Dysphagia

Dysphagia makes it hard or impossible to swallow food, fluids or, in some cases, saliva. As a result, dysphagia can cause weight loss, choking and regular chest infections. It can also make you feel awkward when you’re eating and drinking, and sometimes may be painful.

Although it can happen occasionally, dysphagia is usually a long-term (chronic), persistent condition. It’s more likely to develop when you’re older but dysphagia can affect adults and children of all ages.

Dysphagia tends to be the result of another health condition, which may be serious and need treatment. It is usually caused by a problem with your gullet (oesophagus), but in some cases may be caused by a problem at the back of your mouth or something pressing on your gullet. 

Although it isn’t always possible to cure dysphagia, in many cases dysphagia symptoms can successfully be managed and improved.

Difficulty swallowing or an inability to swallow is the main symptom of dysphagia. Other symptoms include:

• Being hoarse
• Coughing or gagging when eating or drinking
• Drooling
• Frequent heartburn, including regularly regurgitating food or stomach acid
• Pain when swallowing (odynophagia)
• The feeling that a piece of food is stuck in your throat or chest or behind your breastbone (sternum) 

You may also unintentionally lose weight and have to cut your food into smaller pieces to make it easier to swallow. You may need to avoid certain foods altogether.

Children with dysphagia may show signs of delayed development and behavioural problems at mealtimes.

If you’re having problems swallowing, pain when swallowing or any other dysphagia symptoms, however mild, see your GP as soon as possible. This is because mild dysphagia that gets worse over time can be the first sign of a serious condition, such as cancer of the gullet (oesophageal cancer), which is more successfully treated the earlier it is caught. 

Your GP will discuss your dysphagia symptoms and examine your throat. To rule out or confirm possible causes of your dysphagia, they may refer you for tests, including:

• Barium swallow/video fluoroscopy — an X-ray of barium-treated foods and liquids passing through your gullet (oesophagus) and stomach
• Diagnostic gastroscopy — examining your gullet and stomach using a small flexible tube with a tiny camera attached
• Fibre-optic endoscopic evaluation of swallowing (FEES) — examining your throat while you try to swallow by inserting a small, thin flexible tube with a tiny camera attached (endoscope) into your throat via your nose 
• Monitoring the amount of acid in your gullet to see if it’s coming up from your stomach
• Nasoendoscopy — examining your throat using an endoscope that is passed into your throat via your nose
• Water swallow test — timing how long it takes for you to drink 150ml of water

Other tests include: 

• Blood tests
• Imaging scans, such as a CT scan or MRI scan
• Oesophageal muscle test (manometry) — a small tube inserted into your gullet and connected to a pressure recorder is used to measure the contractions of your gullet muscles as you swallow
• pH monitoring — a thin tube is inserted into your gullet via your nose or mouth to measure the pH of your gullet ie how acidic or alkaline it is 

If you’ve lost weight and your GP is concerned that you might be malnourished, they may refer you to a dietitian. Your GP may also refer you to a consultant, such as a neurologist (a doctor who specialises in treating the brain and nervous system), a gastroenterologist (a doctor who specialises in treating the digestive system) or a geriatrician (a doctor who specialises in treating the elderly).

There are two main types of dysphagia: 

• Oesophageal or low dysphagia, which is caused by problems with your gullet — this causes the sensation of food getting stuck in the base of your throat or in your chest after you begin swallowing
• Oropharyngeal or high dysphagia, which is caused by problems with your mouth or weakening of your throat muscles, making it difficult to move food from your mouth into your throat and gullet when you begin swallowing — this causes food or fluids to go down your windpipe (trachea) or up your nose

Oesophageal dysphagia causes

Obstruction

Obstruction can be caused by: 

• Eosinophilic oesophagitis — white blood cells called eosinophils accumulate and damage the lining of your gullet in response to a reaction caused by food, allergens or acid reflux
• Foreign bodies — food or another object can get trapped in your throat or gullet and partially block it; this is more likely in older adults with dentures and people who have trouble chewing their food
• Mouth or throat cancer (eg laryngeal cancer or oesophageal cancer) or certain cancer treatments — radiation to treat cancer can cause scar tissue that narrows your gullet
• Oesophageal ring — a thin, narrow area of the lower gullet that can cause intermittent trouble swallowing food
• Oesophagitis caused by infections, such as thrush or tuberculosis — this causes your gullet to become inflamed and damaged

Muscular conditions

Conditions that affect the muscles that push food down your gullet and into your stomach can cause dysphagia. These conditions are rare but include: 

• Achalasia — muscles in your gullet become unable to relax to allow food or fluids to pass into your stomach 
• Diffuse spasm — multiple high-pressure, uncoordinated contractions of your gullet muscles after you swallow; it specifically affects the involuntary muscles in the walls of your lower gullet
• Scleroderma — your immune system mistakenly attacks healthy tissue, causing stiffening of your throat and gullet muscles 

Other causes

Gastro-oesophageal reflux disease (GORD) is caused by stomach acid escaping into your gullet, which leads to frequent heartburn. This consequently can cause narrowing, scarring or spasming of your gullet, which leads to oesophageal dysphagia.

Oropharyngeal dysphagia causes

Neurological conditions

Damage to your nervous system (brain, spinal cord and nerves) can prevent the nerves that control your swallowing from working properly, causing dysphagia. Conditions include: 

• Brain tumours
• Cerebral palsy
• Degenerative neurological disorders — this includes dementia, multiple sclerosis, motor neurone disease, muscular dystrophy and Parkinson's disease
• Myasthenia gravis
• Sudden neurological damage eg caused by a stroke or brain or spinal cord injury

Other causes

• Certain cancers and certain cancer treatments — radiation to treat cancer can cause scar tissue that narrows your throat
• Congenital and developmental conditions — this includes a cleft lip and palate, cerebral palsy, and learning disabilities
• Pharyngeal (throat) pouches (also called Zenker diverticulum) — a large sac develops in the upper part of your gullet which makes swallowing food and fluids more difficult

Aspiration pneumonia

Aspiration pneumonia is a serious complication of dysphagia and needs medical treatment. It is caused by accidentally inhaling food, saliva or stomach acid. If you have dysphagia, seek immediate medical attention if:

• You’re coughing when you’re eating
• You’re struggling for breath
• Your voice sounds as though you’re gargling when you’re eating

If you only have occasional dysphagia, try chewing your food slowly and properly before swallowing.

Chronic, persistent dysphagia requires medical attention. Your dysphagia treatment will depend on the condition that has triggered your difficulty swallowing.

Once the condition causing your dysphagia has been diagnosed, your GP or consultant will arrange your treatment.

Your GP or consultant may arrange speech and swallowing therapy so you can learn different ways of swallowing. If you have severe dysphagia, they may suggest other treatments, such as surgery or alternative feeding methods.

Oropharyngeal dysphagia treatment

You may be referred to a speech and swallowing therapist for therapy. This may include learning exercises to help coordinate your swallowing muscles or stimulate the nerves that control your swallowing reflex. You may also be taught swallowing techniques. This involves learning ways to place food in your mouth or to position your body and head to aid swallowing. Swallowing techniques are often used to treat dysphagia caused by neurological conditions, such as Alzheimer's disease or Parkinson's disease.

Oesophageal dysphagia treatment

• Medication — this includes: 
• Corticosteroids if your dysphagia is caused by eosinophilic oesophagitis
• Drugs to reduce your stomach acid if your dysphagia is caused by GORD
• Smooth muscle relaxants if your dysphagia is caused by spasms of your gullet
• Oesophageal dilation — an endoscope with a special balloon attached is passed into your gullet to gently stretch it; this treatment is used if your dysphagia is caused by the ring of muscle at the top of your gullet not opening properly or at all (achalasia) or by part of your gullet having tightened up (oesophageal stricture) 
• Surgery to clear a path through your gullet or remove a blockage eg caused by a tumour, achalasia or a pharyngeal pouch 

Severe dysphagia

If your dysphagia is so severe that it stops you from eating and drinking enough, your doctor may recommend a feeding tube to bypass the part of your throat or gullet that isn't working properly. In very severe cases, they may recommend a special liquid diet to help maintain a healthy weight and prevent dehydration.

Surgery

Your doctor may recommend surgery to treat oesophageal cancer, or if your dysphagia is caused by narrowing or blockages of your throat, which can be caused by: 

• Achalasia
• Bony outgrowths
• GORD 
• Pharyngeal pouches
• Vocal cord paralysis

The type of surgery you have will depend on the cause of your dysphagia. Types of surgery include: 

Laparoscopic heller myotomy 

This involves cutting the ring of muscle (sphincter) at the bottom of your gullet if it is not opening properly or at all.

Peroral endoscopic myotomy (POEM) 

This involves passing an endoscope into your throat via your mouth, making a cut in the lining of your gullet and cutting the sphincter at the bottom of your gullet.

Oesophageal dilation 

An endoscope with a special balloon attached is passed into your gullet to gently stretch it. In some cases, instead of using a balloon, a tube or tubes of different diameters will be used. This treatment is used if your dysphagia is caused by: 

• A motility disorder 
• Achalasia — the ring of muscle at the top of your gullet not opening properly or at all (achalasia) 
• Oesophageal stricture — part of your gullet having tightened up
• Schatzki's ring — an abnormal ring of tissue where your gullet meets your stomach 

Stent placement

This involves inserting a metal or plastic tube (stent) to hold open your gullet if it has narrowed or is blocked. Your stents may be permanent or temporary.

Speech and swallowing therapy is usually beneficial after surgery.

Lifestyle changes and home remedies

If you are living with dysphagia, there are things you can do to help manage your symptoms. These include: 

• Avoiding alcohol, tobacco and caffeine — these make heartburn worse, which may worsen your dysphagia
• Chewing your food more thoroughly and eating more slowly
• Cutting your food into smaller pieces
• Eating smaller, more frequent meals
• Trying foods with different textures to find out which are more problematic so you can avoid them — some people with dysphagia find thin liquids (eg coffee and juice) and sticky foods (eg peanut butter and caramel) more difficult to swallow 

Dysphagia can make you choke or cough when food goes down your windpipe instead of your gullet. This may make you anxious about eating and reduce how often you eat or drink, causing dehydration, malnutrition and unintentional weight loss. Dysphagia can also stop you from enjoying meals and social events that involve eating or drinking in front of others. 

In some cases, dysphagia may increase your risk of chest infections, such as aspiration pneumonia. Symptoms of aspiration pneumonia to look out for include: 

• A fever
• A wet or dry cough — you may produce yellow, green, brown or blood-stained phlegm
• Chest pain 
• Difficulty breathing and/or breathlessness at rest — your breathing may become rapid and shallow

In children with dysphagia, they may develop behavioural problems and act out at mealtimes.

You can reduce your risk of having episodes of dysphagia by eating slowly and chewing your food thoroughly. As GORD can lead to dysphagia, getting treatment for GORD as soon as possible will reduce your risk of swallowing difficulties.