Dysphagia (Difficulty Swallowing)

What is dysphagia (difficulty swallowing)?

Dysphagia is the medical term for difficulty swallowing. When you swallow, many muscles and nerves work together to move food or drink from your mouth to your stomach. When there’s an issue with how these parts work, swallowing may feel uncomfortable or slow. You may cough or choke when you try to swallow water, food or even your own saliva (spit).

Most people know what dysphagia feels like. If you’ve ever eaten too fast and felt like food went down the wrong pipe, or if you’ve cleared your throat because something felt stuck — you’re already familiar with dysphagia. The feeling’s unpleasant, and it’s usually not anything to worry about.

But dysphagia can be a sign of something serious. It’s a common symptom following a stroke. Untreated dysphagia can pose risks like food or liquid getting into your airway (aspiration). This can lead to a lung infection or pneumonia.

A specialist in swallowing disorders called a speech-language pathologist (SLP) can assess your ability to swallow and provide treatment if there’s a risk.

Types of dysphagia

Healthcare providers separate dysphagia into three types based on where the problem is. Think of swallowing as a journey that foods and liquids take to your stomach. There are three main stops along the way: your mouth (oral cavity), throat (pharynx) and the food tube that connects to your stomach (esophagus).

Issues at any of these key stops can create slowdowns, making it difficult or impossible to swallow.

• Oral dysphagia: The problem is in your mouth. Your jaw, teeth and tongue work together to tear food into smaller pieces when you chew. Your salivary glands produce spit that softens the food so it breaks apart easily.
• Oropharyngeal dysphagia: The problem is in your throat. After your mouth prepares the food, your tongue pushes it to the back of your throat. Your voice box (larynx) closes to prevent food or liquid from slipping into your airway (trachea) on its way to your esophagus. Oropharyngeal dysphagia is also known as transfer dysphagia. Think of it this way: it involves problems transferring food from your mouth to your throat.
• Esophageal dysphagia: The problem is in your esophagus. Your esophagus squeezes the food or liquid down in a wave-like motion (peristalsis) until it reaches your stomach.

What causes dysphagia?

Any disorder, disease or condition that impacts the muscles or nerves that help you swallow can cause dysphagia.

Nervous system and brain disorders

Conditions and injuries affecting your brain and nervous system (the network of nerves that controls muscles and organs) that cause dysphagia include:

• Amyotrophic lateral sclerosis (ALS): A condition that weakens the nerves that control your muscles.
• Brain tumors: Growths in your brain (both cancerous and benign) that can disrupt the nerve signals that tell your muscles to move.
• Cerebral palsy: A developmental disorder (one you’re born with) that makes it hard to move and coordinate muscles.
• Dementia: A mental state associated with different diseases that involve trouble thinking and coordinating movement.
• Multiple sclerosis (MS): An autoimmune disease that damages the nerves in your brain and spinal cord. With an autoimmune disease, your immune system attacks your body’s healthy cells.
• Parkinson’s disease: A condition that causes tissue in your brain to deteriorate, creating problems with movement and coordination.

Muscle disorders

Conditions that prevent the muscles in your head and neck from helping you swallow include:

• Achalasia: A rare disorder where muscles at the bottom of your esophagus don’t relax to allow food to enter your stomach.
• Cricopharyngeal spasms: Spasms (abnormal contractions) that happen when the muscle at the top of your esophagus squeezes too much, creating the sensation that something’s stuck in your throat.
• Esophageal spasms. Spasms that happen when various muscles in your esophagus squeeze too much.
• Muscular dystrophy: A group of inherited conditions that cause muscles to weaken over time.
• Myasthenia gravis: An autoimmune disease that interrupts the signals nerves send to muscles, making it hard to control movements.
• Myositis: An autoimmune disease that can cause muscle weakness in your throat and esophagus.
• Scleroderma: An autoimmune disease that causes scar tissue to form in your esophagus. The stiff tissue prevents your esophagus muscles from squeezing to move food toward your stomach.

Narrowing, blockages and structural issues

Conditions that create blockages or cause your throat or esophagus to be too narrow can make it hard to swallow. Causes include:

• Cancer: Tumors in your head and neck can obstruct food and drink. Esophageal cancer is the most common type of cancer that causes dysphagia.
• Eosinophilic esophagitis. A condition that happens when too many white blood cells (eosinophils) build up in your esophagus, causing stiffness.
• Esophageal diverticulum: A weakened pouch that forms in the lining of your esophagus. Food bits can collect in the pouch, creating the sensation that something’s stuck in your throat. The most common type is called Zenker’s diverticulum.
• Esophageal webs and (Schatzki) rings: Atypical tissue inside your esophagus that narrows the tube. The smaller tube can cause food to get stuck.
• GERD (acid reflux disease): Stomach acid can flow backward into your esophagus, causing scar tissue. The tissue can cause tightening called esophageal strictures and irritation called Barrett’s esophagus. These conditions can make swallowing painful and difficult.

Other causes

Infections, like strep throat (bacterial tonsillitis), can cause pain and inflammation that lead to dysphagia. Dysphagia can occur after surgery to your head and neck or other types of treatment. For example, radiation therapy for head and neck cancer destroys tumors but can also damage tissue involved in swallowing.

What are the risk factors for dysphagia?

Aging doesn’t cause dysphagia, but it’s a key risk factor. Muscle deteriorates as we get older, making us more susceptible to injury. The risk of developing many neurological conditions associated with dysphagia increases with age.

How is dysphagia diagnosed?

A healthcare provider will ask about your symptoms and perform a physical exam. They may perform one or more tests to check the structures in your head and neck that help you swallow. Different providers specialize in different tests.

Typical tests include:

• Esophagram (barium swallow test): A radiologist gives you a barium solution to drink that shows your throat and esophagus clearly on X-rays. They’ll take X-rays that show a video of how your esophagus works as you swallow.
• Esophagoduodenoscopy (EGD) or upper endoscopy: A gastroenterologist places a scope down your throat that takes pictures of your throat, esophagus and stomach. It can show narrowing, tumors and conditions like Barrett’s esophagus.
• Laryngoscopy: An otolaryngologist (ear, nose and throat doctor) places a small scope in your nose that allows them to examine your throat and voice box for irregularities.
• Modified barium swallow: A speech-language pathologist (SLP) gives you liquid and food covered with barium to swallow. They’ll tell you when to chew and swallow while a radiologist takes X-rays that record how your mouth, throat and esophagus work.
• Fiberoptic endoscopic evaluation of swallowing (FEES): An SLP places a small camera into your nose that allows them to see your voice box and the top of your esophagus. Once the camera’s in place, you’ll consume liquids and food containing a dye that makes them show up on camera. The SLP will watch the swallowing process and check if food enters your airway.
• Esophageal manometry: A gastroenterologist passes a tube from your nose to your stomach. Once the tube is in place, they ask you to drink water. The tube connects to a pressure recorder that measures contractions in your esophagus as you swallow the fluid.

How is dysphagia treated?

Treatment for dysphagia depends on what’s causing it and how severe it is. Your treatment might include:

• Medication: Your healthcare provider may prescribe antimicrobials to treat infections (usually caused by viruses or fungi) causing dysphagia. Treatment for GERD includes drugs to control acid reflux.
• Lifestyle changes: Your provider may recommend changing your diet and eating habits. You may need softer foods that are easier to chew. You may need to avoid food and drink that’s too hot or cold.
• Other medical therapy: If a neurological condition makes it difficult for you to swallow, your provider can offer solutions. Your options might include botulinum toxin (Botox®) injections to relieve muscle spasms. You may need a procedure to enlarge your esophagus or remove an obstruction.
• Feeding tube: Your provider may recommend a feeding tube if you aren’t getting enough to eat or drink or if you’re at risk of choking. A feeding tube delivers nutrients directly to your intestines or your stomach. Your provider will discuss options with you.

Rehabilitation for swallowing problems

Many people find rehabilitation helpful. An SLP can teach you exercises to strengthen your swallowing muscles. To swallow safely, your SLP may recommend:

• Changing how you eat and drink: Your SLP will guide you to take smaller bites and chew food thoroughly. You may need to add a special thickening powder to your drinks since watery liquids can be tough to swallow.
• Sitting upright while eating: To reduce the risk of choking, your SLP will show you the best way to sit while eating. You can also learn how to tilt your head to make swallowing easier. These techniques reduce the risk of food or liquid going down your windpipe.
• Clearing your throat: SLPs can teach you how to safely clear your throat with a little cough if food or drink gets stuck.

What are the complications or risks of not treating dysphagia?

Dysphagia can lead to serious health issues and even be fatal without treatment. Risks include:

• Dehydration.
• Malnutrition.
• Choking.
• Silent aspiration and aspiration pneumonia. Stroke survivors are at an especially high risk of silent aspiration. Silent aspiration is when food and liquid enter your lungs without any coughing, choking or other signs of a swallowing problem. The foreign material can lead to pneumonia.

When should I call my healthcare provider about difficulty swallowing?

Schedule an appointment with your healthcare provider as soon as you notice that your dysphagia isn’t a one-time thing. Recurring dysphagia likely has a cause that your provider can diagnose and treat.

Call 911 or go to the emergency room if you’re having trouble breathing and think something is stuck in your throat. Sudden muscle weakness, paralysis and inability to swallow are also signs of an emergency. Get help right away.