Dysphagia (Difficulty Swallowing)

Overview

What is Dysphagia?

Dysphagia is simply defined as a swallowing disorder. It can occur in any of the three phases of swallowing:

  1. Oral
  2. Pharyngeal
  3. Esophageal

Dysphagia is often noted in stroke survivors and can affect the oral and/or pharyngeal phase of swallowing. The patient may cough or choke while attempting to swallow saliva, liquids, or food. A speech-language pathologist often assesses a patient’s ability to swallow in order to determine the risk of aspiration, (food or liquid going into the lungs) which potentially may lead to a lung infection or pneumonia.

Stroke survivors are at risk for silent aspiration. Silent aspiration is when food and liquid enter into the lungs without any coughing or choking. In these patients, there are no outward signs or symptoms of a swallowing problem.

What does it mean to have difficulty swallowing?

When we swallow, many muscles and nerves work together to get food or drink from our mouths into our stomachs. Trouble with swallowing can originate anywhere in the mouth, throat or esophagus. The esophagus is a muscular tube in your throat that carries food and water to your stomach.

Swallowing problems can be mild or severe. The treatment varies depending on what’s causing the problem. Sometimes, doctors can prescribe medication to help you swallow. If you’re unable to swallow anything at all, you may need a feeding tube to get the nourishment you need.

Possible Causes

What can cause difficulty swallowing?

Many disorders, diseases and conditions can cause trouble swallowing. Doctors separate swallowing problems into three types:

  • Oral cavity dysphagia: The problem is in the mouth. Typical causes include tongue weakness after stroke, difficulty chewing food or neuromuscular problems.
  • Oropharyngeal dysphagia: The problem is in the throat. This can be a result of a neurological or muscular problem.
  • Esophageal dysphagia: This is a problem of the esophagus. This can be caused when something blocks or compresses the esophagus, there’s a muscular disorder or there are pouches in the esophagus.

What conditions can cause swallowing problems?

Possible causes of swallowing difficulties can include:

  • Nervous system and brain disorders: Certain conditions affect your brain and nervous system (the network of nerves that controls muscles and organs). Parkinson’s disease, multiple sclerosis, amyotrophic lateral sclerosis (ALS) and stroke can lead to swallowing difficulties.
  • Muscle disorders: Myasthenia gravis (an autoimmune condition) and muscular dystrophy affect muscles all over the body. Disorders of the esophagus, such as achalasia, systemic sclerosis (scleroderma), cricopharyngeal spasms and esophageal spasms can affect your ability to swallow.
  • Esophagus narrowing and blockages: Esophageal cancer, a tumor or a swollen thyroid gland can constrict the esophagus (make it narrower). A narrowed esophagus can make swallowing a challenge. Some people develop webs or Schatzki rings (pieces of tissue inside the esophagus). This tissue narrows the tube and makes it hard to swallow chunks of food. Disorders of the opening of the esophagus can also contribute to difficulty swallowing such as cricopharyngeal hypertrophy. Swallowing can be difficult or impossible if anything is stuck in your throat.
  • Scarring from acid reflux: Scar tissue can form in your esophagus as a result of GERD (acid reflux disease). GERD can lead to Barrett’s esophagus (irritation in the esophagus lining).
  • Infection: Tonsillitis (sore throat) causes pain and inflammation. It can make swallowing painful.

Care and Treatment

How is dysphagia diagnosed?

Diagnostic tests for swallowing disorders vary. Typical tests include:

  • Flexible laryngoscopy: This test is done by an ENT (ear, nose and throat) specialist. It involves placing a small scope in your nose and looking at your throat and vocal cords.
  • Fiberoptic endoscopic evaluation of swallowing (FEES): Performed by a speech therapist, this test involves passing a small camera into your nose and feeding you dyed liquids and food to see how you are swallowing. During the test, your provider will also look to see if the food is getting into your airway (aspiration).
  • Modified barium swallow: During this test, a speech therapist gives you different foods and liquids to chew and swallow. The food will be covered with barium, a minty tasting liquid or pasty material. Barium allows images of your mouth, throat and esophagus to be seen on X-ray images. The speech therapist will tell you when to chew and swallow and the radiologist will take X-ray images while you’re swallowing.
  • Esophagram: In this test, you drink barium and the radiologist takes pictures of your esophagus.
  • Esophagoduodenoscopy (EGD) or upper endoscopy: This test involves a healthcare provider called a gastroenterologist (GI) who places a scope down your throat. The scope continues down your throat, into your esophagus and down into your stomach. This test is used to look for any narrowing, tumors or Barrett’s esophagus.

How is dysphagia treated?

Treatment for difficulty swallowing depends on the cause and severity of the problem. Your treatment might include:

  • Antibiotics: Your doctor may prescribe antibiotics to treat bacterial tonsillitis (strep throat).
  • Medication and lifestyle changes: Treatment for GERD includes drugs to control acid reflux. Your doctor may also recommend changing your diet and eating habits.
  • Other medical therapy: If a neurological condition makes it difficult for you to swallow, your doctor can offer solutions. Your options might include botulinum toxin (Botox®) injections to relieve muscle spasms or surgery to enlarge the esophagus.

What kinds of rehabilitation help with swallowing problems?

Some people find rehabilitation helpful. A speech-language pathologist (SLP) can teach you exercises to strengthen your swallowing muscles. To swallow safely, your SLP may recommend:

  • Changing how you eat and drink: Your therapist 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 therapist will show you the best way to sit while eating. You can also learn to tilt your head to make swallowing easier. These techniques reduce the risk of liquid getting into your airway (aspiration).
  • Clearing your throat: Therapists can teach you how to clear your throat with a little cough if liquid or a small piece of food gets stuck.

Will I need a feeding tube for difficulty swallowing?

If you can’t get enough of the vitamins and nutrients you need, you are losing significant amounts of weight, or if you have a high risk of choking, your doctor may recommend a feeding tube. This medical device delivers nutrients directly to your intestines or your stomach. Your doctor will discuss your options with you.

When to Call the Doctor

When should I call my doctor about difficulty swallowing?

You should see your doctor to determine the cause of your swallowing difficulties. Call a doctor right away if you’re also having trouble breathing or think something might be stuck in your throat. If you have sudden muscle weakness or paralysis and can’t swallow at all, call 911 or go to the emergency room.

Last reviewed by a Cleveland Clinic medical professional on 03/24/2020.

References

  • Merck Manual. . Accessed 3/31/2020.Difficulty Swallowing (https://www.merckmanuals.com/home/digestive-disorders/symptoms-of-digestive-disorders/difficulty-swallowing)
  • National Institutes of Health. . Accessed 3/31/2020.Dysphagia (https://www.nidcd.nih.gov/health/dysphagia#1)
  • American College of Gastroenterology. . Accessed 3/31/2020.Dysphagia (https://gi.org/topics/dysphagia/)

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