What is difficulty swallowing?
Difficulty swallowing or, medically, dysphagia, refers to any abnormal effort needed to swallow food.
Difficulty swallowing can result from:
Chart 1. MOUTH/THROAT Problems and Difficulty Swallowing
|Dry mouth, fatigue, dizziness||Dehydration, drugs (antibiotics, opiates…) , Sjögren’s syndrome |
|Tightness in the throat between meals||Psychogenic: stress, anxiety [3,18,27]|
|Jaw pain, lockjaw||Temporomandibular
|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 , throat cancer , Zenker’s diverticulum , 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 |
|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
|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) |
|Progressive difficulty swallowing, weight loss||Esophageal cancer |
MOTILITY DISORDERS of the esophagus
|Food stuck in the chest, painful swallowing, heartburn, food regurgitation between meals or at night||
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
- Esophageal rings
- Cricopharyngeal spasm
- 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 that can reveal the cause of dysphagia :
- 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
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) .
- Do not lie down for at least a couple of hours after meals.
To release the food that has stuck behind your breastbone :
- 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.
Proton pump inhibitors can relieve acid reflux .
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 .
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  and diffuse esophageal spasms .
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 .
Removal of the esophagus (esophagectomy) and its replacement by the intestinal tissue can be performed in extreme cases when nothing else helps .
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