Retrograde cricopharyngeal dysfunction (R-CPD) is a little-known disorder first identified in 2019. It causes an inability to burp, accompanied by debilitating symptoms such as bloating, chest pain, excessive flatulence, and gurgling sounds. At EpiCURA, a hospital located in Baudour, Belgium, ENT specialist Jérôme Lechien, MD, PhD, offers an innovative treatment that restores a normal life to 90% of patients.
In a recent interview with MediQuality, a Medscape Network platform, Lechien provided detailed insights into the diagnosis and treatment of the disorder.
What causes R-CPD?
The exact cause is unknown, but I believe that most patients probably experience gastric reflux during the first year of life. In response, they probably develop an esophageal contraction reflex to prevent the reflux from entering the airways and lungs. Most patients who come in are between 20 and 30 years old. They’ve never burped and often have family members — siblings, for example — who have also never burped.
What are the disabling symptoms of this disorder?
Most patients with R-CPD are physically incapable of burping. Normally, we all burp after eating to release the air swallowed during meals. In people who can’t burp, swallowed air accumulates in the esophagus, rises, and becomes trapped at the top because the muscle between the throat, and esophagus doesn’t relax. This causes esophageal distention, which can result in very disabling chest pain.
The second symptom is gurgling noises, often described as croaking sounds. It’s a distinctive sign that, along with the patient’s report of never having burped, helps confirm the diagnosis.
Another symptom is gas and flatulence — naturally, since the trapped air can’t escape upwards, it exits through the lower gastrointestinal tract instead. Patients may also experience abdominal pain and bloating. Less commonly, symptoms include hiccups or, more rarely, acid reflux.
Is burping important?
It is important, but some people who don’t burp aren’t bothered in their daily lives. Others, however, say it’s unbearable and severely impacts their quality of life. One of my patients was on morphine at a pain clinic because of this condition. My theory is that patients who are unaffected have excellent digestive motility, meaning their digestive system moves gas efficiently downward.
Why is this disorder so little known?
The condition was only identified in 2019. The first study was conducted by American ENT specialists. Since then, most larynx and swallowing specialists are aware of the disorder. In Europe, as often happens, awareness came later. It’s virtually unknown in Belgium, and we don’t know how many people it affects. But I see so many patients with this issue that I don’t believe it’s rare.
Diagnosis is straightforward: if a patient can’t burp and makes strange throat noises, the diagnosis is confirmed, and treatment is absolutely possible. So far, I’ve seen about 30 patients for this condition, but in the past week or two, about eight new patients have come in each week. It’s exploding. I believe any gastroenterologist could treat this condition, provided they have the right equipment.
What does the innovative treatment you offer involve?
In 2019, Dr Bastian in the United States [Robert Bastian, MD, laryngologist and founder of the Bastian Voice Institute in Downers Grove, Illinois] developed a treatment involving botulinum toxin (Botox) injections into the upper esophagus. Because the muscle is constantly closed and doesn’t relax, the patient is sedated in the operating room (OR). Once asleep, a rigid metal tube about 25 cm long, called an esophagoscope, is inserted through the mouth into the esophagus. Botox is then injected into the muscle wall, paralyzing it. Within 2-3 days, most patients begin to burp and feel relief from all their symptoms.
There is a second, more complex technique done using electromyography (EMG). This procedure is performed in an outpatient setting rather than the OR. A very long, fine needle is inserted through the neck, carefully avoiding the larynx. The patient is asked to swallow while an electrical signal helps determine whether the needle is in the esophagus or larynx. Once correctly positioned, Botox is injected. This technique requires significant training — not only in Botox use, but also in mastering EMG. There have been cases where the injection mistakenly went into the larynx, causing vocal cord paralysis.
The third technique, developed at EpiCURA, is transnasal injection. I use a long fiberoptic scope — a camera used routinely by ENTs — that goes through the nose into the throat. This scope has an operating channel that allows me to insert micro-instruments, about 1 mm wide. The patient sits in the exam chair; leans their head forward to expose the back of the larynx; and puffs out their cheeks hard, like [when popping their ears] during airplane takeoff. This is called the Valsalva maneuver, and it opens the space fully. Once exposed, I inject the Botox using a very long, flexible needle passed through the scope.
What is the advantage of this third technique?
It’s a brand-new technique. Right now, I have about a 60% success rate, whereas the OR method achieves about 95% success. I think I still need to fine-tune the technique and get longer needles. It’s quite innovative — it takes only 5 minutes. In contrast, surgery involves sedation, intubation, recovery, monitoring, so the OR method limits us to treating five or six patients per day. With the transnasal method, I can treat around 30 patients in a single day.
Does this treatment cure R-CPD?
Yes. In 80% of cases, a single Botox injection is enough. We don’t know why. Typically, Botox lasts 6 months, whether for wrinkles or for laryngeal conditions. But with R-CPD, it seems patients learn how to burp while the Botox is active, and the effect becomes permanent.
Are there any side effects from treatment?
Because the esophagus stays open, there’s a risk that gastric reflux may worsen in patients who are already prone to it. All patients experience difficulty swallowing for 1-8 days after the injection. When we use the nasal and throat approach, this usually resolves within a day. When done in the OR, it can last about 8 days. With the EMG technique, Botox may spread to the larynx, potentially causing voice problems for several months. That’s why it must be done carefully — but no one in Belgium is currently using this method.
This article was translated from MediQuality using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.
Botox isn’t just for wrinkles. It’s also helping patients with retrograde cricopharyngeal dysfunction finally burp and breathe easier.
