Dysphagia (Swallowing difficulty) : Medical guide to causes, diagnosis & treatment

You have a problem swallowing liquids, foods, or saliva. When that happens, eating becomes a challenge. There could be a vast number of events that could lead to difficulty in swelling as this process involves numerous phases and many pairs of muscles and nerves.

You know that you have difficulty in swallowing when its taking longer to chew and swallow or you are choking or coughing while eating and drinking. You will listen your Doctor calling it as ‘Dysphagia’ which is its clinical term.

If you are having this kind of problem, you need to know about it and seek urgent treatment when required.

Though, you could face difficulty in swallowing a few times some day but it requires special attention if it becomes frequent.

Most of the time, Dysphagia coexists with ‘Heartburn’ that is described as a burning discomfort behind your anterior chest wall precisely behind the sternum.

There may also be ‘vomiting’ along with swallowing difficulty. There could be an acute dysphagia if there is a sudden onset or chronic dysphagia if its for a long time.

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We will now see what could be the reason that food is getting stuck in your throat or having a problem in pushing the food down through your mouth.

Table of Contents

What does Dysphagia mean?

Dysphagia is a medical term for ‘Difficulty in swallowing’.

You have a problem swallowing liquids, foods, or saliva. When that happens, eating becomes a challenge.
Often, dysphagia makes it difficult to take in enough calories and fluids to nourish the body and can lead to additional serious medical problems.

As per International classification of diseases, the ICD 10 code for dysphagia is R13.10 .
And the ICD 10 code for dysphagia due to cva (cerebro-vascular accident) is I69.391.

We will now see what could be the reason that food is getting stuck in your throat or having a problem in pushing the food down through your mouth.

In medical terms, let us know about the pathophysiology of dysphagia.

What causes difficulty in swallowing?

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There could be a vast number of events that could lead to difficulty in swelling as this process involves numerous phases and many pairs of muscles and nerves. Some important ones include:

Neurological diseases causing Dysphagia (Neurogenic dysphagia)

Bulbar Palsy

It is a lesion affecting the nuclei of the IXth, Xth, XIth, and XIIth cranial nerves. Dysfunctioning of these cranial nerves causes paralysis of the muscle involved in swallowing process leading to Dysphagia.

Pseudobulbar palsy

It is a lesion affecting the nerve fibres known as corticobulbar tract that are travelling to nuclei of the IXth, and XIIth cranial nerves that controls mastication, deglutition, and speech. Due to nerve injury, these events don’t occur normally.

Myasthenia Gravis

It is a disorder affecting nerves and muscles causing muscle weakness and muscle fatigue. The muscles involved in swallowing process fail to perform their normal function causing the person to face difficulty.

Psychogenic dysphagia

It is a rare cause of dysphagia when patient is not well understood with no structural cause or organic disease. There is a fear of swallowing with fear of choking.

You may read psychogenic dysphagia as phagophobia.

Dementia

Dementia describes a group of symptoms affecting memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life.

Dementia can impact on feeding and swallowing due to the decrease in functional skills and conscious level and result in dysphagia.

Inflammatory causes

Esophageal Candidiasis

It is caused by a fungus called ‘Candida’ which is the same fungus involves in fungal infection of the vagina. This disease is usually seen in person with low immunity like person suffering with AIDS or elderly people. You may hear the same disease with other name ‘Candida Esophagitis’.

Peptic Esophagitis

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This occurs when the acidic contents of stomach and duodenum comes back i.e. regurgitates into the esophagus and causes irritation to the wall of esophagus.

Eosinophilic Esophagitis

Eosinophil is a type of White blood cell (WBC). It usually increases in number in cases of allergy. The increases eosinophil may accumulate in the esophagus and cause injury to it.

Motility disorders

Achalasia

There is a ‘Lower esophageal sphincter’ that separates the esophagus and the stomach. Normally when are eating, the sphincter remains contracted and closed to prevent backflow of gastric contents into the Esophagus.

When you start to swallow, this sphincter relaxes and opens to allow passing of food from Esophagus into Stomach. It is called Achalasia when this sphincter fails to relax and open while swallowing that prevents the food to come down.

Nonspecific motility disorders of esophagus

These include the disorders of esophageal motility that that do not meet the diagnostic criteria for other esophageal motility disorders.

Disorders causing narrowing of the esophagus (Stricture)

Normally, esophagus measures around 30 mm in diameter. A stricture can cause its lumen to narrow down to to 13 mm or less causing Dysphagis. Following are the disorders that may lead to stricture formation in esophagus causing dysphagia.

Carcinoma of Esophagus

It is a malignant type of cancer that develops in the lining of the esophagus. This causes narrowing of the passage through which food and liquids pass into the stomach through the food pipe.

Carcinoma of stomach

It is a malignant type of cancer that occurs in the stomach. It is usually associated with poor outcome as it worsens the condition by causing malnutrition and weight loss.

Extrinsic compression of esophagus

There may be a mass outside the esophagus that compresses it from outside narrowing the passage of the food pipe.

Drugs

Many drugs could cause drug induced esophagitis. Common drugs among them are NSAIDs, potassium chloride tablets, and tetracycline antibiotics. A small percentage of Drug induced esophagitis can progress into narrowing of the lumen of esophagus.

Fibrous rings

There may be buildup of fibrous tissue and collagen deposits due to ulcers or chronic inflammation of the esophagus causing narrowing of the lumen.

Functional dysphagia

It is an uncommon cause of swallowing difficulty.

There is a sensation of transit of an abnormal bolus in the absence of any mucosal, structural, or major functional abnormalities of the esophagus.

This can be due to esophageal hypersensitivity, abnormal central processing of esophageal stimuli, intermittent abnormal esophageal motor disorder and psychological comorbidities.

Sideropenic Dysphagia

This condition is also knowan as Paterson-Kelly syndrome and Plummer-Vinson syndrome. This is marked by anaemia due to iron deficiency and a growth of web like membranes in the throat causing difficulty in swallowing.

Cervical Dysphagia

It includes swallowing difficulties caused by functional and organic disorders of the cervical spine. This includes:

  • Chronic multi segmental dysfunction of the facet joints.
  • Changes in physiological curvature of the cervical spine.
  • Degenerative changes like anterior disc herniation, osteochondrosis, osteoarthritis etc.
  • Inflammatory rheumatic diseases.
  • Injuries.
  • Conditions after anterior cervical spine surgery.
  • Congenital malformations and tumors.

Dysphagia lusoria

This is a condition of swallowing difficulty caused by an abnormal Right Subclavian Artery. Although most cases of this anomaly are asymptomatic but this may cause compression of the esophagus from outside resulting in dysphagia.

This condition was originally described as “dysphagia by freak of nature”.

Signs and Symptoms associated with Dysphagia

Usually, people tend to ignore Dysphagia. Some people may remain asymptomatic too. A person with dysphagia has to readily diagnose Dysphagia as it may lead to complications like malnutrition, dehydration and weight loss if untreated.

Following are the symptoms you would usually see in cases of Dysphagia:

  • Choking : This happens when there is resistance to breathing due to lodging of the unswallowed food in the throat or wind pipe.
  • Nasal regurgitation : Passing back of food or liquid from pharynx into the nasal cavity instead of esophagus.
  • Aspiration in trachea : There is an increased risk of aspiration of food into the trachea in case of dysphagia. The food may enter into the wind pipe instead of going into the food pipe.
  • Drooling : It means flowing of saliva outside the mouth unintentionally.
  • Hoarseness of voice : It is an abnormal change in voice. Vocal sounds may be weak, breathy, scratchy, or husky.
  • Dysarthria : A speech disorder causing weakness, paralysis or damage of the muscles involved in speech production.
  • Coughing or gagging
  • Recurrent Pneumonia

Important differential diagnosis of dysphagia

  • Globus sensation – When anxious people feel a lump in the throat without any organic cause.
  • Odynophagia – When there is pain during swallowing. Usually seen in gastro-oesophageal reflux disease and candidiasis.

Aphagia vs Dysphagia ; What is the difference?

If you have aphagia, there will be total inability to swallow. This is because of the complete obstruction of esophagus, most commonly encountered in case of food bolus or foreign body impaction.

Whereas, Dysphagia is the difficulty in swallowing due to problems in transit of food from mouth to hypopharynx or through esophagus.

What are different types of Dysphagia?

Though swallowing is a complicated process but the problem of swallowing difficulty can be divided into 2 types:

Oropharyngeal Dysphagia

As the name suggests, it is a disorder residing in the oropharynx. It affects the initiation of swallowing at the pharynx and upper esophageal sphnicter that is the inlet of esophagus.

It involves the oral phase of dysphagia in which the food may sit in the mouth and is not moved efficiently to the next phase.

It is mainly caused by certain neurological diseases like Bulbar palsy, Pseudobulbar palsy and Myasthenia gravis. Other than neurological reasons, it can be due to anatomic and structural abnormalities.

Oesophageal dysphagia

The esophageal disorders causes difficulty in swallowing by obstructing the lumen or by affecting motility of oesophagus. Patients with esophageal disease usually complain of ‘food sticking’ after swallowing. Initially, swallowing of liquids is normal until the the lumen of esophagus extremely narrows.

Cricopharyngeal dysphagia

It is a rare swallowing disorder. Although the causes are usually unknown, most cases are thought to be a congenital neuromuscular disorder that results in an inability to transport a normally propelled pharyngeal bolus through the upper esophageal sphincter.

It usually manifests as repeated swallowing attempts, gagging, retching (sensation of vomiting without vomiting), regurgitation, and aspiration.

What increases the risk of having a difficulty in swallowing?

There are certain risk groups and if you belong to any of them, you are more likely to develop this. Following are the risk groups who are more likely to face difficulty in swallowing:

  • Age : Elderly people are at higher risk of developing swallowing difficulty.
  • Stroke : Vast majority of acute stroke patients are affected by dysphagia. Stroke is a condition when blood supply to a part of brain is reduced or interrupted preventing tissues of brain from getting nutrients and oxygen. This leads to damage to brain tissues. Patients with stroke face increased difficulty while swallowing as brain tissues fail to coordinate.
  • Alzheimer’s disease : It is a disease in which brain cells progressively degenerate and die. This also increases the risk of dysphagia.
  • Diabetes and Scleroderma : It is observed that both of the entities causes weak or absent esophageal contractions with ineffective peristalsis (A wave of muscle contraction that moves food below).
  • Younger population with an underlying systemic illness such as autoimmune diseases, gastroesophageal reflux disease (GERD) or eosinophilic esophagitis.
  • Dysphagia in Parkinson’s disease : More than 80 % of patients with Parkinson’s disease (PD) develop dysphagia during the course of their disease. It has been shown that dopaminergic and non-dopaminergic mechanisms are involved in the development of dysphagia in Parkinson’s disease (PD).

Dysphagia in children and infants

Dysphagia in children and infants or pediatric dysphagia is not an uncommon problem. Both oropharyngeal type and esophageal type of dysphagia that are discussed above are found in the pediatric age group.

Differential diagnosis of dysphagia in case of children and infants

Differential diagnosis refers to probable disorder that have similar clinical features. These include :

Congenital esophageal stenosis : Symptoms of vomiting or chest infection due to aspiration typically develop around 6 months of age.

Foreign bodies in esophagus : Sharp foreign bodies and batteries can cause damage by perforation secondary to pressure or chemical necrosis. It can present with dysphagia, inflammation of mediastinum (mediastinitis) and/or upper gastrointestinal bleeding.

Guidelines recommend that no foreign body should be left in esophagus for more than 24 hours.

Achalasia cardia : Children present with dysphagia, vomiting, weight loss, respiratory symptoms and slow eating.

Toddlers present with coughing and feeding aversion (where a baby who is physically capable of feeding or eating – exhibits partial or full food refusal) with failure to thrive (term used when a child doesn’t meet recognised standards of growth).

Diagnosis and assessment of swallowing difficulty

Despite the high prevalance of dysphagia as it occurs in large proportion of population, less than half of the patients report their symptoms to doctors. Others tend to ignore until complications like dehydration, malnutrition or weight loss happens. It is suggested that dysphagia should always be investigated urgently.

After the patients report their symptoms to a doctor, a doctor uses recommended diagnostic approaches to evaluate dysphagia. These approaches can vary and are generally decided on the basis of the symptoms reported by the patient and the risk group to which the patient belongs.

Detailed clinical history

The doctor asks investigative questions about ‘swallowing initiation’,’ regurgitation of food through nose’ or whether you are ‘choking or coughing while swallowing’.

These questions help to distinguish between oropharyngeal dysphagia and esophageal dysphagia with accuracy of 80%.

The doctor may also ask that ‘For how long this problem is?’, ‘How many times does it happen?’, ‘What aggravates the swallowing difficulty?’, or ‘How severe it is?’.

These question help the doctors to pursue the best of the available diagnostic approaches to evaluate the condition.

Physical examination

The doctor evaluates the oropharynx, neck and dentition that may provide some helpful clues.

Barium Esophagography

It is a noninvasive, inexpensive, and readily available test that can simultaneously evaluate swallowing function, esophageal motility, gastroesophageal reflux, and numerous structural abnormalities in the pharynx and esophagus.

It is often utilized as the initial diagnostic test for this condition.

Modified Barium swallow

It is also known as ‘Video Fluoroscopic Swallowing Exam’ (VFSE). The patient is made to sit in an upright and in the lateral and anterior-posterior positions. The clinician then administers thin to thick liquid consistencies of Barium and solids as indicated.

A radiologist and radiology technician perform the fluoroscopy (a type of X-ray) to visualize the swallowing process.

Endoscopy

The doctor uses a thin flexible tube attached with a camera and inserts it down into the food pipe i.e. esophagus. This approach offers dual benefits as it can be used for both diagnostic and therapeutic purposes.

It is valuable when symptoms are suggestive of anatomic abnormality or if there is a concern of malignant or premalignant condition.

Endoscopy is found to be better than Barium swallow in terms of cost benefit as former has twofold application while latter generally requires followup testing or evaluation.

Biopsy

A sample of tissue from the esophagus to taken to examine it microscopically. Even if the appearances in endoscopy are normal, the doctors would do biopsy to look if there is eosinophilic esophagitis.

Manometry

It is a swallowing test that helps to evaluate whether esophagus is able to move the food into the stomach normally or not. Usually food is drove down into the stomach by the contraction and relaxation of muscles of esophagus. This is called ‘Peristalsis’.

In manometry test, a tube attached with a pressure measuring device is inserted into the esophagus and checked for motility of esophagus and pressure transduced when the esophageal muscles contract.

High Resolution manometry

A high resolution catheter tube is inserted through the nose into the esophagus which spans the entire length of it. It has a distal sensor attached at the end which finally gets positioned two to three centimetres below the diaphragm.

This test effectively measures oesophageal motility patterns and help predict response to endoscopic and surgical interventions.

Interventions and management in dysphagia

It is essential to treat the underlying cause that is giving rise to the problem of swallowing difficulty. The management approach varies and is based on the underlying cause. Following are the treatment modalities doctors use to manage the patients facing difficulty in swallowing.

Esophageal dilation with bougies

Before performing this procedure, patients are given a local anaesthetic or a sedative. It keeps the patients from feeling pain during the procedure and help them relax.

Bougies are cone shaped tubes that are inserted into the food pipe. The tubes remain in the place for about 15 seconds. The tubes then stretch the surrounding tissue and widen a part of the esophagus to make easy the passage of food down to the stomach.

Patients may feel a pressure while the tubes are placed in the esophagus.

Esophageal dilation with balloon dilators

Patients are first given a local anaesthetic and a sedative before the procedure. Then the balloon dilators are passed into the esophagus and the balloon is expanded causing stretching of the surrounding tissue.

The dilation helps to resolve mechanical obstriction caused by fibrous rings, webs and benign strictures (narrowing). Balloon dilators exert less dilation pressure as compared to the Bougies dilation and is associated with higher risk of perforation.

Concurrent acid suppression therapy

Even after a successful dilation of esophagus, the stricture (narrowing) may develop again. To reduce the recurrence of stricture after successful dilation, acid suppression therapy is frequently recommended with the dilation procedure.

Botulinum toxin

This toxin when given paralyzes the stiff muscle and prevents its constriction. This is used in condition of achalasia to relax the lower esophageal sphincter and allow the passage of food and liquids into the stomach.

These are less effective and are generally reserved for patients where dilation or surgical interventions are not effective.

Esophageal stents

A tube is placed inside your esophagus to keep it open and allow easy passages of solid and liquids.

Intralesional steroid injection

A corticosteroid is injected in the part of esophagus where narrowing is seen. Studies have shown that these steroids prevents formation of scar tissue and fibrosis and so help resolve narrowing of esophagus which show resistance to other treatment options.

Maneuvers for Dysphagia

Your doctor may use specific strategies to change the strength and timing of a particular swallowing movements. These include:

Mendelsohn maneuver : Your doctor would ask you to elevate the larynx and open the esophagus during the swallow to prevent food/liquid from falling into the airway.

Effortful swallow : You are instructed to swallow and push hard with the tongue against the hard palate.

Supraglottic swallow : You are asked to hold yourr breath just before swallowing to close the vocal folds. The swallow is followed immediately by a voluntary cough.

Super-supraglottic swallow : This is designed to voluntarily move the arytenoids anteriorly, closing the entrance to the laryngeal vestibule before and during the swallow.

Chin Tuck swallowing : In this method, you tuck your chin as close to your chest as possible while holding the food/drink in your mouth and then swallow it. This increases space at the back of the throat where food and drink can wait before you swallow.
This reduces the risk of it going down the wrong way before you are ready to swallow.

Use of thickeners in dysphagia

Thickeners are used to thicken foods and liquids to various consistencies. Thickeners can help slow the transit of foods and liquids. This allows more time to safely coordinate the swallowing process.

This prevents the foods and liquids from entering the lungs and hence prevents serious complications such as chest infections and death due to choking or aspiration pneumonia.

Following are some other conservative measures that are recommended and can be used:

  • Speech and language therapy to learn different swallowing techniques.
  • Eating in an upright position.
  • Avoiding foods that exacerbate the condition.
  • Thorough mastication.
  • Changing the consistency of food and liquids to make them easier and safer to swallow.
  • Alternative forms of feeding, such as tube feeding through the nose or stomach.
  • Oral motor exercises for dysphagia.
  • McNeill Dysphagia Therapy Program (MDTP) : MDTP is a rehabilitation program for dysphagia. It uses swallowing as an exercise and it works to rehabilitate the synergistic swallowing mechanism.

Surgery to treat difficulty in swallowing

Surgical intervention comes into action when all the medications, procedures and lifestyle changes that are mentioned above fails to provide relief to the patient. Following are the ways the doctor can intervene surgically to treat dysphagia:

Laparoscopic Heller Myotomy

A thick muscle of the lower part of the esophagus and the upper part of the stomach is cut and the tight valve between the esophagus and the stomach (lower esophageal sphincter) is opened to relieve the dysphagia. This is a surgical treatment for achalasia.

Peroral endoscopic myotomy (POEM)

It is emerging as the treatment of choice for achalasia and is even utilized for prior failed achalasia treatment including laparoscopic heller myotomy.

In this procedure, a submucosal tunnel is created in the lower part of esophagus to reach the inner circular muscle bundles of the lower esophageal sphicter to perform myotomy (cutting of muscle fibre), while preserving the outer longitudinal muscle bundles.

Availability of this procedure remains limited to specialised centers.

Dysphagia Diets

Diet modification and restriction is necessary if you have difficulty in swelling. It is important to avoid non-pureed foods in dyspagia.

Here are some recommendations based on your level of Dysphagia on what you should eat now:

National Dysphagia Diet (NDD) Levels

  • NDD Level 1: Dysphagia-pureed (homogenous, very cohesive, pudding-like, requiring very little chewing ability).
  • NDD Level 2: Dysphagia-Mechanical Altered (cohesive, moist, semisolid foods, requiring some chewing).
  • NDD Level 3: Dysphagia-Advanced (soft foods that require more chewing ability).

The International Dysphagia Diet Standardization Initiative (IDDSI)

It is a collaboration of professionals who developed a standardized framework for labelling texture-modified foods and thickened liquids.

The framework is designed to avoid the confusion created by variable terminology and definitions to describe modified diets around the world.

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Abhinav
Abhinav is currently working as an Intern doctor. Being an avid reader by day and a freelance writer by night, he has been much active among medical students since past few years. Support him on his journey of being a Medical Influencer.

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