DISEASE

Swallowing Disorder

OVERVIEW | CAUSES | RISK FACTORS | SYMPTOMS | COMPLICATION | DIAGNOSIS | TREATMENT | PREVENTION | REFERENCES

difficulty in swallowing dysphagia

OVERVIEW

Difficulty swallowing (dysphagia) means it takes more time and effort to move food or liquid from your mouth to your stomach. Dysphagia may also be associated with pain. In some cases, swallowing may be impossible.

Occasional difficulty swallowing, which may occur when you eat too fast or don't chew your food well enough, usually isn't cause for concern. But persistent dysphagia may indicate a serious medical condition requiring treatment.

Dysphagia can occur at any age, but it's more common in older adults. The causes of swallowing problems vary, and treatment depends on the cause.

CAUSES

Swallowing is complex, and a number of conditions can interfere with this process. Sometimes the cause of dysphagia can't be identified. However, dysphagia generally falls into one of the following categories.

Esophageal dysphagia

Esophageal dysphagia refers to the sensation of food sticking or getting hung up in the base of your throat or in your chest after you've started to swallow. Some of the causes of esophageal dysphagia include:

Achalasia. When your lower esophageal muscle (sphincter) doesn't relax properly to let food enter your stomach, it may cause you to bring food back up into your throat. Muscles in the wall of your esophagus may be weak as well, a condition that tends to worsen over time.
Diffuse spasm. This condition produces multiple high-pressure, poorly coordinated contractions of your esophagus, usually after you swallow. Diffuse spasm affects the involuntary muscles in the walls of your lower esophagus.
Esophageal stricture. A narrowed esophagus (stricture) can trap large pieces of food. Tumors or scar tissue, often caused by gastroesophageal reflux disease (GERD), can cause narrowing.
Esophageal tumors. Difficulty swallowing tends to get progressively worse when esophageal tumors are present.
Foreign bodies. Sometimes food or another object can partially block your throat or esophagus. Older adults with dentures and people who have difficulty chewing their food may be more likely to have a piece of food become lodged in the throat or esophagus.
Esophageal ring. A thin area of narrowing in the lower esophagus can intermittently cause difficulty swallowing solid foods.
GERD. Damage to esophageal tissues from stomach acid backing up into your esophagus can lead to spasm or scarring and narrowing of your lower esophagus.
Eosinophilic esophagitis. This condition, which may be related to a food allergy, is caused by an overpopulation of cells called eosinophils in the esophagus.
Scleroderma. Development of scar-like tissue, causing stiffening and hardening of tissues, can weaken your lower esophageal sphincter, allowing acid to back up into your esophagus and cause frequent heartburn.
Radiation therapy. This cancer treatment can lead to inflammation and scarring of the esophagus.

Oropharyngeal dysphagia

Certain conditions can weaken your throat muscles, making it difficult to move food from your mouth into your throat and esophagus when you start to swallow. You may choke, gag or cough when you try to swallow or have the sensation of food or fluids going down your windpipe (trachea) or up your nose. This may lead to pneumonia.

Causes of oropharyngeal dysphagia include:

Neurological disorders. Certain disorders- such as multiple sclerosis, muscular dystrophy and Parkinson's disease- can cause dysphagia.
Neurological damage. Sudden neurological damage, such as from a stroke or brain or spinal cord injury, can affect your ability to swallow.
Pharyngoesophageal diverticulum (Zenker's diverticulum). A small pouch that forms and collects food particles in your throat, often just above your esophagus, leads to difficulty swallowing, gurgling sounds, bad breath, and repeated throat clearing or coughing.
Cancer. Certain cancers and some cancer treatments, such as radiation, can cause difficulty swallowing.

RISK FACTORS

The following are risk factors for dysphagia:

Aging. Due to natural aging and normal wear and tear on the esophagus and a greater risk of certain conditions, such as stroke or Parkinson's disease, older adults are at higher risk of swallowing difficulties. But, dysphagia isn't considered a normal sign of aging.
Certain health conditions. People with certain neurological or nervous system disorders are more likely to experience difficulty swallowing.

SYMPTOMS

Signs and symptoms associated with dysphagia may include:

Having pain while swallowing (odynophagia)
Being unable to swallow
Having the sensation of food getting stuck in your throat or chest or behind your breastbone (sternum)
Drooling
Being hoarse
Bringing food back up (regurgitation)
Having frequent heartburn
Having food or stomach acid back up into your throat
Unexpectedly losing weight
Coughing or gagging when swallowing
Having to cut food into smaller pieces or avoiding certain foods because of trouble swallowing

COMPLICATIONS

Difficulty swallowing can lead to:

Malnutrition, weight loss and dehydration. Dysphagia can make it difficult to take in adequate nourishment and fluids.
Aspiration pneumonia. Food or liquid entering your airway when you try to swallow can cause aspiration pneumonia, because the food can introduce bacteria to the lungs.
Choking. When food gets stuck in the throat, choking can occur. If food completely blocks the airway, and no one intervenes with a successful Heimlich maneuver, death can occur.

DIAGNOSIS

Your doctor will likely perform a physical examination and may use a variety of tests to determine the cause of your swallowing problem.

Tests may include:

X-ray with a contrast material (barium X-ray). You drink a barium solution that coats your esophagus, allowing it to show up better on X-rays. Your doctor can then see changes in the shape of your esophagus and can assess the muscular activity. Your doctor may also have you swallow solid food or a pill coated with barium to watch the muscles in your throat as you swallow or to look for blockages in your esophagus that the liquid barium solution may not identify.
Dynamic swallowing study. You swallow barium-coated foods of different consistencies. This test provides an image of these foods as they travel through your mouth and down your throat. The images may show problems in the coordination of your mouth and throat muscles when you swallow and determine whether food is going into your breathing tube.
A visual examination of your esophagus (endoscopy). A thin, flexible lighted instrument (endoscope) is passed down your throat so that your doctor can see your esophagus. Your doctor may also take biopsies of the esophagus to look for inflammation, eosinophilic esophagitis, narrowing or a tumor.
Fiber-optic endoscopic evaluation of swallowing (FEES). Your doctor may examine your throat with a special camera and lighted tube (endoscope) as you try to swallow.
Esophageal muscle test (manometry). In manometry (muh-NOM-uh-tree), a small tube is inserted into your esophagus and connected to a pressure recorder to measure the muscle contractions of your esophagus as you swallow.
Imaging scans. These may include a CT scan, which combines a series of X-ray views and computer processing to create cross-sectional images of your body's bones and soft tissues, or an MRI scan, which uses a magnetic field and radio waves to create detailed images of organs and tissues.

TREATMENT

Treatment for dysphagia depends on the type or cause of your swallowing disorder.

Oropharyngeal dysphagia

For oropharyngeal dysphagia, your doctor may refer you to a speech or swallowing therapist, and therapy may include:

Learning exercises. Certain exercises may help coordinate your swallowing muscles or restimulate the nerves that trigger the swallowing reflex.
Learning swallowing techniques. You may also learn ways to place food in your mouth or to position your body and head to help you swallow. You may be taught exercises and new swallowing techniques to help compensate for dysphagia caused by neurological problems such as Alzheimer's disease or Parkinson's disease.

Esophageal dysphagia

Treatment approaches for esophageal dysphagia may include:

Esophageal dilation. For a tight esophageal sphincter (achalasia) or an esophageal stricture, your doctor may use an endoscope with a special balloon attached to gently stretch and expand the width of your esophagus or pass a flexible tube or tubes to stretch the esophagus (dilation).
Surgery. For an esophageal tumor, achalasia or pharyngoesophageal diverticulum, you may need surgery to clear your esophageal path.
Medications. Difficulty swallowing associated with GERD can be treated with prescription oral medications to reduce stomach acid. You may need to take these medications for an extended period. If you have eosinophilic esophagitis, you may need corticosteroids. If you have esophageal spasm, smooth muscle relaxants may help.

Severe dysphagia

If difficulty swallowing prevents you from eating and drinking adequately, your doctor may recommend:

A special liquid diet. This may help you maintain a healthy weight and avoid dehydration.
A feeding tube. In severe cases of dysphagia, you may need a feeding tube to bypass the part of your swallowing mechanism that isn't working normally.

Surgery

Surgery may be recommended to relieve swallowing problems caused by throat narrowing or blockages, including bony outgrowths, vocal cord paralysis, pharyngoesophageal diverticulum, GERD and achalasia, or to treat esophageal cancer. Speech and swallowing therapy is usually helpful after surgery.

The type of surgical treatment depends on the cause for dysphagia. Some examples are:

Laparoscopic Heller myotomy, which is used to cut the muscle at the lower end of the esophagus (sphincter) when it fails to open and release food into the stomach in people who have achalasia.
Peroral endoscopic myotomy (POEM). The surgeon uses an endoscope inserted through your mouth and down your throat to create an incision in the inside lining of your esophagus. Then, as in a Heller myotomy, the surgeon cuts the muscle at the lower end of the esophageal sphincter.
Esophageal dilation. Your doctor inserts a lighted tube (endoscope) into your esophagus and inflates an attached balloon to gently stretch and expand its width (dilation). This treatment is used for a tight sphincter muscle at the end of the esophagus (achalasia), a narrowing of the esophagus (esophageal stricture), an abnormal ring of tissue located at the junction of the esophagus and stomach (Schatzki's ring) or a motility disorder. Alternatively, your doctor may pass a flexible tube or tubes of different diameters instead of a balloon.
Stent placement. The doctor can also insert a metal or plastic tube (stent) to prop open a narrowing or blockage in your esophagus. Some stents are permanent, such as those for people with esophageal cancer, while others are temporary and are removed later.

PREVENTION

Although swallowing difficulties can't be prevented, you can reduce your risk of occasional difficulty swallowing by eating slowly and chewing your food well. Early detection and effective treatment of GERD can lower your risk of developing dysphagia associated with an esophageal stricture.