If you frequently experience the feeling of taking more time and effort to move food or liquid from your mouth to your stomach, you may have a swallowing disorder called dysphagia. Dysphagia may also be accompanied by pain when swallowing.
Occasional difficulty swallowing, which may occur when you eat or drink too quickly or when you don’t chew your food well enough, is not cause for concern. However, persistent dysphagia may indicate a serious medical condition requiring treatment. Dysphagia can occur at any age but is more common in older adults. The causes of swallowing disorders vary, and treatments vary depending on the cause.
What are the symptoms of a swallowing disorder?
- Pain while swallowing (odynophagia)
- Inability to swallow
- Sensation of food getting stuck in your throat or chest
- Regurgitation (bringing food back up)
- Frequent heartburn
- Food or stomach acid which backs up into your throat
- Unexpected weight loss
- Coughing or gagging when swallowing
- Needing to cut food into smaller pieces
- Avoiding certain foods because of trouble swallowing
If you have been experiencing difficulty swallowing liquids or solids daily for more than 2-4 weeks, you should make an appointment with a specialist.
What causes a swallowing disorder?
Swallowing is complex, and a number of conditions can interfere with this process. Sometimes the cause of dysphagia cannot be identified. Most of the time, dysphagia can be identified as esophageal dysphagia or oropharyngeal dysphagia.
Causes of Esophageal Dysphagia
Esophageal dysphagia refers to the sensation of food sticking in the base of your throat or in your chest after you’ve started to swallow. Some (but not all) of the causes of esophageal dysphagia are:
- Achalasia: When your lower esophageal muscle (sphincter) doesn’t relax properly to let food enter your stomach, it may cause you to bring food back up into your throat.
- Esophageal dysmotility: Once you swallow, the food moves through the esophagus through a series of well-timed contractions. Sometimes, these become irregular or even absent. The food may not move through the esophagus correctly, resulting in the sensation of pressure in the chest or food sticking in the throat.
- 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 Tumor: If an esophageal tumor is present, swallowing tends to become progressively more difficult.
- Foreign Bodies: Sometimes food or another object can partially block your throat or esophagus (though this is rare). 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 the esophagus.
- Esophageal Ring: A thin area of narrowing in the lower esophagus that can intermittently cause difficulty swallowing solid foods.
- Cricopharyngeal muscle dysfunction: The cricopharyngeus is the muscle that serves as the entryway into the esophagus. This must relax enough for food to pass through when you swallow. Sometimes, this muscle remains tight during swallowing, or cannot relax enough to allow all of your food to pass through. You may feel like some foods stick in your throat, or are very difficult to swallow.
- Gastroesophageal Reflux Disease (GERD): Damage to the esophageal tissues from stomach acid backing up into your esophagus can lead to spasm or scarring and narrowing of your lower esophagus.
- Eosinophilic Esophagitis: This condition is caused by an overpopulation of cells called eosinophils in the esophagus and can cause effortful swallowing.
- Radiation Therapy: This type of cancer treatment can lead to inflammation and scarring of the esophagus.
- Zenker’s Diverticulum: An esophageal pouch that develops in the upper esophagus can cause debilitating dysphagia and regurgitation of food. When patients attempt to swallow, food can get caught in the zenker’s diverticulum rather than heading down into the stomach.
Causes of Oropharyngeal Dysphagia
Oropharyngeal dysphagia is characterized by difficulty with timing the movement of food and liquids from your mouth to your throat and esophagus when you start to swallow. If you have oropharyngeal dysphagia, you may experience choking, gagging, or coughing when swallowing. You may have the sensation of liquids and/or solids “going down the wrong pipe” (going into the airway) or going up into the nose. Frequent episodes of liquids/solids going into the airway may lead to pneumonia. Some (but not all) of the causes of oropharyngeal dysphagia are:
- Neurological disorders: Neurological disorders such as multiple sclerosis, muscular dystrophy, Parkinson’s disease, and amyotrophic lateral sclerosis can weaken the swallowing musculature, making oropharyngeal dysphagia a concern.
- Neurological damage: Sudden neurological damage, such as a stroke or brain or spinal cord injury can affect your body’s ability to coordinate the swallow, leading to oropharyngeal dysphagia.
- Cancer and tumors: Depending on their location, some types of cancer and tumors can cause oropharyngeal dysphagia.
- Radiation: Following radiation for some cancers, specifically those that are supraglottic (i.e. pharyngeal cancer, tonsilar cancer, base of tongue cancer), you may experience oropharyngeal dysphagia, because the radiation frequently causes stiffness to the swallowing musculature.
- Age: As you get older, you may experience a weakening of the swallowing musculature, which for some people can lead to difficulty maintaining appropriate timing of swallowing.
How is a swallowing disorder diagnosed?
If you are having difficulty swallowing solids or liquids, your doctor will ask you about your symptoms. He or she will probably perform or refer you for two or more of the following tests:
Flexible laryngoscopy: This test is used to view the structures of the larynx (throat). A small flexible camera is passed through the nasal passage, through the nasopharynx (the connection between the nose and throat), and down into the throat. A topical anesthetic (numbing medication) is used for maximum comfort during the examination. The examination takes around 1 - 2 minutes and is not painful.
Modified barium swallow study (MBS): This test is used to view your swallowing process. You will be asked to swallow a variety of barium-coated substances, such as liquid, applesauce, and a graham cracker. Barium is a whitish paste that allows the substances to light up under an X-ray so the examiner can determine how these substances are moving through your mouth, pharynx, and esophagus.
Flexible endoscopic evaluation of swallowing (FEES): FEES is an instrumental examination of swallowing that allows the examiner to view food and liquid as it passes through the throat. In order to view the swallow, a small flexible laryngoscopy is performed (as described above). While visualizing the throat through the laryngoscope, a variety of foods and liquids are eaten and drank. During this examination, no radiation exposure is necessary. In contrast to the MBS, which does involve a small amount of radiation exposure, this test cannot be used to evaluate the oral and esophageal phases and cannot view the precise moment of aspiration. Therefore, this test is not appropriate for all dysphagia complaints.
Esophageal manometry: This test is used to show whether your esophagus is working properly. The esophagus is a long, muscular tube that connects the throat to the stomach. An esophageal manometry measures the rhythmic muscle contractions that occur in your esophagus when you swallow. It also measures the coordination and force exerted by the muscles of your esophagus. During this test, a thin, flexible tube (catheter) that contains sensors is passed through your nose, down your esophagus, and into your stomach. Your throat and nose will be numbed for this test. During the test, you will be asked to take small sips of water, and swallow on command.
How do you treat a swallowing disorder?
Depending on the type and severity of dysphagia that you are experiencing, treatments can vary greatly. The most important things your doctor will consider when determining treatment are nourishment and risk of pneumonia or other pulmonary infections. Treatments for dysphagia may include (but are not limited to):
- Dysphagia therapy: Exercises and strategies are provided by a speech and language pathologist to help strengthen the muscles of swallowing, re-coordinate the timing of your swallow, and encourage a safe and effective swallow. This is typically only best for patients with oral or oropharyngeal dysphagia and does not work for esophageal related dysphagias.
- Diet modifications: Various diet modifications may be recommended depending on your specific type of dysphagia. These may include thickening liquids, eating purees, etc. This is highly individualized.
- Esophageal Dilation: If you have a tight esophageal sphincter or an esophageal stricter, your doctor may perform a procedure to stretch or dilate the esophagus.
- Medical management: Some mild dysphagias can be caused by gastroesophageal reflux disease (GERD) and these can be treated with reflux medications.
- Feeding Tube: In most severe cases, a swallowing disorder can lead to an inability to eat or drink completely or not enough to maintain proper nutrition. In these cases, a feeding tube is placed.
- Botox Injection: If you have cricopharyngeal muscle dysfunction where the muscle will not relax enough to let food pass into the esophagus, Botox can be injected to essentially inhibit the muscle contraction.
- Surgery: Minimally invasive surgical techniques such as an endoscopic cricopharyngeal myotomy or Zenker's divericulectomy can be performed in an office setting while the patient is awake, instead of in an operating room under anesthesia.
Complications of a swallowing disorder
Dysphagia can be frustrating because it takes the joy out of eating and drinking. It can also lead to more severe complications such as malnutrition, weight-loss, and dehydration. In addition, if you are aspirating (having liquids or solids enter the airway while swallowing), respiratory problems can occur such as pneumonia, bronchitis, or other upper respiratory infections.