 13 1 1 0 0 0 0 0 0
MRV head without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 11 1 2 1 0 0 0 0 0
CT head with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 3 3 3 4 3 2 2 1 0 0 0
References Study Quality
17 (28461783) 3
CT head without and with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 5 3 4 1 1 1 0 0 0
References Study Quality
17 (28461783) 3
CT head without IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 3 3 3 1 7 2 0 1 1 0 0
References Study Quality
17 (28461783) 3
CT temporal bone without and with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv 2 2 6 2 3 0 2 2 0 0 0
References Study Quality
16 (23713470) 3
13 (23158050) 4
2 (19733309) 4
CTA head with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 10 1 3 0 0 1 0 0 0
Variant 4: Mixed conductive and sensorineural hearing loss. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
MRI head and internal auditory canal without and with IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 8 8 0 0 0 0 1 1 2 7 4
References Study Quality
2 (19733309) 4
MRI head and internal auditory canal without IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 7 7 1 0 0 0 2 4 6 1 1
References Study Quality
2 (19733309) 4
CT temporal bone without IV contrast Usually appropriate Limited ☢☢☢ 1-10 mSv 9 9 0 0 1 0 1 0 0 1 12
References Study Quality
31 (27364152) 3
32 (23235550) 4
MRA head without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 11 1 3 0 0 0 0 0 0
MRA head without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 11 1 3 0 0 0 0 0 0
MRV head with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 13 2 0 0 0 0 0 0 0
MRV head without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 11 1 3 0 0 0 0 0 0
CT head with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 3 3 4 3 2 2 3 1 0 0 0
References Study Quality
17 (28461783) 3
CT head without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 6 3 3 2 1 0 0 0 0
CT head without IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 3 3 3 2 6 2 0 1 1 0 0
References Study Quality
17 (28461783) 3
CT temporal bone with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv 3 3 4 1 4 2 3 1 0 0 0
References Study Quality
31 (27364152) 3
32 (23235550) 4
CT temporal bone without and with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv 3 3 6 1 4 1 2 1 0 0 0
References Study Quality
31 (27364152) 3
32 (23235550) 4
CTA head with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 9 1 3 1 1 0 0 0 0
Variant 5: Congenital hearing loss or total deafness or cochlear implant candidate. Surgical planning.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
MRI head and internal auditory canal without and with IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 8 8 0 0 0 0 1 2 4 5 3
References Study Quality
39 (24892366) 4
38 (16151346) 3
37 (11950658) 4
MRI head and internal auditory canal without IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 7 7 1 0 0 0 4 0 5 2 3
References Study Quality
39 (24892366) 4
38 (16151346) 3
37 (11950658) 4
CT temporal bone without IV contrast Usually appropriate Limited ☢☢☢ 1-10 mSv 9 9 0 0 0 0 0 0 0 2 13
References Study Quality
35 (26810296) 3
33 (25573134) 3
34 (25208295) 4
36 (24232063) 3
24 (306012) 4
MRA head without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 11 2 2 0 0 0 0 0 0
MRA head without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 11 2 2 0 0 0 0 0 0
MRV head with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 13 1 0 1 0 0 0 0 0
MRV head without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 11 2 2 0 0 0 0 0 0
CT head with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 1 1 8 2 5 0 0 0 0 0 0
CT head without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 9 1 5 0 0 0 0 0 0
CT head without IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 1 1 9 0 5 0 0 0 0 1 0
CT temporal bone with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv 3 3 5 2 4 0 2 2 0 0 0
References Study Quality
35 (26810296) 3
33 (25573134) 3
34 (25208295) 4
36 (24232063) 3
24 (306012) 4
CT temporal bone without and with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv 2 2 7 1 3 1 2 1 0 0 0
References Study Quality
35 (26810296) 3
33 (25573134) 3
34 (25208295) 4
36 (24232063) 3
24 (306012) 4
CTA head with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 10 1 2 1 1 0 0 0 0
Variant 6: Episodic vertigo with or without associated hearing loss or aural fullness (peripheral vertigo). Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
MRI head and internal auditory canal without and with IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 8 8 0 0 0 0 2 0 1 5 7
References Study Quality
46 (27300452) 3
5 (27430449) 4
53 (26333096) 3
45 (25985318) 2
54 (25956665) 3
49 (25742875) 2
52 (25457542) 2
44 (25251300) 2
51 (24769636) 3
47 (23995329) 4
50 (23474961) 3
48 (22201445) 3
42 (22201289) 3
43 (21330087) 2
4 (18646412) 4
3 (24314796) 4
MRI head and internal auditory canal without IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 7 7 1 0 0 0 2 1 5 5 1
References Study Quality
46 (27300452) 3
5 (27430449) 4
53 (26333096) 3
45 (25985318) 2
54 (25956665) 3
49 (25742875) 2
52 (25457542) 2
44 (25251300) 2
51 (24769636) 3
47 (23995329) 4
50 (23474961) 3
48 (22201445) 3
42 (22201289) 3
43 (21330087) 2
4 (18646412) 4
3 (24314796) 4
CT temporal bone without IV contrast Usually appropriate Strong ☢☢☢ 1-10 mSv 8 8 0 0 1 0 0 0 1 6 7
References Study Quality
14 (26351038) 2
5 (27430449) 4
8 (12563123) 2
9 (16424241) 2
MRA head and neck without and with IV contrast May be appropriate Limited O 0 mSv O 0 mSv [ped] 4 4 1 2 3 5 2 2 0 0 0
References Study Quality
55 (10459295) 3
CTA head and neck with IV contrast May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 4 4 1 1 4 5 2 2 0 0 0
References Study Quality
41 (28328808) 3
MRA head and neck without IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 3 3 1 3 5 4 1 1 0 0 0
References Study Quality
55 (10459295) 3
MRV head with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 10 2 3 0 0 0 0 0 0
MRV head without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 7 1 3 0 2 1 0 1 0
CT head with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 3 3 4 2 5 1 3 0 0 0 0
References Study Quality
40 (22940762) 4
CT head without and with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 3 3 4 3 5 3 0 0 0 0 0
References Study Quality
40 (22940762) 4
CT head without IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 3 3 2 4 3 3 2 0 1 0 0
References Study Quality
40 (22940762) 4
CT temporal bone with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 3 3 5 2 3 1 2 2 0 0 0
CT temporal bone without and with IV contrast Usually not appropriate Strong ☢☢☢ 1-10 mSv 2 2 7 1 3 1 1 2 0 0 0
References Study Quality
14 (26351038) 2
5 (27430449) 4
8 (12563123) 2
9 (16424241) 2
Variant 7: Persistent vertigo with or without neurological symptoms (central vertigo). Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
MRI head and internal auditory canal without and with IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 0 1 2 12
References Study Quality
56 (27495834) 3
54 (25956665) 3
59 (24920847) 2
57 (23336972) 3
40 (22940762) 4
58 (11698800) 4
3 (24314796) 4
MRI head and internal auditory canal without IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 8 8 0 0 0 0 1 1 5 5 3
References Study Quality
56 (27495834) 3
54 (25956665) 3
59 (24920847) 2
57 (23336972) 3
40 (22940762) 4
58 (11698800) 4
3 (24314796) 4
MRA head and neck without and with IV contrast May be appropriate Limited O 0 mSv O 0 mSv [ped] 6 6 0 0 1 0 1 7 6 0 0
References Study Quality
55 (10459295) 3
MRA head and neck without IV contrast May be appropriate Limited O 0 mSv O 0 mSv [ped] 6 6 0 0 1 0 3 8 3 0 0
References Study Quality
55 (10459295) 3
CT head with IV contrast May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 5 5 0 1 5 0 7 1 1 0 0
References Study Quality
56 (27495834) 3
54 (25956665) 3
40 (22940762) 4
CT head without IV contrast May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 6 6 0 0 1 1 3 7 2 0 1
References Study Quality
56 (27495834) 3
54 (25956665) 3
40 (22940762) 4
CTA head and neck with IV contrast May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 6 6 0 0 1 0 1 8 5 0 0
References Study Quality
41 (28328808) 3
MRV head with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 10 3 1 0 1 0 0 0 0
MRV head without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 8 3 2 1 1 0 0 0 0
CT head without and with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 3 3 2 3 5 0 3 2 0 0 0
References Study Quality
56 (27495834) 3
54 (25956665) 3
40 (22940762) 4
CT temporal bone with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 10 1 2 2 0 0 0 0 0
CT temporal bone without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 9 2 2 2 0 0 0 0 0
CT temporal bone without IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 2 2 7 1 3 2 1 1 0 0 0
Appendix Key

A more complete discussion of the items presented below can be found by accessing the supporting documents at the designated hyperlinks.

Appropriateness Category:The panel’s recommendation for a procedure based on the assessment of the risks and benefits of performing the procedure for the specified clinical scenario.

SOE: Strength of Evidence. The assessment of the amount and quality of evidence found in the peer reviewed medical literature for an appropriateness recommendation.

  • References: The citation number and PMID for the reference(s) associated with the recommendation.
  • Study Quality: The assessment of the quality of an individual reference based on the number of study quality elements described in the reference.

RRL: Relative Radiation Level. A population based assessment of the amount of radiation a typical patient may be exposed to during the specified procedure.

Rating: The final rating (1-9 scale) for the procedure as determined by the panel during rating rounds.

Median: The median rating (1-9 scale) for the procedure as determined by the panel during rating rounds.

Final tabulations: A histogram showing the number of panel members who rated the procedure as noted in the column heading (ie, 1, 2, 3, etc.).

Additional supporting documents about the AC methodology and processes can be found at www.acr.org/ac.