Difficulty swallowing (dysphagia)

What is dysphagia?

Swallowing is a complex process that requires many muscles and nerves of the mouth, tongue, throat (pharynx), voice box and food pipe (oesophagus) to work together within seconds. A problem in any link of this chain can cause difficulty swallowing (dysphagia).

Broadly, two types of dysphagia are described. In throat-related (oropharyngeal) dysphagia it is difficult to start the swallow; coughing or choking during meals, liquid coming out of the nose or a gurgly voice after eating may occur. In food-pipe-related (oesophageal) dysphagia, food feels as if it sticks in the chest or low in the throat a few seconds after swallowing. However, where the sticking is felt does not always show where the problem is; a problem in the lower food pipe can also be felt in the throat.

Symptoms

• Coughing, choking or frequent throat clearing while eating or drinking.
• A feeling of food sticking in the throat or chest, or food coming back up, sometimes through the nose.
• A wet, gurgly voice after eating or drinking.
• Difficulty chewing, food or saliva leaking from the mouth and meals taking much longer than usual.
• Pain when swallowing (odynophagia).
• Over time, unintended weight loss, dehydration and repeated chest infections or pneumonia.

Possible causes

A feeling of a lump in the throat that does not actually make swallowing difficult is called globus; it is usually harmless, but assessment may be needed to distinguish it from true dysphagia.

When to see a doctor

Dysphagia is a symptom rather than a disease; its cause and the most suitable treatment are determined by examination and the necessary tests.

Examination and tests

The assessment begins with questions about when the problem started, whether solids or liquids are harder to swallow, weight loss, reflux, the medicines you take and past illnesses. After examining the mouth, neck and nervous system, the necessary tests are planned.

• Flexible laryngoscopy: a thin camera passed through the nose is used to examine the throat and voice box; a lump, paralysis or pooled secretions may be seen.
• Flexible endoscopic evaluation of swallowing (FEES): with the same thin camera in place, foods and drinks of different textures are swallowed, and whether material enters the airway (aspiration) or is left behind in the throat is watched directly.
• Videofluoroscopy (modified barium swallow): an X-ray video is recorded while you swallow foods and drinks mixed with barium, showing the mouth, throat and food-pipe stages of swallowing.
• Barium swallow (oesophagram): used to show narrowings, pouches or motility problems in the food pipe.
• Upper GI endoscopy: the food pipe and stomach are examined with a camera, biopsies are taken if needed, and narrowings can be widened in the same session. In selected patients, measurement of food-pipe pressures (manometry) or imaging such as CT may also be requested.

Treatment

Treatment depends on the cause and severity of the swallowing difficulty and often requires an ENT specialist, gastroenterology, a speech and language therapist and a dietitian working together.

• Swallowing therapy: a speech and language therapist teaches exercises that strengthen the swallowing muscles, head and neck positions during meals and safe swallowing techniques.
• Texture changes: soft or puréed foods or thickened liquids can reduce the risk of aspiration; the right texture is chosen according to the test results.
• Treating the cause with medicines: in conditions such as reflux or eosinophilic oesophagitis, medication can markedly reduce swallowing complaints.
• Procedures: endoscopic widening of narrowings (dilatation), endoscopic or surgical treatment of Zenker's diverticulum or achalasia, and in selected cases botulinum toxin injection into the muscles may be considered. If the cause is a tumour, treatment is planned separately.
• Nutritional support: if eating by mouth is not safe or sufficient, temporary or long-term feeding through a tube placed via the nose into the stomach, or directly into the stomach, may be needed.

Tips for eating safely

• Eat in a calm setting and sit as upright as possible.
• Take small bites, chew well and swallow each mouthful before taking the next.
• Avoid talking while eating; if one side of your face is weaker, chew on the stronger side.
• Do not wash solid food down with liquid unless your therapist recommends it, and stick to the advised liquid thickness.
• Stay upright for 30 to 45 minutes after eating.
• Keep your mouth clean; good oral hygiene helps reduce the risk of chest infection if aspiration occurs.
• Check your weight regularly; see your doctor if you develop fever, cough, shortness of breath or weight loss.