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Appropriateness Criteria

Variant 1: Adult. Otitis externa, uncomplicated. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Radiography skull Usually not appropriate Expert Consensus ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 1 15 0 1 0 0 0 0 0 0
MRI head and internal auditory canal with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 14 0 1 0 0 1 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 14 0 1 0 0 1 0 0 0
MRI head and internal auditory canal without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 15 0 1 0 0 0 0 0 0
MRI head with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 14 0 1 1 0 0 0 0 0
MRI head without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 14 0 1 1 0 0 0 0 0
MRI head without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 15 0 1 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 13 0 3 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 13 0 3 0 0 0 0 0 0
CT head without IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 2 2 8 0 6 1 1 0 0 0 0
References Study Quality
14 (23351401) 4
CT temporal bone with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 12 0 3 0 0 0 1 0 0
CT temporal bone without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 13 0 2 0 0 0 1 0 0
CT temporal bone without IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv 2 2 8 0 4 2 1 0 1 0 0
References Study Quality
14 (23351401) 4
Variant 2: Adult. Otitis externa, complicated. 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 0 6 5 4
References Study Quality
28 (34966623) 4
27 (23439909) 4
26 (33502545) 2
19 (33511482) 4
15 (29738387) 4
2 (23089314) 4
CT temporal bone with IV contrast Usually appropriate Strong ☢☢☢ 1-10 mSv 7 7 0 0 0 0 3 0 6 3 4
References Study Quality
25 (32498757) 4
24 (31977136) 2
23 (30987522) 4
22 (35382682) 2
21 (35042578) 2
20 (34226993) 2
19 (33511482) 4
15 (29738387) 4
MRI head without and with IV contrast May be appropriate Limited O 0 mSv O 0 mSv [ped] 5 5 1 0 1 3 9 2 0 0 0
References Study Quality
27 (23439909) 4
26 (33502545) 2
19 (33511482) 4
15 (29738387) 4
2 (23089314) 4
CT temporal bone without IV contrast May be appropriate Strong ☢☢☢ 1-10 mSv 6 6 0 0 0 1 5 3 5 1 1
References Study Quality
25 (32498757) 4
24 (31977136) 2
19 (33511482) 4
23 (30987522) 4
22 (35382682) 2
WBC scan with SPECT or SPECT/CT skull base May be appropriate Strong ☢☢☢ 1-10 mSv 5 5 0 0 1 5 8 2 0 0 0
References Study Quality
28 (34966623) 4
26 (33502545) 2
24 (31977136) 2
22 (35382682) 2
19 (33511482) 4
18 (21722540) 4
17 (26223723) 4
15 (29738387) 4
2 (23089314) 4
Radiography skull Usually not appropriate Limited ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 1 14 1 1 0 0 0 0 0 0
References Study Quality
28 (34966623) 4
MRI head and internal auditory canal with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 12 0 1 1 0 0 1 1 0
MRI head and internal auditory canal without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 3 3 7 0 4 1 2 2 0 0 0
MRI head with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 13 0 1 0 1 1 0 0 0
MRI head without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 10 1 3 0 2 0 0 0 0
CT head and neck with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv 3 3 7 0 6 2 1 0 0 0 0
References Study Quality
18 (21722540) 4
17 (26223723) 4
16 (24169084) 4
15 (29738387) 4
4 (28301961) 4
2 (23089314) 4
CT head and neck without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 13 0 1 1 1 0 0 0 0
CT head and neck without IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 12 0 2 2 0 0 0 0 0
CT head with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 3 3 6 2 5 1 1 1 0 0 0
References Study Quality
18 (21722540) 4
17 (26223723) 4
16 (24169084) 4
15 (29738387) 4
4 (28301961) 4
2 (23089314) 4
CT head without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 13 0 1 2 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 12 0 3 1 0 0 0 0 0
CT temporal bone without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 13 0 0 0 1 1 1 0 0
Variant 3: Adult. Acute otitis media, uncomplicated. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Radiography skull Usually not appropriate Expert Consensus ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 1 14 0 1 1 0 0 0 0 0
MRI head and internal auditory canal with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 13 0 2 1 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 13 0 2 0 1 0 0 0 0
MRI head and internal auditory canal without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 13 0 2 1 0 0 0 0 0
MRI head with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 13 0 2 1 0 0 0 0 0
MRI head without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 13 0 2 1 0 0 0 0 0
MRI head without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 13 0 2 1 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 13 0 1 2 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 13 0 1 2 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 13 0 1 1 0 0 1 0 0
CT temporal bone with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 13 0 1 2 0 0 0 0 0
CT temporal bone without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 13 0 1 2 0 0 0 0 0
CT temporal bone without IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 13 0 1 1 0 0 0 0 1
Variant 4: Adult. Complicated otitis media. 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 0 1 6 4 5
References Study Quality
38 (26607577) 2
9 (28801828) 2
CT temporal bone with IV contrast Usually appropriate Strong ☢☢☢ 1-10 mSv 8 8 0 0 0 0 1 0 5 5 5
References Study Quality
38 (26607577) 2
32 (23589156) 2
30 (25447953) 4
29 (23852990) 4
9 (28801828) 2
CTV head with IV contrast Usually appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 7 7 0 0 0 0 5 1 5 5 0
References Study Quality
37 (26590005) 4
MRV head with IV contrast May be appropriate Limited O 0 mSv O 0 mSv [ped] 5 5 0 0 0 3 9 3 1 0 0
References Study Quality
37 (26590005) 4
MRV head without IV contrast May be appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 5 5 3 0 1 4 7 1 0 0 0
CT temporal bone without IV contrast May be appropriate Expert Consensus ☢☢☢ 1-10 mSv 5 5 0 0 0 3 9 2 2 0 0
Radiography skull Usually not appropriate Expert Consensus ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 1 14 0 2 0 0 0 0 0 0
MRI head and internal auditory canal with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 14 1 1 0 0 0 0 0 0
MRI head and internal auditory canal without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 12 3 1 0 0 0 0 0 0
MRI head with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 12 0 1 1 0 1 1 0 0
MRI head without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 8 0 1 1 4 1 1 0 0
MRI head without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 11 1 2 1 0 1 0 0 0
MRV head without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 11 2 2 1 0 0 0 0 0
CT head with IV contrast Usually not appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 1 1 10 2 3 0 1 0 0 0 0
References Study Quality
37 (26590005) 4
36 (21431950) 2
35 (33386931) 4
30 (25447953) 4
9 (28801828) 2
6 (22961223) 2
CT head without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 12 1 1 1 0 1 0 0 0
CT head without IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 1 1 12 0 0 2 2 0 0 0 0
CT temporal bone without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 13 1 1 0 0 1 0 0 0
CTV head and neck with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 11 0 0 2 1 2 0 0 0
WBC scan with SPECT or SPECT/CT skull base Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 12 0 2 1 0 1 0 0 0
Variant 5: Adult. Chronic otitis media. 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] 7 7 0 0 0 1 2 0 9 1 3
References Study Quality
47 (34557138) 2
46 (30920387) 4
45 (20927654) 4
44 (34509081) 2
CT temporal bone without IV contrast Usually appropriate Strong ☢☢☢ 1-10 mSv 9 9 0 0 0 1 0 1 4 2 8
References Study Quality
43 (24818630) 2
42 (31155942) 2
41 (24582323) 2
40 (23764962) 2
39 (23521408) 2
36 (21431950) 2
35 (33386931) 4
Radiography skull Usually not appropriate Limited ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 1 14 0 2 0 0 0 0 0 0
References Study Quality
36 (21431950) 2
MRI head and internal auditory canal with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 12 0 1 1 1 0 1 0 0
MRI head and internal auditory canal without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 10 3 2 0 1 0 0 0 0
MRI head with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 11 1 1 1 1 1 0 0 0
MRI head without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 9 0 3 2 1 1 0 0 0
MRI head without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 10 1 3 1 0 1 0 0 0
CT head with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 1 1 11 0 3 2 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 12 0 2 2 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 11 1 2 2 0 0 0 0 0
CT temporal bone with IV contrast Usually not appropriate Strong ☢☢☢ 1-10 mSv 1 1 10 2 3 0 0 1 0 0 0
References Study Quality
39 (23521408) 2
36 (21431950) 2
35 (33386931) 4
CT temporal bone without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 15 0 1 0 0 0 0 0 0
Variant 6: Adult. Postoperative cholesteatoma. Surveillance 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 1 0 0 0 1 0 5 3 6
References Study Quality
50 (20360335) 4
49 (33461853) 2
48 (33926901) 2
CT temporal bone without IV contrast Usually appropriate Limited ☢☢☢ 1-10 mSv 8 8 0 0 0 0 0 0 4 8 4
References Study Quality
44 (34509081) 2
Radiography skull Usually not appropriate Expert Consensus ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 1 14 1 1 0 0 0 0 0 0
MRI head and internal auditory canal with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 14 1 0 0 0 1 0 0 0
MRI head and internal auditory canal without IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 3 3 6 2 6 0 1 1 0 0 0
References Study Quality
50 (20360335) 4
MRI head with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 12 0 1 1 1 1 0 0 0
MRI head without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 9 1 2 1 1 1 0 0 1
MRI head without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 10 0 3 0 3 0 0 0 0
CT head with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 1 1 11 1 3 0 1 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 12 0 3 0 1 0 0 0 0
CT head without IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 1 1 11 1 4 0 0 0 0 0 0
CT temporal bone with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 10 0 3 1 0 0 2 0 0
CT temporal bone without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 15 0 1 0 0 0 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.