Difficulty Swallowing (Dysphagia)

What is difficulty swallowing?

Difficulty swallowing or, medically, dysphagia, refers to any abnormal effort needed to swallow food.

Causes

Difficulty swallowing can result from:

• Mouth and throat problems
• Esophageal problems

Chart 1. MOUTH/THROAT Problems and Difficulty Swallowing
SYMPTOMS	CAUSE
Dry mouth, fatigue, dizziness	Dehydration, drugs (antibiotics, opiates…) [13], Sjögren’s syndrome [15]
Tightness in the throat between meals	Psychogenic: stress, anxiety [3,18,27]
Jaw pain, lockjaw	Temporomandibular joint disorder
Sudden sore and swollen throat, swollen neck lymph nodes, fever	Infections: strep throat
A feeling of a lump or pain in the throat, hoarseness, dry cough	Foreign body [4], throat cancer [28], Zenker’s diverticulum [17], cricopharyngeal dysfunction [6,35,36]
Difficulty initiating swallowing, foods entering the nose, choking, slurred speech, weakness, numbness, eyelid drooping, double vision	Stroke, Parkinson’s disease, multiple sclerosis, brainstem tumor, dementia [1,8,12,16]; polymyositis, myasthenia gravis, muscle dystrophy [19,29]
Swelling and pain at the front of the neck	Enlarged thyroid (goiter), hypothyroidism, hyperthyroidism [8]
Pain at the back of the neck, neck stiffness	Bone spurs in the spine (osteoarthritis) [11,12]

Chart 2. ESOPHAGEAL Problems and Difficulty Swallowing
MECHANICAL OBSTRUCTION of the esophagus
SYMPTOMS	CAUSES
Solid foods stuck in the chest	Esophageal strictures, webs or rings due to acid reflux, Crohn’s disease, asthma, eosinophilic esophagitis, chronic iron deficiency anemia [10,14,22,30]
Heartburn, metallic taste, belching, choking at night, indigestion	A hiatal hernia with gastroesophageal reflux disease (GERD) [3,9,25]
Low-grade fever, chest pain	Enlarged lymph nodes in the chest (in lung cancer, lymphoma, tuberculosis, sarcoidosis) [1]
Progressive difficulty swallowing, weight loss	Esophageal cancer [3]
MOTILITY DISORDERS of the esophagus
SYMPTOMS	CAUSES
Food stuck in the chest, painful swallowing, heartburn, food regurgitation between meals or at night	Achalasia [3,21,34] Diffuse esophageal spasm [3,24,46] Diabetic neuropathy [5,26] Presbyesophagus (in elderly) [32] Scleroderma [3,20] Drugs: antipsychotics, anxiolytics…[13]

What causes difficulty swallowing liquids or solids?

Difficulty swallowing LIQUIDS or SALIVA but not solids can be due to anxiety, laryngopharyngeal reflux or brain/stem disorders.

Difficulty swallowing SOLIDS (meat, bread, rice…) or PILLS but not liquids can be due to mechanical obstruction of the esophagus (a hiatal hernia, strictures, rings, cancer…) or cricopharyngeal spasm ^[3,36].

Difficulty swallowing LIQUIDS and SOLIDS can be due to motility disorders of the esophagus (achalasia, esophageal spasm, scleroderma), Zenker’s diverticulum or advanced esophageal cancer ^[2,3,21].

What can cause difficulty swallowing the first bite of food?

• Dry mouth
• Anxiety
• Esophageal rings
• Cricopharyngeal spasm
• Achalasia
• References: 6,7,35,36,37

What are complications of dysphagia?

• Unintentional weight loss or malnutrition
• Aspiration (breathing in foods) resulting in:
  • Inflammation of the larynx (vocal cords) with hoarseness and “wet voice”
  • Inflammation of the lungs (pneumonitis) with shortness of breath, dry cough, low-grade fever or even death
• Food impaction in the esophagus, which requires emergency endoscopic removal of the food bolus

Diagnosis and Treatment

What type of doctor to see for difficulty swallowing?

Your primary doctor can recognize certain causes of difficulty swallowing. For final diagnosis, you may need to visit a dentist, a specialist for ear, nose and throat (ENT), gastroenterologist, neurologist or internist.

Investigations

Investigations that can reveal the cause of dysphagia ^[2]:

• An endoscopy of the esophagus or larynx
• An X-ray of the chest with barium swallow
• Esophageal manometry
• 24-hour pH monitoring of the esophagus
• Endoscopic ultrasound
• A CT or MRI of the brain, throat, mouth, neck or chest
• Microbiological tests of the throat or esophageal lining
• Neurological investigations

Home Remedies

To prevent or limit difficulty swallowing ^[1,38]:

• Have small meals and chew food well.
• Avoid dry, rough and cold foods.
• Try pureed or liquid foods.
• In neurological disorders: bend the head and neck before swallowing (chin-tuck maneuver) ^[31,42].
• In esophageal motility disorders (achalasia, scleroderma): swallow and push hard with the tongue against the palate (effortful swallow) ^[44].
• Do not lie down for at least a couple of hours after meals.

To release the food that has stuck behind your breastbone ^[3]:

• Repeat the swallowing.
• Throw the shoulders back or raise your arms over the head.
• Pinch the nose with the fingers and blow air through it (Valsalva maneuver).

Read more about dysphagia diet and swallowing maneuvers and exercises at ASHA.org. Discuss with your doctor what may be appropriate for you.

Medications

Proton pump inhibitors can relieve acid reflux ^[47].

Smooth muscle relaxants may help in esophageal spasms or achalasia ^[41,47].

There is INSUFFICIENT EVIDENCE about the effectiveness of prokinetic drugs (buspirone, cisapride, tegaserod), in the treatment of difficulty swallowing ^[45].

Endoscopic Procedures

Endoscopic procedures involve passing a tube with a light and instruments at the end through the nose into the esophagus.

Botulinum toxin injection into the esophageal wall can improve difficulty swallowing in achalasia ^[40,43] and cricopharyngeal dysfunction; the effect lasts for several months ^[33,38,39].

Endoscopic balloon dilation can improve difficulty swallowing due to esophageal strictures, webs or rings, diffuse esophageal spasm and achalasia; the effect can last for several years ^{[38,40,41,43,47]}.

Endoscopic myotomy (cutting a muscular valve) can provide long-term relief in cricopharyngeal dysfunction ^[33] and diffuse esophageal spasms ^[47].

Surgery

Surgery can permanently improve difficulty swallowing in a hiatal hernia, cancers, Zenker’s diverticulum, disorders of the neck spine and congenital abnormalities ^[38,40].

Achalasia can be treated by laparoscopic myotomy, which refers to the insertion of an endoscope through a small cut in the abdominal wall into the abdominal cavity and cutting the muscular valve at the bottom of the esophagus ^[41].

Removal of the esophagus (esophagectomy) and its replacement by the intestinal tissue can be performed in extreme cases when nothing else helps ^[47].

• References

  1. Merando A, 2013, Dysphagia and Odynophagia  Cancertherapy Advisor
  2. Spechler S, 2013, Approach to the patient with dysphagia  Clinical Advisor
  3. Richter JE, Dysphagia, odynophagia, heartburn and other esophageal symptoms  University of Alberta
  4. Hiorns MP et al, 2003, Dysphagia caused by a foreign body  PubMed Central
  5. Poretsky L, Dysphagia, Odynophagia and Chest Pain  Principles of Diabetes Mellitus, 2nd Edition, 2004, p. 422
  6. Swallowing Disorders: Introduction  Hopkins Medicine
  7. Patient Comments: Schatzki’s Ring – Symptoms  MedicineNet
  8. Spieker MR et al, 2000, Evaluating dysphagia  American Family Physician
  9. Mosca F et al, 2006, Manifestations of gastro-pharyngo-laryngeal reflux disease  PubMed Central
  10. Eosinophilic esophagitis  American Academy of Allergy, Asthma & Immunology
  11. Grgic V, 2013, Cervicogenic dysphagia: swallowing difficulties caused by functional and organic disorders of the cervical spine   PubMed
  12. McCulloch TM et al, 2006, Head and neck disorders affecting swallowing  GI Motility Online
  13. Medications and dysphagia/swallowing risks  CT.gov
  14. Dysphagia  Cleveland Clinic
  15. Sjögren’s syndrome  MedlinePlus
  16. Barone DA, Swallowing disorders  Multiple Sclerosis Association of America
  17. Aggarwal N et al, 2016, Are there alternatives to surgery for Zenker diverticulum?  MDedge
  18. Swallowing difficulty  MedlinePlus
  19. Effects of myasthenia gravis on voice, speech and swallowing, Myasthenia Gravis Foundation
  20. Systemic scleroderma  Cleveland Clinic
  21. Achalasia  MedlinePlus
  22. Kumbum K, Esophageal strictures  Emedicine
  23. Vasudeva R, Schatzki Ring Clinical Presentation  Emedicine
  24. Esophageal spasms and strictures  Cleveland Clinic
  25. Kabul JK et al, 1990, The Cause of Dysphagia in Uncomplicated Sliding Hiatal Hernia and its Relief by Hiatal Herniorrhaphy  PubMed Central
  26. Ippoliti A, 1983, Esophageal Disorders in Diabetes Mellitus  PubMed Central
  27. Franko DL et al, 1997, Phagophobia: A form of Psychogenic Dysphagia a New Entity  SAGE Journals
  28. Signs and Symptoms of Laryngeal and Hypopharyngeal Cancers  American Cancer Society
  29. Dysphagia  The Myositis Association
  30. Smith MS, 2010, Diagnosis and Management of Esophageal Rings and Webs  PubMed Central
  31. Kagaya H et al, 2011, Body Positions and Functional Training to Reduce Aspiration in Patients with Dysphagia  Japan Medical Association
  32. Presbyesophagus  Minnesota Gastroenterology
  33. Kocdor P et al, 2016, Cricopharyngeal dysfunction: A systematic review comparing outcomes of dilatation, botulinum toxin injection, and myotomy  PubMed
  34. Chagas disease (American trypanosomiasis)  World Health Organization
  35. Pelemans W, Cricopharyngeal achalasia seems the commonest cause of oro-pharyngeal dysphagia in the elderly  OESO
  36. Cricopharyngeal dysfunction (CPD)  Laryngopedia
  37. Trouble Swallowing – Food Stuck In Throat  SteadyHealth
  38. Paik N-J, Dysphagia treatment & management  Emedicine
  39. Persaud R et al, 2013, An evidence-based review of botulinum toxin (Botox) applications in non-cosmetic head and neck conditions  PubMed Central
  40. Achalasia treatment  Mayo Clinic
  41. Gaumnitz EA, Esophageal Motility Disorders Treatment & Management  Emedicine
  42. Saconato M et al, 2016, Effectiveness of Chin-tuck Maneuver to Facilitate Swallowing in Neurologic Dysphagia
      PubMed Central
  43. Esophageal motility disorders  Keck School of Medicine, University of Southern California
  44. Lever TE et al, 2007, The effect of an effortful swallow on the normal adult esophagus  PubMed
  45. Scheerens C et al, 2015, Buspirone, a new drug for the management of patients with ineffective esophageal motility?  PubMed Central
  46. April 3, 2014, Understanding & Managing Swallowing Disorders, Online Health Chat with Scott Gabbard, MD and Siva Raja, MD, PhD  Cleveland Clinic
  47. Esophageal spasms, treatment & management  Emedicine