Pediatric retrograde cricopharyngeal dysfunction diagnosed by high-resolution impedance manometry

OBJECTIVES

The inability to burp, known as retrograde cricopharyngeal dysfunction (R-CPD), was initially described in adults. The proposed clinical diagnostic criteria for R-CPD include belching inability, abdominal bloating and discomfort/nausea, postprandial chest pain, and involuntary noises. Botulinum toxin injection to the cricopharyngeal muscle has been reported to be beneficial. High-resolution esophageal impedance-manometry (HRIM) features in adolescent patients with R-CPD have not been described yet.  The aim of our study was to describe the clinical and HRIM findings of pediatric patients with R-CPD.

METHODS

Clinical and manometric features of five pediatric patients diagnosed with R-CPD were reviewed. HRIM study protocol was modified to include the consumption of carbonated drink to provoke symptoms and distinctive manometric features.

RESULTS

We report five female patients aged 15-20 years who presented with an inability to burp and involuntary throat sounds. HRIM revealed normal upper esophageal sphincter (UES) relaxation during swallowing, but abnormal UES relaxation with concurrent high esophageal impedance reflecting air entrapment and secondary peristalsis following the carbonated drink challenge. Four patients exhibited esophageal motility disorder. All patients reported improvement or resolution of symptoms after botulinum toxin injection to the cricopharyngeus muscle.

CONCLUSIONS

Adolescents with an inability to burp, reflux-like symptoms, bloating, and involuntary throat noises should be assessed for R-CPD by pediatric gastroenterologists with HRIM. The relatively recent recognition of this novel condition is the likely reason for its under- and misdiagnosis in children.

Retrograde cricopharyngeus dysfunction: How does the inability to burp affect daily life?

BACKGROUND

Retrograde cricopharyngeus dysfunction (R-CPD), a condition first detailed in 1987 and termed in 2019, refers to the cricopharyngeal muscle's inability to relax to allow the retrograde passage of gas. Limited research exists on the fundamental characteristics of this condition, including its impact on one's life. The purpose of this study is to characterize R-CPD and how the inability to burp affects the social lives of people who suffer from it.

METHODS

A Qualtrics survey was distributed on the subreddit "r/noburp," a community of 26,000 individuals sharing information about R-CPD. Adults aged 18-89 experiencing R-CPD symptoms were invited to participate. Participants reported on their experiences with R-CPD and its effects on social life on a 4-point Likert scale (1 = strongly disagree to 4 = strongly agree). Data was analyzed using descriptive statistics.

KEY RESULTS

Among the 199 respondents, the mean age was 30.9, and gender identity was 74%/25% female/male. 99% reported inability to burp, 98% reported abdominal bloating, 93% reported socially awkward gurgling noises, 89% reported excessive flatulence, and 55% reported difficulty vomiting. Only half discussed their symptoms with their primary care provider (PCP), and 90% disagreed with receiving adequate help. Average Likert scores indicated embarrassment (3.4), anxiety/depression (3.1), negative impact on relationships (2.6), and work disruption (2.7) due to R-CPD.

CONCLUSIONS & INFERENCES

R-CPD is unfamiliar to many healthcare providers, leaving patients underserved. It not only affects daily life but also personal and professional relationships. Raising awareness by understanding disease basic features may increase diagnosis and treatment rates, improving quality of life.

Hypnosis in the treatment of retrograde cricopharyngeus dysfunction: A case report

Retrograde cricopharyngeus dysfunction (R-CPD) causes an inability to belch. This case report describes the successful treatment of R-CPD with the use of hypnosis. Thereafter, the patient was able to burp small amounts of air, and was encouraged to continue his use of hypnosis as needed. Hypnosis and possibly other noninvasive treatments should be used for R-CPD before employment of more invasive and costly treatments such as botulinum toxin administration.

Change in glottic view during intubation using a KoMAC videolaryngoscope: A retrospective analysis

Intubation with videolaryngoscopy has become popular in various clinical settings. However, despite the use of a videolaryngoscope, difficult intubation still exists and intubation failure has been reported. This retrospective study assessed the efficacy of the 2 maneuvers in improving the glottic view during videolaryngoscopic intubation. The medical records of patients who underwent videolaryngoscopic intubation and whose glottal images were stored in electronic medical charts were reviewed. The videolaryngoscopic images were divided into 3 categories according to the applied optimization techniques as follows: conventional method, with the blade tip located in the vallecular; backward-upward-rightward pressure (BURP) maneuver; and epiglottis lifting maneuver. Four independent anesthesiologists scored the visualization of the vocal folds using the percentage of glottic opening (POGO, 0-100%) scoring system. A total of 128 patients with 3 laryngeal images were analyzed. The glottic view was the most improved in the epiglottis lifting maneuver among all the techniques. The median POGO scores were 11.3, 36.9, and 63.1 in the conventional method, BURP, and epiglottis lifting maneuver, respectively (P < .001). There were significant differences in the distribution of POGO grades according to the application of BURP and epiglottis lifting maneuvers. In the POGO grades 3 and 4 subgroups, the epiglottis lifting maneuver was more effective than the BURP maneuver in improving the POGO score Inadequate visualization of the vocal folds occurred even when intubation was performed using a videolaryngoscope. The application of optimization maneuvers, such as BURP and epiglottis lifting by the blade tip, could improve the glottic view.

The Long-term Efficacy of Botulinum Toxin Injection to Treat Retrograde Cricopharyngeus Dysfunction

Objectives

To report the percentage of patients with symptom relief 6 or more months after botulinum toxin injection into the cricopharyngeus muscle for retrograde cricopharyngeus dysfunction (R-CPD).

Study Design

Retrospective case series of consecutively treated patients.

Setting

Tertiary care laryngology clinic.

Subjects and Methods

A review was performed of the first 200 patients who were diagnosed with R-CPD and treated with botulinum toxin injection into the cricopharyngeus muscle by a single surgeon. The study group was limited to those for whom a minimum of 6 months has elapsed since the injection. Items assessed were efficacy, safety, complications, and duration of benefit.

Results

Of 200 patients treated, (99.5%) gained the ability to burp and 95% experienced relief of the cardinal symptoms of R-CPD: inability to belch, socially awkward gurgling noises, abdominal/chest pressure and bloating, and excessive flatulence. For those who experienced relief, 159 (79.9%) maintained a satisfactory ability to burp after 6 months. Of those who did not maintain the ability, 12 underwent a second injection, 1 patient underwent 3 subsequent injections, and 3 patients underwent partial myotomy. No patients experienced complications of botulinum toxin injection itself, and 4 patients had complications from esophagoscopy or anesthesia.

Conclusion

In a case series of 200 patients with retrograde cricopharyngeus dysfunction, 99% experienced relief of the cardinal symptoms and 79.9% experienced lasting relief of their symptoms beyond pharmacologic duration of action after a single injection of botulinum toxin into the cricopharyngeus muscle. Relief can be reestablished in the remainder via additional injection or cricopharyngeus myotomy.

A Rare Case Involving the Inability to Belch

A 17-year-old girl was referred to our hospital with an inability to belch, while experiencing chest gurgling noises, and severe abdominal bloating. She reported having these symptoms all her life. A timed barium esophagogram revealed a moderate amount of bubbles in the esophagus and gastric fundus, which significantly increased after the examination. High resolution manometry revealed that the basal upper esophageal sphincter pressure increased with a rise in the cervical esophageal pressure. A pathological inability to belch is rare; at present, no specific name exists to describe the disorder. Further research is needed in this unexplored field.

Inability to Belch and Associated Symptoms Due to Retrograde Cricopharyngeus Dysfunction: Diagnosis and Treatment

Objective

To propose and test the validity of a new syndrome called retrograde cricopharyngeus dysfunction (R-CPD) that explains inability to belch and the associated symptoms of loud gurgling noises, chest and abdominal pain/distention, and excessive flatulence, as well as to report the results of botulinum toxin (BT) injection into the cricopharyngeus muscle (CPM) for both diagnosis and treatment of R-CPD.

Study Design

To develop a case series of consecutive patients matched to the syndromic features of R-CPD, inject the CPM with BT as a concurrent diagnostic and therapeutic maneuver, and assess results.

Setting

Bastian Voice Institute (Downers Grove, Illinois).

Subjects and Methods

Consecutive (unselected) patients presenting with inability to belch and associated symptoms were matched to the proposed syndrome of R-CPD, treated with BT, and followed for effect on symptoms over time.

Results

All 51 patients achieved ability to belch and relief of associated symptoms, and the majority seem to have “retrained” the ability to belch on a potentially “permanent” basis.

Conclusion

R-CPD can be diagnosed syndromically, using a symptom complex; clinical diagnosis is validated by relief of symptoms after BT injection; and BT into the CPM is an efficacious treatment, whose benefit appears to often last longer than the pharmacologic duration of action of BT.