Case report: A case of novel treatment for retrograde cricopharyngeal dysfunction

Health-Related Quality of Life Metrics in Patients With Retrograde Cricopharyngeus Dysfunction

OBJECTIVE

We sought to objectively characterize functional quality of life and social anxiety metrics in patients with retrograde - cricopharyngeus dysfunction (R-CPD) using validated questionnaires.

METHODS

A survey was posted to a private R-CPD Facebook group and a public R-CPD Reddit group. The survey contained demographic and clinical questions, as well as the PROMIS-29 questionnaire and the Social Anxiety Questionnaire (SAQ). The PROMIS-29 questionnaire contains 7 subdomains of quality of life functioning and is scored against a national average. The SAQ is a 30-item questionnaire with 5 subdomains of social anxiety. Comparisons of means were performed using t-tests and logistic regressions.

RESULTS

Survey results from 239 respondents were included. The majority of respondents were young (<30 years, 51.1%) and female (73.6%). Two hundred twenty (92.1%) reported all 3 cardinal R-CPD symptoms and were included in the analysis of PROMIS-29 and SAQ results. On the PROMIS-29 questionnaire, respondents reported high levels of anxiety (71.0%), depression (55.1%), fatigue (66.8%), sleep impairment (43.0%), social avoidance (54.3%), and pain impairment (58.8%). The mean SAQ score was 96.4, with 52.0% of respondents scoring above the cutoff for social anxiety. Reported anxiety was highest in interactions with strangers (71.1%, 95% confidence interval [CI]: 64.3%-77.9%) and lowest in interactions with the sex 1 is attracted to (44.5%, 95% CI: 37.0%-52.0%).

CONCLUSIONS

Patients with R-CPD have high levels of anxiety and other impairment. Results may help clinicians understand and treat patients with R-CPD, and provide benchmarks by which clinicians may better monitor response to therapy, and provide benchmarks for clinicians to better monitor therapy response.

Etiology, Clinical Presentation, and Management of Retrograde Cricopharyngeus Dysfunction: A Systematic Review

ImportanceThe retrograde cricopharyngeus dysfunction (R-CPD) is an emerging topic in otolaryngology, gastroenterology, and primary care.ObjectiveTo review the current literature about the etiology, clinical presentation, and management of retrograde cricopharyngeus dysfunction (R-CPD).DesignSystematic review.SettingThree investigators conducted the PubMED, Scopus, and Cochrane Library review of the literature related to the etiologies and management of patients with R-CPD through the PRISMA statements.ParticipantsStudies that incorporated R-CPD patients.InterventionsIn-office, or operating room botulinum toxin injection, or no treatment.Main outcome measuresEtiology, clinical presentation, and therapeutic outcomes.ResultsSeventeen studies met the inclusion criteria (826 patients). A family history was reported in 28.0% of cases with most patients developing R-CDP symptoms in childhood (55.5%). In addition to the cardinal symptom of the inability to belch, associated complaints of bloating and chest pain, gurgling noises, and excessive flatulence were found in 95.7%, 86%, and 80.2% of cases, respectively.The diagnosis was recognized by patients themselves in 78.9% of cases. The immediate success rate of botulinum toxin injection into the cricopharyngeal sphincter in facilitating burping was 92.5%. Recurrence occurred in the first month of follow-up in 9.5% of cases, whereas 12.6% and 27.9% of patients had recurrence during the 1-5 months and more than 6 months posttreatment, respectively. Transient dysphagia is the most prevalent complication after botulinum toxin injection (31.1%). The heterogeneity was high across studies, limiting the establishment of further combined analyses.Conclusion and relevanceR-CPD is a recently-recognized and likely-underdiagnosed condition associated with severe symptoms affecting the quality of life of patients. Future studies are needed to elucidate the etiology of this condition, develop adequate patient-reported outcome questionnaires for the baseline and follow-up evaluations of symptoms, and propose therapeutic consensus.

Diagnosis and Management of Retrograde Cricopharyngeal Dysfunction: A Systematic Review

Objective

Retrograde cricopharyngeal dysfunction (R-CPD) is a syndrome with rapidly increasing awareness since being first described in March 2019. As such, few cases of R-CPD are currently reported in the literature. The goal of this study is to provide a comprehensive systematic review of the available literature on R-CPD, including patient characteristics, diagnosis, and management.

Data Sources

PubMed, Scopus, EMBASE.

Review Methods

A systematic review of the available English literature was conducted using the data sources PubMed, Scopus, and EMBASE. Studies with original data of patients experiencing classic symptoms of R-CPD were included. Independent abstract screening followed by full-text screening was performed to assess study eligibility. Data extraction of patient demographics, symptoms, treatment, and follow-up were subsequently performed.

Results

Common presentations of R-CPD include abelchia (100%), abdominal bloating (83%), and gurgling noises (75%). 554 (86.9%) patients had improved symptoms after initial treatment with BTX. The most common initial dose was 50 units in 204 (37.3%) patients. Subsequent BTX injections resolved symptoms in 40 (80%) patients. Six patients ultimately received CP myotomy for recurrent symptoms, resulting in long-term resolution in 4 (67%) patients.

Conclusion

R-CPD is a newly recognized syndrome with effective treatment options including botulinum toxin injections and cricopharyngeal myotomy, where appropriate. Diagnostic modalities including esophageal manometry may aid in the initial work up of R-CPD, however further studies are required to assess its diagnostic utility.

Retrograde cricopharyngeal dysfunction and treatment with botulinum toxin: a systematic review

PURPOSE

Retrograde cricopharyngeal dysfunction (RCPD) is a disease first described systematically in 2019. The main symptom is inability to belch due to cricopharyngeal muscle dysfunction. Other symptoms include gurgling noises, chest pain, bloating, and excessive flatulence. This paper aims to describe RCPD, the aetiology and diagnosis, treatment options, follow-up, and treatment with botulinum toxin (BT).

METHODS

A systematic review was done according to the PRISMA guidelines, using the databases PubMed, Embase, and Cochrane at 8/3/2024. The search combined BT with different descriptions of RCPD. All papers were screened by two authors.

RESULTS

120 papers were identified in the search. After screening 13 papers describing 472 patients in total were included. Mean age was 29.3 years with 51.1% men. Diagnosis was established in 82.4% of the cases by symptomatology, 2.1% by high-resolution manometry, and 15.3% by oesophagoscopy. The mean amount of BT was 66 units (U). Mean follow-up time was 13 months. After 1-4 weeks 93.7% had an effect post-treatment and 81.0% after 6 months. Common symptoms were inability to belch (99.8%), chest pain and/or bloating (95.4%), gurgling noises (84.9%), and excessive flatulence (75.9%). Common complications were mild and transient dysphagia (59.4%) and reflux (35.4%).

CONCLUSION

The accumulated numbers of patients with RCPD indicates a growing attention to the plausible condition. Injection with BT is a good and safe treatment of RCPD. Most patients only experience mild and transient complications to the treatment. Much is still unknown about RCPD and conditions for setting the diagnosis needs to be evaluated and established internationally.

Inability to belch syndrome: what the gastroenterologist needs to know

PURPOSE OF REVIEW

To review recent publications on the inability to belch syndrome.

RECENT FINDINGS

Five recent retrospective case series indicate that the inability to belch syndrome usually starts in early childhood and is often accompanied by gurgling noises in the chest, pain in the chest or upper abdomen, bloating, and excessive flatulence. Currently, the vast majority of patients who have been identified with inability to belch have self-diagnosed the syndrome on the basis of information available on the internet. A favorable response to injection of botulinum toxin in the cricopharyngeus muscle is regarded as confirmation of the diagnosis. In a mechanistic study in eight patients, absence of reflexogenic relaxation of the upper esophageal sphincter upon rapid gaseous esophageal distension was confirmed to play a pivotal role in the pathogenesis of the syndrome.

SUMMARY

The inability to belch syndrome, caused by failure of the upper esophageal sphincter to relax when the esophageal body is distended, clearly exists and may not be as rare as thought hitherto. However, overdiagnosis is also likely to occur because the diagnosis is usually made on the basis of symptoms only. The efficacy of botulinum toxin injection in the upper sphincter needs to be assessed in double-blind placebo-controlled studies.

Retrograde Cricopharyngeus Dysfunction, a New Motility Disorder: Single Center Case Series and Treatment Results

Background/Aims

Retrograde cricopharyngeus dysfunction (R-CPD) is a new clinical entity characterized by inability to belch and associated symptoms of loud gurgling noises, chest and/or abdominal pressure, abdominal bloating, and excessive flatulence. R-CPD can be treated with botulinum toxin (BT) injection in the upper esophageal sphincter. We hereby report patient demographics, symptomatology, and treatment results of a series of consecutive patients who presented at our center.

Methods

Data on 50 consecutive patients presenting with R-CPD were prospectively collected using a standardized questionnaire prior to, 1 month after treatment and at the end of follow-up. All patients were diagnosed using a set of clinical symptoms.

Results

Fifty patients (26 females) were included, median age was 27.5 years (range, 17-65). Median body mass index was 22.7 kg/m2 (range, 16.6-37.5). Inability to belch was present in all patients, > 90% of patients experienced gurgling noises and abdominal/chest discomfort as result of their condition. One month after injection of BT, 40.8% of patients experienced complete relief of symptoms, 24.5% good symptom improvement, 24.5% some symptom improvement and 10.2% no improvement. At median follow-up of 29 months (range, 3-50) post-treatment, 51.3% (n = 20/39) of patients reported persistent complete relief of symptoms, 12.8% good improvement of symptoms (n = 5/39), in 15.4% some improvement (6/39) and 20.5% loss of or no response (n = 8/39). Only minor and transient side effects were reported.

Conclusions

Our case series of 50 patients with R-CPD shows very good short-term and good long-term improvement of symptoms after injection of BT. These results are in line with previous studies.

Retrograde Cricopharyngeal Dysfunction: A Review

Retrograde cricopharyngeal dysfunction (RCPD), also referred to as retrograde cricopharyngeus dysfunction, is a condition characterized by the inability to burp. The pathophysiology of this condition is thought to result from failure of cricopharyngeal sphincter relaxation during periods of esophageal distension, which leads to patients' bothersome symptoms. RCPD negatively impacts patients' quality of life and is associated with bloating, gurgling, avoidance of carbonation, self-imposed dietary and lifestyle changes designed to minimize discomfort, and flatulence. Complaints often start during adolescence, and many patients search for a diagnosis for years before obtaining treatment. A recent increase in awareness through patient-led social media discussion boards describing the 'no burp' syndrome is leading to an increasing incidence of presentations, often with patients making a self-diagnosis. The increased incidence of RCPD is fueling a larger case series investigating treatment options and outcomes. In this review, we discuss what is known about the pathophysiology of this condition, the otolaryngologic perspective on diagnosis and treatment, the patients' lived experience of this condition, and the influence of social media on RCPD.

Retrograde Cricopharyngeus Dysfunction effectively treated with low dose botulinum toxin. A case report from Italy

A large constellation of hitherto unexplained symptoms including inability to burp, gurgling noises from the chest and lower neck, abdominal bloating, flatulence, painful hiccups and emetophobia was defined as Retrograde Cricopharyngeus Dysfunction (R-CPD) in 2019. First choice treatment of R-CPD involves injection of botulinum toxin into the cricopharyngeus muscle under local or general anesthesia. This treatment has been found to be effective in the vast majority of subjects, with limited adverse events and prolonged therapeutic effects. Notwithstanding, R-CPD is still a poorly understood and underestimated disease, and a specific therapeutic dosage range of botulinum toxin (BT) has not been yet established. In this report, we describe the first case of R-CPD diagnosed in Italy, successfully treated with unilateral, anesthesia-free injection of 10 units of onabotulinum toxin into the cricopharyngeus muscle, representing the lowest dose reported to date.