be_ixf;ym_202112 d_04; ct_50

Dysphagia

Overview

Esophagus

The esophagus is a muscular tube that connects your mouth and your stomach. Rings of muscle (sphincters) in the upper and lower portions contract and relax to allow food and liquid to pass.

Dysphagia is difficulty swallowing — taking more time and effort to move food or liquid from your mouth to your stomach. Dysphagia can be painful. In some cases, swallowing is impossible.

Occasional difficulty swallowing, such as when you eat too fast or don't chew your food well enough, usually isn't cause for concern. But persistent dysphagia can be 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.

Symptoms

Signs and symptoms associated with dysphagia can include:

  • Pain while swallowing
  • Inability to swallow
  • A sensation of food getting stuck in the throat or chest or behind the breastbone (sternum)
  • Drooling
  • Hoarseness
  • Food coming back up (regurgitation)
  • Frequent heartburn
  • Food or stomach acid backing up into the throat
  • Weight loss
  • Coughing or gagging when swallowing

When to see a doctor

See your health care provider if you regularly have difficulty swallowing or if weight loss, regurgitation or vomiting accompanies your dysphagia.

If an obstruction interferes with breathing, call for emergency help immediately. If you're unable to swallow because you feel that food is stuck in your throat or chest, go to the nearest emergency department.

Causes

Swallowing is complex, involving many muscles and nerves. Any condition that weakens or damages the muscles and nerves used for swallowing or leads to a narrowing of the back of the throat or esophagus can cause dysphagia.

Dysphagia generally falls into one of the following categories.

Esophageal dysphagia

Esophageal dysphagia refers to the sensation of food sticking or getting caught 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 the lower esophageal muscle (sphincter) doesn't relax properly to let food enter the stomach, it can cause food to come back up into the throat. Muscles in the wall of the esophagus might be weak as well, a condition that tends to worsen over time.
  • Diffuse spasm. This condition causes high-pressure, poorly coordinated contractions of the esophagus, usually after swallowing. Diffuse spasm affects the involuntary muscles in the walls of the 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 due to narrowing of the esophagus.
  • Foreign bodies. Sometimes food or another object can partially block the 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 cause difficulty swallowing solid foods off and on.
  • GERD. Damage to esophageal tissues from stomach acid backing up into the esophagus can lead to spasm or scarring and narrowing of the lower esophagus.
  • Eosinophilic esophagitis. This condition, which might be related to a food allergy, is caused by too many cells called eosinophils in the esophagus.
  • Scleroderma. Development of scar-like tissue, causing stiffening and hardening of tissues, can weaken the lower esophageal sphincter. As a result, acid backs up into the esophagus and causes frequent heartburn.
  • Radiation therapy. This cancer treatment can lead to inflammation and scarring of the esophagus.

Oropharyngeal dysphagia

Certain conditions can weaken the throat muscles, making it difficult to move food from your mouth into your throat and esophagus when you start to swallow. You might 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 can 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 the ability to swallow.
  • Pharyngoesophageal diverticulum (Zenker's diverticulum). A small pouch that forms and collects food particles in the throat, often just above the 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 as well as 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 have difficulty swallowing.

Complications

Difficulty swallowing can lead to:

  • Malnutrition, weight loss and dehydration. Dysphagia can make it difficult to take in enough nourishment and fluids.
  • Aspiration pneumonia. Food or liquid entering the airway during attempts to swallow can cause aspiration pneumonia as a result of the food introducing bacteria into the lungs.
  • Choking. Food stuck in the throat can cause choking. If food completely blocks the airway and no one intervenes with a successful Heimlich maneuver, death can occur.

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. However, if you have signs or symptoms of dysphagia, see your health care provider.

If you have GERD, see your health care provider for treatment.

Diagnosis

Your health care provider will likely ask you for a description and history of your swallowing difficulties, perform a physical examination, and use various tests to find the cause of your swallowing problem.

Tests can include:

  • X-ray with a contrast material (barium X-ray). You drink a barium solution that coats your esophagus, making it easier to see on X-rays. Your health care provider can then see changes in the shape of your esophagus and can assess the muscular activity.

    Your health care provider might 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 might not identify.

  • Dynamic swallowing study. You swallow barium-coated foods of different consistencies. This test provides an image of these foods as they travel down your throat. The images might 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 health care provider can see your esophagus. Your health care provider might take biopsies of the esophagus to look for inflammation, eosinophilic esophagitis, narrowing or a tumor.
  • Fiber-optic endoscopic evaluation of swallowing (FEES). Your health care provider might 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 can 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 health care provider might refer you to a speech or swallowing therapist. Therapy might include:

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

Esophageal dysphagia

Treatment approaches for esophageal dysphagia might include:

  • Esophageal dilation. For a tight esophageal sphincter (achalasia) or an esophageal stricture, your health care provider might use an endoscope with a special balloon attached to gently stretch and expand your esophagus or pass a flexible tube or tubes to stretch the esophagus (dilation).
  • Surgery. For an esophageal tumor, achalasia or pharyngoesophageal diverticulum, you might 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 might need to take these medications for a long time.

    Corticosteroids might be recommended for eosinophilic esophagitis. For esophageal spasm, smooth muscle relaxants might help.

  • Diet. Your health care provider might prescribe a special diet to help with your symptoms, depending on the cause of the dysphagia. If you have eosinophilic esophagitis, diet might be used as treatment.

Severe dysphagia

If difficulty swallowing prevents you from eating and drinking enough and treatment doesn't allow you to swallow safely, your health care provider might recommend a feeding tube. A feeding tube provides nutrients without the need to swallow.

Surgery

Surgery might be needed to relieve swallowing problems caused by throat narrowing or blockages, including bony outgrowths, vocal cord paralysis, pharyngoesophageal diverticula, 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 of dysphagia. Some examples are:

  • Laparoscopic Heller myotomy. This involves cutting 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 or gastroenterologist uses an endoscope inserted through the mouth and down the throat to create an incision in the inside lining of the esophagus to treat achalasia Then, as in a Heller myotomy, the surgeon or gastroenterologist cuts the muscle at the lower end of the esophageal sphincter.
  • Esophageal dilation. The health care provider inserts a lighted tube (endoscope) into the esophagus and inflates an attached balloon to stretch it (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), and motility disorders. Long flexible tubes of varying diameter also may be inserted through the mouth into the esophagus to treat strictures and rings.
  • Stent placement. The health care provider can also insert a metal or plastic tube (stent) to prop open a narrowing or blocked esophagus. Some stents are permanent, such as those for people with esophageal cancer, while others are removed later.
  • OnabotulinumtoxinA. This can be injected into the muscle at the end of the esophagus (sphincter) to cause it to relax, improving swallowing in achalasia. Less invasive than surgery, this technique might require repeat injections. More study is needed.

Lifestyle and home remedies

If you have trouble swallowing, be sure to see a health care provider and follow his or her advice. Also, some things you can try to help ease your symptoms include:

  • Changing your eating habits. Try eating smaller, more frequent meals. Cut your food into smaller pieces, chew food thoroughly and eat more slowly. If you have difficulty swallowing liquids, there are products you can buy to thicken liquids.
  • Trying foods with different textures to see if some cause you more trouble. Thin liquids, such as coffee and juice, are a problem for some people, and sticky foods, such as peanut butter or caramel, can make swallowing difficult. Avoid foods that cause you trouble.
  • Limiting alcohol and caffeine. These can dry your mouth and throat, making swallowing more difficult.

Preparing for an appointment

See your health care provider if you're having problems swallowing. Depending on the suspected cause, your health care provider might refer you to an ear, nose and throat specialist, a doctor who specializes in treating digestive disorders (gastroenterologist), or a doctor who specializes in diseases of the nervous system (neurologist).

Here's some information to help you prepare for your appointment.

What you can do

When you make the appointment, ask if there's anything you need to do in advance, such as restrict your diet.

Make a list of:

  • Your symptoms, including any that seem unrelated to the reason for which you scheduled the appointment, and when they began
  • Key personal information, including major stresses or recent life changes
  • All medications, vitamins and supplements you take, including doses
  • Questions to ask your health care provider

For dysphagia, questions to ask your health care provider include:

  • What's the likeliest cause of my symptoms?
  • What are other possible causes?
  • What tests do I need?
  • Is this condition temporary or long lasting?
  • I have other health conditions. How can I best manage them together?
  • Do I need to restrict my diet?
  • Are there brochures or other printed material I can have? What websites do you recommend?

What to expect from your doctor

Your health care provider is likely to ask you a number of questions, including:

  • Have your symptoms been continuous or occasional?
  • Does anything seem to improve your symptoms?
  • What, if anything, appears to worsen your symptoms? For example, are certain foods harder to swallow than others?
  • Do you have difficulty swallowing solids, liquids or both?
  • Do you cough or gag when you try to swallow?
  • Did you first have trouble swallowing solids and then develop difficulty swallowing liquids?
  • Do you bring food back up (regurgitate) after swallowing it?
  • Do you ever vomit or bring up blood or black material?
  • Have you lost weight?

What you can do in the meantime

Until your appointment, it might help to chew your food more slowly and thoroughly than usual. If you have heartburn or GERD, try eating smaller meals and not eating right before bedtime. Antacids that you can get without a prescription also might help temporarily.

Last Updated: October 20th, 2021