Inability to burp or belch

Inability to burp or belch occurs when the upper esophageal sphincter (cricopharyngeus muscle) loses its ability to relax in order to release the “bubble” of air. The sphincter is a muscular valve that encircles the upper end of the esophagus just below the lower end of the throat passage. If looking from the front at a person’s neck, it is just below the “Adam’s / Eve’s apple” and more specifically, directly behind the cricoid cartilage. If you care to see this on a model, look at the photo below. That sphincter muscle relaxes for about a second every time we swallow saliva, food, or drink. All of the rest of the time it is contracted. Whenever a person belches, the same sphincter needs to let go for a split second in order for the excess air to escape upwards. In other words, just as it is necessary  that the sphincter “let go” to admit food and drink downwards in the normal act swallowing, it is also necessary that the sphincter be able to “let go” to release air upwards for belching.

People who cannot release air upwards are miserable.  They can feel the “bubble” sitting at the mid to low neck with nowhere to go. Or they experience gurgling when air comes up the esophagus only to find that the way of escape is blocked by a non-relaxing sphincter.  It is as though the muscle of the esophagus continually churns and squeezes without success. The person so wants and needs to burp, but continues to experience this inability to burp.  Sometimes this can even be painful.  Such people often experience abdominal bloating as the air must make its way through the intestines before finally being released as flatus.

Approaches for treating the inability to burp:

For people who experience this problem to the point of discomfort and reduced quality of life, here is one approach: First, a videofluoroscopic swallow study, perhaps with effervescent granules.  This establishes that the sphincter works normally in a forward (antegrade) swallowing direction, but not in a reverse (retrograde) burping or regurgitating fashion.  Along with the symptoms described above, this establishes the diagnosis of retrograde-only cricopharyngeus dysfunction (non-relaxation).

Second, a treatment trial involving placement of Botox into the malfunctioning sphincter muscle. The desired effect of Botox in muscle is to weaken it for at least several months.  The person thus has many weeks to verify that the problem is solved or at least minimized. The Botox injection could potentially be done in an office setting, but we recommend the first time (at least) placing it during a very brief general anesthetic in an outpatient operating room.  That’s because the first time, it is important to answer the question definitively, that is, that the sphincter’s inability to relax when presented with a bubble of air from below, is the problem.

For a few months at least, patients should experience dramatic relief of their symptoms.  And, early experience suggests that It may be that this single Botox injection allows the system to “reset” and the person may never lose his or her ability to burp.  Of course, if the problem returns, the individual could elect to pursue additional Botox treatments, or in a truly severe case, might even elect to undergo endoscopic laser cricopharyngeus myotomy.


Photos of the cricopharyngeus muscle:

1. The highlighted oval represents the location of the cricopharyngeus muscle.
2. The cricopharyngeus muscle in the open position.
3. The cricopharyngeus muscle in the contracted position.
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Marfan syndrome

A genetic connective tissue disorder caused by a defect in gene FBN1, which codes for abnormal structure of fibrillin-1, a protein crucial for formation of normal connective tissue. Most critical is Marfan syndrome’s effect on heart and blood vessels, which tend to dilate and be at risk of rupture. Connective tissue in bones, ligaments, and other parts of the body is also affected.

Laryngologists may encounter Marfan syndrome because parts or all of the aorta may need to be replaced over time, due to abnormal dilation of the weakened arterial wall, with risk of rupture. When such surgery is done, the left recurrent nerve is at risk of injury, and this would lead to left vocal cord paralysis. With Marfan syndrome, it is rare to live to age 70.


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Presbylarynx

Literally, “old age larynx.” The term presbylarynx is used to signify vocal cord changes (and, by extension, vocal limitations) that accompany aging. Typically, these vocal cord changes include bowing of the cords, atrophy, flaccidity, and sometimes reduced wetness and lubrication of the vocal cords. The symptoms of these changes include foggy or weak voice quality, difficulty being heard in noisy places, and decreased vocal endurance.

Such findings are by no means universal in older individuals, however, and some of these changes may be resisted with vocal conditioning exercises. Moreover, some “presbylarynx” changes can be seen in individuals who are only 40 or 50, due to disuse of the voice or familial predisposition. For these reasons, presbylarynx does not seem to be a very useful term; instead, a precise description of the patient’s vocal cords seems to be more useful.


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Bilateral vocal cord fixation

Immobility of both vocal cords due to a scarring rather than paralytic cause. The scarring might manifest as a synechia that tethers the vocal cords to each other and prevents them from separating during breathing. Or it could mean that both cricoarytenoid joints are ankylosed, or “frozen.”

The commonest cause of bilateral vocal cord fixation is prolonged endotracheal intubation, such as in gravely ill or injured persons, who may spend weeks in an intensive care unit and on a ventilator. Vocal cord fixation can rarely be caused by rheumatoid arthritis. It is also seen infrequently as a progressive, late complication of radiation therapy for larynx cancer.


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Necrosis

The death of cells or tissue. In laryngology, necrosis is seen most commonly after radiation therapy to the larynx for cancer treatment. Radiation kills the tumor but at the same time damages the blood supply of normal tissue on a permanent basis. Necrosis in this instance is called “radionecrosis.” Or, necrosis could result from trauma (a physical wound) that disrupts blood supply, or occasionally in the context of ulcerative laryngitis, which seems to necrose the superficial layers of the vocal cords. Necrotic tissue typically sloughs off down to viable (living) tissue.


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Phonatory insufficiency

When the vocal cords cannot close sufficiently or vibrate adequately to produce a serviceable voice. An inability to close is usually evidenced by air-wasting phenomenology.

This phonatory insufficiency could have one of several causes. It could be due to the loss of part or all of one or both vocal cords, such as after removal of a vocal cord cancer. Or it could follow prolonged intubation and resulting pressure necrosis of the posterior ends of the vocal cords 1. Another possibility might be scarring of the anterior joint capsule of the cricoarytenoid joints, also as a complication of prolonged endotracheal intubation due to grave illness. Yet another cause might be vocal cord paralysis or paresis. The latter problems not only interfere with the cords’ ability to close, but also make the affected cord flaccid, so that it blows out of the way too easily, further wasting the air stream.

When a person with any of these causes of poor vocal cord closure tries to produce voice, maximum phonation time is typically reduced, because only a fraction of the air pushed up from the lungs is converted to sound, with the remainder of the air quickly “wasted.”

The second main category of phonatory insufficiency, in which the vocal cords cannot vibrate adequately, is seen in a person with stiff or scarred vocal cords. Such a person may not waste air, but just be unable to produce other than a harsh whispery sound, because the stiffened vocal cords (now more like thick leather rather than like, as is normal, plastic wrap overlying a thin layer of jello) cannot vibrate as freely or at all.


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  1. Bastian RW, Richardson BE. Postintubation phonatory insufficiency: an elusive diagnosis. Otolaryngol Head and Neck Surg. 2001; 124(6): 625-33. 

Arytenoid chondritis / perichondritis

An infectious or inflammatory response with ongoing ulceration or granulation on the superstructure of the arytenoid cartilage. Here we are talking of the arytenoid cartilage and/ or its thin “envelope” of fibrous tissue called perichondrium. The root chondr- refers to cartilage.

A similar and much more common disorder, contact granuloma or contact ulcer, occurs on the medial surface of the arytenoid cartilage, but low and at the level of the vocal process. When arytenoid chondritis or perichondritis occurs, it causes significant chronic pain (in contrast to contact granuloma, which can be pain-free or bring only minor discomfort). We have never diagnosed the underlying cause. Treatment tends to require definitive removal of the area of cartilage involved (not the entire arytenoid, of course), and then typically the area will heal, though often only after a time of re-granulation.


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Flaccidity of vocal cords

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Voice Building:

Voice Building (shorter version):

Vocal cord scissoring

Mismatching of the levels of the vocal cords. Vocal cord scissoring may in some cases be asymptomatic, but more often it introduces a rough quality to the voice, because the desired mirror-image bilateral symmetry of oscillation will be lost.


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