Dysphagia - When Swallowing Becomes Difficult

Most people take swallowing for granted - take a bite of food, chew, swallow and don't think much more about it. But for some people, difficult swallowing is a common, if not every-meal, occurrence.

Having difficulty swallowing is called dysphagia (dis-FAY-jee-uh). It can be painful, as well as annoying. Causes vary, but in many cases effective treatments are available.

The mechanics of swallowing

When you swallow, your tongue pushes food to the back of your throat. Muscle contractions then quickly move food down your pharynx - the area that extends from the back of your throat to the top of your esophagus - past your windpipe (trachea) and into your esophagus, the tube that connects your throat to your stomach.

Muscles (sphincters) at the top and bottom of your esophagus open every time you swallow to allow food past, then quickly close. The lower sphincter's job is to allow food to enter the stomach while keeping stomach acid from coming up into the esophagus.

What's your 'hang up'?

Several conditions can interfere with swallowing. They generally fall into one of two categories:

• Oropharyngeal dysphagia - This results when a stroke or neuromuscular disorder leaves throat muscles weakened, making it difficult to get food from your mouth into your throat. You may choke or cough on whatever you attempt to swallow. You may also sense food going down your windpipe.
• Esophageal dysphagia - This is the most common type of dysphagia and refers to the sensation of food sticking or getting "hung up" in the base of your throat or chest. It may be accompanied by pressure or pain in your chest. Peptic stricture, a narrowing of the lower esophagus, is a common cause of esophageal dysphagia. It results from having stomach acid back up into the esophagus (gastroesophageal reflux), causing inflammation and scarring. Tumors or the presence of a band of tissue that constricts the lower esophagus (Schatzki's ring) can also narrow the esophagus and cause dysphagia.
  
  Other causes include certain muscle problems, development of a diverticulum (a small pouch that can form in the back of the throat or esophagus) and radiation burns from cancer treatment.
  
  In addition, some people experience throat difficulties for which there is no anatomical basis. For example, some people can't seem to swallow pills or tablets, even though they have no other difficulty swallowing. And some have the sensation of a lump in the throat when no lump is present (globus).

What are your symptoms?

Slight or occasional dysphagia often doesn't represent a serious condition. However, dysphagia can indicate a serious medical problem, such as esophageal cancer. So you should see your doctor if you regularly have difficulty swallowing.

Consider these questions before your appointment:

• How would you describe your symptoms?
• Do you choke or cough on food?
• Does food stick on its way down? If yes, where does it stick and for how long?
• Do you ever have to bring the food back up?
• How often do you have difficulty swallowing? With every meal? Occasionally?
• Do you have trouble swallowing solids? Liquids?
• Do you have frequent heartburn?
• Do you have pain while swallowing?
• Does food or stomach acid back up into your throat?
• When did your symptoms begin? Are they getting worse?
• Have you lost weight? How much?

Tests help with diagnosis

Several tests may be used to diagnose the problem. These include:

• Barium X-ray - For this test, you drink a barium solution. The barium, which shows up on X-rays, coats the inside of your esophagus, allowing your doctor to see changes in the shape of your esophagus.
• Endoscopy - A thin, flexible instrument called an endoscope is passed down your throat so your doctor can view your esophagus.
• Manometry (muh-NOM-uh-tree) test - A small tube is inserted into the esophagus and connected to a pressure recorder. This measures the muscle contractions of your esophagus as you swallow.

Cause determines treatment

If you have pharyngeal dysphagia, you may be referred to a throat specialist or neurologist for further diagnostic tests, then to a speech pathologist for therapy. Certain exercises may help.

If pharyngeal dysphagia is preventing you from eating enough to maintain a healthy weight, special liquid diets may be recommended. In severe cases of dysphagia, tube feeding may be necessary.

If you have an esophageal stricture, a Schatzki's ring or tight sphincters, your doctor may use an endoscope with a special balloon attached at its end to gently expand the width of your esophagus. This procedure is called dilatation.

For a tumor or a diverticulum, surgery may be necessary.

For dysphagia associated with acid reflux, your doctor may prescribe oral medications to reduce stomach acid. You may need to be on these long term. Tranquilizers or muscle-relaxing drugs may be prescribed for esophageal spasms.

Originally Published by Mayo Clinic Health Letter August 1998

© 1999 Mayo Foundation for Medical Education and Research.