Difficulty Swallowing
(Dysphagia)
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), in which people have the sensation of a lump in their throat but have no difficulty swallowing.
Complications
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
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:
Brain and nervous system disorders that cause difficulty swallowing include stroke, Parkinson disease, multiple sclerosis, and amyotrophic lateral sclerosis (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, dermatomyositis, and muscular dystrophy.
A physical blockage can result from cancer of the esophagus, rings or webs 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 (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. Systemic sclerosis (scleroderma) may also cause a motility disorder.
Evaluation
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.
Warning signs
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).
During the history, doctors ask about the following:
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).
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:
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Tremors present while the person is at rest
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Muscle strength (including muscles of the eyes, mouth, and face)
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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)
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The way people walk and their balance
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The skin for rash and thickening or texture changes, particularly on the fingertips
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Muscles, to see whether any are wasting away or visibly twitching under the skin (fasciculations) or feel tender
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The neck for an enlarged thyroid gland or other mass
Some Causes and Features of Swallowing Difficulty
Cause |
Common Features* |
Tests |
Neurologic disorders |
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Usually a previous diagnosis of a stroke Weakness or paralysis on one side of the body, difficulty speaking, difficulty walking, or a combination |
CT or MRI of the brain |
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Muscle stiffness and fewer voluntary movements than normal Involuntary, rhythmic, shaking movements (tremors), incoordination (ataxia), and balance disturbance |
A doctor’s examination Sometimes CT or MRI |
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Come-and-go symptoms involving various parts of the body, including vision problems, muscle weakness, and/or abnormal sensations Sometimes weak, clumsy movements |
MRI Often a spinal tap |
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Some motor neuron disorders, such as |
Muscle twitching, wasting, and weakness Progressive difficulty with chewing, swallowing, and talking |
Electrodiagnostic tests (such as needle electromyography, which involves stimulating muscles then recording their electrical activity) Laboratory tests MRI of the brain |
Muscle disorders |
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Weak, drooping eyelids and weak eye muscles Excessive weakness of muscles after they are used |
Use of a drug (given intravenously) that temporarily improves strength if the cause is myasthenia Blood tests |
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Muscle weakness Fever, fatigue, and weight loss Sometimes joint pain and/or swelling Sometimes a dusky, red rash |
Blood tests Electromyography Muscle biopsy |
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Muscle weakness beginning in childhood |
Muscle biopsy Genetic testing |
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Motility (movement) disorders of the esophagus |
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Achalasia (rhythmic contractions of the esophagus are greatly decreased, and the lower esophageal muscle does not relax normally) |
Difficulty swallowing (dysphagia) solids and liquids that worsens over months to years Sometimes regurgitation (spitting up) of undigested food while sleeping Discomfort in the chest Fullness after a small meal (early satiety), nausea, vomiting, bloating, and symptoms that are worsened by food |
Barium swallow (see Testing) Measurements of pressure produced during contractions of the esophagus (esophageal manometry) |
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Diffuse esophageal spasm |
Chest pain Swallowing difficulty comes and goes |
Barium swallow Esophageal manometry |
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Systemic sclerosis (scleroderma) |
Joint pain and/or swelling Swelling, thickening, and tightening of the skin of the fingers and sometimes of the face and other areas Occasionally heartburn, difficulty swallowing, and shortness of breath |
A doctor’s examination Usually blood tests |
Physical blockage of the esophagus |
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Narrowing by scar tissue resulting from exposure to stomach acid (peptic stricture) |
A long history of gastrointestinal reflux symptoms (such as heartburn) |
Endoscopy (examination of internal structures with a flexible viewing tube) |
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Constant difficulty swallowing foods and liquids that worsens over weeks or days Weight loss Chest pain |
Endoscopy Biopsy |
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Swallowing difficulty comes and goes |
Barium swallow |
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Compression of the esophagus, as may be caused by
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Sometimes an enlarged thyroid gland |
Barium swallow X-rays taken after a radiopaque contrast agent (which is visible on x-rays) is injected into an artery (arteriography) If aortic aneurysm or a tumor is suspected, CT |
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Ingestion of a caustic substance, such as strong acids and alkalis |
Swallowing difficulty occurs weeks to months after a known ingestion |
Endoscopy |
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* Features include symptoms and the results of the doctor's examination. Features mentioned are typical but not always present. |
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CT = computed tomography; MRI = magnetic resonance imaging. |
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Testing
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).
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 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.
Treatment
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:
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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.
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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.
