Dysphagia refers to a difficulty in swallowing - it takes more effort than normal to transport food from the mouth to the stomach. Usually caused by nerve or muscle problems, it is more common in older people.
Although the medical term "dysphagia" is often regarded as a symptom or sign, it is sometimes used to describe a condition in its own right.
In this article, we will discuss the types of dysphagia, causes, symptoms, diagnosis, and potential treatments of dysphagia.
Fast facts on dysphagia
Here are some key points about dysphagia. More detail and supporting information is in the main article.
- Dysphagia is a difficulty swallowing and sometimes occurs after stroke
- Swallowing is complex and, consequently, there are a number of ways in which it can be disturbed
- Symptoms can include drooling, hoarseness, and unexplained weight loss
What is dysphagia?
Dysphagia is a difficulty swallowing and can be caused by a number of factors.
A typical "swallow" involves several different muscles and nerves; it is a complex process:
- Seeing, smelling, and tasting - when we see, smell, or taste food or drink we produce saliva, which is designed to make chewing easier.
- We chew the food until it becomes a soft bolus - a mass of food that is ready to swallow. The tongue pushes the bolus to the back of the mouth to the pharynx. From this moment onward, the swallowing movement is a reflex action (automatic).
- The larynx (voice box) closes to prevent food and liquid from going down the windpipe into the lungs. The gulping action pushes the food into the esophagus which has muscular walls and pushes the food down to the stomach.
Dysphagia can be caused by a difficulty anywhere in the swallowing process described above. There are two general types of dysphagia:
- Oropharyngeal dysphagia (high dysphagia) - the problem is in the mouth and/or throat, sometimes caused by tongue weakness after a stroke, or due to a difficulty making saliva. Issues in the throat are often caused by a neurological problem that affects the nerves (such as Parkinson's disease, stroke, or amyotrophic lateral sclerosis).
- Esophageal dysphagia (low dysphagia) - the problem is in the esophagus. This is usually because of a blockage or irritation. Often, a surgical procedure is required.
It is worth noting that pain when swallowing (odynophagia) is different than dysphagia, but it is possible to have both at the same time. And, globus is the sensation of something being stuck in the throat without dysphagia.
Symptoms of dysphagia
Some patients may have dysphagia and be unaware of it - in such cases, it may go undiagnosed and not be treated, raising the risk of aspiration pneumonia (a lung infection that can develop after accidentally inhaling saliva or food particles).
Aspiration means inhaling food into the lungs, or swallowing the food down "the wrong way."
Symptoms linked to dysphagia include:
- Choking when eating
- Coughing or gagging when swallowing
- Food or stomach acid backing up into the throat
- Recurrent heartburn
- Sensation of food getting stuck in the throat or chest, or behind the breastbone
- Unexplained weight loss
- Bringing food back up (regurgitation)
- Difficulty controlling food in the mouth
- Difficulty initiating swallowing (gulping action)
- Recurrent pneumonia
- Inability to control saliva in the mouth
Patients may notice "the food has got stuck."
Causes of dysphagia
Possible causes of dysphagia can include:
- Amyotrophic lateral sclerosis - an incurable form of progressive neurodegeneration - over time, the nerves in the spine and brain progressively lose function.
- Stroke - brain cells die due to lack of oxygen because blood flow is impaired. If the brain cells that control swallowing are affected, it can cause dysphagia.
- Eosinophilic esophagitis - severely elevated levels of eosinophils - a type of white blood cell - in the esophagus. These eosinophils grow in an uncontrolled way and attack the gastrointestinal system, leading to vomiting and difficulty with swallowing food.
- Multiple sclerosis - the central nervous system is attacked by the person's own immune system, destroying myelin, which protects the nerves.
- Myasthenia gravis (Goldflam disease) - the muscles under voluntary control become easily tired and weak because there is a problem with how the nerves stimulate the contraction of muscles. This is also an autoimmune disorder.
- Parkinson's disease & Parkinsonism syndromes - Parkinson's disease is a gradually progressive, degenerative neurological disorder which typically impairs the patient's motor skills.
- Radiation - some patients who received radiation therapy (radiotherapy) to the neck and head area may have swallowing difficulties.
- Cleft lip and palate - types of abnormal developments of the face during pregnancy - they are due to incomplete fusing of bones in the head, resulting in gaps (clefts) in the palate and lip to nose area.
- Scleroderma - a group of rare autoimmune diseases in which the skin and connective tissues tighten and harden.
- Esophageal cancer - a type of cancer in the esophagus, usually related to either alcohol and smoking or GERD.
- Esophageal stricture - a narrowing of the esophagus that can cause difficulty with food passing down the esophagus, it is often related to GERD
- Xerostomia (dry mouth) - there is not enough saliva to keep the mouth wet.
Complications of dysphagia
Pneumonia and upper respiratory infections - specifically aspiration pneumonia which can occur if something is swallowed down the "wrong way" and it enters the lungs.
Malnutrition - this is especially the case with people who are not aware of their dysphagia and are not being treated for it. They may simply not be getting enough vital nutrients for good health.
Dehydration - if an individual cannot drink properly, their fluid intake may not be sufficient, leading to dehydration (shortage of water in the body).
Diagnosis of dysphagia
A barium swallow test followed by an X-ray can help diagnose the cause of dysphagia.
The doctor will try to determine where the problem lies - which part of the swallowing process is causing the difficulty.
The patient will be asked about symptoms, how long they have been present, whether the problem is with liquids, solids, or both.
Additionally, the patient will be weighed and asked if their current weight is about right.
Swallow study - a swallow study is usually administered by a speech therapist. They test different consistencies of food and liquid to see which cause difficulty. They may also do a video swallow test to see where the problem is.
Barium swallow test - the patient swallows a barium-containing liquid. Barium shows up in X-rays and helps the doctor identify what is happening in the esophagus in more detail, especially muscular activity.
Endoscopy - a doctor uses a camera to look down into the esophagus. They may take a biopsy if they find something concerning for cancer.
Manometry - this study measures the pressure changes produced by contractions of the muscular portions of the esophagus. This may be used when an endoscopy yields normal results.
Treatment for dysphagia
Treatment depends on the type of dysphagia:
Treatment for oropharyngeal dysphagia (high dysphagia)
Because oropharyngeal dysphagia is often a neurological problem, providing effective treatment is challenging. Patients with Parkinson's disease may respond well to Parkinson's disease medication which helps the dysphagia too.
- Swallowing therapy - this will be done with a speech and language therapist. The patient will learn new ways of swallowing properly. Some exercises will be taught and practiced to improve the muscles and how they respond.
- Diet - this is usually done with a nutritionist. Some foods and liquids, or combinations of them, are easier to swallow. While eating the easiest-to-swallow foods, it is also important that the patient has a well-balanced diet.
- Feeding through a tube - if the patient is at risk of pneumonia, malnutrition, or dehydration they may need to be fed through a nasal tube (nasogastric tube) or PEG (percutaneous endoscopic gastrostomy). PEG tubes are surgically implanted directly into the stomach and pass through a small incision in the abdomen.
Treatment for esophageal dysphagia (low dysphagia)
Surgical intervention is usually required for esophageal dysphagia.
- Dilation - if the esophagus needs to be widened (due to a stricture for example), a small balloon may be inserted and then inflated (it is then removed).
- Botulinum toxin (Botox) - commonly used if the muscles in the esophagus have become stiff (achalasia). Botulinum toxin is a strong toxin that can paralyze the stiff muscle, reducing constriction.
If the dysphagia is caused by cancer, the patient will be referred to an oncologist for treatment and may need surgical removal of the tumor.