Swallowing Problems (Dysphagia)

Two types of swallowing problems

Pain on swallowing (odynophagia) is different from difficulty. It suggests inflammation or infection, such as a sore throat, esophagitis from pills, or candida infection.

Causes of swallowing problems

Esophageal causes

• Esophageal stricture from long-term acid reflux (GERD): slowly worsening difficulty with solid food, often with a history of heartburn.
• Eosinophilic esophagitis: an allergic inflammation of the esophagus. Common in young men with allergies or asthma, who often have food stuck (impaction) episodes.
• Schatzki ring: a thin ring at the lower esophagus causing intermittent sticking with meat or bread ("steakhouse syndrome").
• Achalasia: the lower esophageal muscle does not relax. Difficulty with both solids and liquids, regurgitation of undigested food and weight loss.
• Esophageal spasm: chest pain and intermittent sticking.
• Esophageal cancer: progressive difficulty, first with solids then liquids, with weight loss. Risk factors include long-term reflux (Barrett's esophagus), smoking, heavy alcohol use and obesity.
• Pills: some tablets, such as doxycycline, bisphosphonates, potassium and NSAIDs, can cause ulcers if they stick.
• Infections: candida or herpes esophagitis in people with weakened immunity.
• Scleroderma: weak esophageal muscles and severe reflux.

Throat and nerve causes

• Stroke: a very common cause. Swallowing is screened after every stroke.
• Parkinson's disease, multiple sclerosis, dementia and ALS
• Myasthenia gravis: fatigable weakness that worsens during a meal
• Head and neck cancer and its treatment with surgery or radiation
• Zenker's diverticulum: a pouch in the throat that traps food, causing gurgling, regurgitation and bad breath
• Aging (presbyphagia): slower, weaker swallowing in older adults
• Dry mouth from medicines or Sjögren's syndrome

Globus

A constant sensation of a lump in the throat, without difficulty swallowing food, is called globus. It is often linked to reflux, stress or throat muscle tension, and is not dangerous. See lump in throat.

Swallowing problems in the elderly

Swallowing difficulties are common in older adults, especially after stroke, with dementia or Parkinson's, and in care homes. Warning signs include coughing during meals, a wet or gurgly voice after drinking, taking a long time to eat, pocketing food in the cheeks, weight loss and repeated chest infections. These raise the risk of malnutrition, dehydration and aspiration pneumonia. A speech-language pathologist can assess swallowing safely.

How doctors diagnose dysphagia

1. History: solids vs liquids, where food sticks, how long, whether it is getting worse, heartburn, weight loss, medicines and neurological symptoms.
2. Examination of the mouth, neck and nervous system.
3. Upper endoscopy (EGD): a camera looks at the esophagus, takes biopsies (essential for eosinophilic esophagitis and cancer) and can stretch a narrowing at the same time.
4. Barium swallow: X-rays while you swallow contrast, showing narrowing, rings, pouches and achalasia.
5. Videofluoroscopic swallow study or FEES: a speech-language pathologist watches how you swallow different textures, for throat-level problems.
6. High-resolution manometry: measures esophageal muscle pressures for achalasia and spasm.

Treatment

Treatment depends on the cause:

• Reflux and strictures: acid-reducing medicines (PPIs) and endoscopic dilation (stretching).
• Eosinophilic esophagitis: PPIs, swallowed topical steroids, elimination diets or biologic treatment, plus dilation if needed.
• Achalasia: balloon dilation, surgical myotomy or POEM (an endoscopic muscle cut), or botulinum toxin injections.
• Cancer: surgery, chemotherapy, radiotherapy and stents to keep the esophagus open.
• Neurological dysphagia: swallowing therapy with exercises and safe swallowing strategies, texture-modified diets and thickened fluids, and sometimes a feeding tube.

Practical tips while you wait

• Eat slowly, take small bites and chew well.
• Sit upright for meals and for 30 minutes after.
• Take tablets with a full glass of water while upright.
• Choose softer, moist foods and avoid dry bread and tough meat if they stick.
• Avoid alcohol with meals, and do not talk while chewing.

Frequently asked questions

What is the most common cause of difficulty swallowing?

In older adults, stroke and other neurological conditions are leading causes of throat-level difficulty, while reflux-related narrowing is a common esophageal cause. In younger adults, especially men with allergies, eosinophilic esophagitis is a frequent cause of food sticking.

When should I worry about difficulty swallowing?

See a doctor if swallowing difficulty keeps happening, is getting worse, or comes with weight loss, vomiting, blood, chest pain or frequent choking. Food stuck so you cannot swallow saliva is an emergency. New difficulty after age 60 needs prompt investigation.

Can anxiety cause swallowing problems?

Anxiety can cause a lump-in-the-throat feeling (globus) and a sense of tightness, but it does not usually cause food to physically stick. Real difficulty with food, choking or weight loss should not be put down to anxiety without tests.

What does it feel like when food gets stuck in your esophagus?

People describe pressure or a stuck sensation behind the breastbone, sometimes with pain, drooling or regurgitation. If it passes with sips of water, see a doctor soon. If you cannot swallow saliva, go to the ER, because it may need endoscopic removal.

Is difficulty swallowing a sign of cancer?

It can be, especially if it is progressive, starting with solids and then liquids, with weight loss, in someone over 60 or with long-term reflux, smoking or heavy drinking. Most swallowing problems have non-cancer causes, but endoscopy is the way to be sure.