Severe Dysphagia: When You Cannot Swallow

What severe dysphagia looks like

People with severe dysphagia may:

• be unable to swallow solid food, then soft food, then liquids
• feel food stuck in the throat or behind the breastbone
• drool or spit out saliva because it will not go down
• regurgitate undigested food
• cough, choke or have a wet, gurgly voice when eating or drinking
• lose weight and become dehydrated
• avoid eating because it is frightening

Doctors divide swallowing problems into two types:

Sudden severe dysphagia

Food bolus impaction

The most common cause of sudden inability to swallow in adults. A piece of meat or bread lodges in the esophagus, often at a narrowing such as a ring, stricture or eosinophilic esophagitis. People feel it stick, then cannot swallow saliva and drool or regurgitate. It needs emergency endoscopy, ideally within 24 hours, and within about 6 hours if saliva cannot be swallowed, to prevent perforation.

Do not try to force it down with bread or large gulps of fizzy drink, and do not induce vomiting.

Swallowed objects

Coins, bones, dentures and especially button batteries and magnets are dangerous. Button batteries can burn through the esophagus within 2 hours. See foreign body in the gastrointestinal tract.

Stroke

A stroke affecting the brainstem or swallowing areas can cause sudden severe dysphagia, often with other signs. People with stroke should not be given food or drink until their swallow has been tested.

Throat infections and swelling

Peritonsillar abscess, epiglottitis, and deep neck infections cause severe painful swallowing, drooling and a muffled voice. Anaphylaxis and angioedema swell the throat.

Progressive severe dysphagia

Esophageal cancer

Esophageal cancer typically causes swallowing trouble with solids first, progressing to soft foods and then liquids over weeks to months, with weight loss. Risk factors include long-standing reflux, Barrett's esophagus, smoking and heavy alcohol use.

Benign strictures and rings

Scarring from long-term acid reflux (esophageal stricture), Schatzki rings and webs cause intermittent sticking of solids that can become severe.

Achalasia

In achalasia, the lower esophageal valve fails to relax and the esophagus loses its squeezing action. It causes difficulty with both solids and liquids from early on, regurgitation of undigested food, chest pain and weight loss.

Eosinophilic esophagitis

An allergic inflammation of the esophagus, common in young men with allergies, causing recurrent food impactions.

Neurological and muscle diseases

ALS, myasthenia gravis, Parkinson's disease, multiple sclerosis, muscular dystrophy and myositis cause oropharyngeal dysphagia with choking and aspiration.

How doctors diagnose the cause

• Upper endoscopy: a camera examines the esophagus, removes stuck food, takes biopsies and can stretch narrowings.
• Barium swallow: X-ray images show narrowings, rings, achalasia and pouches.
• Videofluoroscopic swallow study or FEES: shows whether food or liquid enters the airway.
• Esophageal manometry: measures muscle pressures to diagnose achalasia and motility disorders.
• CT scan for suspected perforation, cancer staging or neck infection.
• Neurological tests such as brain MRI or antibody tests when a nerve or muscle disease is suspected.

Treatment

• Emergency endoscopic removal of impacted food or objects.
• Dilation of strictures and rings, and acid-suppressing medicine to stop them recurring.
• Achalasia: pneumatic dilation, Heller myotomy surgery or POEM (an endoscopic muscle cut).
• Eosinophilic esophagitis: proton pump inhibitors, swallowed steroids, dietary elimination or biologic medicine.
• Cancer: surgery, chemotherapy and radiotherapy, and stents to keep the esophagus open.
• Swallowing therapy: a speech-language pathologist teaches exercises, posture changes and safe food textures.
• Nutrition support: thickened fluids, modified diets, or a feeding tube when swallowing is unsafe.

Living with a severe swallowing problem

Sit upright for meals and 30 minutes after, take small bites, chew thoroughly, avoid talking while eating, and follow texture advice from your speech-language pathologist. Keep the mouth clean to reduce the risk of pneumonia if food or saliva goes into the lungs.

Frequently asked questions

What should I do if I can't swallow my saliva?

Go to an emergency department immediately or call 911 or your local emergency number. Being unable to swallow saliva usually means the esophagus is completely blocked, often by food, and it needs prompt endoscopy to clear it and prevent damage. Spit into a cup rather than trying to force it down.

How long can food be stuck in the esophagus?

Some food passes on its own within minutes to an hour. If you cannot swallow saliva, endoscopy is needed urgently, ideally within about 6 hours. If you can swallow saliva, removal within 24 hours is recommended. Leaving food longer raises the risk of injury and perforation.

What causes sudden difficulty swallowing?

The most common causes are food stuck in the esophagus, a swallowed object, throat infection or abscess, severe allergic swelling and stroke. Sudden trouble swallowing with stroke signs or breathing difficulty is an emergency.

Is severe dysphagia a sign of cancer?

It can be. Swallowing trouble that gets steadily worse over weeks, starting with solids, especially with weight loss in someone over 50, a smoker or heavy drinker, or someone with long-term reflux, needs prompt endoscopy to rule out esophageal cancer. Many other causes are benign.

Can anxiety cause severe difficulty swallowing?

Anxiety can cause a lump-in-the-throat feeling (globus) and fear of swallowing, but it does not usually cause true inability to swallow food or saliva. Severe or progressive swallowing problems need medical investigation before being attributed to anxiety.