What is difficulty swallowing (dysphagia)?
Dysphagia is difficulty in swallowing. Although classified under “symptoms and signs” in ICD-10, in some contexts it is classified as a condition in its own right. People with dysphagia are sometimes unaware of having it.
It may be a sensation that suggests difficulty in the passage of solids or liquids from the mouth to the stomach, a lack of pharyngeal sensation or various other inadequacies of the swallowing mechanism. Dysphagia is distinguished from other symptoms including odynophagia, which is defined as painful swallowing, and globus, which is the sensation of a lump in the throat. A person can have dysphagia without odynophagia (dysfunction without pain), odynophagia without dysphagia (pain without dysfunction) or both together. A psychogenic dysphagia is known as phagophobia.
Types of dysphagia
Swallowing occurs in four phases: oral preparatory, oral, pharyngeal, and esophageal. Swallowing difficulty can be broken down into two categories: oropharyngeal (which includes the first three phases) and esophageal.
Oropharyngeal dysphagia is caused by disorders of the nerves and muscles in the throat. These disorders weaken the muscles, making it difficult for a person to swallow without choking or gagging. The causes of oropharyngeal dysphagia are conditions that primarily affect the nervous system such as:
- multiple sclerosis
- Parkinson’s disease
- nerve damage from surgery or radiation therapy
- post-polio syndrome
Oropharyngeal dysphagia can also be caused by esophageal cancer and head or neck cancer. It may be caused by an obstruction in the upper throat, pharynx, or pharyngeal pouches that collect food.
Esophageal dysphagia is the feeling that something is stuck in your throat. This condition is caused by:
- spasms in the lower esophagus, such as diffuse spasms or the inability of the esophageal sphincter to relax
- tightness in the lower esophagus due to an intermittent narrowing of the esophageal ring
- narrowing of the esophagus from growths or scarring
- foreign bodies lodged in the esophagus or throat
- a swelling or narrowing of the esophagus from inflammation or GERD
- scar tissue in the esophagus due to chronic inflammation or post-radiation treatment
If you think you may have dysphagia, there are certain symptoms that may be present along with difficulty swallowing.
- a hoarse voice
- feeling that something is lodged in the throat
- unexpected weight loss
- coughing or choking when swallowing
- pain when swallowing
- difficulty chewing solid foods
These sensations may cause a person to avoid eating, skip meals, or lose their appetite.
Children who have difficulty swallowing when eating may:
- refuse to eat certain foods
- have food or liquid leaking from their mouths
- regurgitate during meals
- have trouble breathing when eating
- lose weight without trying
What causes swallowing difficulty?
According to the National Institute on Deafness and Other Communication Disorders, there are 50 pairs of muscles and nerves used to help you swallow. In other words, there are lots of things that can go wrong and lead to problems swallowing. Some conditions include:
- Acid reflux and GERD: Acid reflux symptoms are caused when stomach contents flow up from the stomach back into the esophagus, causing symptoms like heartburn, stomach pain, and burping. Learn more the causes, symptoms, and treatment of acid reflux and GERD.
- Heartburn: Heartburn is a burning sensation in your chest that often occurs with a bitter taste in your throat or mouth.
- Epiglottitis: Epiglottitis is characterized by inflamed tissue in your epiglottis. It’s a potentially life-threatening condition.
- Goiter: Your thyroid is a gland found in your neck just below your Adam’s apple. A condition that increases the size of your thyroid is called a goiter.
- Esophagitis: Esophagitis is inflammation of the esophagus that can be caused by acid reflux or certain medications.
- Esophageal cancer: Esophageal cancer occurs when a malignant (cancerous) tumor forms in the lining of the esophagus, which can cause difficulty swallowing.
- Stomach cancer (gastric adenocarcinoma): Stomach cancer occurs when cancerous cells form in the stomach lining. Because it’s difficult to detect, it’s often not diagnosed until it’s more advanced.
- Herpes esophagitis: Herpes esophagitis is caused by the herpes simplex virus type 1 (HSV-1). The infection can cause some chest pain and difficulty swallowing.
- Recurrent herpes simplex labialis: Recurrent herpes simplex labialis, also known as oral or orolabial herpes, is an infection of the mouth area caused by the herpes simplex virus.
- Thyroid nodule: A thyroid nodule is a lump that can develop in your thyroid gland. It can be solid or filled with fluid. You can have a single nodule or a cluster of nodules.
- Infectious mononucleosis: Infectious mononucleosis, or mono, refers to a group of symptoms usually caused by the Epstein-Barr virus (EBV).
- Snake bites: A bite from a venomous snake should always be treated as a medical emergency. Even a bite from a harmless snake can lead to an allergic reaction or infection.
Symptoms 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).
Undiagnosed dysphagia may also lead to dehydration and malnutrition.
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.”
How is swallowing difficulty diagnosed?
Talk to your doctor about your symptoms and when they began. Your doctor will do a physical examination and look in your oral cavity to check for abnormalities or swelling.
More specialized tests may be needed to find the exact cause.
A barium X-ray is often used to check the inside of the esophagus for abnormalities or blockages. During this examination, you will swallow liquid or a pill containing a dye that shows up on an abdominal X-ray. The doctor will look at the X-ray image as you swallow the liquid or pill to see how the esophagus functions. This will help identify any weaknesses or abnormalities.
A videofluorscopic swallowing evaluation is a radiologic exam that uses a type of X-ray called fluoroscopy. This test is performed by a speech-language pathologist. It shows the oral, pharyngeal, and esophageal phases of the swallow. During this examination, you’ll swallow a variety of consistencies ranging from purees to solids and thin and thickened liquid. This will help the doctor detect the ingestion of food and liquid into the trachea. They can use this information to diagnose muscle weakness and dysfunction.
An endoscopy may be used to check all areas of your esophagus. During this examination, the doctor will insert a very thin flexible tube with a camera attachment down into your esophagus. This allows the doctor to see the esophagus in detail.
The manometry is another invasive test that can be used to check the inside of your throat. More specifically, this test checks the pressure of the muscles in your throat when you swallow. The doctor will insert a tube into your esophagus to measure the pressure in your muscles when they contract.
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 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.
What Is the Medical Definition of Dysphagia?
- Dysphagia means difficulty swallowing. Odynophagia means painful swallowing. Sometimes it is not easy for individuals to distinguish between these two problems.
- For example, food that sticks in the esophagus (swallowing tube) can be painful. Is this dysphagia or odynophagia or both? Technically it is dysphagia, but individuals may describe it as painful swallowing (odynophagia).
- Nevertheless, it is important to attempt to distinguish between the two because the causes of each may be quite different. When dysphagia is mild, it may cause an individual only to stop eating for a minute or less and drink a few sips of water.
- When it is severe, however, it can prevent an individual from eating and taking in enough calories for adequate nutrition and to maintain weight.
What Causes Dysphagia?
- Some conditions associated with dysphagia affect the area of the lower throat, primarily conditions in which there are abnormalities of nerves or muscles that control the function of the throat. This area also is the area from which the trachea, the main airway leading to the lungs, begins.
Can You Die of Dysphagia?
- As a result, abnormalities with the function of the nerves and muscles of this area can lead to discoordination and food may be more easily aspirated into the lungs, potentially leading to bacterial infection and a form of pneumonia known as aspiration pneumonia.
- The same complication in the lungs can occur when food sticks in the esophagus further down and remains there until a person sleeps. At night, food can regurgitate from the esophagus and into the throat, and then the lungs, because in the lying position gravity does not prevent the food from coming up, and swallowing, which can keep food in the esophagus, is not occurring.
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