Dysphagia (Difficulty Swallowing)

How swallowing works

A normal swallow has three phases:

1. Oral: the tongue forms the food into a ball (bolus) and pushes it back.
2. Pharyngeal: in under a second, the airway closes, the voice box lifts and the upper esophageal sphincter opens to let food in.
3. Esophageal: waves of muscle contraction (peristalsis) carry food down the esophagus over about 8 to 10 seconds; the lower sphincter relaxes to let it into the stomach.

A problem at any stage causes dysphagia.

Oropharyngeal vs esophageal dysphagia

Causes

Oropharyngeal causes

• Neurological: stroke (dysphagia affects many patients early after stroke), Parkinson's disease, dementia, multiple sclerosis, ALS, myasthenia gravis
• Muscle disorders: myositis, muscular dystrophies
• Structural: head and neck cancer and its treatment, Zenker's diverticulum, cricopharyngeal dysfunction, cervical spine bone spurs
• Aging and frailty, dry mouth and dental problems

Esophageal causes

• Mechanical (solids mainly, often progressive): - esophageal stricture from long-standing reflux - Schatzki ring: intermittent sticking of large bites, especially meat - eosinophilic esophagitis: an allergic inflammation, common in young men with allergies; food impaction is a classic presentation - esophageal cancer: progressive dysphagia with weight loss, mostly over 50 - pill esophagitis and external compression
• Motility (solids and liquids from the start): - achalasia: failure of the lower sphincter to relax, with regurgitation and weight loss - esophageal spasm - scleroderma
• Infections and inflammation: candida esophagitis, viral esophagitis (painful swallowing), reflux esophagitis

Symptoms

• feeling food or pills stick
• coughing or choking during or after eating or drinking
• needing to swallow repeatedly or wash food down with liquid
• regurgitating food or liquid, sometimes through the nose
• pain when swallowing (odynophagia)
• drooling
• hoarseness or a gurgly voice
• heartburn
• avoiding certain foods, eating slowly, weight loss
• repeated chest infections from aspiration

A lump-in-the-throat sensation that does not interfere with eating, and is relieved by swallowing food, is usually globus rather than true dysphagia.

Diagnosis

A doctor will ask what foods cause problems (solids, liquids or both), where food sticks, whether it is getting worse, and about heartburn, weight loss, medicines and neurological symptoms.

Tests depend on the type:

• Upper endoscopy (EGD): the first test for esophageal dysphagia. It finds strictures, rings, tumors and inflammation, takes biopsies (for eosinophilic esophagitis or cancer) and can stretch narrowings during the same procedure.
• Barium swallow: X-rays while drinking barium; shows rings, strictures, diverticula and achalasia.
• Videofluoroscopic swallow study (modified barium swallow): with a speech-language pathologist, to assess the oral and throat phases and aspiration.
• Fiberoptic endoscopic evaluation of swallowing (FEES): a thin scope through the nose to watch swallowing.
• High-resolution esophageal manometry: measures muscle contractions and sphincter relaxation; diagnoses achalasia and spasm.
• Other: CT for suspected cancer staging; neurological tests when needed.

Treatment

Treat the cause

• Reflux and strictures: proton pump inhibitors and endoscopic dilation
• Eosinophilic esophagitis: PPIs, swallowed topical steroids, elimination diets, dupilumab, and dilation for narrowing
• Achalasia: pneumatic dilation, Heller myotomy, POEM (peroral endoscopic myotomy) or Botox
• Cancer: surgery, chemotherapy, radiation, and stents for palliation
• Infections: antifungals or antivirals
• Cricopharyngeal dysfunction or Zenker's diverticulum: dilation, Botox, myotomy

Swallowing rehabilitation

A speech-language pathologist assesses and treats oropharyngeal dysphagia:

• exercises to strengthen swallowing muscles (Shaker exercise, tongue strengthening)
• postures such as tucking the chin during swallows
• strategies like small bites, slow eating and alternating solids and liquids
• texture-modified diets and thickened liquids, often using the IDDSI framework from soft and bite-sized to pureed foods

Nutrition

Dietitians help prevent weight loss and dehydration. A feeding tube (nasogastric tube or gastrostomy) may be needed when swallowing is unsafe or nutrition cannot be maintained.

Complications

• aspiration pneumonia
• malnutrition and weight loss
• dehydration
• food impaction
• social isolation and reduced quality of life

Tips for safer eating

• sit fully upright and stay upright for 30 minutes after meals
• take small bites and sips; eat slowly
• avoid talking while chewing
• cut meat finely and choose moist foods
• take pills one at a time with plenty of water, standing or sitting up; ask a pharmacist about liquid forms
• keep good mouth hygiene to reduce pneumonia risk

Frequently asked questions

What causes difficulty swallowing?

Throat-level problems often come from stroke, Parkinson's disease, other nerve and muscle conditions, or aging. Food sticking in the chest is usually from narrowing due to reflux, eosinophilic esophagitis, esophageal rings, motility disorders like achalasia, or, less often, cancer.

When should I worry about trouble swallowing?

See a doctor for any new or worsening difficulty swallowing, especially with weight loss, age over 50, vomiting, bleeding or pain. Get emergency care if food is stuck and you cannot swallow saliva, or if swallowing trouble starts suddenly with stroke symptoms.

Can anxiety cause difficulty swallowing?

Anxiety can cause a lump-in-the-throat feeling (globus) and tension, but it does not usually make food stick. True dysphagia, where food or liquid has trouble going down, should be investigated before it is attributed to anxiety.

What is the difference between oropharyngeal and esophageal dysphagia?

Oropharyngeal dysphagia is difficulty starting a swallow, with coughing, choking or food going into the nose, usually due to nerve or muscle problems. Esophageal dysphagia is food sticking in the chest a few seconds after swallowing, usually due to narrowing or motility problems in the esophagus.

How is dysphagia treated?

Treatment depends on the cause. Esophageal narrowing is often stretched during endoscopy, reflux and eosinophilic esophagitis are treated with medicines, and achalasia with procedures. Throat-level dysphagia is treated with swallowing therapy, diet texture changes and treating the underlying condition.