A narrative review on the role and main findings of the Videofluoroscopic Study of Swallowing in Parkison's disease.

PURPOSE: Dysphagia is a common symptom in patients with Parkinson's disease (PD), though it may go undiagnosed until severe complications arise. Dysphagia can be suspected on a clinical basis, but an instrumental assessment is mandatory to confirm its presence and evaluate pathophysiological aspects and severity of the swallowing impairment. Aim of this review is to inform the clinician and the radiologist on the importance and the main radiological findings of the Video-Fluoroscopic-Swallow-Study (VFSS) in patients with PD starting from the most recent literature data on the topic. MATERIALS AND METHODS: Databases analysis identified 98 papers (January 2000/October 2022) of which 55 were excluded after reading title, abstract and full-text. After evaluation of the selected articles and their references 7 additional papers were added. RESULTS: Fifty papers were reviewed to answer the following four main questions: Should VFSS be routinely used to screen dysphagia? Compared to other diagnostic tools, what is the role of VFSS in PD patients with suspected dysphagia? What are the main VFSS findings and technical expedients ? What is the role of VFSS in the choice of the best treatment strategy ? CONCLUSIONS: VFSS represents a gold standard technique in the diagnostic evaluation of dysphagia in PD, having a fundamental role in the identification of patients with high risk of aspiration pneumonia and also being extremely helpful to guide to the choice of treatment strategies for dysphagia.

A multinational consensus on dysphagia in Parkinson's disease: screening, diagnosis and prognostic value.

BACKGROUND: Parkinson's disease (PD) is a neurodegenerative disorder characterized by a combination of motor and non-motor dysfunction. Dysphagia is a common symptom in PD, though it is still too frequently underdiagnosed. Consensus is lacking on screening, diagnosis, and prognosis of dysphagia in PD. OBJECTIVE: To systematically review the literature and to define consensus statements on the screening and the diagnosis of dysphagia in PD, as well as on the impact of dysphagia on the prognosis and quality of life (QoL) of PD patients. METHODS: A multinational group of experts in the field of neurogenic dysphagia and/or PD conducted a systematic revision of the literature published since January 1990 to February 2021 and reported the results according to PRISMA guidelines. The output of the research was then analyzed and discussed in a consensus conference convened in Pavia, Italy, where the consensus statements were drafted. The final version of statements was subsequently achieved by e-mail consensus. RESULTS: Eighty-five papers were used to inform the Panel's statements even though most of them were of Class IV quality. The statements tackled four main areas: (1) screening of dysphagia: timing and tools; (2) diagnosis of dysphagia: clinical and instrumental detection, severity assessment; (3) dysphagia and QoL: impact and assessment; (4) prognostic value of dysphagia; impact on the outcome and role of associated conditions. CONCLUSIONS: The statements elaborated by the Consensus Panel provide a framework to guide the neurologist in the timely detection and accurate diagnosis of dysphagia in PD.

Dynamic Fast Imaging Employing Steady State Acquisition Magnetic Resonance Imaging of the Vocal Tract in One Overtone Male Singer: Our Preliminary Experience.

AIMS: To demonstrate physiological changing of vocal tract's structures during overtone singing with commercial magnetic resonance imaging (MRI) Fast Imaging Employing Steady State Acquisition (FIESTA) dynamic sequence. METHODS AND MATERIALS: A 1.5 T MRI with a 16 channel head-and-neck coil and a FIESTA sequence were used. A temporal resolution of 0.155 sec (7 image/s). A single professional singer was studied. The MR acquisition is made while the singer performed a predetermined singing sequence. Three different overtone singing techniques were examined (L-technique, J-technique, and NG technique) and one effect (Ezengileer) applied to L-technique. For each overtone technique we evaluated MRI movement of lips, tongue, velopharyngeal closure, and relationship among tongue and pharyngeal posterior wall/soft palate. To cancel the noise over-imposed, the dynamic MRI was subsequently dubbed in studio with the audio of the preset overtone sing. Dubbed MR images were analyzed with an Overtone Analyzer Software and different sound frequencies were identified and pointed out as colored lines. RESULTS: This study shows that different overtone techniques are related to a specific conformation of tongue, lips, soft and hard palate and motion's relation changing between them. Only a correct conformation of vocal tract's structure allows resonance and so to hear desired fundamental and harmonic pitch in overtone singing. CONCLUSION: The preliminary data of our study demonstrates that FIESTA dynamic MRI sequence can be used to depict changing of position of vocal tract's structure in overtone singing techniques with a good temporal and anatomic resolution.

Consensus on the treatment of dysphagia in Parkinson's disease.

BACKGROUND: Dysphagia is common in Parkinson's disease (PD). The effects of antiparkinsonian drugs on dysphagia are controversial. Several treatments for dysphagia are available but there is no consensus on their efficacy in PD. OBJECTIVE: To conduct a systematic review of the literature and to define consensus statements on the treatment of dysphagia in PD and related nutritional management. METHODS: A multinational group of experts in the field of neurogenic dysphagia and/or Parkinson's disease conducted a systematic evaluation of the literature and reported the results according to PRISMA guidelines. The evidence from the retrieved studies was analyzed and discussed in a consensus conference organized in Pavia, Italy, and the consensus statements were drafted. The final version of statements was subsequently achieved by e-mail consensus. RESULTS: The literature review retrieved 64 papers on treatment and nutrition of patients with PD and dysphagia, mainly of Class IV quality. Based on the literature and expert opinion in cases where the evidence was limited or lacking, 26 statements were developed. CONCLUSIONS: The statements developed by the Consensus panel provide a guidance for a multi-disciplinary treatment of dysphagia in patients with PD, involving neurologists, otorhinolaryngologists, gastroenterologists, phoniatricians, speech-language pathologists, dieticians, and clinical nutritionists.

Multi-Detector CT Enterography to detect jejunal angiodysplasia: challenging cause of gastrointestinal bleeding.

The small bowel angiodysplasia is a rare cause of intestinal bleeding. Usually, the diagnosis is performed with selective conventional angiography. We report a case of 73-year-old man, who was hospitalized after recurrent episodes of melena and anaemia. MDCT-enterography performed before and after intravenous administration of contrast medium, detected an increased density area which was confirmed to be a jejunal angiodysplasia.

Vocal tract physiology and its MRI evaluation / Fisiología del tracto vocal y su evaluación por resonancia magnética

Introduction. The rapid technological evolution in Magnetic Resonance Imaging (MRI) has recently offered a great opportunity for the analysis of voice production.Objectives. This article is aimed to describe main physiological principles at the base of voice production (in particular of vocal tract), and an overview about liter-ature on MRI of the vocal tract. This is presented in order to analyze both present results and future perspectives.Method. A narrative review was performed by searching the MeSH terms "vocal tract" and "MRI" in Pub Med database. Then, the obtained studies were subse-quently selected by relevancy.Results. Main fields described in literature concern technical feasibility and op-timization of MRI sequences, modifications of vocal tract in vowel or articulatory phonetics, modifications of vocal tract in singing, 3D reproduction of vocal tract and segmentation, and describing vocal tract in pathological conditions.Conclusions. MRI is potentially the best method to study the vocal tract physi-ology during voice production. Most recent studies have achieved good results in representation of changes in the vocal tract during emission of vowels and singing. Further developments in MR technique are necessary to allow an equally detailed study of faster movements that participate in the articulation of speaking, which will allow fascinating perspectives in clinical use.

Introducción. La rápida evolución tecnológica en la resonancia magnética (MRI) ha ofrecido recientemente una gran oportunidad para el análisis de la producción de voz.Objetivos. Este artículo tiene como objetivo describir los principales principios fisiológicos en la base de la producción de la voz (en particular, del tracto vocal) y una descripción general de la literatura sobre resonancia magnética del tracto vocal. Esto se presenta con el fin de analizar tanto los resultados actuales como las perspectivas futuras.Método. Se realizó una revisión narrativa mediante la búsqueda de los términos MeSH "tracto vocal" y "MRI" en la base de datos PubMed. Los estudios obtenidos se seleccionaron posteriormente por relevancia.Resultados. Los campos principales descritos en la literatura se refieren a la viabi-lidad técnica y optimización de secuencias de resonancia magnética, modificaciones del tracto vocal en una vocal o fonética articulatoria, modificaciones del tracto vocal en el canto, reproducción 3D del tracto vocal y segmentación y descripción del tracto vocal en condiciones patológicas.Conclusiones. La resonancia magnética es potencialmente el mejor método para estudiar la fisiología del tracto vocal en el momento de la producción de la voz. Los estudios más recientes han obtenido buenos resultados en la representación de cambios en el tracto vocal durante la emisión de vocales y el canto. Se necesitan más desarrollos en la técnica de RM para permitir un estudio igualmente detallado de los movimientos más rápidos que participan en la articulación del habla, lo que permi-tirá perspectivas fascinantes en el uso clínico.

CT and MR imaging of chemotherapy-induced hepatopathy.

Chemotherapy-induced hepatopathy includes a wide variety of parenchymal and vascular hepatic changes on imaging, including diffuse or focal hepatopathies (i.e. hepatitis, steatosis, fibrosis, pseudocirrhosis, or sinusoidal obstruction). These changes can profoundly alter the hepatic parenchyma on imaging and result in both false negative and false-positive diagnoses of hepatic metastases and lead to errors in patient management strategies. It is therefore important for radiologists to have a comprehensive knowledge of the imaging patterns that may develop following chemotherapy. The purpose of this review is to explore the broad spectrum of hepatic parenchymal and vascular chemotherapy-induced changes on CT and MR imaging.

Real-life experience with liver iron concentration R2 MRI measurement in patients with hemoglobinopathies: baseline data from LICNET.

BACKGROUND: Real-life data on the use of R2 MRI for the assessment of liver iron concentration (LIC) remain limited. METHODS: We conducted a cross-sectional analysis on 363 patients (mean age 35.6 yr, 44.1% men) with hemoglobinopathies (204 ß-thalassemia major [TM], 102 ß-thalassemia intermedia [TI], and 57 sickle cell disease [SCD]) that were evaluated with R2 MRI as part of LICNET, an MRI network of 13 Italian treatment centers. RESULTS: The mean LIC was 7.8 mg/g (median: 4.0), with high LIC (>7 mg/g) noted in both transfused (TM, TI 37%; SCD 38%) and non-transfused (TI 20%) patients. Ferritin levels correlated with LIC in both transfused (TM, TI, SCD) and non-transfused (TI) patients (P < 0.001), although lower values predicted high LIC in non-transfused patients (1900 vs. 650 ng/mL in TM vs. non-transfused TI). A correlation between LIC and ALT levels was only noted in HCV-negative patients (rs = 0.316, P < 0.001). The proportion of patients with high LIC was significantly different between iron chelators used (P = 0.023), with the lowest proportion in deferasirox (30%) and highest in deferiprone (53%)-treated patients. CONCLUSIONS: High LIC values persist in subgroups of patients with hemoglobinopathy, warranting closer monitoring and management optimization, even for non-transfused patients with relatively low ferritin levels.

Accuracy of the water-siphon test associated to barium study in a high prevalence gastro-oesophageal reflux disease population: a novel statistical approach.

RATIONALE, AIMS AND OBJECTIVES: Gastro-oesophageal reflux disease (GORD) is 'a condition which develops when the reflux of gastric content causes troublesome symptoms or complications'. Instrumental diagnostic tests generally used for GORD are 24-hour pH-metry and upper gastrointestinal (GI) endoscopy but barium study associated with provocative manoeuvres such as the water-siphon test (WST), has also been used for GORD. The aim of this paper was to estimate the accuracy of several tests in patients with GORD in a tertiary care setting, focusing on WST, which is rapid and non-invasive, simple to perform and well-tolerated by patients. METHOD: A total of 172 consecutive patients, symptomatic for reflux referred to a tertiary medical centre, were considered and data regarding the WST, 24-hour pH-metry, upper GI endoscopy with histology were analysed using latent class analysis, a multivariable statistical method for estimating the accuracy of tests when a gold standard is not available. RESULTS: The overall proportion of GORD in the sample was estimated at 0.664 [95% confidence interval (CI) = (0.589; 0.731)]. WST proved to be the most sensitive [Se = 0.886; 95% CI = (0.688; 1.000)] compared with pH-metry [Se = 0.620; 95% CI = (0.493; 0.745)] and endoscopy with histology [Se = 0.534; 95% CI = (0.273; 0.789)]. It was less specific [Sp = 0.537; 95% CI = (0.003; 1.000)] than pH-metry [Sp = 0.547; 95% CI = (0.281; 0.813)], and even less than endoscopy with histology [Sp = 0.862; 95% CI = (0.495; 1.00)]. Positive predictive values were estimated at 0.792 [95% CI = (0.721; 0.862)] for WST, 0.731 [95% CI = (0.643; 0.819)] for pH-metry and 0.886 [95% CI = (0.811; 0.961)] for endoscopy with histology. Negative predictive values were estimated at 0.707 [95% CI = (0.573; 0.841)] for WST, 0.422 [95% CI = (0.310; 0.534)] for pH-metry and 0.484 [95% CI = (0.387; 0.581)] for endoscopy with histology. CONCLUSION: Water-siphon test might possibly be useful in patients with suspected GORD because it is highly sensitive and predictive. A positive outcome of the WST associated with a barium study can certainly justify upper GI endoscopy and support any pharmacological treatment of GORD.

Stercorary aseptic peritonitis due to diastatic caecal perforation: computed tomography findings.

Caecal perforation is a complication secondary to colon obstruction. It may present with insidious clinical features and may be associated with chronic constipation. The event may become severe due to the peritonitic development. We present a case of caecal perforation associated with sub-occlusive carcinoma of the left colon and hypotonic colitis caused by chronic lavative abuse, demonstrated with Computed Tomography.

[Digital videofluorography and esophageal achalasia: from diagnosis to follow-up]. / Videofluorografia digitale e acalasia esofagea: dalla diagnosi al follow-up postoperatorio.

The aim of this retrospective study was to evaluate the use of digital videofluorography in the preoperative and postoperative management of esophageal achalasia surgical treatment. From 1990 to 2004, 25 patients with achalasia, diagnosed by digital videofluorography and confirmed by motility studies and endoscopy, underwent surgery. All patients underwent digital videofluorography at 1, 6 and 12 months in order to evaluate the completeness of the myotomy and the efficacy of the antireflux procedures. At postoperative videofluorography esophageal transit time was decreased in all patients (100%); esophageal motor activity was unchanged in 23 (92%), and modified in two patients (8%) with onset of peristaltic-like motor activity; 8 patients (35%) presented decreased preoperative dilatation; all patients had a WST negative for post-myotomy reflux. On the basis of our experience and the advantages of the procedure we suggest videofluorography as a first-approach diagnostic examination useful for surgical indications and postoperative follow-up in achalasic patients.

[Hiatal hernia, gastro-oesophageal reflux and oesophagitis: videofluorographic, endoscopic and histopathological correlation]. / Ernia iatale, reflusso gastroesofageo ed esofagite: correlazione videofluorografica, endoscopica ed istopatologica.

The aim of the study was to evaluate the correlation between hiatal hernia and gastro-oesophageal reflux and related histological abnormalities in patients without endoscopic oesophagitis. A consecutive series of 78 patients with a history of gastro-oesophageal reflux symptoms and hiatal hernia, as defined by videofluorography combined with a water siphon test, underwent oesophagogastroduodenoscopy and multiple biopsies. Hiatal hernia was confirmed endoscopically in 99% of cases. The water siphon test was positive for reflux in 72% of cases. At endoscopy 42% of patients had oesophagitis and/or Barrett's oesophagus and 58% had no lesions. In the group without endoscopic lesions, at histology oesophagitis-related alterations were found in 98% and intestinal metaplasia in 27%. In conclusion, this study shows that symptomatic gastro-oesophageal reflux patients with radiologically defined hiatal hernia should undergo endoscopy with multiple biopsies above the squamocolumnar junction, even when endoscopy is normal. This is in order to detect histological gastro-oesophageal-reflux-related alterations, above all, when a positive water siphon test is also present, owing to its known correlation with intestinal metaplasia.

[Digital cineradiology in the diagnosis and surgical treatment of pharyngo-oesophageal junction motor disorders]. / La cineradiografia digitale nella diagnosi e nel trattamento chirurgico dei disordini motori della giunzione faringo-esofagea.

The aim of the study was to report our experience with the use of radiology in functional disorders of the cricopharyngeal muscle and their surgical therapy using digital cineradiology. Five-hundred and seventy dysphagic patients underwent dynamic study of the oral and pharyngeal phases of swallowing (Videofluoroscopic Swallowing Study, VFSS). A motor disorder of the cricopharyngeal muscle was diagnosed by videofluorography in 19 patients: the disorder was mild in 8, moderate in 7 and severe in 4. Two of these underwent cricopharyngeal myotomy, with an improvement in their dysphagia and swallowing mechanisms. VFSS provides a morphological and functional view of the aero-digestive tracts: this is essential in the diagnosis of cricopharyngeal dysfunction and is capable of revealing the related laryngeal penetration and tracheal aspiration. VFSS must always include an oesophageal phase study because of the known clinical and physico-pathological correlations between the gastro-oesophageal junction and the upper oesophageal sphincter. On the basis of our experience we believe that VFSS could be used as a primary investigation, followed by motility studies, and that it may be a useful complementary procedure both in the diagnosis of pharyngo-oesophageal junction motor disorders and with a view to surgical indications.

Digital cineradiographic study of swallowing in infants with neurologic disease. Our experience.

PURPOSE: The study is aimed at proposing the use of digital cineradiography in the evaluation of swallowing disorders in children affected by severe neurological or developmental disability, in order to correctly identify these conditions and provide therapeutic approaches that could solve their feeding problem, improve their nutritional conditions and decrease the risk of infections. MATERIALS AND METHODS: In the period between March 2001 and July 2003, 12 children (8 males and 4 females), aged between 9 months and 13 years, (average 6.2 years), affected by severe neurological or psychomotor disorders were evaluated with digital cineradiography. This investigation was requested for recurrent pulmonary infections and/or dysphagia with weight loss. All the examinations were performed with radio-controlled equipment provided with a digital C arm. RESULTS: Using the above mentioned technique, in all 12 patients, it was possible to differentiate those with disorders of the oral and/or pharyngeal swallowing phase (9/12) from those without swallowing dysfunction (3/12). In 9/9 patients passage of contrast medium into the upper airways was observed during swallowing: in 2 of them this was limited to the laryngeal vestibule (sub-epiglottic penetration), while in 7/9 cases aspiration of contrast medium into the trachea (5/9) or into the right bronchus (1/9) or into both bronchi (1/9) was recorded. In one patient the aspiration decreased in the sequences acquired with hyperflexion of the head. In 3/9 patients we recorded the transition of contrast medium into the nasopharynx during swallowing caused by incomplete closing of the oropharyngeal isthmus by the soft palate. In 3/9 patients there was incomplete clearing of the pharynx with contrast medium deposition in glosso-epiglottic vallecules and in the pyriform sinuses; only in one case did this stagnation result in post-swallowing aspiration. More than one disorder was found in 5/9 patients, and one only in 4/9. CONCLUSIONS: On the basis of our preliminary data it is possible to conclude that the dynamic swallowing study with digital technique allows a clear-cut evaluation of the swallowing process with minimum discomfort for the patient. On the other hand, the technique exposes to the risk of ionizing radiation; however, in consideration of the important clinical and therapeutic implications and in agreement with the literature, we believe that the importance of the information provided by the technique outweighs the risks linked to radiations.

Radiology and adult celiac disease. Current indications of small bowel barium examinations.

PURPOSE: To evaluate the current role of small bowel (SB) radiologic barium examinations in adult celiac disease (ACD). MATERIALS AND METHODS: Retrospective review of 61 SB barium examinations in 280 ACD patients. Sixty-one examinations in 61 patients were performed: 7/61 with small bowel ''follow-through'' (SBFT) method, and 54/61 with small bowel double-contrast enteroclysis (SBE). Radiological criteria for ACD diagnosis were divided in four groups: 1) definite ACD (reversal of jejuno-ileal fold pattern); 2) possible ACD (malabsorption pattern and ileal jejunization); 3) malabsorption (fluid, dilatation, ''moulage'', flocculation); 4) complicated ACD (irregular, thickened, nodular folds; wall thickening; masses). RESULTS: In 49/61 patients RX examinations were performed before ACD diagnosis. In this group, clinical presentations included one or more of the following: diarrhea, weight loss, malabsorption, anemia, abdominal pain; 7/49 had a SBFT, and 42/49 a SBE. All 7 SBFTs showed pattern 3, and 8/42 SBEs showed pattern 2 (suspected ACD). In 34/42 patients SBE allowed a definite ACD diagnosis (pattern 1); however, 6/34 were also false-positive for complicated ACD (pattern 4). Ten out of sixty-one patients were clinically suspected of having complicated ACD, correctly excluded (8/8) or confirmed (2/2) by SBE. None of these 59/61 patients had a radiologic diagnosis of normal' SB. The last 2/61 patients with ACD, examined for persisting chronic anemia, had a normal SBE. CONCLUSIONS: This study confirm that SB radiology may be of value either in ACD diagnosis or in excluding complications: SBE is currently the most accurate examination. SBE alone is however less accurate in confirming complicated ACD; further imaging techniques are always needed in this clinical context.

[Digital cineradiography of the pharynx and the oesophagus after total or partial laryngectomy].

PURPOSE: The aim of the present study is to report our experience using digital cineradiography to assess morphological and functional disorders of the pharynx in patients with prior partial or total laryngectomy. MATERIALS AND METHODS: From March 2000 to October 2002, 21 patients (18 males and 3 females) with prior total laryngectomy (12 patients), total laryngopharyngectomy (2 patients) and partial laryngectomy (7 patients) were examined. A digital cineradiography with 12 frames/second acquisition was performed in all patients. In four patients the procedure was interrupted for massive barium aspiration, without cough (silent aspiration). In 17 patients standing in the left posterior oblique position and prone in the right posterior oblique position the oesophagus and oesophagogastric junction were also examined. The water siphon test was performed at the end of the procedure. Small boluses (10 ml) of liquid (60% w/v) and high-density (250% w/v) barium, barium paste (110% w/v), and solid meal (obtained spreading a dry biscuit with barium paste) were used. RESULTS: All patients with prior total laryngectomy and total laryngopharyngectomy showed morphological and functional disorders of the neopharynx: parapharyngeal diverticulum (2 cases), submandibular pouch (6 cases), fistulas (2 cases), lumen narrowing and post-surgical stenoses (2 cases), tumour recurrence (1 case), prominent cricopharynx (5 cases) and rhinopharyngeal reflux (4 cases). All patients with prior partial laryngectomy (7 cases) presented silent aspiration. Eleven patients had an oesophageal motility disorder, which was very serious in three of them with decrease in oesophageal clearing and barium retention in the oesophagus. Oesophagogastric junction evaluation showed hiatus hernia in six cases, two of them with associated gastro-oesophageal reflux. CONCLUSIONS: Digital cineradiography appears able to identify the organic and functional postoperative complications of patient treated with partial or total laryngectomy. A special swallowing study can suggest to the speech therapist the best compensatory mechanism for improving patient swallowing and therefore quality of life.

The role of MRI in traumatic rupture of the diaphragm. Our experience in three cases and review of the literature.

PURPOSE: To evaluate the role and effectiveness of Magnetic Resonance Imaging (MRI) in blunt diaphragmatic injuries by reviewing the literature and our experience in three cases. MATERIALS AND METHODS: We reviewed the medical records and MRI findings of three patients with diaphragmatic injury due to blunt abdominal trauma. All patients were previously examined with chest X-ray and CT and later with MRI at our institution. Coronal and sagittal SE TI-w and fast SE T2-w sequence images were acquired. All patients underwent surgery. RESULTS: MRI showed a 5.5 cm tear in the left hemidiaphragmatic dome with herniation of the stomach and colon into the thoracic cavity in the first case; a 1 cm tear in the diaphragmatic dome with herniation of the stomach and posterior abscess in the second case; and an 8 cm breach in the left diaphragm with visceral herniation in the third case. CONCLUSIONS: The major advantage of MRI lies in its capability of directly acquiring coronal and sagittal images allowing evaluation of the entire diaphragm, both in normal and in pathological conditions. In our experience, MRI showed the exact site and size of the diaphragmatic rupture in all cases. However, this technique cannot be performed in emergency situations or in multitrauma patients. Therefore, in agreement with the literature, helical CT remains the modality of choice in traumatic patients. MR imaging is useful only in doubtful cases and in haemodynamically stable patients.

[Supra-esophageal manifestations of gastroesophageal reflux, a different diagnostic approach and an indication for laparoscopic Nissen fundoplication: our experience]. / Manifestazioni sopraesofagee della GERD, un diverso approccio diagnostico ed un'indicazione alla Nissen laparoscopica: nostra esperienza.

24-hour oesophageal pH monitoring with a dual pH probe is considered to be the most sensitive test for diagnosing GORD-related otolaryngological manifestations. In this study we evaluate an initial diagnostic approach with digital videofluorography associated to the water siphon test and primary "ex juvantibus" therapy with proton pump inhibitors for patients with supra-oesophageal symptoms of GORD. The results of Nissen fundoplication surgical treatment are also assessed in some of these patients. Two hundred and thirty patients with suspected GORD-related supra-oesophageal symptoms were referred for videofluorography and the water siphon test. When hiatal hernia and/or reflux were found, patients were referred for medical therapy with proton pump inhibitors. Five patients, who had had a good or excellent response to the medical therapy, but had a recurrence underwent laparoscopic Nissen fundoplication and videofluorography 6 months after surgery. Within 6 months, more than 80% of patients had an excellent or good response to medical therapy. In patients undergoing laparoscopic Nissen fundoplication, hoarseness and chronic cough disappeared within 3 months and videofluorography showed good morphofunctional results of the surgery. In patients with GORD-related supra-oesophageal manifestations, videofluorography plus the water siphon test is useful initial investigation, and laparoscopic Nissen fundoplication can be a valid alternative therapeutic option.