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Objectives The aim of this study was to compare the quality of images obtained using single-energy computed tomography (SECT) performed with automated tube voltage adaptation (TVA) with dual-energy CT (DECT) weighted average images. Methods Eighty patients were prospectively randomized to undergo either SECT with TVA ( n  = 40, ref. mAs 200) or radiation dose–matched DECT ( n  = 40, 80/Sn150 kV, ref. mAs tube A 91/tube B 61) on a dual-source CT scanner. Objective image quality was evaluated as dose-normalized contrast-to-noise ratio (CNRD) for the jugular veins relative to fatty tissue and muscle tissue and for muscle tissue relative to fatty issue. For subjective image quality, reproduction of anatomical structures, image artifacts, image noise, spatial resolution, and overall diagnostic acceptability were evaluated at sixteen anatomical substructures using Likert-type scales. Results Effective radiation dose (ED) was comparable between SECT and DECT study groups (2.9 ± 0.6 mSv/3.1 ± 0.7 mSv,  p  = 0.5). All examinations were rated as excellent or good for clinical diagnosis. Compared to the CNRD in the SECT group, the CNRD in the DECT group was significantly higher for the jugular veins relative to fatty tissue (7.51/6.08,  p  &lt; 0.001) and for muscle tissue relative to fatty tissue (4.18/2.90,  p  &lt; 0.001). The CNRD for the jugular veins relative to muscle tissue (3.33/3.18,  p  = 0.51) was comparable between groups. Image artifacts were less pronounced and overall diagnostic acceptability was higher in the DECT group (all  p  = 0.01). Conclusions DECT weighted average images deliver higher objective and subjective image quality than SECT performed with TVA in head and neck imaging. Key Points • Weighted average images derived from dual-energy CT deliver higher objective and subjective image quality than single-energy CT using automated tube voltage adaptation in head and neck imaging.  • If available, dual-energy CT acquisition may be preferred over automated low tube voltage adopted single-energy CT for both malignant and non-malignant conditions.

Image quality comparison of single-energy and dual-energy computed tomography for head and neck patients: a prospective randomized study