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Laryngopedia

To educate about voice, swallowing, airway, coughing, and other head and neck disorders

Laryngopedia By Bastian Medical Media

Multimedia Encyclopedia


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Normal Larynx

Below are images of a normal larynx, offered as a point of comparison for all of the examples of laryngeal diseases and disorders elsewhere on Laryngopedia. One can reasonably call the vocal cords, “laryngeal lips.” Thinking of a trumpeter’s lips as an analogy, he or she separates them to take a breath, and then pinches them together to “buzz” into the mouth piece of the trumpet. Similarly, the laryngeal lips separate for breathing, though in a V-shaped opening, and then press together in a line to “buzz” into the vocal tract. One could almost play the trumpet using the laryngeal lips!

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Vocal cords (1 of 7)

The line of sight is from directly above these open (for breathing) vocal cords, and downward in the line of the trachea. The difference in vocal cord width is not real, but a function of the angle of viewing. This is the position of the vocal cords while breathing.

Vocal cords during voice (2 of 7)

Here the vocal cords are producing sound at G2 (98Hz). Under standard light, vibration is so rapid that it is perceived as a blurring of the margins.

Vibration in rubber bands (3 of 7)

Twang a thick rubber band and you will see the same kind of blurring phenomenon because vibration is so rapid.

Phonation under strobe light (4 of 7)

During voicing (phonation), under strobe light, to provide apparent slow motion view of vibration. This is the closed phase of vibration at A2 (110 Hz, or 110 vibration cycles per second).

Open phase of vibration (5 of 7)

The open phase of vibration, also at A2. For emphasis: This cycling between open and closed phases of vibration occurs 110 times per second at A2!

Clodes phase of vibration (6 of 7)

Now at A4 (440 Hz), this is one of 440 closed phases of vibration per second.

Open phase (7 of 7)

One of 440 open phases of vibration that occurs per second, again as seen under strobe light.


Glottic Stenosis or Scarring

Glottic stenosis refers to scarring in the larynx at the level of the vocal cords (glottis). It usually narrows the space available between the cords for inflow of air to the lungs while breathing. Or it can cause divots in the posterior vocal cords. Examples of possible causes:

Congenital Web

A baby can be born with vocal cords fused together due to a developmental defect.

Endotracheal (breathing) tube injury

Breathing tubes go through the mouth, down into the larynx, between the vocal cords and into the upper trachea. If a person requires ventilation due to critical illness and the breathing tube sits between the vocal cords for several weeks, then raw surfaces can be created. A scar between the raw surfaces on opposite cords can bind the vocal cords together with insufficient remaining space for easy breathing. Or there can be scarring (ankylosis) of the cricoarytenoid joints.

Radiation for Larynx Cancer

When larynx cancer is radiated for cure, occasionally the radiation burns are deep enough to create scarring between the cords, or to progressively fibrose (stiffen) the cricoarytenoid joints.

Other causes are gunshot wounds, or swallowed plumber’s lye injury (usually young children).

The Effect of Glottic Stenosis

Persons with glottic stenosis describe exercise intolerance and/ or noisy inspiratory breathing (causing involuntary inspiratory phonation or stridor) if the scarring is only the posterior vocal cords. Or if there is scarring of the anterior 2/3 of the cords, voice will also be affected.

Treatment Options

Treatment options include microsurgical release of scar tissue, with or without steroid injection and topical anti-scarring agents, and occasionally an open reconstruction with grafting.


Breathing Tube Injury, not Vocal Cord Paralysis

This middle-aged woman was injured severely in an auto accident as a teenager. Recovery involved a long stay in ICU, and ventilation via a breathing (endotracheal) tube for a few weeks prior to tracheotomy. Fifteen years earlier, a posterior commissuroplasty was done by me on the left side.  Severely short of breath before that procedure, she said the improvement was such that she was able to do most activities of daily living remarkably well for many years. While still much better than prior to the posterior commissuroplasty, she has felt a little more limited in the past few years and wants now another similar airway-widening procedure. Speaking voice can easily pass for normal, though she thinks it is occasionally a little rough.
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Aperture is very narrow (1 of 6)

Seen from a distance, during exhalation, the vocal cord aperture is perhaps 30% of normal.

Involuntary inspiratory phonation (2 of 6)

When asked to inspire rapidly, even in this distant view, the vocal cords can be seen to in-draw and vibrate (see blur), creating involuntary inspiratory phonation. Inspiratory phonation time is estimated at 2.5 seconds, rather than the normal 1 second or less.

Divot on left vocal cord (3 of 6)

The shallow “divot” of the left cord (right of photo) is all that remains of what would have been a much deeper divot created at the time of posterior commissuroplasty, 15 years earlier. The dashed line indicates the likely magnitude of laser excision.

Endotracheal tube injury (4 of 6)

The full extent of the original endotracheal tube injury is seen best in this view of the extreme posterior commissure. One can almost see the upper surface of the cricoid cartilage marked with “C” showing also a scar band between arytenoid and cricoid cartilages, especially on the right (at S).

Laser cookie bite (5 of 6)

The posterior commissure during phonation shows the divot on the left cord (right of photo). The dashed line shows the approximate magnitude of the laser “cookie bite” to be created at the time of surgery. But the lighter dotted line is a typical remaining divot after full healing. Interestingly, (as explained by Charles’ Law) if even this small area is added to the size of the glottic aperture while breathing, the patient will notice a significant improvement of exercise tolerance.

Surface scarring in the tracheotomy (6 of 6)

When there is a scar anywhere in the airway, the clinician must make sure there isn’t another causing narrowing. In this case there is no narrowing, but the tracheotomy site shows surface scarring at the arrow.

Supraglottic, Glottic, and Subglottic Endotracheal Tube Injury

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Breathing tube injury (1 of 4)

This 20-something individual was premature at birth and intubated for several weeks. Decades later, the evidence of breathing tube injury can be seen. Here, parallel lines outline likely trajectory of tube, taped at right corner of mouth. This fits as well with the left medial arytenoid divot at arrow. Dotted lines indicate aryepiglottic cord margins. Note deficit on right (left of photo) suggesting pressure necrosis from the endotracheal tube.

Aryepiglottic cord defect (2 of 4)

Aryepiglottic cord defect is better seen during phonation. The details of posterior commissure injury are obscured at this distance.

Phonation (3 of 4)

During phonation, low voice, note that the posterior vocal cords cannot come together, (even with cough or breath-holding) due to joint capsule injury from the endotracheal tube. Voice is intractably breathy.

Posterior subglottic thickening (4 of 4)

Posterior subglottic thickening surrounded by dotted lines, indicating a third level of old injury, here with no functional consequence.


Can’t Burp? Comprehensive Resources for R-CPD (in One Place)

You may have

R-CPD

Inability to belch or “burp” (Also known as Retrograde Cricopharyngeus Dysfunction, or R-CPD for short) occurs when the upper esophageal sphincter (cricopharyngeus muscle) loses its ability to relax in order to release the “bubble” of air. 

Overview of R-CPD

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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. Common symptoms include the inability to belch, gurgling noises, chest/abdominal pressure and bloating, and flatulence.

Symptoms of R-CPD

The Big Four Symptoms Of R-CPD That Provide Virtually 100% Accuracy In Diagnosis

Inability to burp

This is almost always, but not exclusively “lifelong,” though persons may not recognize this as a “problem” or “difference from others” until early childhood or teenage years.

R-CPD frog icon

Socially awkward gurgling noises

This is almost always, but not exclusively “lifelong,” though persons may not recognize this as a “problem” or “difference from others” until early childhood or teenage years. These noises can be mostly quiet and “internal,” but more often are loud enough to be embarrassing. Mouth opening makes them louder. Almost everyone says they are easily heard several feet away; not infrequently “all the way to the door.” They engender social anxiety in most persons with R-CPD, causing some to avoid eating or drinking for hours before social occasions and even during them. Carbonation makes them much worse and is to be avoided at all costs. Some more colorful patient descriptions:

  • Symphony of gurgles
  • Croaking frogs
  • Creaking floorboards
  • Dinosaur sounds
  • Strangled whale.
R-CPD Bloating icon

Bloating & Pressure

Most common location is high central abdomen. Distention is common, especially later in the day. Using pregnancy as an analogy even in men, the usual degree of distention is described as “3 or 4 months.” “Six months” is not rare, and one slender young man was “full term.” Almost as often as abdominal distress, patients describe chest pressure, and for some that is the worst symptom. Some have pressure in the low neck. While “pressure” is the frequent descriptor, some experience occasional sharp pain in abdomen, back, or between shoulder blades. Some have to lie down after eating to find some relief.

R-CPD Flatulence leaf blower icon

Flatulence

Routinely, this is described as “major,” or even “ridiculous.” Flatulence increases as the day progresses, and many experience it into the night. When around others, some scan their surroundings at all times for a place they can go briefly to pass gas. Understandably, the social ramifications of this problem can also be major.

Other Common Symptoms

Nausea

especially after eating larger than normal amounts or drinking carbonated beverages.

Hypersalivation

when symptoms of bloating are major.

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Inability to Vomit

A few simply cannot vomit; more often it is possible but only after strenuous retching. Vomiting (spontaneous or self-induced) always begins with a very loud noise and major release of air in a phenomenon we call “air vomiting.” Emetophobia can be major.

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Painful hiccups

again, more commonly after eating.

constipation

(Still under evaluation): Flatulence can’t always be responded to, and the result is descending colon appears to dilate, making stretched muscles in its wall less effective in moving colon contents along.

Shortness of breath

A person can be so full of air that athletics, or even ability to climb stairs, etc. are impaired.

Anxiety & social inhibition

This can be MAJOR due to gurgling, flatulence, and discomfort.

Where Do Patients Come From?

0
No-burpers turned burpers!

What Causes R-CPD?

Inability to burp or belch occurs when the upper esophageal sphincter (cricopharyngeus muscle) cannot 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,” 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 and 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 can’t. 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.

Botox Injection at Bastian Voice Institute

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 belch. 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.

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Photo Essays

Abdominal Distention of R-CPD

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Gastric Air Bubble (1 of 3)

This abdominal xray of an individual with R-CPD shows a remarkably large gastric air bubble (dotted line), and also excessive air in transverse (T) and descending (D) colon. All of this extra air can cause abdominal distention that increases as the day progresses.

Bloated Abdomen (2 of 3)

Flatulence in the evening and even into the night returns the abdomen to normal, but the cycle repeats the next day. To ask patients their degree of abdominal distention, we use pregnancy as an analogy in both men and women. Not everyone describes this problem. Most, however, say that late in the day they appear to be “at least 3 months pregnant.” Some say “6 months” or even “full term.” In a different patient with untreated R-CPD, here is what her abdomen looked like late in every day. Her abdomen bulges due to all of the air in her GI tract, just as shown in Photo 1.

Non-bloated Abdomen (3 of 3)

The same patient, a few weeks after Botox injection. She is now able to burp. Bloating and flatulence are remarkably diminished, and her abdomen no longer balloons towards the end of every day.

Can’t Burp: Progression of Bloating and Abdominal Distention – a Daily Cycle for Many with R-CPD

This young woman has classic R-CPD symptoms—the can’t burp syndrome. Early in the day, her symptoms are least, and abdomen at “baseline” because she has “deflated” via flatulence through the night.  In this series you see the difference in her abdominal distention between early and late in the day.  The xray images show the remarkable amount of air retained that explains her bloating and distention.  Her progression is quite typical; some with R-CPD distend even more than shown here especially after eating a large meal or consuming anything carbonated.

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Side view of a bloated abdomen (1 of 6)

Early in the day, side view of the abdomen shows mild distention. The patient’s discomfort is minimal at this time of day as compared with later.

Mild distension (2 of 6)

Also early in the day, a front view, showing again mild distention.

Front view (3 of 6)

Late in the same day, another side view to compare with photo 1. Accumulation of air in stomach and intestines is distending the abdominal wall.

Another view (4 of 6)

Also late in the day, the front view to compare with photo 2, showing considerably more distention. The patient is quite uncomfortable, bloated, and feels ready to “pop.” Flatulence becomes more intense this time of day, and will continue through the night.

X-ray of trapped air (5 of 6)

Antero-posterior xray of the chest shows a very large stomach air bubble (at *) and the descending colon is filled with air (arrow).

Side view (6 of 6)

A lateral view chest xray shows again the large amount of excess air in the stomach and intestines that the patient must rid herself of via flatulence, typically including through the night, in order to begin the cycle again the next day.
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A Rare “abdominal crisis” Due to R-CPD (inability to burp)

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X-Ray of Abdominal Bloating (1 of 2)

This young man had an abdominal crisis related to R-CPD. He has had lifelong symptoms of classic R-CPD: inability to burp, gurgling, bloating, and flatulence. During a time of particular discomfort, he unfortunately took a “remedy” that was carbonated. Here you see a massive stomach air bubble. A lot of his intestines are air-filled and pressed up and to his right (left of photo, at arrow). The internal pressure within his abdomen also shut off his ability to pass gas. Note arrow pointing to lack of gas in the descending colon/rectum. NG decompression of his stomach allowed him to resume passing gas, returning him to his baseline “daily misery” of R-CPD.

X-Ray of Abdominal Bloating (2 of 2)

X-Ray without markings

Shortness of Breath Caused by No-Burp (R-CPD)

Persons who can’t burp and have the full-blown R-CPD syndrome often say that when the bloating and distention are particularly bad—and especially when they have a sense of chest pressure, they also have a feeling of shortness of breath. They’ll say, for example, “I’m a [singer, or runner, or cyclist or _____], but my ability is so diminished by R-CPD.  If I’m competing or performing I can’t eat or drink for 6 hours beforehand.”  Some even say that they can’t complete a yawn when symptoms are particularly bad.  The xrays below explain how inability to burp can cause shortness of breath.

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X-ray of trapped air (1 of 2)

In this antero-posterior xray, one can see that there is so much air in the abdomen, that the diaphragm especially on the left (right of xray) is lifted up, effectively diminishing the volume of the chest cavity and with it, the size of a breath a person can take.

Side view (2 of 2)

The lateral view again shows the line of the thin diaphragmatic muscle above the enormous amount of air in the stomach. The diaphragm inserts on itself so that when it contracts it flattens. That action sucks air into the lungs and simultaneously pushes abdominal contents downward. But how can the diaphragm press down all the extra air? It can’t fully, and the inspiratory volume is thereby diminished. The person says “I can’t get a deep breath.”

Esophageal Findings

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Aortic shelf (1 of 3)

A view of the mid-esophagus in a young person (early 30’s). The esophagus is kept open by the patient’s un-burped air. Note the “aortic shelf” at A, delineated by dotted lines.

Bony spur emerges due to stretched esophagus (2 of 3)

A moment later, additional air is pushed upwards from the stomach to dilate the mid-esophagus even more. A bony “spur” in the spine is thrown into high relief by the stretched esophagus.

Stretched esophagus due to unburpable air (3 of 3)

A view of the upper esophagus (from just below the cricopharyngeus muscle sphincter) shows what appears to be remarkable lateral dilation (arrows) caused over time by the patient’s unburpable air. Dilation can only occur laterally due to confinement of the esophagus by trachea (anteriorly) and spine (posteriorly), as marked.

More Interesting Esophageal Findings of R-CPD (Inability to Burp)

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Stretched Esophagus (1 of 4)

Using a 3.7mm ENT scope with no insufflated air, note the marked dilation of the esophagus by swallowed air the patient is unable to belch. T = trachea; A = aortic shelf; S = spine

Tracheal Wall (2 of 4)

The posterior wall of the trachea (T) is better seen here from a little higher in the esophagus. A = aorta

Over-dilation (3 of 4)

The photo is rotated clockwise at a moment when air from below is pushed upward so as to transiently over-dilate the esophagus. Note that the esophagus is almost stretching around the left side of the trachea in the direction of the arrow.

Bronchus (4 of 4)

Now deeper in the esophagus (with it inflated throughout the entire examination by the patient’s own air), it even appears that the left mainstem bronchus (B) is made visible by esophageal dilation stretching around it.

R-CPD and Esophageal Dilation

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Posterior pharyngeal wall (1 of 3)

Here, in the panoramic view of the "bottom of the throat," between posterior pharyngeal wall (marked PPW) and arytenoid eminences (A). The airway is indicated by the short arrow, and the dotted line shows the waiting "entrance" to the upper esophagus just above the CPM. The "entrance" opens for a second to permit passage of food or liquid through the sphincter and into the upper esophagus. The * is for reference with photo 2.

Is it R-CPD? (2 of 3)

At the entrance to the esophagus, at closer range. Notice that the mucosa is redundant, a common but not universal finding in R-CPD.

Stretched esophagus indicates R-CPD (3 of 3)

Now the view is within the upper esophagus. It almost appears that the lumen is dilated, especially in a lateral direction (arrows). Purely speculatively, one wonders if constant forcing of air upwards again a barrier ( the non-relaxing cricopharynxgeus muscle, aka upper esophageal sphincter), dilates the esophagus over time. Certainly, many with R-CPD experience not only gurgling, but also chest pressure and even pain that may be from "stretching" of the esophagus.

What the Esophagus Can Look Like “Below A Burp”

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Baseline (1 of 3)

Mid-esophagus of a person with R-CPD who is now burping well after Botox injection into the cricopharyngeus muscle many months earlier. The esophagus remains somewhat open likely due to esophageal stretching from the years of being unable to burp and also a “coming burp.”

Pre-burp (2 of 3)

A split-second before a successful burp the esophagus dilates abruptly from baseline (photo 1) as the excess air briefly enlarges the esophagus. An audible burp occurs at this point.

Post-burp (3 of 3)

The burp having just happened, the esophagus collapses to partially closed as the air that was “inflating it” has been released.

Additional Resources

Read this initial peer-reviewed article on this condition, written by Dr. Bastian and colleague.

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Amyloid

A waxy, translucent protein substance deposited into tissue in response either to unknown local factors, or as a manifestation of systemic disease, such as multiple myeloma. Treatment is generally directed at improving function, for example via local laser excision.

See also: Amyloidosis

Amyloidosis of the Larynx as Seen Over Time, with Treatment

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Primary laryngeal amyloidosis (1 of 7)

An example of primary laryngeal amyloidosis of the larynx. In this case, the yellowish, “candle-wax” proteinaceous material is being deposited just below the margin of the vocal cords (arrows)

Bulky swelling (2 of 7)

When this person produces voice, the bulky swelling just below the margin of the vocal cords creates turbulence, incomplete match, and a rough voice quality. After laser debulking, the patient had a much improved voice for many years.

Amyloidosis (3 of 7)

Eight years later, the patient reappeared. She said voice had been good for many years but had been getting increasingly hoarse for the prior couple of years. Here you see major re-deposition of amyloid material.

Amyloid deposits (4 of 7)

At very close range, the yellowish color typical of amyloid deposits is better seen.

Vocal cords cannot close completely (5 of 7)

During voice production under strobe light, the amyloid deposit under the left vocal cord prevents closure.

Amyloids Remain (6 of 7)

A year after laser debulking, the patient continued to have a very good voice, and only reappeared due to an unrelated question. As expected, smally amyloid deposits remain.

Voice remains clear (7 of 7)

When she produces voice, match and vibratory ability are very good, explaining her normal voice. It remans to be seen if amyloid will gradually reaccumulate over the next many years and need another debulking.


Abdominal Distention of R-CPD Including Before and After Botox Injection

One of the primary symptoms of R-CPD (inability to burp) is bloating. Bloating is often accompanied by actual abdominal distention due to excess air in both stomach and intestines. Since the person is unable to burp, air must now pass through the entire GI tract and be dispelled as flatulence.

Photos:

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Gastric Air Bubble (1 of 3)

This abdominal xray of an individual with R-CPD shows a remarkably large gastric air bubble (dotted line), and also excessive air in transverse (T) and descending (D) colon. All of this extra air can cause abdominal distention that increases as the day progresses.

Bloated Abdomen (2 of 3)

Flatulence in the evening and even into the night returns the abdomen to normal, but the cycle repeats the next day. To ask patients their degree of abdominal distention, we use pregnancy as an analogy in both men and women. Not everyone describes this problem. Most, however, say that late in the day they appear to be “at least 3 months pregnant.” Some say “6 months” or even “full term.” In a different patient with untreated R-CPD, here is what her abdomen looked like late in every day. Her abdomen bulges due to all of the air in her GI tract, just as shown in Photo 1.

Non-bloated Abdomen (3 of 3)

The same patient, a few weeks after Botox injection. She is now able to burp. Bloating and flatulence are remarkably diminished, and her abdomen no longer balloons towards the end of every day.

Can’t Burp: Progression of Bloating and Abdominal Distention – a Daily Cycle for Many with R-CPD

This young woman has classic R-CPD symptoms—the can’t burp syndrome. Early in the day, her symptoms are least, and abdomen at “baseline” because she has “deflated” via flatulence through the night.  In this series you see the difference in her abdominal distention between early and late in the day.  The xray images show the remarkable amount of air retained that explains her bloating and distention.  Her progression is quite typical; some with R-CPD distend even more than shown here especially after eating a large meal or consuming anything carbonated.

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Side view of a bloated abdomen (1 of 6)

Early in the day, side view of the abdomen shows mild distention. The patient’s discomfort is minimal at this time of day as compared with later.

Mild distension (2 of 6)

Also early in the day, a front view, showing again mild distention.

Front view (3 of 6)

Late in the same day, another side view to compare with photo 1. Accumulation of air in stomach and intestines is distending the abdominal wall.

Another view (4 of 6)

Also late in the day, the front view to compare with photo 2, showing considerably more distention. The patient is quite uncomfortable, bloated, and feels ready to “pop.” Flatulence becomes more intense this time of day, and will continue through the night.

X-ray of trapped air (5 of 6)

Antero-posterior xray of the chest shows a very large stomach air bubble (at *) and the descending colon is filled with air (arrow).

Side view (6 of 6)

A lateral view chest xray shows again the large amount of excess air in the stomach and intestines that the patient must rid herself of via flatulence, typically including through the night, in order to begin the cycle again the next day.

Shortness of Breath Caused by No-Burp (R-CPD)

Persons who can’t burp and have the full-blown R-CPD syndrome often say that when the bloating and distention are particularly bad—and especially when they have a sense of chest pressure, they also have a feeling of shortness of breath. They’ll say, for example, “I’m a [singer, or runner, or cyclist or _____], but my ability is so diminished by R-CPD.  If I’m competing or performing I can’t eat or drink for 6 hours beforehand.”  Some even say that they can’t complete a yawn when symptoms are particularly bad.  The xrays below explain how inability to burp can cause shortness of breath. 

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X-ray of trapped air (1 of 2)

In this antero-posterior xray, one can see that there is so much air in the abdomen, that the diaphragm especially on the left (right of xray) is lifted up, effectively diminishing the volume of the chest cavity and with it, the size of a breath a person can take.

Side view (2 of 2)

The lateral view again shows the line of the thin diaphragmatic muscle above the enormous amount of air in the stomach. The diaphragm inserts on itself so that when it contracts it flattens. That action sucks air into the lungs and simultaneously pushes abdominal contents downward. But how can the diaphragm press down all the extra air? It can’t fully, and the inspiratory volume is thereby diminished. The person says “I can’t get a deep breath.”


Long Haul Covid-19 Breathing Tube Injuries Affecting Voice and Breathing

The term “long-haulers” has been used to refer to persons with lingering systemic symptoms after successful initial recovery from Covid-19. Symptoms such as coughing, fatigue, loss of taste and smell, brain fog, etc. occur weeks or months after first falling ill. Even some whose bout with Covid-19 seemed mild can experience this “long-haul” phenomenon. For more, here’s a link to a CDC publication describing this scenario before the words “long-haul” were attached to this syndrome.

Laryngologists are now seeing patients weeks or months after their recovery from severe Covid-19 infection that required hospitalization and intubation/ventilation. These patients seem to be presenting primarily for chronic breathing and voice complaints. We are finding what could be called “long-haul” injuries from the breathing tube used while they were on ventilators. These injuries can be unavoidable when it is necessary to leave these breathing tubes in place for days to weeks due to grave illness. Such injuries in non-Covid patients are documented on Laryngopedia (see, for example: Intubation injury – Laryngopedia). Below are photos showing tracheal stenosis (narrowing), and post-intubation phonatory (voice) insufficiency, in “long-haul” breathing tube injury Covid-19 patients.

Wheezing after Covid-19 can also be Large Airway Wheezing: Series of 4 photos

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Vocal Cords (1 of 4)

This person was experiencing some shortness of breath on exertion. She was not wheezing at rest and had no personal or family history of asthma. Still, auscultation of the lungs by a prior physician while requesting that she exhale forcefully revealed wheezing sounds. She was sent for evaluation of vocal cord dysfunction. At the beginning of airway examination, during forced exhalation and audible wheezing these widely separated vocal cords tell us the source of the sound is not the vocal cords.

Trachea & Anterior Carina (2 of 4)

Suspecting large airway wheezing, topical anesthesia was used to obtain this view of the trachea in an office setting. The anterior carina is designated in this and following photos with a *.

Trachea Bulges Inward (3 of 4)

Here, the patient has just begun exhaling forcefully. The membranous tracheal wall begins to bulge inward, not as an anatomical abnormality, but as a functional phenomenon that might occur in virtually any person.

Trachea Bulges Inward (4 of 4)

At forceful end-expiration, however, the patient demonstrates unusually good ability to bulge her membranous trachea inward and nearly obstruct both mainstem bronchi. The result? Very audible wheezing. To distinguish this from actual asthma, the examiner need only listen over the manubrium and then peripheral lung fields. If this comparison reveals that wheezing is much louder centrally than peripherally, the explanation in my experience has always been large airway wheezing and not asthma. Of course, asthma AND large airway wheezing can occur together.

Tracheal stenosis as a complication of Covid-19 treatment: Series of 2 photos

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Narrowing in the Trachea > 50% (1 of 2)

This patient was in hospital for Covid-19 infection and was intubated for approximately 7 days. Now, 4 months later, she is well in general, and lung damage is mostly repaired. Yet, she is still short of breath. A key clue to the explanation is that she has “noisy breathing.” In this photo, seen in the distance below her open vocal cords, is a > 50% narrowing in her trachea (arrow). Air “squeezing” through this narrowing makes her harsh breathing noise.

Expected Size of Tracheal Opening (2 of 2)

At much closer range, the dots outline the expected size of tracheal opening. This tracheal stenosis, has been caused by the combination of inflammation and infection coupled with the pressure of the sealing balloon of her breathing tube. It is possible that balloon had to be inflated more than preferred to handle high pressure ventilation (though we do not have this information).

Injury to the vocal cords causing voice change, as a complication of Covid-19 treatment: Series of 5 photos

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Erosions in the Posterior Vocal Cords (1 of 5)

This second patient was also intubated for Covid-19 and now, months later, continues to experience a drastic voice change. Initial examiners were unable to explain this voice change. Here, the vocal cords are fully apart, and the experienced eye can see erosions in the posterior vocal cords (arrows). Erosions like these do not cause the magnitude of hoarseness this patient is experiencing. A more likely is tissue loss + cricoarytenoid joint injury (as we shall see is the case…)

Pre-phonatory Instant (2 of 5)

This is the “pre-phonatory instant.” The vocal cords have been put into position for making voice, but vibration has not yet commenced. The cords seem to come together fairly well, and so again, the reason for her very severe hoarseness is not yet evident.

Phonatory Instant (3 of 5)

Vibration has now commenced, producing an extremely hoarse voice, the cause for which is not yet seen in these “distant” views.

Close Up of Vocal Cords (4 of 5)

Now at much closer range, we again view the pre-phonatory instant, exactly as seen more distantly in photo 4. We see here that the gap between the cords is greater than appreciated from “afar.” And the erosions seen in photo 1 are actually significant divots, caused by pressure necrosis of the endotracheal tube.

Insufficient Compression of the Cords (5 of 5)

Vibration commences, exactly as in photo 3. But there is tremendous air-wasting through the keyhole created by the divots, and there is insufficient compression between the vibrating parts of the cords. Hence, the patient’s inability to say a normal number of words on one breath, and her severely degraded “breathy-pressed” voice quality.


Larynx Lipoma

Lipoma is a benign fatty tumor that can occur in any part of the body. On the neck or some other unseen part of the body, it does not require removal. But in the larynx, slow enlargement may disturb voice or even breathing, and therefore these tumors need to be removed. Removal needs to be complete to prevent re-enlargement.


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Larynx Lipoma (1 of 5)

This extremely hoarse man underwent unsuccessful attempt elsewhere to remove this submucosal mass bulging the left vocal cord (right of photo). It is a lipoma (benign fatty tumor).

CT image of tumor (2 of 5)

This coronal CT image shows the large tumor (radiolucent (black) lesion at the arrow). This tumor was removed definitively via a small neck incision. The intent was to make a small thyroid cartilage window to be sure of complete removal, but instead, the entire mass was able to be teased out through the cricothyroid space.

Lipoma removed (3 of 5)

A few weeks after removal of the mass. The patient’s voice is virtually normal. Note that the bulge of the left vocal cord (right of photo) is mostly gone, with residual swelling due to recent surgery.

Cords match (4 of 5)

When the patient produces voice, the cords match (straight dark line), explaining why his voice is now “normal.”

CT image 6 months after surgery (5 of 5)

CT image, taken 6 months after removal of the lipoma. Compare with photo 2.


R-CPD Esophageal Findings

The details of the following photos may support the R-CPD diagnosis, though they should not be considered diagnostic. Take note that all photos are non-channel scope images; that is, the scope is not able to insufflate (blow in) air. The significance: the esophagus is typically collapsed around endoscopes inserted into them and air is pumped in through a tiny channel in order to gently expand the esophagus so that its walls can be seen. Here, the air the patient cannot belch/evacuate is doing that work for us. And the esophagus remains open for extended time, the full duration of the examination. Four findings are being evaluated and compared with normal esophagoscopy images (also without insufflated air to make the comparison valid):

1) Reflux from the lower esophagus, suggesting damage to the lower esophageal sphincter from constant upward pressure trying unsuccessfully to belch.

2) What we call an “aortic shelf,” meaning that rather than an indentation of the medial circumference of the aorta, dilation of the esophagus drapes its mucosa across the upper surface of the esophagus, making a “horizontal shelf.” Keep in mind again that this is without insufflating any air.

3) Continuous patency with very infrequent, partial “clamping” down of the lumen or, often no closure at all, suggesting that there is sustained opening pressure of unbelchable air and/or that the contractile ability of the esophagus is reduced, in similar fashion to what happens to an overly-distended urinary bladder.

4) Upper esophageal dilation in a medial-lateral axis so that the upper esophagus becomes stretched in an exaggerated “oval” rather than a more gentle oval or even “circle.”

More Interesting Esophageal Findings of R-CPD (Inability to Burp)

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Stretched Esophagus (1 of 4)

Using a 3.7mm ENT scope with no insufflated air, note the marked dilation of the esophagus by swallowed air the patient is unable to belch. T = trachea; A = aortic shelf; S = spine

Tracheal Wall (2 of 4)

The posterior wall of the trachea (T) is better seen here from a little higher in the esophagus. A = aorta

Over-dilation (3 of 4)

The photo is rotated clockwise at a moment when air from below is pushed upward so as to transiently over-dilate the esophagus. Note that the esophagus is almost stretching around the left side of the trachea in the direction of the arrow.

Bronchus (4 of 4)

Now deeper in the esophagus (with it inflated throughout the entire examination by the patient’s own air), it even appears that the left mainstem bronchus (B) is made visible by esophageal dilation stretching around it.

The Esophagus Doesn’t Like Being Stretched for Years Due to Untreated R-CPD

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Lateral dilation from R-CPD (1 of 3)

In this middle-aged patient with R-CPD (inability to burp), now fully resolved (burping well for more than a year) after botox therapy. This view is pre-treatment, at mid-esophagus using an ENT scope. No air was insufflated to get this photo; the patient “has her own.” The aortic shelf is prominent, but observe the dramatic lateral dilation (arrows). S = spine; T = trachea.

Lateral dilation in the upper esophagus (2 of 3)

Now in the upper esophagus, arrows again depict the remarkable lateral dilation.

Medial-lateral stretch (3 of 3)

Opening of the esophagus is constant, due to the patient’s retained air, but as air goes downward transiently, the lumen size is reduced, almost accentuating the medial-lateral “stretch” of the esophagus. * denotes the same place in photos 2 and 3, for reference.

Emerging Esophageal Findings

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Aortic shelf (1 of 3)

A view of the mid-esophagus in a young person (early 30’s). The esophagus is kept open by the patient’s un-burped air. Note the “aortic shelf” at A, delineated by dotted lines.

Bony spur emerges due to stretched esophagus (2 of 3)

A moment later, additional air is pushed upwards from the stomach to dilate the mid-esophagus even more. A bony “spur” in the spine is thrown into high relief by the stretched esophagus.

Stretched esophagus due to unburpable air (3 of 3)

A view of the upper esophagus (from just below the cricopharyngeus muscle sphincter) shows what appears to be remarkable lateral dilation (arrows) caused over time by the patient’s unburpable air. Dilation can only occur laterally due to confinement of the esophagus by trachea (anteriorly) and spine (posteriorly), as marked.
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Saliva bubbles (1 of 5)

Saliva bubbles in the lower esophagus. Note that no air has been insufflated to obtain this view.

Symptoms point to GERD (2 of 5)

Approximately 0.5 second later, saliva wells up from below while the esophagus itself remains unchanged (Red dots in photos one and two mark identical reference points). Either abdominal wall or stomach wall compression lifts a column of stomach contents superiorly (retrograde) in the esophagus, explaining significant rates of GERD symptoms in this group, especially after treatment, which allows air to evacuate and might potentiate a higher rise of the material in the stomach/ lower esophagus.

Pocket in the aorta (3 of 5)

Seen here is what almost appears like a pocket (arrow) at the upper surface of the aorta (A). Compare with the next photo.

Trapped air expands the esophagus (4 of 5)

The patient’s unburped air further expands the esophagus and makes more of a “shelf” of the upper surface of the aorta (A).

Exaggerated laterally-stretched esophagus (5 of 5)

Now visualizing the upper esophagus, just below the cricopharyngeus muscle (UES): It appears that there is exaggerated lateral “stretch” of the esophagus. It cannot stretch posteriorly due to immovable spine (S) nor can it expand anteriorly due to the non-collapsible trachea (T). Consequently, it can only dilate laterally (arrows).

Abdominal Distention of R-CPD

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Gastric Air Bubble (1 of 3)

This abdominal xray of an individual with R-CPD shows a remarkably large gastric air bubble (dotted line), and also excessive air in transverse (T) and descending (D) colon. All of this extra air can cause abdominal distention that increases as the day progresses.

Bloated Abdomen (2 of 3)

Flatulence in the evening and even into the night returns the abdomen to normal, but the cycle repeats the next day. To ask patients their degree of abdominal distention, we use pregnancy as an analogy in both men and women. Not everyone describes this problem. Most, however, say that late in the day they appear to be “at least 3 months pregnant.” Some say “6 months” or even “full term.” In a different patient with untreated R-CPD, here is what her abdomen looked like late in every day. Her abdomen bulges due to all of the air in her GI tract, just as shown in Photo 1.

Non-bloated Abdomen (3 of 3)

The same patient, a few weeks after Botox injection. She is now able to burp. Bloating and flatulence are remarkably diminished, and her abdomen no longer balloons towards the end of every day.

Can’t Burp: Progression of Bloating and Abdominal Distention – a Daily Cycle for Many with R-CPD

This young woman has classic R-CPD symptoms—the can’t burp syndrome. Early in the day, her symptoms are least, and abdomen at “baseline” because she has “deflated” via flatulence through the night.  In this series you see the difference in her abdominal distention between early and late in the day.  The xray images show the remarkable amount of air retained that explains her bloating and distention.  Her progression is quite typical; some with R-CPD distend even more than shown here especially after eating a large meal or consuming anything carbonated.

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Side view of a bloated abdomen (1 of 6)

Early in the day, side view of the abdomen shows mild distention. The patient’s discomfort is minimal at this time of day as compared with later.

Mild distension (2 of 6)

Also early in the day, a front view, showing again mild distention.

Front view (3 of 6)

Late in the same day, another side view to compare with photo 1. Accumulation of air in stomach and intestines is distending the abdominal wall.

Another view (4 of 6)

Also late in the day, the front view to compare with photo 2, showing considerably more distention. The patient is quite uncomfortable, bloated, and feels ready to “pop.” Flatulence becomes more intense this time of day, and will continue through the night.

X-ray of trapped air (5 of 6)

Antero-posterior xray of the chest shows a very large stomach air bubble (at *) and the descending colon is filled with air (arrow).

Side view (6 of 6)

A lateral view chest xray shows again the large amount of excess air in the stomach and intestines that the patient must rid herself of via flatulence, typically including through the night, in order to begin the cycle again the next day.

Shortness of Breath Caused by No-Burp (R-CPD)

Persons who can’t burp and have the full-blown R-CPD syndrome often say that when the bloating and distention are particularly bad—and especially when they have a sense of chest pressure, they also have a feeling of shortness of breath. They’ll say, for example, “I’m a [singer, or runner, or cyclist or _____], but my ability is so diminished by R-CPD.  If I’m competing or performing I can’t eat or drink for 6 hours beforehand.”  Some even say that they can’t complete a yawn when symptoms are particularly bad.  The xrays below explain how inability to burp can cause shortness of breath. 

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X-ray of trapped air (1 of 2)

In this antero-posterior xray, one can see that there is so much air in the abdomen, that the diaphragm especially on the left (right of xray) is lifted up, effectively diminishing the volume of the chest cavity and with it, the size of a breath a person can take.

Side view (2 of 2)

The lateral view again shows the line of the thin diaphragmatic muscle above the enormous amount of air in the stomach. The diaphragm inserts on itself so that when it contracts it flattens. That action sucks air into the lungs and simultaneously pushes abdominal contents downward. But how can the diaphragm press down all the extra air? It can’t fully, and the inspiratory volume is thereby diminished. The person says “I can’t get a deep breath.”

Dramatic Lateral Dilation of the Upper Esophagus

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(1 of 3)

This photo is at the level of (estimated) C6 of the spine (at S). This person has known cervical arthritis, accounting for the prominence. Opposite the spine is the trachea (T). Note the remarkable lateral dilation (arrows) in this picture obtained with with no insufflated air using a 3.6mm ENF-VQ scope. It is the patient’s own air keeping the esophagus open for viewing.

(2 of 3)

At a moment when air from below further dilates the upper esophagus, the tracheal outline is particularly well-seen (T) opposite the spine (S). The “width” of the trachea indicated further emphasizes the degree of lateral dilation, which is necessary because spine and trachea resist anteroposterior dilation.

(3 of 3)

Just for interest, at mid-esophagus, the familiar aortic “shelf” is seen. Again, this esophagus is being viewed with a 3.6 mm scope with only the patient own (un-burped) air allowing this view.

Dramatic Dilation of the Esophagus in a Person with R-CPD due to Buildup of Swallowed Air that He Cannot Belch to get Rid of.

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View of the mid-esophagus (1 of 2)

This view in the mid-esophagus was obtained with a 3.6mm scope without an air channel. The dilation is from the patient’s own unbelchable air. Note quite major lateral dilation of the esophagus, indicated by concentric dotted lines and arrows. Dilation is not possible in the direction of unyielding spine (S) and trachea (T).

View of the mid-esophagus (2 of 2)

A view that shows more clearly the indentation of trachea (T). Persons with this much dilation of esophagus often complain as much of chest pressure as they do abdominal bloating. This man has experienced “large” reduction of R-CPD symptoms after botulinum toxin injection into his upper esophageal sphincter (cricopharyngeus muscle).


Mycobacterium Abscessus: An Infection of the Larynx

A photo gallery of mycobacterium abscessus infection located on the larynx.

Mycobacterium Abscessus

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scarring or extra tissue (1 of 6)

This immunocompromised patient is receiving monthly immunoglobulin infusions and has experienced many months of severe hoarseness. From a distance, one sees what looks like scarring or extra tissue mostly posteriorly.

Vascular stippling (2 of 6)

Under narrow band light and at closer range, notice the vascular stippling. The initial impression was that this might be a fungal infection such as blastomycosis.

Enlarged Abnormalities (3 of 6)

A month later, due to delay while optimizing her medical condition for brief general anesthesia, the abnormalities seem to have progressed/enlarged. Voice is even worse, and now the patient has mild symptoms of airway restriction.

Recovery after surgery (4 of 6)

A week after surgical debulking. Both voice and breathing are much improved.

Inflammatory polyp (5 of 6)

Six weeks later, airway remains excellent; voice has re-deteriorated due to this inflammatory “polyp.”

Thulium laser (6 of 6)

Office based thulium laser coagulation in progress…


Laryngomalacia Due to Breathing Tube Injury

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(1 of 4)

After a life-threatening illness including weeks in an ICU on a ventilator (breathing tube involved), this person underwent tracheotomy. Here, the old breathing tube injury of the vocal cords is clearly seen and explains a very hoarse voice. Arrows point out divots of tissue loss from pressure necrosis. Dotted lines indicate where the margins of the vocal cords would be if uninjured.

(2 of 4)

Viewing from barely below the vocal cords, the white tracheotomy tube enters the airway in the distance, and a synechia (s) and lateral scarring (sc) are seen in the foreground.

(3 of 4)

Viewing from deeper into the subglottis while the patient exhales with trach tube plugged, there is “blow-by” dark room around the #6 tracheotomy tube. The diagonal line, upper right, indicates junction between membranous (M) and cartilaginous (C) trachea.

(4 of 4)

When she inhales with tracheotomy tube plugged, the walls of the trachea collapse inward, and the patient cannot fill her lungs. Most noteworthy is the indrawing of the cartilaginous wall (arrow at C). Tracheal narrowing for exhalation can be managed with expiratory straw breathing. Collapse of this magnitude during inspiration implies the need for repair (resection of the bad segment and re-anastomosis).