No Burp RCPD resources

Treatment

RCPD treatment: Botox and what to expect

The main treatment for RCPD (no-burp syndrome) is an injection of botulinum toxin (Botox) into the cricopharyngeus muscle, which relaxes it so trapped air can escape. In systematic reviews, about 87–94% of people improve after their first injection, and most start to burp within a week. Many keep the ability after the Botox wears off; some need a second injection.

Updated · Compiled from the peer-reviewed studies listed under Sources. This is general information, not medical advice.

At a glance

  • Treatment: botulinum toxin injected into the cricopharyngeus, usually 25–100 units; 50 units is the most common first dose.3
  • Where it's done: most often in the operating room under general anesthesia; some clinics inject awake, in the office.3
  • Does it work? About 87–94% improve after a first injection; about 80% still have the benefit months later.3,4,5
  • How fast? Small “micro-burps” often start within 1–2 days; in one 200-patient series, 93% could burp within a week.1,2
  • Main side effect: temporary difficulty swallowing, usually gone within 1–4 weeks.7,8
  • Who does it: usually a laryngologist (a throat-focused ENT), sometimes with a gastroenterologist. Find one near you.

The procedure

How the Botox injection is done

The goal is the same either way: put botulinum toxin into the cricopharyngeus, the ring of muscle at the top of the esophagus that won't relax in RCPD. There are two main approaches.

In the operating room, under general anesthesia

This is the most common approach, used for 79% of patients in a 2024 review of about 637 cases.3 While you're asleep, the surgeon passes a scope through the mouth to see the muscle directly and injects it in several spots. In one UK series it took about 30 minutes.1,6

In the office, awake

Some clinics inject through the skin of the neck under local anesthetic, using electromyography (EMG) to guide the needle. There are also through-the-nose and flexible-endoscope techniques.9,17 Office injection avoids general anesthesia, and it usually uses a lower dose.10

Which is better?

The studies don't agree yet. Some found both approaches work about equally well at first.10 Others found the operating-room approach more reliable, or found that people who start with office injections more often need a repeat.10,11 Swallowing difficulty can be worse after the operating-room approach, which usually uses a higher dose. The best choice depends on your doctor's experience, your preferences, and whether general anesthesia is an issue for you.

Afterwards

What to expect after the injection

The first burps. In the original 51-patient study, nearly everyone noticed small “micro-burps” 24–48 hours after the injection and built up to normal burping over the next few weeks.1 In a later series of 200 patients, 93% could burp within one week and the rest within four weeks.2 Lower doses may take longer to start working.6 Burping can take some effort at first; some “slow starters” found that turning the head helped.1

The other symptoms. Bloating, gurgling and excess gas usually ease as burping starts. In the first study, 50 of 51 patients were relieved of their abdominal bloating.1

Side effects

  • Temporary difficulty swallowing is the most common side effect. Depending on the study, it's reported by roughly a third to over half of patients.4,5 Food may feel like it “hangs” in the throat. It usually settles within 1–4 weeks; in one study it lasted 16 days on average.2,7,8
  • Reflux or regurgitation can appear or get worse for a while.2,4
  • Sore throat for up to about three days is common.12
  • Voice changes or breathlessness are uncommon and short-lived. They've mainly been reported after office injections through the neck.9

Serious problems are rare. In the 200-patient series, no one had complications from the Botox itself. Four had problems from the scope or anesthesia, such as a chipped tooth.2

Does it last?

Botox wears off after a few months, but for many people the ability to burp stays. In the 200-patient series, 80% could still burp satisfactorily six months or more later.2 Across studies, about 80% still had the benefit between 3 and 29 months after treatment.5

Not every study is that positive. One Belgian series found that 51% had complete relief about two and a half years later.12 Results vary partly because studies define “success” differently.

If the effect fades, it usually happens within the first few months, and a second injection often works. Some evidence suggests higher doses last longer.2,3,5

If Botox isn't enough

Other treatment options

A repeat injection is the usual next step. In the 2024 systematic review, repeat Botox resolved symptoms for 80% of those who needed it.3

Cricopharyngeal myotomy is surgery that partly cuts the muscle, for example with a laser through the mouth. It is sometimes offered when symptoms keep coming back after injections. Evidence for RCPD is limited to small numbers: in the review, 4 of 6 people who had it got long-term relief.3,13 It carries risks that injections don't, including rare but serious infection in the chest.13

Burp retraining with a speech-language pathologist is being studied. In one small 2025 report, 6 of 7 people whom Botox hadn't helped gained lasting relief.14 It's promising, but it isn't widely available yet.

Posture tricks and avoiding fizzy drinks can take the edge off symptoms, but they don't fix the muscle.

Getting diagnosed first

RCPD is usually diagnosed from your symptoms, especially a lifelong inability to burp with gurgling, bloating and excess gas. Standard tests like endoscopy often come back normal.1,4 No validated test exists yet.15 Some centres are studying manometry with a fizzy-drink challenge.17 A good response to the injection can itself help confirm the diagnosis.1

Check your symptoms →

Cost and insurance

Costs vary widely by country, clinic and setting. Operating-room injections involve anesthesia and facility fees that office injections don't. In the US, coverage varies by insurer. At least one clinic says some insurers have denied the procedure as “experimental.”16 Ask the clinic for the procedure codes and check with your insurer before booking.

Be prepared

Questions to ask your doctor

  • How many people with RCPD have you treated?
  • Do you inject in the office or the operating room, and why?
  • What dose do you usually use?
  • What should I eat and drink while swallowing feels difficult afterwards?
  • What happens if it doesn't work, or wears off? Do you offer repeat injections or myotomy?
  • What will it cost, and will my insurance cover it?

Next step

Find a doctor who treats RCPD

The directory lists 282 clinicians across 42 countries who patients have reported treat RCPD, with their contact details.

Find a doctor Read the research

Sources

  1. Bastian RW, Smithson ML. Inability to belch and associated symptoms due to retrograde cricopharyngeus dysfunction: diagnosis and treatment. OTO Open, 2019. PMC6572913
  2. Hoesli RC et al. Long-term efficacy of botulinum toxin for retrograde cricopharyngeus dysfunction (200 patients). OTO Open, 2020. PMC7325547
  3. Malhotra et al. Diagnosis and management of retrograde cricopharyngeal dysfunction: a systematic review. OTO Open, 2024. PMC11474230
  4. Jönsson & Plaschke. Systematic review (13 studies, 472 patients). European Archives of Oto-Rhino-Laryngology, 2024. doi:10.1007/s00405-024-08619-8
  5. Yeo et al. Meta-analysis (13 studies, 699 patients). Laryngoscope, 2025. doi:10.1002/lary.32296
  6. Karagama Y. Abelchia: inability to belch/burp — a new disorder? European Archives of Oto-Rhino-Laryngology, 2021. PMC8553696
  7. Mailly et al. In-office injection series (106 patients). JAMA Otolaryngology–Head & Neck Surgery, 2025. doi:10.1001/jamaoto.2024.5046
  8. Cleveland Clinic. RCPD (retrograde cricopharyngeus dysfunction). health.clevelandclinic.org
  9. Wajsberg et al. In-office EMG-guided injection (18 patients). OTO Open, 2021. PMC7863157
  10. Doruk et al. Office vs operating-room injection, prospective cohort. Laryngoscope, 2024; and Doruk & Pitman, Laryngoscope, 2023. doi:10.1002/lary.31591; doi:10.1002/lary.30871
  11. Kutler, Siddiqui et al. Office vs operating-room injection, prospective (185 patients). Laryngoscope, 2025. doi:10.1002/lary.32322
  12. Arnaert et al. Long-term outcomes (50 patients). Journal of Neurogastroenterology and Motility, 2024. PMC10999848
  13. Bastian RW, Hoesli RC. Partial cricopharyngeal myotomy for retrograde cricopharyngeus dysfunction. OTO Open, 2020. PMC7163242
  14. Keltz et al. Behavioral eructation retraining protocol. Laryngoscope, 2025. doi:10.1002/lary.32427
  15. Chia & Leong. Review. Current Opinion in Otolaryngology & Head and Neck Surgery, 2026. doi:10.1097/moo.0000000000001153
  16. Bastian Voice Institute. R-CPD fees (published by the practice). bastianvoice.com
  17. Sanagapalli et al. American Journal of Gastroenterology, 2024 (flexible-endoscope injection and manometry); Lechien et al. Laryngoscope, 2025 (transnasal injection). doi:10.14309/ajg.0000000000003242; doi:10.1002/lary.32336