Dysphagia
Dysphagia is difficulty in swallowing. Although classified under “symptoms and signs” in ICD-10, in some contexts it is classified as a condition in its own right. People with dysphagia are sometimes unaware of having it.
It may be a sensation that suggests difficulty in the passage of solids or liquids from the mouth to the stomach, a lack of pharyngeal sensation or various other inadequacies of the swallowing mechanism. Dysphagia is distinguished from other symptoms including odynophagia, which is defined as painful swallowing, and globus, which is the sensation of a lump in the throat. A person can have dysphagia without odynophagia (dysfunction without pain), odynophagia without dysphagia (pain without dysfunction) or both together. A psychogenic dysphagia is known as phagophobia.
Dysphagia Signs and Symptoms
Depending upon the cause of the dysphagia, the difficulty swallowing can be mild or severe. Some affected individuals may have trouble swallowing both solids and liquids, while others may experience problems only when attempting to swallow solid foods. Occasionally, there is more trouble with liquid than the solid food.
- If there is an aspiration of food (most common with liquids), swallows may induce coughing due to the entrance of the liquid into the voice box (larynx) at the top of the trachea or into the lungs.
- If solid food becomes lodged in the lower throat, it may induce choking and gagging and interfere with breathing.
- If solid food lodges in the esophagus, it may be felt as severe chest discomfort.
- If food stuck in the lower esophagus regurgitates at night, individuals may awaken coughing and choking due to food entering the throat, larynx, or lungs.
- Less commonly, swallowed food may regurgitate effortlessly into the mouth immediately after it is swallowed.
If dysphagia is associated with aspiration of food into the lungs, aspiration pneumonia may occur with all of the symptoms of pneumonia (fever, chills, and respiratory distress). This is a particular danger in individuals who have had a stroke. Dysphagia is present in approximately 51%-73% of individuals with stroke and poses a major risk for the development of aspiration pneumonia.
Other symptoms associated with dysphagia depend upon its exact cause and are specific to the condition that results in dysphagia, such as stroke, cancer, etc.
What causes swallowing difficulty?
According to the National Institute on Deafness and Other Communication Disorders, there are 50 pairs of muscles and nerves used to help you swallow. In other words, there are lots of things that can go wrong and lead to problems swallowing. Some conditions include:
- Acid reflux and GERD: Acid reflux symptoms are caused when stomach contents flow up from the stomach back into the esophagus, causing symptoms like heartburn, stomach pain, and burping.
- Heartburn: Heartburn is a burning sensation in your chest that often occurs with a bitter taste in your throat or mouth.
- Epiglottitis: Epiglottitis is characterized by inflamed tissue in your epiglottis. It’s a potentially life-threatening condition.
- Goiter: Your thyroid is a gland found in your neck just below your Adam’s apple. A condition that increases the size of your thyroid is called a goiter.
- Esophagitis: Esophagitis is inflammation of the esophagus that can be caused by acid reflux or certain medications.
- Esophageal cancer: Esophageal cancer occurs when a malignant (cancerous) tumor forms in the lining of the esophagus, which can cause difficulty swallowing.
- Stomach cancer (gastric adenocarcinoma): Stomach cancer occurs when cancerous cells form in the stomach lining. Because it’s difficult to detect, it’s often not diagnosed until it’s more advanced.
- Herpes esophagitis: Herpes esophagitis is caused by the herpes simplex virus type 1 (HSV-1). The infection can cause some chest pain and difficulty swallowing.
- Recurrent herpes simplex labialis: Recurrent herpes simplex labialis, also known as oral or orolabial herpes, is an infection of the mouth area caused by the herpes simplex virus.
- Thyroid nodule: A thyroid nodule is a lump that can develop in your thyroid gland. It can be solid or filled with fluid. You can have a single nodule or a cluster of nodules.
- Infectious mononucleosis: Infectious mononucleosis, or mono, refers to a group of symptoms usually caused by the Epstein-Barr virus (EBV).
- Snake bites: A bite from a venomous snake should always be treated as a medical emergency. Even a bite from a harmless snake can lead to an allergic reaction or infection.
Dysphagia Types
Swallowing occurs in four phases: oral preparatory, oral, pharyngeal, and esophageal. Swallowing difficulty can be broken down into two categories: oropharyngeal (which includes the first three phases) and esophageal.
Oropharyngeal
Oropharyngeal dysphagia is caused by disorders of the nerves and muscles in the throat. These disorders weaken the muscles, making it difficult for a person to swallow without choking or gagging. The causes of oropharyngeal dysphagia are conditions that primarily affect the nervous system such as:
- Multiple sclerosis
- Parkinson’s disease
- Nerve damage from surgery or radiation therapy
- Post-polio syndrome
Oropharyngeal dysphagia can also be caused by esophageal cancer and head or neck cancer. It may be caused by an obstruction in the upper throat, pharynx, or pharyngeal pouches that collect food.
Esophageal
Esophageal dysphagia is the feeling that something is stuck in your throat. This condition is caused by:
- Spasms in the lower esophagus, such as diffuse spasms or the inability of the esophageal sphincter to relax
- Tightness in the lower esophagus due to an intermittent narrowing of the esophageal ring
- Narrowing of the esophagus from growths or scarring
- Foreign bodies lodged in the esophagus or throat
- Swelling or narrowing of the esophagus from inflammation or GERD
- Scar tissue in the esophagus due to chronic inflammation or post-radiation treatment
Dysphagia Identification
If you think you may have dysphagia, there are certain symptoms that may be present along with difficulty swallowing.
They include:
- Drooling
- A hoarse voice
- Feeling that something is lodged in the throat
- Regurgitation
- Unexpected weight loss
- Heartburn
- Coughing or choking when swallowing
- Pain when swallowing
- Difficulty chewing solid foods
These sensations may cause a person to avoid eating, skip meals, or lose their appetite.
Children who have difficulty swallowing when eating may:
- Refuse to eat certain foods
- Have food or liquid leaking from their mouths
- Regurgitate during meals
- Have trouble breathing when eating
- Lose weight without trying
Dysphagia Risk factors
The following are risk factors for dysphagia:
- Aging. Due to natural aging and normal wear and tear on the esophagus and a greater risk of certain conditions, such as stroke or Parkinson’s disease, older adults are at higher risk of swallowing difficulties. But, dysphagia isn’t considered a normal sign of aging.
- Certain health conditions. People with certain neurological or nervous system disorders are more likely to experience difficulty swallowing.
Dysphagia Complications
Difficulty swallowing can lead to:
- Malnutrition, weight loss, and dehydration. Dysphagia can make it difficult to take in adequate nourishment and fluids.
- Aspiration pneumonia. Food or liquid entering your airway when you try to swallow can cause aspiration pneumonia because the food can introduce bacteria to the lungs.
- Choking. When food gets stuck in the throat, choking can occur. If food completely blocks the airway, and no one intervenes with a successful Heimlich maneuver, death can occur.
Dysphagia Prevention
Although swallowing difficulties can’t be prevented, 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.
How is swallowing difficulty diagnosed?
Talk to your doctor about your symptoms and when they began. Your doctor will do a physical examination and look in your oral cavity to check for abnormalities or swelling.
More specialized tests may be needed to find the exact cause.
Barium X-ray
A barium X-ray is often used to check the inside of the esophagus for abnormalities or blockages. During this examination, you will swallow liquid or a pill containing a dye that shows up on an abdominal X-ray. The doctor will look at the X-ray image as you swallow the liquid or pill to see how the esophagus functions. This will help identify any weaknesses or abnormalities.
A videofluoroscopic swallowing evaluation is a radiologic exam that uses a type of X-ray called fluoroscopy. This test is performed by a speech-language pathologist. It shows the oral, pharyngeal, and esophageal phases of the swallow.
During this examination, you’ll swallow a variety of consistencies ranging from purees to solids and thin and thickened liquid. This will help the doctor detect the ingestion of food and liquid into the trachea. They can use this information to diagnose muscle weakness and dysfunction.
Endoscopy
An endoscopy may be used to check all areas of your esophagus. During this examination, the doctor will insert a very thin flexible tube with a camera attachment down into your esophagus. This allows the doctor to see the esophagus in detail.
Manometry
The manometry is another invasive test that can be used to check the inside of your throat. More specifically, this test checks the pressure of the muscles in your throat when you swallow. The doctor will insert a tube into your esophagus to measure the pressure in your muscles when they contract.
Treating swallowing difficulty
Some swallowing difficulties can’t be prevented and dysphagia treatment is necessary. A speech-language pathologist will perform a swallowing evaluation to diagnosis your dysphagia. Once the evaluation is completed, the speech pathologist may recommend:
- Diet modification
- Oropharyngeal swallowing exercises to strengthen muscles
- Compensatory swallowing strategies
- Postural modifications that you should follow while eating
However, if swallowing problems are persistent, they can result in malnutrition and dehydration, especially in the very young and in older adults. Recurrent respiratory infections and aspiration pneumonia are also likely. All of these complications are serious and life-threatening and must be treated definitively.
If your swallowing problem is caused by a tightened esophagus, a procedure called esophageal dilation may be used to expand the esophagus. During this procedure, a small balloon is placed into the esophagus to widen it. The balloon is then removed.
If there are any abnormal growths in the esophagus, surgery may be necessary to remove them. Surgery may also be used to remove scar tissue.
If you have acid reflux or ulcers, you may be given prescription medication to treat them and encouraged to follow a reflux diet.
In severe cases, you may be admitted to the hospital and given food through a feeding tube. This special tube goes right into the stomach and bypasses the esophagus. Modified diets may also be necessary until the swallowing difficulty improves. This prevents dehydration and malnutrition.
Frequently Asked Questions
What is Dysphagia?
Dysphagia is a disorder that means an individual is having difficulty swallowing. Dysphagia may impact one’s ability to chew, manipulate and move foods, liquids, secretions or medications through the mouth, throat, and esophagus into the stomach.
Who does Dysphagia affect?
Dysphagia impacts close to 15 million Americans. Approximately 1 million individuals receive a diagnosis of dysphagia annually. Dysphagia may affect men, women, and children.
What are some commons causes of Dysphagia?
Dysphagia commonly results from stroke and other traumatic brain injuries (TBI). However, dysphagia can also result from dementia, Parkinson’s disease, neurodegenerative diseases (e.g., Amyotrophic Lateral Sclerosis, Multiple Sclerosis) Head and neck cancer, other trauma (injury to head/facial/neck region), and natural aging in the elderly.
What are some signs and symptoms of Dysphagia?
There are many signs and symptoms of Dysphagia. Some may include coughing or choking during eating, drinking or taking medications, difficulty chewing and drooling. Additionally, other signs and symptoms are increased chest congestion or secretions, food sticking in the mouth or throat, wet, gurgly vocal quality, pneumonia or other respiratory infections or disorders, unplanned weight loss, malnutrition or dehydration, and avoiding eating are common signs of Dysphagia.
Who diagnoses and treats a swallowing problem?
A speech-language pathologist (SLP) with special training in swallowing disorders is the primary individual responsible for diagnosing and treating dysphagia. Some SLPs are board-certified in Swallowing and Swallowing Disorders by the American Board of Swallowing and Swallowing Disorders (ABSSD).
What are some different treatment methods for people with dysphagia?
The speech-language pathologist (SLP) will formulate a plan that may include compensatory strategies or maneuvers that may improve the flow of food or liquid through the mouth and throat. The SLP may also provide information regarding changing the textures or consistencies or the food and liquid for safer and more efficient swallowing.
The SLP may also put together an exercise program to target specific muscles in the mouth and throat to help improve your swallowing. *Since each treatment plan is patient-specific and there are multiple interventions available, it is recommended that you follow the guidelines provided specifically to you by a certified SLP. Many of these exercises and maneuvers can be found on our treatment program, ”
Why is dysphagia a concern?
Aspiration or the entry of foreign material (food, liquid, secretions, medications) into the airway/lungs puts an individual at risk for developing pneumonia, which can be life-threatening. Dysphagia may also result in malnutrition, dehydration, weight loss, decreased overall quality of life, and even death.
How do we swallow?
Swallowing is a complex process that involves the coordination of multiple muscles and nerves. The tongue works to move food onto the teeth for chewing and to propel food towards the back of the throat to be swallowed. The muscles of the throat work to squeeze the food down towards the esophagus where the food is carried to the stomach.
The airway (windpipe) and esophagus are very close together and even share a wall. When the food or liquid is being passed from the mouth to the esophagus, the larynx and vocal folds, which lie at the top of the airway, are closed shut in order prevent any material from going ‘down the wrong pipe’. If the strength of the muscles or the timing and coordination of the muscles and nerves are affected, the airway closure may be impaired. Food may then enter the airway, resulting in aspiration.
What other medical professionals may be involved in treating Dysphagia?
There are other medical professionals that may be involved in the treatment and management of dysphagia. Some of these professionals may include Dieticians/Nutritionists, Respiratory Therapists, Ear, Nose and Throat Doctors (Otolaryngologist), Gastrointestinal Doctors (GI), Dentists, Neurologists, Nurses, Occupational Therapists, Radiologists, Psychologists, Social Workers, and Physiatrists.
How is a swallowing problem diagnosed?
A speech-language pathologist will perform a swallow evaluation which typically includes: Obtaining a case history including any pertinent medical conditions and symptoms, evaluating the strength and movement of the muscles involved in swallowing, observing posture, feeding behaviors, and oral movements during eating and drinking.
What is a Modified Barium Swallow?
If deemed appropriate and necessary, a speech-language pathologist may recommend further testing be performed to further evaluate the swallow, such as a
Modified Barium Swallow Study (also referred to as the videofluoroscopic swallowing evaluation). This test takes place in the radiology department of the hospital and can be done as both an inpatient or outpatient.
How is a Modified Barium Swallow performed?
For this test, the individual eats or drinks food or liquid with barium in it, and the swallowing process is viewed on a moving X-ray. The clinician and radiologist are present for the evaluation and following the procedure, the speech pathologist will provide the individual and/or family regarding the results, diagnosis and safest foods/liquids to consume.
What is Endoscopic swallowing assessment?
Endoscopic swallow assessment (also referred to as Fiberoptic Endoscopic Evaluation of Swallowing or FEES). A lighted scope is inserted through the nose and passed right to the level of your uvula in your throat. The swallow can be viewed on a screen with the scope in place. The individual ingests food and liquid with color dye in it (usually blue or green) and the clinician can view any swallow abnormalities.
How is Endoscopic swallowing assessment used in evaluating Dysphagia?
During these tests, the clinician is able to view if food or liquid is going into your airway instead of your stomach (aspiration). This will allow the clinician to see what parts of your mouth and throat may not be working properly as well as determine what kinds of food are safest for you to swallow. The clinician may also try different body positions or strategies that may help you swallow better.
Why is dysphagia a concern?
If left untreated dysphagia can lead to aspiration, the entry of foreign material (such as food, liquid, or secretions) into the airway. Aspiration increases the risk of developing pneumonia. Dysphagia can cause malnutrition, dehydration, decreased quality of life, weight loss, and even death.
Who is at risk for dysphagia?
Dysphagia affects nearly 15 million adults and many millions of infants and children in the US alone. It is a global condition, affecting men, women, and children worldwide. Dysphagia commonly results from conditions such as stroke, dementia, Parkinson’s disease, or a wide variety of neuromuscular diseases. Swallowing difficulties may also occur in patients with head and neck cancer or injury. Additionally, swallowing changes caused by declining muscle strength through the body that occurs with natural aging make older adults more vulnerable to developing dysphagia.
What are the common signs and symptoms of a swallowing problem?
If you notice the following in yourself or someone you know, you might suspect a swallowing disorder:
- Coughing or choking when eating, drinking, or taking medication
- Food sticking in the mouth or throat
- Drooling
- Difficulty chewing
- Wet sounding voice
- Unplanned weight loss
- Pneumonia or other respiratory infections
Who diagnoses and treats a swallowing problem?
A speech-language pathologist (SLP) with special skills and knowledge in swallowing disorders is typically responsible for diagnosing and treating dysphagia. Some SLPs are board-certified in Swallowing and Swallowing Disorders by the American Board of Swallowing and Swallowing Disorders.
How is a swallowing problem diagnosed?
The clinician (usually a speech-language pathologist) who evaluates swallowing typically will:
- Take a careful history of medical conditions and symptoms
- Look at the strength and movement of the muscles involved in swallowing
- Observe posture, behavior, and oral movements during eating and drinking
- Possibly perform special tests to evaluate swallowing, such as:
- Videofluoroscopic swallowing evaluation – individual eats or drinks food or liquid with barium in it, and then the swallowing process is viewed on a moving X-ray
- Endoscopic assessment – a lighted scope is inserted through the nose, and then the swallow can be viewed on a screen