Retrograde cricopharyngeus dysfunction (R-CPD) is a medical condition first identified by Dr Robert Bastian of the Bastian Voice Institute in which people are unable to burp. [1] Some with the condition are also unable to vomit, or can only do so with great difficulty. It is a lifelong problem that is usually first noted in adolescence, but has also been reported as early as infancy. Most people with this condition also complain of frequent bloating, "gurgling noises" from the throat, frequent flatulence and poor tolerance to carbonated beverages. Many sufferers experience noticeable abdominal distension, with men and women alike saying they look "six months pregnant" by the end of the day. As air is released through the night, the abdomen will assume a more normal appearance by morning.
The cricopharyngeus muscle is also described as the upper esophageal sphincter. It is a circular muscle at the base of the throat, behind the larynx. The muscle is closed (actively contracting) at all times and opens for swallowing or to allow relief of pressure in the esophagus via burping or vomiting. In R-CPD, the swallowing function of the muscle is normal but the response to pressure in the esophagus is absent.
Diagnosis of R-CPD is achieved primarily through a positive match of telltale symptoms. Many patients finally get an accurate diagnosis of R-CPD after having been subjected to years of testing for, and unsuccessful treatment of, gastronomical disorders like GERD, aerophagia, gallbladder dysfunction, and IBS.
The initial treatment of R-CPD is injection of botox into the cricopharyngeus muscle. botox will temporarily weaken or paralyze the muscle. The direct effects of botox last for three months on average. For most patients with R-CPD, injection of botox into the cricopharyngeus muscle will reverse the symptoms, and for many, the effect will last beyond the first three months. 30% of patients describe some swallowing difficulty after the injection that usually resolves after the first 3-4 weeks.
The first treatment is usually performed under general anesthesia. The procedure lasts 15-20 minutes and results in a mild sore throat. The effect of botox is delayed for three days on average and most patients with successful results report the ability to burp by the fifth day after the procedure. Subsequent injections can be considered and administered with local anesthesia. [2]
An alternative if the injection is unsuccessful is to undergo partial cricopharyngeal myotomy. [3]
A study from 2022 showed 88.2% efficacy of the botox treatment. The most common side effect in the study was mild and temporary difficulty swallowing, which went away on its own. This affected 30.6% of the participants. [4]
A small percentage of patients will require a subsequent injection of Botox for lasting results.
Gastroenterology is the branch of medicine focused on the digestive system and its disorders. The digestive system consists of the gastrointestinal tract, sometimes referred to as the GI tract, which includes the esophagus, stomach, small intestine and large intestine as well as the accessory organs of digestion which include the pancreas, gallbladder, and liver.
Esophageal achalasia, often referred to simply as achalasia, is a failure of smooth muscle fibers to relax, which can cause the lower esophageal sphincter to remain closed. Without a modifier, "achalasia" usually refers to achalasia of the esophagus. Achalasia can happen at various points along the gastrointestinal tract; achalasia of the rectum, for instance, may occur in Hirschsprung's disease. The lower esophageal sphincter is a muscle between the esophagus and stomach that opens when food comes in. It closes to avoid stomach acids from coming back up. A fully understood cause to the disease is unknown, as are factors that increase the risk of its appearance. Suggestions of a genetically transmittable form of achalasia exist, but this is neither fully understood, nor agreed upon.
An esophageal motility disorder (EMD) is any medical disorder resulting from dysfunction of the coordinated movement of esophagus, which causes dysphagia.
An endoscopy is a procedure used in medicine to look inside the body. The endoscopy procedure uses an endoscope to examine the interior of a hollow organ or cavity of the body. Unlike many other medical imaging techniques, endoscopes are inserted directly into the organ.
Trismus is a condition of restricted opening of the mouth. The term was initially used in the setting of tetanus. Trismus may be caused by spasm of the muscles of mastication or a variety of other causes. Temporary trismus occurs much more frequently than permanent trismus. It is known to interfere with eating, speaking, and maintaining proper oral hygiene. This interference, specifically with an inability to swallow properly, results in an increased risk of aspiration. In some instances, trismus presents with altered facial appearance. The condition may be distressing and painful. Examination and treatments requiring access to the oral cavity can be limited, or in some cases impossible, due to the nature of the condition itself.
Vaginismus is a condition in which involuntary muscle spasm interferes with vaginal intercourse or other penetration of the vagina. This often results in pain with attempts at sex. Often it begins when vaginal intercourse is first attempted. Vaginismus may be considered an older term for pelvic floor dysfunction.
Burping is the release of gas from the upper digestive tract of animals through the mouth. It is usually audible.
Aerophagia is a condition of excessive air swallowing, which goes to the stomach instead of the lungs. Aerophagia may also refer to an unusual condition where the primary symptom is excessive flatus (farting), belching (burping) is not present, and the actual mechanism by which air enters the gut is obscure or unknown. Aerophagia in psychiatry is sometimes attributed to nervousness or anxiety.
The inferior pharyngeal constrictor muscle is a skeletal muscle of the neck. It is the thickest of the three outer pharyngeal muscles. It arises from the sides of the cricoid cartilage and the thyroid cartilage. It is supplied by the vagus nerve. It is active during swallowing, and partially during breathing and speech. It may be affected by Zenker's diverticulum.
Eosinophilic esophagitis (EoE) is an allergic inflammatory condition of the esophagus that involves eosinophils, a type of white blood cell. In healthy individuals, the esophagus is typically devoid of eosinophils. In EoE, eosinophils migrate to the esophagus in large numbers. When a trigger food is eaten, the eosinophils contribute to tissue damage and inflammation. Symptoms include swallowing difficulty, food impaction, vomiting, and heartburn.
Oropharyngeal dysphagia is the inability to empty material from the oropharynx into the esophagus as a result of malfunction near the esophagus. Oropharyngeal dysphagia manifests differently depending on the underlying pathology and the nature of the symptoms. Patients with dysphagia can experience feelings of food sticking to their throats, coughing and choking, weight loss, recurring chest infections, or regurgitation. Depending on the underlying cause, age, and environment, dysphagia prevalence varies. In research including the general population, the estimated frequency of oropharyngeal dysphagia has ranged from 2 to 16 percent.
Keratosis Pharyngis is a medical condition where keratin grows on the surface of the pharynx, that is the part of the throat at the back of the mouth. Keratin is a protein that normally occurs as the main component of hair and nails. It is characterized by the presence of whitish-yellow dots on the pharyngeal wall, tonsils or lingual tonsils. They are firmly adherent and cannot be wiped off. The surrounding region does not show any sign or inflammation or any other symptoms that make affect the rest of the body.
Globus pharyngis, globus hystericus or globus sensation is the persistent but painless sensation of having a pill, food bolus, or some other sort of obstruction in the throat when there is none. Swallowing is typically performed normally, so it is not a true case of dysphagia, but it can become quite irritating. It is common, with 22–45% of people experiencing it at least once in their lifetime.
Pseudodysphagia, in its severe form, is the irrational fear of swallowing or, in its minor form, of choking. The symptoms are psychosomatic, so while the sensation of difficult swallowing feels authentic to the individual, it is not based on a real physical symptom. It is important that dysphagia be ruled out before a diagnosis of pseudodysphagia is made.
Esophageal spasm is a disorder of motility of the esophagus.
Nutcracker esophagus, jackhammer esophagus, or hypercontractile peristalsis, is a disorder of the movement of the esophagus characterized by contractions in the smooth muscle of the esophagus in a normal sequence but at an excessive amplitude or duration. Nutcracker esophagus is one of several motility disorders of the esophagus, including achalasia and diffuse esophageal spasm. It causes difficulty swallowing (dysphagia) with both solid and liquid foods, and can cause significant chest pain; it may also be asymptomatic. Nutcracker esophagus can affect people of any age but is more common in the sixth and seventh decades of life.
Vocal cord paresis, also known as recurrent laryngeal nerve paralysis or vocal fold paralysis, is an injury to one or both recurrent laryngeal nerves (RLNs), which control all intrinsic muscles of the larynx except for the cricothyroid muscle. The RLN is important for speaking, breathing and swallowing.
Laryngopharyngeal reflux (LPR) or laryngopharyngeal reflux disease (LPRD) is the retrograde flow of gastric contents into the larynx, oropharynx and/or the nasopharynx. LPR causes respiratory symptoms such as cough and wheezing and is often associated with head and neck complaints such as dysphonia, globus pharyngis, and dysphagia. LPR may play a role in other diseases, such as sinusitis, otitis media, and rhinitis, and can be a comorbidity of asthma. While LPR is commonly used interchangeably with gastroesophageal reflux disease (GERD), it presents with a different pathophysiology.
Cricopharyngeal spasms occur in the cricopharyngeus muscle of the pharynx. Cricopharyngeal spasm is an uncomfortable but harmless and temporary disorder.
Cricopharyngeal myotomy is a surgical sectioning of the cricopharyngeus muscle, also known as the upper esophageal sphincter, that has been advocated for the treatment of cricopharyngeal spasm, or cricopharyngeal achalasia, that leads to cervical dysphagia in the clinical setting.