Doctor, I Have Trouble Swallowing

Insight into dysphagia-swallowing problems

Swallowing Disorders

Difficulty in swallowing (dysphagia) is common among all age groups, especially the elderly. The term dysphagia refers to the feeling of difficulty passing food or liquid from the mouth to the stomach. This may be caused by many factors, most of which are temporary and not threatening. Difficulties in swallowing rarely represent a more serious disease, such as a tumor or a progressive neurological disorder. When the difficulty does not clear up by itself in a short period of time, you should see an otolaryngologist-head and neck surgeon.

How you swallow

People normally swallow hundreds of times a day to eat solids, drink liquids, and swallow the normal saliva and mucus that the body produces. The process of swallowing has four stages:

1. The first is oral preparation, where food or liquid is manipulated and chewed in preparation for swallowing.
2. During the oral stage, the tongue propels the food or liquid to the back of the mouth, starting the swallowing response.
3. The pharyngeal stage begins as food or liquid is quickly passed through the pharynx, the canal that connects the mouth with the esophagus, into the esophagus or swallowing tube.
4. In the final, esophageal stage, the food or liquid passes through the esophagus into the stomach. Although the first and second stages have some voluntary control, stages three and four occur by themselves, without conscious input.

Although the first and second stages have some voluntary control, stages three and four occur by themselves, without conscious input.

What causes swallowing disorders?

Any interruption in the swallowing process can cause difficulties. It may be due to simple causes such as poor teeth, ill fitting dentures, or a common cold. One of the most common causes of dysphagia is gastroesophageal reflux. This occurs when stomach acid moves up the esophagus to the pharynx, causing discomfort. Other causes may include: stroke; progressive neurologic disorder; the presence of a tracheostomy tube; a paralyzed or unmoving vocal cord; a tumor in the mouth, throat, or esophagus; or surgery in the head, neck, or esophageal areas.

Symptoms

Symptoms of swallowing disorders may include:

• drooling;
• a feeling that food or liquid is sticking in the throat;
• discomfort in the throat or chest (when gastroesophageal reflux is present);
• a sensation of a foreign body or "lump" in the throat;
• weight loss and inadequate nutrition due to prolonged or more significant problems with swallowing; and
• coughing or choking caused by bits of food, liquid, or saliva not passing easily during swallowing, and being sucked into the lungs.

Who evaluates and treats swallowing disorders?

When dysphagia is persistent and the cause is not apparent, the otolaryngologist-head and neck surgeon will discuss the history of your problem and examine your mouth and throat. This may be done with the aid of mirrors or a small tube (flexible laryngoscope), which provides vision of the back of the tongue, throat, and larynx (voice box). If necessary, an examination of the esophagus, stomach, and upper small intestine (duodenum) may be carried out by the otolaryngologist or a gastroenterologist. These specialists may recommend X-rays of the swallowing mechanism, called a barium swallow or upper G-I, which is done by a radiologist.

If special problems exist, a speech pathologist may consult with the radiologist regarding a modified barium swallow or videofluroscopy. These help to identify all four stages of the swallowing process. Using different consistencies of food and liquid, and having the patient swallow in various positions, a speech pathologist will test the ability to swallow. An exam by a neurologist may be necessary if the swallowing disorder stems from the nervous system, perhaps due to stroke or other neurologic disorders.

Possible Treatments

Many of these disorders can be treated with medication. Drugs that slow stomach acid production, muscle relaxants, and antacids are a few of the many medicines available. Treatment is tailored to the particular cause of the swallowing disorder.

Gastroesophageal reflux can often be treated by changing eating and living habits - for example:

• eat a bland diet with smaller, more frequent meals;
• eliminate alcohol and caffeine;
• reduce weight and stress;
• avoid food within three hours of bedtime; and
• elevate the head of the bed at night.

If these don't help, antacids between meals and at bedtime may provide relief.

Many swallowing disorders may be helped by direct swallowing therapy. A speech pathologist can provide special exercises for coordinating the swallowing muscles or restimulating the nerves that trigger the swallow reflex. Patients may also be taught simple ways to place food in the mouth or position the body and head to help the swallow occur successfully.

Some patients with swallowing disorders have difficulty feeding themselves. An occupational therapist can aid the patient and family in feeding techniques. These techniques make the patient as independent as possible. A dietician or nutritional expert can determine the amount of food or liquid necessary to sustain an individual and whether supplements are necessary.

Once the cause is determined, swallowing disorders may be treated with:

• medication
• swallowing therapy
• surgery

Surgery is used to treat certain problems. If a narrowing or stricture exists, the area may need to be stretched or dilated. If a muscle is too tight, it may need to be dilated or released surgically. This procedure is called a myotomy and is performed by an otolaryngologist-head and neck surgeon.

Many causes contribute to swallowing disorders. If you have a persistent problem swallowing, see an otolaryngologist-head and neck surgeon.

© 2004 AAO-HNS/AAO-HNSF