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Dysphagia is the medical term used to describe difficulty swallowing. Dysphagia can make eating, drinking, and swallowing medications uncomfortable or unsafe, and can affect quality of life since eating is often a social experience.
Swallowing is one of the few parts of the digestive process that begins under our conscious control. It is something we do many times throughout the day, yet we don’t tend to give it much thought, unless it stops working properly. In a healthy individual, swallowing involves a complex coordination of several muscles that ensure the food makes it to the stomach.
When something causes an interruption to this normal process, you can develop dysphagia. Most often, dysphagia is a symptom of another condition but, in some cases, dysphagia is its own condition. There are two primary forms of dysphagia. One involves difficulty starting a swallow and moving the food/liquid/saliva into the throat and passing into the esophagus (oropharyngeal dysphagia) and the other involves food being stuck in the throat or the sensation of food being stuck in the throat after start of swallow (esophageal dysphagia).
Oropharyngeal dysphagia usually results from a problem in the mouth (oral cavity) or the throat area between the mouth and esophagus (pharynx). In esophageal dysphagia, the cause is usually related to the esophagus or upper stomach (gastric cardia). Both forms of dysphagia can be from an organic cause, such as a stricture or blockage, or a functional cause, where there is no visible physical damage causing symptoms, but rather a problem in the muscles and nerves coordinating swallowing.
Dysphagia is a common condition; it affects approximately 13.5% of the general population but is more common in the aging population.1 As more people live to older ages, the incidence of dysphagia is increasing. It affects 19-33% of individuals older than 80 years-of-age,2 and up to 50% of individuals living in a nursing home experience dysphagia.1 In addition, older individuals are more likely to experience severe complications from dysphagia than those who are younger. The most common complaint is a lump feeling where there is no actual limitation to passage of food or drink (globus).
Symptoms and Complications of Dysphagia
Symptoms include pain or discomfort while swallowing, the sensation of food stuck in the throat or chest, coughing, choking on food, heartburn, drooling, frequent throat clearing, and hoarseness. The severity and duration of symptoms can vary greatly between individual patients and throughout time.
Some complications that can occur include nutritional deficiencies, weight loss, and dehydration from not eating and drinking enough due to symptoms. One of the more serious effects of dysphagia is when food, liquid, or saliva goes into the airway instead of the esophagus. This may lead to coughing or a feeling of choking and some individuals may develop chest infections or pneumonia (aspiration pneumonia). Some individuals may also experience a change to their voice.
Causes of Dysphagia
In some cases, dysphagia occurs for no obvious reason. However, dysphagia is typically caused by an illness or condition that affects the muscles and nerves in the tongue, mouth, and throat. Individuals that may be at risk include:
- those with abnormal growths, outpouchings, structural changes, or tissue damage in the mouth or esophagus
- those who have a disease or disorder that affects the nervous system, including multiple sclerosis, amyotrophic lateral sclerosis, Parkinson’s disease, and muscular dystrophy
- those with gastroesophageal reflux disease (GERD)
- those with allergic reactions to food causing microscopic inflammation of the esophagus called eosinophilic esophagitis
- those who have had a stroke
- those with dementia or Alzheimer’s disease
- older adults who may be weak or frail or have changes to their muscle and nerve function with aging
To diagnose dysphagia, your physician will ask you questions about your symptoms and eating/drinking habits and review your medical history. If they suspect you might have dysphagia, they may conduct diagnostic tests.
The most common test for diagnosing esophageal dysphagia is the barium swallow. A technician will take X-ray images of your upper digestive tract while you drink a mixture of barium and water. The barium coats the walls of the digestive tract, which appears white on the X-rays and allows your physician to see the structure and function of your upper digestive tract. With this test, your physician can detect both physical causes and functional causes of dysphagia.
Your physician might also recommend a dynamic swallowing study, or a modified barium swallow. This is most often used to diagnose oropharyngeal dysphagia, and involves swallowing foods coated in a barium mixture and taking X-rays. This provides more real-life insight into the way your throat functions when you swallow different foods.
Depending on the suspected cause of your dysphagia, an endoscopy might be useful. During this procedure, your physician will use a long, narrow tube with a small camera attached to the end to view the structure of your pharynx and esophagus to see if there are any physical anomalies. You might also undergo a flexible endoscopic evaluation of swallow study (FEES), which is more helpful for oropharyngeal dysphagia assessment.
Management of Dysphagia
The first step in treating dysphagia is identifying what is causing the difficulty in swallowing, and then treating that accordingly. However, there are some options for treating dysphagia directly, which can vary depending on the unique circumstances of each individual. Acid lowering drugs such as proton pump inhibitors can be useful if acid reflux from the stomach up into the esophagus is causing inflammation or scarring. If helpful, these medications usually have to be taken long-term to maintain control of refluxing acid.
Lifestyle and dietary modifications
Not everyone needs the same course of treatment. It is important for individuals with dysphagia to focus on consuming foods that are less likely to cause choking or aspiration. These are generally foods that are softer and easy to chew and swallow. Changing the texture of foods and/or the thickness of liquids may be helpful for some people with dysphagia. Your health care provider will suggest the types of foods and liquids that might work best to help manage your swallowing difficulties. Having good teeth and being able to chew and break up food, as well as eating slowly, are very important
When it comes to solids, as a general rule, foods that are easier to swallow include well-cooked or canned fruits and vegetables, tender meats, pasta and rice, soups, yogurt, cottage cheese, tofu, well-cooked beans, eggs, and foods that are moist.
Foods that are more difficult to swallow include dry or coarse bread, crackers, and cereals, dry or tough meats, nuts and seeds, raw fruits and vegetables, popcorn and chips, and foods that are very chewy.
How strict you need to be on dietary modifications will depend on the severity of your dysphagia. Some individuals with oropharyngeal dysphagia may need to thicken the liquids they drink to slow down how fast they move in the mouth and throat. While thin liquids might be problematic, thicker liquids such as smoothies and milkshakes might be tolerable.3
It might be helpful to eat while sitting upright and to remain upright for at least 30 minutes after you finish eating. Chew all your food well and take your time. Your physician might refer you to a speech-language pathologist who can teach you exercises to help make your swallowing easier and safer.
If you have dysphagia, ask for an appointment with a registered dietitian who can help you figure out which foods and liquids are right for you. There are commercial thickener products available in pharmacies to help thicken liquids to the consistency that is right for you. Your health care professional may recommend using liquid oral nutrition supplements and other strategies to help provide the calories, protein, and nutrients you need. In some cases, a tube feeding might be recommended for all or part of your nutrition each day. If pills or medications are a challenge, discuss options for chewable or liquid medications with your pharmacist.
Dilation or Surgery
While generally uncommon, depending on the cause and severity of your dysphagia, dilation or surgery might be an effective treatment. Dilation or stretching the esophagus, done during gastroscopy, can be beneficial when dysphagia results from strictures, tumours, esophageal narrowing, achalasia, or any other change to the physical structure of the oral cavity, pharynx, esophagus, or gastric cardia. The exact method and type of procedure will depend on the nature of the problem causing dysphagia, so please speak with your physician about any concerns regarding such interventions. Sometimes, previous chest or neck radiation treatment or head or neck surgery for other reasons might lead to difficulty swallowing from scarring.
Dysphagia can vary in terms of severity, underlying cause, and duration of the condition. It may be chronic, progressive, stable, or temporary depending on what is causing the swallowing difficulty. Working with members of your health care team – physician, registered dietitian, speech and language therapist – can help you learn more about dysphagia and what options are right for you.