Some people have difficulty swallowing (dysphagia). In dysphagia, foods and/or liquids do not move normally from the throat (pharynx) to the stomach. People feel as though food or liquids become stuck on the way down the tube that connects the throat to the stomach (esophagus). Dysphagia should not be confused with lump in throat (globus sensation Overview of Inflammatory Bowel Disease (IBD) In inflammatory bowel diseases, the intestine (bowel) becomes inflamed, often causing recurring abdominal pain and diarrhea. The two primary types of inflammatory bowel disease (IBD) are Crohn... read more ), in which people have the sensation of a lump in their throat but have no difficulty swallowing.
Dysphagia can cause people to inhale (aspirate) mouth secretions and/or material they eat or drink. Aspiration can cause acute pneumonia. If aspiration occurs over a long period of time, people may develop chronic lung disease. People who have had dysphagia for a long time are often inadequately nourished and lose weight.
Causes of Difficulty Swallowing
Although most people take swallowing for granted, it is actually a complicated process. For swallowing to take place normally, the brain must unconsciously coordinate the activity of numerous small muscles of the throat and the esophagus. These muscles must contract strongly and in the proper sequence to push food from the mouth to the back of the throat and then down the esophagus. Finally, the lower part of the esophagus must relax to allow food to enter the stomach. Thus, swallowing difficulty can result from the following:
Disorders of the brain or nervous system
Disorders of the muscles in general
Disorders of the esophagus (a physical blockage or a motility [movement] disorder)
Brain and nervous system disorders that cause difficulty swallowing include stroke Overview of Stroke A stroke occurs when an artery to the brain becomes blocked or ruptures, resulting in death of an area of brain tissue due to loss of its blood supply (cerebral infarction). Symptoms occur suddenly... read more , Parkinson disease Parkinson Disease (PD) Parkinson disease is a slowly progressive degenerative disorder of specific areas of the brain. It is characterized by tremor when muscles are at rest (resting tremor), increased muscle tone... read more , multiple sclerosis Multiple Sclerosis (MS) In multiple sclerosis, patches of myelin (the substance that covers most nerve fibers) and underlying nerve fibers in the brain, optic nerves, and spinal cord are damaged or destroyed. The cause... read more , and amyotrophic lateral sclerosis Amyotrophic Lateral Sclerosis (ALS) and Other Motor Neuron Diseases (MNDs) Motor neuron diseases are characterized by progressive deterioration of the nerve cells that initiate muscle movement. As a result, the muscles stimulated by these nerves deteriorate, become... read more (ALS). People with these disorders typically have other symptoms in addition to difficulty swallowing. Many have already been diagnosed with these disorders.
General muscle disorders that cause difficulty swallowing include myasthenia gravis Myasthenia Gravis Myasthenia gravis is an autoimmune disorder that impairs communication between nerves and muscles, resulting in episodes of muscle weakness. Myasthenia gravis results from malfunction of the... read more , dermatomyositis Autoimmune Myositis Autoimmune myositis causes inflammation and weakness in the muscles (polymyositis) or in the skin and muscles (dermatomyositis). Muscle damage may cause muscle pain and muscle weakness may cause... read more , and muscular dystrophy Introduction to Muscular Dystrophies and Related Disorders Muscular dystrophies are a group of inherited muscle disorders in which one or more genes needed for normal muscle structure and function are defective, leading to muscle weakness of varying... read more .
A physical blockage can result from cancer of the esophagus Esophageal Cancer Esophageal cancers develop in the cells that line the wall of the esophagus (the tube that connects the throat to the stomach). Tobacco and alcohol use, human papillomavirus infections, and... read more , rings Lower Esophageal Ring A lower esophageal ring narrows the lower esophagus and is most likely present at birth. The esophagus is the hollow tube that leads from the throat (pharynx) to the stomach. (See also Overview... read more or webs Esophageal Webs Esophageal webs are thin membranes that grow across the inside of the upper part of the esophagus and may cause difficulty swallowing (dysphagia). (See also Overview of Esophageal Obstructions... read more of tissue across the inside of the esophagus, and scarring of the esophagus from chronic acid reflux or from swallowing a caustic liquid. Sometimes the esophagus is compressed by a nearby organ or structure such as an enlarged thyroid gland, a bulge in the large artery in the chest (aortic aneurysm), or a tumor in the middle of the chest.
Esophageal motility disorders include achalasia Achalasia Achalasia is a disorder in which the rhythmic contractions of the esophagus (called peristalsis) are missing or impaired, the lower esophageal sphincter does not relax normally, and the resting... read more (in which the rhythmic contractions of the esophagus are greatly decreased and the lower esophageal muscle does not relax normally to allow food to pass into the stomach) and esophageal spasm Esophageal Spasm Esophageal spasm is a disorder of the rhythmic waves of muscular contractions (peristalsis) of the esophagus. The cause of this disorder is not known. Symptoms include chest pain and difficulty... read more . Systemic sclerosis Systemic Sclerosis Systemic sclerosis is a rare, chronic autoimmune connective tissue disorder characterized by degenerative changes and scarring in the skin, joints, and internal organs and by blood vessel abnormalities... read more (scleroderma) may also cause a motility disorder.
Evaluation of Difficulty Swallowing
Not every episode of dysphagia requires immediate evaluation by a doctor. The following information can help people decide when a doctor’s evaluation is needed and help them know what to expect during the evaluation.
In people with dysphagia, certain symptoms and characteristics are cause for concern. They include
Symptoms of a complete physical blockage (such as drooling or inability to swallow anything at all)
Dysphagia resulting in weight loss
Painful swallowing (odynophagia)
A new problem in nerve, spinal cord, or brain function, particularly any weakness
Recurring aspiration pneumonia (lung infection caused by inhaling mouth secretions, stomach contents, or both)
When to see a doctor
People who have warning signs should see a doctor right away unless the only warning sign is weight loss. In such cases, a delay of a week or so is not harmful.
People with dysphagia but no warning signs should see their doctor within a week or so. However, people who cough or choke whenever they eat or drink should be evaluated sooner.
What the doctor does
Doctors first ask questions about the person's symptoms and medical history. Doctors then do a physical examination. What they find during the history and physical examination often suggests a cause of the dysphagia and the tests that may need to be done ( see Table: Some Causes and Features of Swallowing Difficulty Some Causes and Features of Swallowing Difficulty ).
During the history, doctors ask about the following:
Any difficulty swallowing solids, liquids, or both
Food coming out the nose
Drooling or food spilling from the mouth
Coughing or choking while eating
People with equal difficulty swallowing liquids and solids are more likely to have a motility disorder. People who have gradually increasing difficulty swallowing first solids and then liquids may have a worsening physical blockage, such as a tumor. Food unintentionally coming out of the nose or mouth suggests a neurologic or muscular problem rather than a problem with the esophagus.
Doctors look for symptoms that suggest neuromuscular, gastrointestinal, and connective tissue disorders. Major neuromuscular symptoms include weakness, either constant weakness of a body part (such as an arm or leg) or off-and-on weakness that occurs during activity and is relieved by rest; walking (gait) or balance disturbance; involuntary, rhythmic, shaking movements (tremors); and difficulty speaking. Doctors also need to know whether the person has a known disease that causes dysphagia ( see Table: Some Causes and Features of Swallowing Difficulty Some Causes and Features of Swallowing Difficulty ).
Doctors then do a physical examination. The physical examination is focused on the neurologic examination, but doctors also pay attention to the person's nutritional status and any abnormalities of the skin and/or muscles. During the physical examination, doctors look at the following:
Tremors present while the person is at rest
Muscle strength (including muscles of the eyes, mouth, and face)
The performance of a repetitive action (such as blinking or counting aloud) by people who become weak with activity (to see how rapidly their performance worsens)
The way people walk and their balance
The skin for rash and thickening or texture changes, particularly on the fingertips
Muscles, to see whether any are wasting away or visibly twitching under the skin (fasciculations) or feel tender
The neck for an enlarged thyroid gland or other mass
Possible tests include
For people who have symptoms of a complete or nearly complete blockage, doctors immediately look in the esophagus with a flexible tube (upper endoscopy Endoscopy Endoscopy is an examination of internal structures using a flexible viewing tube (endoscope). In addition to examinations, doctors can use endoscopy to do biopsies and give treatment. Endoscopes... read more ). During endoscopy, doctors take biopsies to look for eosinophilic esophagitis (inflammation of the esophagus caused by white blood cells).
For people whose symptoms do not suggest a complete blockage, doctors usually take x-rays while the person swallows barium liquid (which shows up on x-rays). Typically, people first swallow plain barium liquid and then barium liquid mixed with some material such as a marshmallow or cracker. If the barium swallow X-Ray Studies of the Digestive Tract X-rays often are used to evaluate digestive problems. Standard x-rays ( plain x-rays) can show some blockages or paralysis of the digestive tract, or abnormal air patterns in the abdominal cavity... read more suggests blockage, doctors usually then do upper endoscopy to look for the cause (particularly to rule out cancer). If the barium test is negative or suggests a motility disorder, doctors do esophageal motility tests. In motility tests, people swallow a thin tube containing many pressure sensors. As people swallow, the pressure sensors show whether the esophagus is contracting normally and whether the lower part of the esophagus is relaxing normally.
Impedance testing Impedance Testing Impedance testing is a type of test that uses a probe that inflates a balloon inside the esophagus and measures how much pressure it takes to expand it a certain amount. An esophagus that is... read more is a new technology wherein a probe inflates a balloon inside the esophagus and measures how much pressure it takes to expand it a certain amount. The pressure measurements and data help doctors further evaluate people who are having trouble swallowing.
Treatment of Difficulty Swallowing
The best way to treat dysphagia is to treat the specific cause.
To help relieve symptoms of dysphagia, doctors usually advise people to take small bites and chew food thoroughly.
People with dysphagia caused by a stroke may benefit from treatment by a rehabilitation specialist. Rehabilitation measures may involve changing head position while eating, retraining the swallowing muscles, doing exercises that improve the ability to accommodate a lump of food in the mouth, or doing strength and coordination exercises for the tongue.
People who cannot swallow without a high risk of choking may need to stop eating and be fed through a feeding tube placed through the wall of their abdomen into their stomach or small intestine.
Essentials for Older People
Chewing, swallowing, tasting, and communicating require intact, coordinated neurologic and muscular function in the mouth, face, and neck. Oral motor function in particular declines measurably with age, even in healthy people. Decline in function may occur in several ways:
As people age, the muscles required for chewing decrease in strength and coordination, especially among people with partial or complete dentures. This decrease may lead to a tendency to swallow larger food particles, which can increase the risk of choking or aspiration.
With increased age, it takes longer to move food from the mouth to the throat, which increases the likelihood of aspiration.
After age-related changes, the most common causes of oral motor disorders are neuromuscular disorders (such as cranial neuropathies caused by diabetes, stroke, Parkinson disease, amyotrophic lateral sclerosis, or multiple sclerosis). Sometimes, treatments can contribute to oral motor disorders. For example, drugs (such as anticholinergics or diuretics), radiation therapy to the head and neck, and chemotherapy can greatly impair saliva production. Reduced saliva production (hyposalivation) is a major cause of delayed and impaired swallowing.
In addition to their regular doctor, people with oral motor disorders or dysfunction are also treated by specialists in prosthetic dentistry, rehabilitative medicine, speech pathology, otolaryngology, and gastroenterology.
People who have dysphagia typically need upper endoscopy or a barium swallow test.
If the endoscopy and barium test are normal or if they suggest a motility disorder, doctors do esophageal motility tests.
Treatment is aimed at the cause.