Photon-counting CT in head and neck radiology: bridging detector physics and clinical applications

Photon-counting computed tomography (PCCT) represents a significant advancement in head and neck imaging, offering both technical and clinical benefits over conventional energy-integrating CT (EID-CT). This revolution is mainly based on the five technical aspects: improved spatial resolution, reduced image noise and metal artifacts, lower radiation exposure, decreased iodinated contrast dose, and spectral imaging capabilities. In the head and neck, enhanced spatial resolution enables detailed visualization of fine anatomical structures, including small vessels, ossicles, and cartilage, thereby enhancing preoperative planning and postoperative assessment. Noise reduction and metal artifact mitigation facilitate the evaluation of patients with cochlear implants, dental hardware, or post-surgical materials, enabling more confident assessment of adjacent soft tissues and bone. Reduced radiation and contrast doses are particularly valuable in pediatric patients and in individuals requiring repeated surveillance, minimizing long-term risks while preserving diagnostic quality. Finally, spectral imaging, including iodine maps, virtual non-contrast, and virtual non-calcium reconstructions, improves tissue characterization, potentially useful in the head and neck region in several clinical scenarios ranging from lesion detection to carotid plaque characterization. While each technical feature has independent value, in clinical practice, they act synergistically, enabling radiologists to enhance lesion detection, tissue characterization, and overall diagnostic performance. As clinical experience grows and evidence accumulates, PCCT is poised to become an essential tool for comprehensive, safer, and more precise evaluation of head and neck pathologies, from routine head and neck imaging to complex oncologic and post-treatment follow-up studies. KEY POINTS: Question Can photon-counting CT, with optimal spatial resolution, reduced noise and metal artifacts, and spectral capabilities, improve the visualization of complex head and neck anatomy? Findings Technical advances translate into enhanced lesion detection, improved tissue characterization, and more confident assessment in patients with dental hardware, implants, or postoperative materials. Clinical relevance By combining physical innovations with clinical applicability, photon-counting CT offers safer, more precise imaging, with lower radiation and contrast doses, supporting improved diagnostic performance in head and neck radiology.