Difficulty swallowing

Definition

Difficulty swallowing (dysphagia) means it takes more time and effort to move food or liquid from your mouth to your stomach. Difficulty swallowing may also be associated with pain. In some cases, you may not be able to swallow at all.

Occasional difficulty swallowing usually isn't cause for concern, and may simply occur when you eat too fast or don't chew your food well enough. But persistent difficulty swallowing may indicate a serious medical condition requiring treatment.

Difficulty swallowing can occur at any age, but is more common in older adults. The causes of swallowing difficulties vary, and treatment depends on the cause.

Symptoms

Signs and symptoms that can be associated with dysphagia may include:

• Pain while swallowing (odynophagia)
• Not being able to swallow
• Sensation of food getting stuck in your throat or chest, or behind your breastbone (sternum)
• Drooling
• Hoarseness
• Bringing food back up (regurgitation)
• Frequent heartburn
• Food or stomach acid backing up into your throat
• Unexpected weight loss
• Coughing or gagging when swallowing

In infants and children, signs and symptoms of swallowing difficulties may include:

• Lack of attention during feeding or meals
• Tensing of the body during feeding
• Refusing to eat foods of different textures
• Lengthy feeding or eating times (30 minutes or longer)
• Breast-feeding problems
• Food or liquid leaking from the mouth
• Coughing or choking during feeding or meals
• Spitting up or vomiting during feeding or meals
• Inability to coordinate breathing with eating and drinking
• Weight loss or slow weight gain or growth
• Recurrent pneumonia

When to see a doctor

• Obstructions. If an obstruction interferes with breathing, call for emergency help immediately. If you're unable to swallow due to an obstruction, go to the nearest emergency department.
• Ongoing problems. Slight or occasional difficulty swallowing usually isn't cause for concern or action. But difficulty swallowing can indicate a serious medical problem, such as esophageal cancer. See your doctor if you regularly have difficulty swallowing or if difficulty swallowing is accompanied by weight loss, regurgitation or vomiting.
• Children. If you suspect that your child has trouble swallowing, contact your child's doctor. He or she may refer you and your child to a doctor who specializes in treating children with feeding and swallowing disorders.

Causes

You may take swallowing for granted — you take a bite of food, chew and swallow. But, it takes about 50 pairs of muscles and nerves to accomplish the simple act of swallowing.

When you swallow, your tongue pushes food to the back of your throat. Muscle contractions quickly move food through your pharynx, the area from the back of your throat to the top of your esophagus. Next, the food moves past your windpipe (trachea) into your esophagus, the tube connecting your throat and stomach. Circular bands of muscles (sphincters) at the top and bottom of your esophagus open and close to let food pass, while preventing a backwash of stomach acid. Muscles in the wall of your esophagus help push food toward your stomach.

When there's a problem
Difficulty swallowing occurs when there's a problem with any part of the swallowing process.

A number of conditions can interfere with swallowing, and they generally fall into one of several main categories.

Esophageal dysphagia
Esophageal dysphagia refers to the sensation of food sticking or getting hung up in the base of your throat or chest. Common causes of esophageal dysphagia include:

• Achalasia. This occurs when your lower esophageal muscle (sphincter) doesn't relax properly to let food enter your stomach. Muscles in the wall of your esophagus are often weak as well. This can cause regurgitation of food not yet mixed with stomach contents, sometimes causing you to bring food back up into your throat.
• Aging. With age, your esophagus tends to lose some of the muscle strength and coordination needed to push food into your stomach. However, any persistent trouble swallowing needs to be evaluated by your doctor; it's not necessarily a normal part of aging.
• Diffuse spasm. This condition produces multiple, high-pressure, poorly coordinated contractions of your esophagus usually after you swallow. Diffuse spasm is a rare disorder that affects the smooth (involuntary) muscles in the walls of your lower esophagus. The contractions often occur intermittently, and may become more severe over a period of years.
• Esophageal stricture. Narrowing of your esophagus (stricture) causes large chunks of food to get caught. Narrowing may result from the formation of scar tissue, often caused by gastroesophageal reflux disease (GERD), or from tumors.
• Esophageal tumors. Difficulty swallowing tends to get progressively worse when esophageal tumors are present.
• Foreign bodies. Sometimes, food, such as a large piece of meat, or another object can become lodged in your throat or esophagus. Older adults with dentures and people who have difficulty chewing their food properly may be more likely to have an obstruction of the throat or esophagus. Children may swallow small objects, such as pins, coins or pieces of toys, that can become stuck.
• Esophageal ring. This thin area of narrowing in the lower esophagus can intermittently cause difficulty swallowing solid foods.
• Gastroesophageal reflux disease (GERD). Damage to esophageal tissues from stomach acid backing up (refluxing) into your esophagus can lead to spasm or scarring and narrowing of your lower esophagus, making swallowing difficult.
• Eosinophilic esophagitis. This condition, caused by an overpopulation of cells called eosinophils in the esophagus, can lead to difficulty swallowing. It may be related to a food allergy, but often no cause is found.
• Scleroderma. This disease is characterized by the development of scar-like tissue, causing stiffening and hardening of tissues. It can weaken your lower esophageal sphincter, allowing acid to reflux into your esophagus and causing symptoms and complications similar to those of GERD.
• Radiation therapy. This cancer treatment can lead to inflammation and scarring of the esophagus, which may cause difficulty swallowing.

Oropharyngeal dysphagia
Certain problems related to your nerves and muscles can weaken your throat muscles, making it difficult to move food from your mouth into your throat and esophagus (pharyngeal paralysis). You may choke, gag or cough when you attempt to swallow, or have the sensation of food or fluids going down your windpipe (trachea) or up your nose. This may lead to pneumonia. Causes of oropharyngeal dysphagia include:

• Neurological disorders. Certain disorders, such as post-polio syndrome, multiple sclerosis, muscular dystrophy and Parkinson's disease, may first be noticed because of oropharyngeal dysphagia.
• Neurological damage. Sudden neurological damage, such as from a stroke or brain or spinal cord injury, can cause difficulty swallowing or an inability to swallow.
• Pharyngeal diverticula. A small pouch forms and collects food particles in your throat, often just above your esophagus, leading to difficulty swallowing, gurgling sounds, bad breath, and repeated throat clearing or coughing.
• Cancer. Certain cancers and some cancer treatments can cause difficulty swallowing.

Dysphagia in infants and children
Common causes of swallowing difficulties in infants and children include:

• Developmental problems due to premature birth or low birth weight
• Nervous system disorders, such as cerebral palsy or meningitis
• Cleft lip or cleft palate

Unexplained dysphagia
Some people experience dysphagia that has no anatomical cause. Unexplained swallowing difficulties include:

• Difficulty taking oral medications. Some people can't seem to swallow pills or tablets, even though they have no other difficulty swallowing.
• Lump in your throat (globus). Some people feel the sensation of a foreign body or lump in their throats when, in reality, no foreign body or lump exists. Stress or excitement may worsen this sensation. Oftentimes, this condition improves with time.

Trouble swallowing

Trouble swallowing

Swallowing problems (dysphagia) can occur anywhere along the path from your mouth to your stomach. ...

Risk factors

The following are risk factors for difficulty swallowing:

• Aging. Due to natural aging and normal wear and tear on the esophagus, older adults are at higher risk of swallowing difficulties.
• Premature birth. Babies born prematurely are more prone to developmental problems, including gastrointestinal disorders, and these may cause difficulty swallowing.
• Certain health conditions. People with neurological or nervous system disorders are more likely to experience difficulty swallowing.

Complications

Difficulty swallowing can lead to:

• Malnutrition and dehydration. Dysphagia can make it difficult for you to take in enough food and fluids to stay adequately nourished. People with difficulty swallowing are at risk of malnutrition and dehydration.
• Respiratory problems. If food or liquid enters your airway (aspiration) as you attempt to swallow, respiratory problems or infections can occur, such as frequent bouts of pneumonia or upper respiratory infections.

Preparing for your appointment

You're likely to start by first seeing your family doctor or a general practitioner. Depending on the cause, your doctor may then refer you to an ear, nose and throat specialist (otolaryngologist), a doctor who specializes in treating digestive disorders (gastroenterologist) or an expert in diseases of the nervous system (neurologist).

Because appointments can be brief, and there's often a lot of ground to cover, it's a good idea to be well prepared. Here's some information to help you get ready for your appointment, and what to expect from your doctor.

What you can do

• Be aware of any pre-appointment restrictions. At the time you make the appointment, be sure to ask if there's anything you need to do in advance, such as restrict your diet.
• Write down any symptoms you're experiencing, including any that may seem unrelated to the reason for which you scheduled the appointment.
• Write down key personal information, including any major stresses or recent life changes.
• Make a list of all medications, vitamins and supplements that you're taking.
• Write down questions to ask your doctor.

Your time with your doctor is limited, so preparing a list of questions can help you make the most of your time together. List your questions from most important to least important in case time runs out. For difficulty swallowing, some basic questions to ask your doctor include:

• What's the most likely cause of my symptoms?
• Are there other possible causes for my symptoms?
• What kinds of tests do I need? Do these tests require any special preparation?
• Is this condition temporary or long lasting?
• What treatments are available, and which do you recommend?
• What types of side effects can I expect from treatment?
• Are there any alternatives to the primary approach that you're suggesting?
• I have other health conditions. How can I best manage them together?
• Are there any dietary restrictions that I need to follow?
• Are there any brochures or other printed material that I can take home with me? What Web sites do you recommend visiting?

In addition to the questions that you've prepared to ask your doctor, don't hesitate to ask questions during your appointment at any time that you don't understand something.

What to expect from your doctor
Your doctor is likely to ask you a number of questions. Being ready to answer them may reserve time to go over any points you want to spend more time on. Your doctor may ask:

• When did you first begin experiencing symptoms?
• Have your symptoms been continuous or occasional?
• How severe are your symptoms?
• Does anything seem to improve your symptoms?
• What, if anything, appears to worsen your symptoms? For example, are certain foods harder to swallow than others?
• Do you have difficulty swallowing solids, liquids or both?
• Are your symptoms getting worse or becoming more frequent?
• Did your symptoms start with difficulty swallowing solids and then progress to difficulty swallowing liquids?
• Do you have to chew your food more thoroughly now or cut it up into small pieces to eat?
• Have you ever had to bring food back up to relieve your symptoms?
• If you have brought food back up or vomited, have you ever seen blood or black material?
• Have you unintentionally lost weight?
• Do you have any pain?
• How much alcohol do you regularly consume?
• Do you smoke?

What you can do in the meantime
While you're waiting for your appointment, it may help if you chew your food more slowly and thoroughly than you normally do. If heartburn or GERD is part of your problem, try eating smaller meals and don't eat just before going to bed. Over-the-counter antacids also may provide temporary relief.

Tests and diagnosis

Your doctor will likely perform a physical examination and may use a variety of tests to determine the cause of your swallowing problem.

Tests that your doctor or a specialist uses may include:

• Barium X-ray. For this test, you drink a barium solution. The barium coats the inside of your esophagus, allowing it to show up better on X-rays. Your doctor can then see changes in the shape of your esophagus and can assess the muscular activity. Your doctor may also have you swallow solid food or a pill coated with barium to watch the muscles in your throat as you swallow or to look for subtle blockages in your esophagus that the liquid barium solution may not identify.
• Endoscopy. A thin, flexible, lighted instrument (endoscope) is passed down your throat so that your doctor can view your esophagus. Your doctor may also do a test called a fiber-optic endoscopic evaluation of swallowing (FEES), which uses a small lighted tube (flexible laryngoscope) placed in the nose. This allows your doctor to see what's going on when you swallow.
• Esophageal muscle test. In this test, called manometry (muh-NOM-uh-tree), a small tube is inserted into your esophagus and connected to a pressure recorder. This allows measurement of the muscle contractions of your esophagus as you swallow.

Treatments and drugs

Treatment for swallowing difficulties is often tailored to the particular type or cause of your swallowing disorder:

Oropharyngeal dysphagia
For oropharyngeal dysphagia, your doctor will most likely refer you to a throat specialist or neurologist for further diagnostic testing and to a speech or swallowing specialist for therapy. Therapy may include:

• Exercises. Certain exercises may help coordinate your swallowing muscles or restimulate the nerves that trigger the swallowing reflex.
• Learning swallowing techniques. You may also learn simple ways to place food in your mouth or to position your body and head to help you swallow successfully.

Esophageal dysphagia
Treatment approaches for esophageal dysphagia may include:

• Esophageal dilation. For a tight esophageal sphincter (achalasia) or an esophageal stricture, your doctor may use an endoscope with a special balloon attached to gently stretch and expand the width of your esophagus or pass a flexible tube or tubes to stretch the esophagus (dilatation).
• Surgery. For an esophageal tumor or pharyngeal diverticula, you may need surgery to clear your esophageal path.
• Medications. Difficulty swallowing associated with GERD can be treated with prescription oral medications to reduce stomach acid after a stricture is dilated. You may need to take these medications for an extended period of time.

If you have esophageal spasm but your esophagus appears normal and without GERD, you may be treated with medications to relax your esophagus and reduce discomfort.

Severe dysphagia
If difficulty swallowing prevents you from eating and drinking adequately, your doctor may recommend:

• Special liquid diets. This may help you maintain a healthy weight and avoid dehydration.
• Feeding tube. In severe cases of dysphagia, you may need a feeding tube to bypass the part of your swallowing mechanism that isn't working normally.

Coping and support

Living with swallowing difficulties can be challenging. Dysphagia may affect your interaction with friends and family, your productivity at work, and the overall quality of your life.

You may find that talking to a counselor or therapist can help you cope with the effects of swallowing difficulties. Or you may find encouragement and understanding in a support group.

Although support groups aren't for everyone, they can be good sources of information. Group members often know about the latest treatments and tend to share their own experiences. If you're interested, your doctor may be able to recommend a support group in your area.

Prevention

Although swallowing difficulties can't be prevented when the cause is neurological damage or disorders, you can reduce your risk of occasional difficulty swallowing by eating slowly and chewing your food well. Early detection and effective treatment of GERD can lower your risk of developing dysphagia associated with an esophageal stricture.