Dysphagia: Difficulty in Swallowing Explained

What dysphagia means

The word comes from Greek: dys (difficult) and phagein (to eat). Swallowing has three phases:

1. Oral phase: chewing and forming a soft ball of food (bolus), then pushing it back with the tongue. This is voluntary.
2. Pharyngeal phase: a reflex closes off the airway and nose, and throat muscles squeeze the bolus into the esophagus in under a second.
3. Esophageal phase: waves of muscle contraction (peristalsis) carry food down to the stomach in about 8 to 10 seconds.

Dysphagia can result from a problem in any phase. Pain on swallowing has a separate name, odynophagia, usually from infection or inflammation. The sensation of a lump in the throat without real difficulty swallowing is called globus.

Types of dysphagia

Solids only or solids and liquids?

• Solids only, gradually worse: suggests a mechanical narrowing such as a stricture or cancer.
• Solids only, comes and goes: suggests a ring or eosinophilic esophagitis.
• Solids and liquids from the start: suggests a motility disorder such as achalasia or esophageal spasm.

Causes of oropharyngeal dysphagia

• Stroke: swallowing problems affect a large proportion of people after a stroke, though many recover over weeks.
• Parkinson's disease and dementia: slow, uncoordinated swallowing.
• Motor neuron disease (ALS), multiple sclerosis and muscular dystrophies.
• Myasthenia gravis: swallowing that tires during a meal.
• Zenker's diverticulum: a pouch at the top of the esophagus in older adults, causing regurgitation of undigested food, bad breath and gurgling.
• Head and neck cancer and its treatment with surgery or radiation.
• Aging (presbyphagia): a slower, weaker swallow that becomes significant with illness.

Causes of esophageal dysphagia

• Peptic stricture: scarring from long-term acid reflux.
• Eosinophilic esophagitis: an allergic inflammation of the esophagus, common in young men with allergies; often causes food to get stuck.
• Schatzki ring: a thin ring at the lower esophagus causing intermittent sticking of meat or bread.
• Achalasia: the lower esophageal valve fails to relax, and peristalsis is lost.
• Esophageal cancer: progressive difficulty with solids, then liquids, with weight loss, mostly over age 50.
• Esophageal spasm and scleroderma.
• External pressure: an enlarged thyroid, lymph nodes or an enlarged blood vessel.
• Medicines: some pills can injure the esophagus if swallowed without enough water (pill esophagitis).

How dysphagia is diagnosed

Your doctor will ask where food sticks, whether solids, liquids or both are affected, how long it has been happening, whether it is getting worse, and about heartburn, weight loss, voice changes, coughing during meals and neurological symptoms.

Tests

• Bedside swallow screen: watching you swallow water, often done by nurses after a stroke.
• Videofluoroscopic swallow study (modified barium swallow): an x-ray video while you swallow foods of different textures, run by a speech-language pathologist. It shows whether food enters the airway.
• Fiberoptic endoscopic evaluation of swallowing (FEES): a thin camera passed through the nose to watch the throat during swallowing.
• Upper endoscopy (EGD): a camera into the esophagus and stomach to find strictures, rings, inflammation or cancer, with biopsies. A narrowing can be stretched at the same time.
• Barium swallow: x-rays after drinking contrast liquid show the shape and emptying of the esophagus.
• High-resolution esophageal manometry: measures pressure waves to diagnose achalasia and spasm.

Treatment of dysphagia

Swallowing therapy

A speech-language pathologist teaches exercises to strengthen swallowing muscles and safe-swallow techniques, such as tucking the chin, taking small sips and swallowing twice.

Diet modification

Food may be softened, minced or pureed, and drinks thickened, following standardized texture levels. Thickened liquids move more slowly and give the airway time to close.

Medical and procedural treatment

• Dilation: stretching strictures or rings with a balloon or bougie during endoscopy.
• Acid suppression: proton pump inhibitors heal reflux damage and prevent strictures returning.
• Eosinophilic esophagitis: proton pump inhibitors, swallowed steroids, diet elimination or biologic medicines.
• Achalasia: balloon dilation, surgical myotomy, endoscopic myotomy (POEM) or botulinum toxin.
• Cancer: surgery, chemotherapy, radiotherapy or a stent to keep the esophagus open.

Tube feeding

When swallowing is unsafe or nutrition cannot be maintained, a feeding tube (nasogastric or gastrostomy) may be used, sometimes temporarily while swallowing recovers.

Complications

• Aspiration pneumonia: food or liquid entering the lungs causes infection
• Choking
• Malnutrition and dehydration
• Weight loss and loss of enjoyment of meals, with social isolation

Frequently asked questions

What is the medical term for difficulty swallowing?

The medical term is dysphagia. It covers any difficulty moving food or liquid from the mouth to the stomach. Pain when swallowing is called odynophagia, and the feeling of a lump in the throat without true difficulty is called globus.

What are the two types of dysphagia?

Oropharyngeal dysphagia is difficulty starting a swallow, causing coughing, choking or nasal regurgitation, usually from nerve or muscle problems such as stroke. Esophageal dysphagia is a feeling of food sticking after swallowing, usually from narrowing, inflammation or motility disorders of the esophagus.

What is the most common cause of dysphagia?

In older adults, stroke and other neurological conditions are the leading causes of oropharyngeal dysphagia. For esophageal dysphagia, reflux-related strictures and eosinophilic esophagitis are among the most common causes. Esophageal cancer is less common but must be ruled out.

Is dysphagia serious?

It can be. Dysphagia can lead to choking, pneumonia from inhaled food, dehydration and malnutrition. It can also be the first sign of esophageal cancer. Any new or worsening swallowing difficulty should be assessed by a doctor.

Can dysphagia be cured?

It depends on the cause. Strictures and rings respond well to dilation, achalasia to procedures, and eosinophilic esophagitis to medicines and diet. Swallowing after a stroke often improves with therapy. Progressive neurological conditions are managed with therapy, diet changes and sometimes tube feeding.

What is the difference between this and difficulty swallowing?

They mean the same thing. Dysphagia is the medical term for difficulty swallowing. For practical tips on what to do when food gets stuck, which foods to avoid and how to swallow pills, see our page on difficulty swallowing.