November 28, 2020

Unable to Burp? You May Have "Retrograde Cricopharyngeus Dysfunction"

There is a very rare condition that prevents certain individuals from being able to burp which on the face of it seems an inconsequential issue... but for those afflicted, is anything but. This condition known medically as retrograde cricropharyngeus dysfunction (R-CPD), it causes daily issues for afflicted patients that profoundly affects quality of life. Such patients report among others:

• The inability to belch

• Gastric bloating, discomfort/nausea, chest pain, especially and profoundly after eating

• Socially awkward gurgling noises from the chest and lower neck as though the esophagus is churning and straining to eject the air 

• Excessive flatulence

• Social inhibition as a result of above

• Difficulty vomiting (common but not universal)

Oftentimes, such patients undergo extensive testing with no specific diagnosis and more frustratingly, no clear course of treatment. 

Normally, the cricopharyngeus (CP) muscle acts like a one-way valve or sphincter that briefly opens to allow food and liquids to pass into the esophagus during normal swallow. However, when air for whatever reason is present and builds up in the stomach, the air can erupt up into the esophagus during which the CP muscle can also transiently relax allowing an individual to burp. However, for patients suffering from R-CPD, the CP muscle normally relaxes during swallow, but NOT when air erupts into the esophagus leading to symptoms. Watch video below.

Fortunately, Dr. Bastian in Chicago, published a small series that points to a seemingly simple, yet effective treatment for those suffering from R-CPD, mainly botox injections into the cricopharyngeus muscle, specifically 4 injections containing a total of 50-75 units diluted in 2-4ml saline. This procedure is technically not difficult.

Even better, unlike most conditions for which botox must be readministered every few months for continued relief, for most patients, only a single treatment often resolved R-CPD. A more "permanent" treatment would be to divide the cricopharyngeus muscle (cricopharyngeal myotomy).

At least in my clinic, typical studies that may need to be performed prior to any surgical intervention include esophagoscopy, barium swallow, and 24 hour impedance with manometry. For young adults, only a barium swallow is typically obtained. Ever since publishing this blog article as well as video, we see about one patient every week or 2 with this condition.

Some non-surgical interventions that can be tried for relief (but may not necessarily work for everyone) include:

Air Vomit: This technique is basically attempting to trigger a vomit by sticking a finger or two down the back of the throat.

Laying on your back slightly upside down (head lower than the feet): This causes the air to "rise" away from the throat and into the stomach and intestines. Eventually, you fart the air out.

• Take Gas-X

Shaker Exercise: Lie flat on your back. Lift your head and look at your toes (lift head only, do not raise shoulders). Hold this position (the goal is 60 seconds). Relax, lower head and rest one minute. Perform these steps three times. Then, lift head up and lower head quickly 30 times (head only, do not raise shoulders). Remember to breathe while doing exercises. Do all steps three times a day. Wait at least 30 minutes after eating before doing exercises. Confused? Watch demonstration here.


The Long-term Efficacy of Botulinum Toxin Injection to Treat Retrograde Cricopharyngeus Dysfunction. Open . 2020 Jun 29;4(2):2473974X20938342. doi: 10.1177/2473974X20938342. eCollection Apr-Jun 2020. 

Inability to Belch and Associated Symptoms Due to Retrograde Cricopharyngeus Dysfunction: Diagnosis and Treatment. OTO Open. 2019 Jan-Mar; 3(1): 2473974X19834553.

Dysfunction of the belch reflex: a cause of incapacitating chest pain. Gastroenterology. 1987;93:818-822.

Chest pain and inability to belch. Gastroenterology. 1989;96:274-275.

A case of inability to belch. J Gastroenterol Hepatol. 2001;16:349-351.

Fauquier blog
Fauquier ENT

Dr. Christopher Chang is a private practice otolaryngology, head & neck surgeon specializing in the treatment of problems related to the ear, nose, and throat. Located in Warrenton, VA about 45 minutes west of Washington DC, he also provides inhalant allergy testing/treatment, hearing tests, and dispenses hearing aids.

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