What causes difficulty swallowing (dysphagia)?
Usually caused by nerve or muscle problems, dysphagia can be painful and is more common in older people and babies.
Although the medical term "dysphagia" is often regarded as a symptom or sign, it is sometimes used to describe a condition in its own right. There is a wide range of potential causes of dysphagia; if it only happens once or twice, there is probably no serious underlying problem, but, if it occurs regularly, it should be checked out by a doctor.
Because there are many reasons why dysphagia can occur, treatment depends on the underlying cause.
In this article, we will discuss the various causes of dysphagia along with symptoms, diagnosis, and potential treatments.
What is dysphagia?
Dysphagia is more common in older adults.
A typical "swallow" involves several different muscles and nerves; it is a surprisingly complex process. Dysphagia can be caused by a difficulty anywhere in the swallowing process.
There are three general types of dysphagia:
Oral dysphagia (high dysphagia) — the problem is in the mouth, sometimes caused by tongue weakness after a stroke, difficulty chewing food, or problems transporting food from the mouth.
Pharyngeal dysphagia — the problem is in the throat. Issues in the throat are often caused by a neurological problem that affects the nerves (such as Parkinson's disease, stroke, or amyotrophic lateral sclerosis).
Esophageal dysphagia (low dysphagia) — the problem is in the esophagus. This is usually because of a blockage or irritation. Often, a surgical procedure is required.
It is worth noting that pain when swallowing (odynophagia) is different from dysphagia, but it is possible to have both at the same time. And, globus is the sensation of something being stuck in the throat.
Causes of dysphagia
Possible causes of dysphagia include:
Amyotrophic lateral sclerosis — an incurable form of progressive neurodegeneration; over time, the nerves in the spine and brain progressively lose function.
Achalasia — lower esophageal muscle does not relax enough to allow food into the stomach.
Diffuse spasm — the muscles in the esophagus contract in an uncoordinated way.
Stroke — brain cells die due to lack of oxygen because blood flow is reduced. If the brain cells that control swallowing are affected, it can cause dysphagia.
Esophageal ring — a small portion of the esophagus narrows, preventing solid foods from passing through sometimes.
Eosinophilic esophagitis — severely elevated levels of eosinophils (a type of white blood cell) in the esophagus. These eosinophils grow in an uncontrolled way and attack the gastrointestinal system, leading to vomiting and difficulty with swallowing food.
Multiple sclerosis — the central nervous system is attacked by the immune system, destroying myelin, which normally protects the nerves.
Myasthenia gravis (Goldflam disease) — the muscles under voluntary control become easily tired and weak because there is a problem with how the nerves stimulate the contraction of muscles. This is an autoimmune disorder.
Parkinson's disease and Parkinsonism syndromes — Parkinson's disease is a gradually progressive, degenerative neurological disorder that impairs the patient's motor skills.
Radiation — some patients who received radiation therapy (radiotherapy) to the neck and head area may have swallowing difficulties.
Cleft lip and palate — types of abnormal developments of the face due to incomplete fusing of bones in the head, resulting in gaps (clefts) in the palate and lip to nose area.
Scleroderma — a group of rare autoimmune diseases where the skin and connective tissues become tighter and harden.
Esophageal stricture — a narrowing of the esophagus, it is often related to GERD.
Xerostomia (dry mouth) — there is not enough saliva to keep the mouth wet.
Symptoms of dysphagia
Coughing when swallowing can be a symptom of dysphagia.
Some patients have dysphagia and are unaware of it — in these cases, it may go undiagnosed and not be treated, raising the risk of aspiration pneumonia (a lung infection that can develop after accidentally inhaling saliva or food particles).
Symptoms linked to dysphagia include:
- Choking when eating.
- Coughing or gagging when swallowing.
- Food or stomach acid backing up into the throat.
- Recurrent heartburn.
- Sensation of food getting stuck in the throat or chest, or behind the breastbone.
- Unexplained weight loss.
- Bringing food back up (regurgitation).
- Difficulty controlling food in the mouth.
- Difficulty starting the swallowing process.
- Recurrent pneumonia.
- Inability to control saliva in the mouth.
Patients may feel like "the food has got stuck."
Risk factors for dysphagia
The risk factors of dysphagia include:
Aging — older adults are more at risk. This is due to general wear and tear on the body over time. Also, certain diseases of old age can cause dysphagia, such as Parkinson's disease.
Neurological conditions — certain nervous system disorders make dysphagia more likely.
Complications of dysphagia
Pneumonia and upper respiratory infections - specifically aspiration pneumonia, which can occur if something is swallowed down the "wrong way" and enters the lungs.
Malnutrition — this is especially the case with people who are not aware of their dysphagia and are not being treated for it. They may simply not be getting enough vital nutrients for good health.
Dehydration — if an individual cannot drink properly, their fluid intake may not be sufficient, leading to dehydration (shortage of water in the body).
Diagnosis of dysphagia
A barium swallow test can be useful for understanding the reason behind a case of dysphagia.
A speech-language pathologist will try to determine where the problem lies - which part of the swallowing process is causing difficulty.
The patient will be asked about symptoms, how long they have been present, whether the problem is with liquids, solids, or both.
Swallow study — this is usually administered by a speech therapist. They test different consistencies of food and liquid to see which cause difficulty. They may also do a video swallow test to see where the problem is.
Barium swallow test — the patient swallows a barium-containing liquid. Barium shows up in X-rays and helps the doctor identify what is happening in the esophagus in more detail, especially the activity of the muscles.
Endoscopy — a doctor uses a camera to look down into the esophagus. They will take a biopsy if they find something they think might be cancer.
Manometry — this study measures pressure changes produced when muscles in the esophagus are working. This may be used if nothing is found during an endoscopy.
Treatment for dysphagia
Treatment depends on the type of dysphagia:
Treatment for oropharyngeal dysphagia (high dysphagia)
Because oropharyngeal dysphagia is often a neurological problem, providing effective treatment is challenging. Patients with Parkinson's disease may respond well to Parkinson's disease medication.
Swallowing therapy — this will be done with a speech and language therapist. The individual will learn new ways of swallowing properly. Exercises will help improve the muscles and how they respond.
Diet — Some foods and liquids, or combinations of them, are easier to swallow. While eating the easiest-to-swallow foods, it is also important that the patient has a well-balanced diet.
Feeding through a tube — if the patient is at risk of pneumonia, malnutrition, or dehydration they may need to be fed through a nasal tube (nasogastric tube) or PEG (percutaneous endoscopic gastrostomy). PEG tubes are surgically implanted directly into the stomach and pass through a small incision in the abdomen.
Treatment for esophageal dysphagia (low dysphagia)
Surgical intervention is usually required for esophageal dysphagia.
Dilation — if the esophagus needs to be widened (due to a stricture, for example), a small balloon may be inserted and then inflated (it is then removed).
Botulinum toxin (Botox) — commonly used if the muscles in the esophagus have become stiff (achalasia). Botulinum toxin is a strong toxin that can paralyze the stiff muscle, reducing constriction.
If the dysphagia is caused by cancer, the patient will be referred to an oncologist for treatment and may need surgical removal of the tumor.