Hello, Robert Bastian here. Recently I had a patient that I had treated for R-CPD
tell me that she felt that I hadn't explained to her enough about the
possible complications. She happened to be someone who experienced laryngospasm
and I didn't know that it had happened to her, and so I thought to myself, "Well, let
me sit down and make a little video about all of the complications that we've encountered
over the the caseload of about 865 patients." So here we go, just an informal discussion. And
865 people; not going chart by chart but just consulting with our data manager and database
and things that I am pulling out of my head, so here we go. Before we do complications
though, a quick review of the disorder itself: R-CPD, retrograde crycopharyngeus dysfunction,
really miserable disorder. It's defined syndromically by four primary symptoms, and I've
got an asterisk after each of these because this is a spectrum disorder. And so, sometimes people
want to be literal and exact and I can't do that because for example, can't burp, every now and again
a person says well, once or twice a week I have a little micro burp. It's unexpected and I can't
harness it, and so they think, well, maybe that means I don't have it? Because I have those couple little
micro burps. No, it's basically, you can't burp to relieve symptoms, that, a lot of air build up.
So can't burp, gurgling noises, (a few say it's kind of quiet) and internal but most people say
it's audible at least a few feet away when it's at its worst, and some people say across a large room.
Bloating is primarily abdominal and can be with actual distension of the abdomen. We use
pregnancy as an analogy and some people have chest pressure and even low neck symptoms. So bloating,
and then the flatulence is almost universal. Occasionally there's a person who says I don't
have much of that, and they're usually people who do the air vomiting. They gag themselves to
to stay ahead of the accumulation of the air. Now lesser but quite common symptoms are
painful hiccups, nausea (especially after eating large amounts), a feeling of shortness of breath
if I'm very symptomatic. I it's like I can't take a deep breath because there's no room
in there. Hypersalivation; I get a little nauseated a little uncomfortable and my mouth kind of waters,
and then i'm swallowing extra and it just makes it all worse. And then constipation.
Well, we have to distinguish between complications and early effects of botox, so there are some early
effects that might be a bit unpleasant in a small percentage, but those are not
complications, those are just early effects, and all of these early effects are transient.
They are the most obvious at the beginning, and as we work some weeks into the botox cycle
they subside. So let's talk about early effects that are sort of outlier at the end of the
spectrum; excessive burping doesn't happen in most people but they're just a few who
say, "Boy I'm ready to stop burping now, I think I've caught up for my whole life. Every time I
swallow I burp." Or a few people have said, "I take a deep breath and and air goes into my esophagus
and then when I exhale, a burp happens." Again, transient on the way through to a good result for
excessive burping. Most people, it's fun and it's funny, and it's so relieving of all the symptoms,
but in that very small subset, excessive burping. Swallowing weirdness happens in most people
and they, once they get the hang of it it's not a big deal. They just, whenever they're eating solid
food they keep liquid nearby, and they eat their food and it sort of hangs in this limp zone and
they just quickly take a sip and that takes care of it. But a very small subset will say,
"I had to do smoothies and liquids for the first few weeks because it was a little bit off-putting,
trying to swallow solids." So again, not most people, but a few. Sour burps, a few have complained of that
and that's because not only is air coming up, but a little bit of stomach contents.
A few people have said their reflux. Reflux is common in R-CPD, of course, and they, when
you evacuate the pillow of air, because now you can burp, so that pillow of air comes out, well
now the liquid stomach contents can come higher in the esophagus, and so heartburn can be worse, again
transiently. All of these things are temporary in the first few weeks, and we're on our way to,
to much better. So now we're to complications. And again this is not a chart by chart by chart,
so I could have missed a few here, but what I did was went to the database, I went to my data manager
PA Wingo, and then I took out of my head, and these are the, this is the list that we together made up.
Chip tooth. Anytime a person has endoscopy, esophagus, larynx, bronchoscopy,
there is a chance of a chip tooth because there's a little pressure on these upper teeth.
It's really uncommon. We use a tooth guard, a lot of care, but in that person who has large upper
teeth, can't open the mouth, a short neck, there's a little risk of this chipped tooth. So in the
many many procedures I do across a year, I do a lot more than just R-CPD. A couple times a year,
we are very small number, we may have a chip tooth and what I mean is, usually it's a little roughened
area, and we just smooth it off and it's not a problem. But there is a very tiny risk to teeth.
If your jaw is normal your anatomy is basically normal, it's a vanishingly rare kind of a thing.
Sensitive tooth. I've only had this once in an entire career. A person from out of country who
said he had little microelectric shocks. It wasn't that the shocks themselves were
a big deal, he wasn't taking pain medicine, but he was really focused on this because it shouldn't
be happening and he needed an explanation. And it was extremely troubling to him
and it went away after a couple of months. I have no idea what that's about, has never happened
before or since. One individual, my caseload all time most difficult anatomy, middle aged woman,
no jaw, very tiny lower jaw, large upper teeth, small mouth opening. I work the hardest to get
the view in her of anyone before, since. And I scraped, put a little scrape on the back
wall of the throat. It, she got what's called cellulitis infection, some fever.
She took a few days of antibiotics and no harm came to her, but that was a definite complication.
Then anesthesia complications. We have laryngospasm on emerging from anesthesia, which is a very
different thing from laryngospasm in an awake person who's living their life. So first we'll talk
about the one episode of laryngospasm emerging from anesthesia that was a very strong laryngospasm,
actually an out-of-country patient also. And, so it creates a lot of excitement.
No harm came to him, no hospitalization. but it's a sort of a memory and
in my career, I've seen plenty of laryngospasm on emerging from anesthesia, but just maybe a
half a dozen cases where it was quite severe. Such as it was in this man.
No—none of the patients in my entire caseload have come to any harm, but again it creates
excitement and that's anesthesia on—that's laryngospasm upon emerging from anesthesia,
very different thing from laryngospasm at home or so forth. So tongue laceration. Now this is the
one where I'm actually a little embarrassed, but I had a another patient with very difficult anatomy
and of course i'm working and focused and trying to get the view through the scope, and I didn't
notice that the tongue got caught between the scope and the teeth, and so she had a laceration.
No stitches needed, no permanent damage but I'm sure quite sore and embarrassing for me.
It's one of those things my bad, and again, it shouldn't happen. It's one person out of 865 and
one too many. And then finally laryngospasm after completing the procedure and going home
and living their lives in the next few weeks. I knew about two where laryngospasm was an
issue in those people because it came to my attention and it was very frightening to them.
And I consulted with PA Wingo, and there have been a handful of others who contacted her, and I
didn't realize that it was reported to her, and she said they just basically shrugged, they needed an
explanation. They must have been mild laryngospasm because she said they weren't upset
or bothered in any way, but these three where the laryngospans were a little bit more intense.
Now, laryngospasm, again, not dangerous. I have created a teaching video you can
go to Laryngopedia.com and find that video if you think you might be that one out of 300
people who might have laryngospasm. Also, I again i didn't think to mention it as a potential
complication because it just is so uncommon. But that is the list that I can come up with and I
just don't like being in the circumstance where any patient thinks that I haven't told them all
the things that I should have told them, and so that's why I decided to just make this video.
And so if you're one of my patients who had this done and there's
a complication you had that i didn't mention please contact me and let me know, because i
do want people to know all of the potential issues. The vast majority, it's a very smooth
I mean, it's a little weird at the beginning with the burping and the swallowing, but it's
absolutely not an issue for them. So there you have my discussion, and thank you for listening!