Dysphagia (Difficulty Swallowing): Causes and Treatments

Dysphagia is the medical term for difficulty swallowing. It can be a symptom of many different medical conditions, including neurological disorders, muscle issues, and structural blockages in the throat or esophagus (the tube that carries food from the mouth to the stomach). 

Some people with dysphagia (swallowing difficulties) have pain or trouble swallowing certain types of food or liquid, while others cannot swallow at all. People of all ages can develop a swallowing disorder, but it’s more common in older adults due to the weakening of mouth and throat muscles that occurs naturally with aging. Treatment of dysphagia depends on the underlying cause.

Note: Odynophagia is a medical term that means painful swallowing.

Recognizing Dysphagia Symptoms

The average human swallows 500-700 times a day. Occasional trouble swallowing is typically not a cause for concern. Occasional difficulty swallowing can occur due to improper chewing, eating too quickly, or specific food textures, often leading to a sensation of being "choked up."  

However, ongoing swallowing problems can be a sign of a serious underlying health condition and should be evaluated by a healthcare professional. Untreated dysphagia can lead to an increased risk of aspiration pneumonia, where food or liquid enters the airway. Therefore, being able to recognize dysphagia symptoms is vital for timely medical intervention, helping to prevent further complications.

Why Is Swallowing Important For Overall Health? 

Swallowing (medical term: deglutition) is the process of moving food or liquid from the mouth to the stomach. It is essential to maintain nutrition and hydration. The swallowing process is divided into the oral phase (mouth), pharyngeal phase (throat), and esophageal phase (food pipe). The first phase is voluntary while the other two are involuntary. 

The swallowing mechanism is an innate physiological human function. But while it sounds simple, swallowing is actually a complex, multistep process that involves a number of muscles and cranial nerves. 

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Types of Dysphagia

There are three main types of dysphagia, categorized based on the location of the problem. To understand this concept more clearly, it's helpful to visualize the path that foods and liquids take once they are swallowed. The swallowing process begins in the mouth, moves to the throat, and then continues down the esophagus, which is the hollow tube that connects the throat to the stomach, allowing foods and liquids to pass through.

• Oral dysphagia refers to difficulties that occur in the mouth, which affect the ability to chew food. This type of dysphagia is also known as "high dysphagia."

• Pharyngeal dysphagia occurs in the throat and is often caused by neurological conditions, such as strokes or Parkinson's disease. It is commonly referred to as "transfer dysphagia" because it involves challenges in moving food or liquids from the mouth to the throat. 

• Esophageal dysphagia occurs in the esophagus, where the esophagus has problems pushing food or liquids down to the stomach. As oral dysphagia is referred to as "high dysphagia," esophageal dysphagia is known as "low dysphagia."

What Are the Causes of Dysphagia?

There is no single main cause of dysphagia. Swallowing problems can occur due to a wide range of medical conditions, some of which are listed below.

Causes of Oropharyngeal Dysphagia

Oropharyngeal dysphagia occurs when a medical condition makes it difficult to move the food bolus or liquid from the mouth to the throat and esophagus. Possible causes include:

• Neuromuscular Dysfunction:

  • Brain and spinal cord injuries.

  • Nervous system disorders such as multiple sclerosis, Parkinson’s disease, muscular dystrophy, pseudobulbar palsy, or cerebral palsy.

  • Neuromuscular disorders like myasthenia gravis or myopathy.

  • Neurodegenerative disorders like amyotrophic lateral sclerosis (ALS).

• Mechanical Obstruction:

  • Pharyngoesophageal diverticulum (Zenker’s diverticulum), which is a small pouch that forms in the throat and accumulates food.

  • Head and neck cancers.

  • Cancer treatments such as radiation therapy.

  • Cleft lip and cleft palate.

Causes of Esophageal Dysphagia

Possible causes of esophageal dysphagia include:

• Neurological Conditions:

  • Achalasia: a condition in which the nerves and muscles of the esophagus are damaged, making it hard to move food and liquid from the mouth to the stomach. In people with cricopharyngeal achalasia, the upper esophageal sphincter does not open properly.

  • Esophageal spasms or uncontrolled contractions of the esophageal muscles.

  • Scleroderma: a condition in which scar tissue causes stiffening of the lower esophagus, leading to damage and frequent heartburn.

• Structural Causes:

  • Esophageal stricture (narrowing of the esophagus) due to gastroesophageal reflux disease (GERD) or scar tissue formation.

  • Schatzki ring or esophageal ring (an area of narrowing in the lower esophagus).

  • Esophageal webs (thin membranes in the lower or upper esophagus that cause narrowing).

  • Foreign bodies stuck in the esophagus

  • Gastroesophageal reflux disease (GERD) or acid reflux, which occurs due to a weak lower esophageal sphincter, a ring-like muscle at the lower end of the esophagus. This causes stomach acid to back up into the esophagus, which causes inflammation and damage to esophageal tissues.

  • Esophageal cancer

  • Eosinophilic esophagitis: an immune system condition that causes inflammation.

  • Cancer treatment with radiation therapy.

Causes of Esophagogastric Dysphagia

Possible causes of esophagogastric dysphagia include:

• Neuromuscular Causes:

  • Achalasia.

• Structural Causes:

  • Stomach cancer.

  • Esophageal stricture.

Causes of Paraesophageal Dysphagia

Possible causes of paraesophageal dysphagia are conditions that press upon the esophagus, for example:

• Thyromegaly (goiter) or abnormal enlargement of the thyroid gland.

• Cervical spine disease.

• Left atrial enlargement (the left atrium is one of the heart’s chambers).

• Post-surgical scarring.

• Cervical or mediastinal lymphadenopathy (swollen lymph nodes in the neck or chest).

Dysphagia Symptoms

• Pain with swallowing

• Inability to swallow food or liquid

• A feeling of food sticking to the base of the throat or the center of the chest behind the breastbone

• Choking, gagging, or coughing with swallowing

• A feeling that food is going up into the nose or down into the trachea (windpipe)

• Hoarse voice

• Drooling

• Gurgly sounds

• Regurgitation (food coming back up)

• Frequent heartburn

• Sour taste in the mouth due to stomach acid backing up into the throat

• Bad breath

• Repeated throat clearing

• Weight loss

Diagnosing Dysphagia

A healthcare provider can make a diagnosis of dysphagia and identify the underlying cause based on your symptoms, medical history, physical exam, and diagnostic tests. Some of the tests that are done to evaluate swallowing problems include: 

Modified Barium Swallow

A modified barium swallow or esophagram is a type of X-ray that is done using a contrast material called barium. It involves swallowing a solution (liquid), but can also involve swallowing solid food containing barium or a barium pill. The barium coats the inside of your esophagus. This makes it easier for your doctors to see abnormalities in your esophagus on X-rays which are subsequently obtained.

Dynamic Swallowing Study

Also called a videofluoroscopic swallowing study (VFSS), this is a diagnostic test in which you swallow barium-coated foods of varying consistencies. Your healthcare provider obtains images as these foods go down your esophagus. The test can help in identifying problems with the swallowing muscles and their coordination during the swallowing process. It can also show if food is entering the trachea (windpipe). 

Upper Endoscopy

Upper endoscopy or esophagoscopy is a minimally invasive procedure in which the doctor passes a thin, flexible instrument called an endoscope or esophagoscope into your esophagus. The endoscope has a light and camera at its tip and allows your healthcare team to directly see inside your esophagus. Your doctor can also collect a biopsy (small tissue sample) for examination in the laboratory, to look for signs of inflammation or cancer cells, for example. 

A variation of this test is called a fiber-optic endoscopic evaluation of swallowing (FEES) study. This is done using an endoscope during active swallowing.

Manometry

Manometry is an esophageal muscle test that is done by inserting a small tube into the esophagus. This tube is connected to a device that can record pressure. It measures muscle contractions in the esophagus during swallowing.

Imaging Studies

Your healthcare provider may order diagnostic imaging such as a CT scan or MRI scan to obtain more detailed images of your mouth, esophagus, and surrounding organs. 

What Are The 4 Stages of Dysphagia?

Doctors sometimes classify dysphagia into 4 stages as follows based on severity:

How is Dysphagia Treated?

Dysphagia treatment depends on the underlying cause. Some of the treatments offered to people with dysphagia include:

Exercises and Swallowing Techniques

People with dysphagia can benefit from working with a speech and language therapist to learn exercises that can lead to better coordination of the swallowing muscles and stimulation of the nerves involved in the swallowing reflex. A speech-language pathologist can also teach you swallowing techniques such as chin tuck, head turn, or supraglottic swallow to help you swallow safely. 

Esophageal Dilation

In people with swallowing dysfunction due to structural reasons, such as achalasia, esophageal stricture, Schatzki ring, or motility disorders, an endoscope can be used to dilate (widen) the esophagus. 

Botox Injection

Injection of onabotulinumtoxinA (brand name: Botox) into an esophageal sphincter can help to relax this muscle and relieve swallowing problems caused by achalasia. This treatment needs to be repeated every 3-4 months. More research is needed on its effectiveness in treating dysphagia.

Medications

People who have swallowing difficulties due to GERD (acid reflux) can benefit from prescription drugs that reduce stomach acid production. Examples include:

• Antacids such as Maalox, Mylanta, Tums, Rolaids, and others.

• H2 blockers (histamine H2-receptor antagonists) such as cimetidine (Tagamet HB), famotidine (Pepcid AC), and nizatidine (Axid AR). 

• Proton pump inhibitors (PPIs) such as omeprazole (Prilosec), lansoprazole (Prevacid), pantoprazole (Protonix), esomeprazole (Nexium), and rabeprazole (Aciphex).

Other medications for dysphagia may include: 

• Corticosteroids in people with inflammatory conditions like eosinophilic esophagitis. 

• Muscle relaxants in people with dysphagia due to esophageal spasm.

Surgical Interventions for Dysphagia

Surgery may be performed to remove an esophageal tumor or treat achalasia or Zenker diverticulum. Your healthcare team might also recommend surgical procedures to treat swallowing problems caused by a narrowing or blockage in the esophagus or GERD. 

Some of the surgical treatments done to treat dysphagia include:

• Laparoscopic Heller myotomy to cut the esophageal sphincter (the muscle at the lower end of the esophagus) in people with achalasia. When this muscle fails to open, it can prevent food from going into the stomach. Learn about laparoscopy.

• Peroral endoscopic myotomy (POEM) to make an incision (cut) in the inner lining of the esophagus to treat achalasia. 

• Stent placement (a metal or plastic tube is left in place to keep a narrowed or blocked esophagus open). The stent may be temporary or permanent. 

In people with severe or profound dysphagia, a feeding tube is needed to maintain nutrition. A feeding tube such as percutaneous endoscopic gastrostomy (PEG) bypasses the esophagus and provides nutrition directly into the stomach without the need to swallow.

Lifestyle Changes and Home Remedies for Dysphagia

It’s important to get a proper diagnosis and find out the reason for your swallowing problems. Once you know what is causing your swallowing disorder, your healthcare provider will prescribe the appropriate treatment for dysphagia. In addition, the following lifestyle changes can help to make the swallowing process easier:

Make changes in eating habits:

• Eat smaller, more frequent meals. 

• Cut food into smaller pieces.

• Chew more thoroughly.

• Eat more slowly. 

• Thicken thin liquids (there are products available to do this).

Avoid certain foods and drinks:

• Avoid thin liquids like juice and coffee, which may be problematic. 

• Avoid alcohol and caffeine, which can have a drying effect on your mouth and throat and cause problems with swallowing.

• Avoid dry and tough foods like certain meats, nuts, dried fruits, dry bread, coarse cereals, and raw vegetables.

• Avoid sticky foods like caramel and peanut butter.

Potential Health Risks of Dysphagia

Problems swallowing can lead to malnutrition, dehydration, and weight loss. Dysphagia can also increase the risk of choking and aspiration pneumonia (food going down into the trachea (breathing tube), introducing bacteria into the lungs, and causing a lung infection).

Long-Term Management Strategies

The goal of treating dysphagia is to maintain adequate nutritional intake and protect your airway (prevent food from entering your breathing tube). 

Depending on the cause of dysphagia, you may need to continue dysphagia treatment long-term. For example, you may need to take medicines for acid reflux long-term. 

Recovery and Quality of Life: Can I Live A Long Life With Dysphagia?

Yes, you can likely live a long life with dysphagia. Most causes of dysphagia are treatable, and many are curable with a full recovery and good quality of life. However, dysphagia can sometimes be a symptom of terminal conditions like amyotrophic lateral sclerosis (ALS). 

Frequently Asked Questions

What Is The First Symptom of Dysphagia?

The first symptom of dysphagia is usually trouble swallowing. This could include discomfort with swallowing or a feeling that food is getting stuck in your throat or chest.

Can A Person Recover From Dysphagia?

Most people can recover from dysphagia. Swallowing problems are often caused by treatable conditions. Difficulty swallowing can also occur due to improper chewing, eating too quickly, or specific food textures. In these instances, it’s generally not something to be concerned about. 

However, it’s important to consult a healthcare provider if you have trouble swallowing. This will ensure you get the proper diagnosis and treatment. Your primary care provider may refer you to a gastroenterologist (specialist in disorders of the digestive tract). Treatment depends on the cause, but once you have a diagnosis, lifestyle changes such as making sure you chew food properly and eat slowly can also help. 

Is Dysphagia Life-Threatening?

Dysphagia can be life-threatening due to the risk of choking and aspiration pneumonia if left untreated (food particles entering the breathing tube and lungs).

How Quickly Does Dysphagia Progress?

How quickly dysphagia progresses depends on the underlying cause. For example, someone with acid reflux may notice a gradual worsening of swallowing problems over a period of many years. On the other hand, a person with cancer of the oral cavity or esophagus may have a more rapid progression of dysphagia over 6-12 months.