Health

What normally happens when you swallow?

Swallowing is a complex process that requires multiple muscles to work together. When you swallow:

• Your tongue moves food or liquid in your mouth to the back of your throat.
• As food enters the throat, a small flap called the epiglottis covers the windpipe to direct food toward the stomach and prevent you from inhaling it.
• Once food enters the esophagus (the tube connecting the throat and the stomach), esophageal muscles push the food down into the stomach.
• A ring of muscles at the bottom end of the esophagus opens up to empty the food into the stomach.  

A problem in one or more of these areas can make it difficult or painful to swallow.

What is dysphagia?

The term dysphagia refers to difficulty swallowing. It is used regarding a variety of swallowing disorders. Not all swallowing problems are dysphagia — it is normal to have occasional difficulty swallowing certain foods or liquids, such as when taking large bites of food. However, ongoing difficulty swallowing could be a cause for concern.

Depending on which part of the swallowing process is affected, dysphagia can be described as:

• Oral dysphagia — when the problem is in the mouth, usually due to the movement of the tongue
• Pharyngeal or oropharyngeal dysphagia — when the problem is regarding food passing through the throat
• Esophageal dysphagia — when food is unable to move down through the esophagus

Dysphagia Symptoms

Swallowing disorders cause a variety of symptoms that include:

• The feeling that food or liquid is hard to swallow, and that it is getting caught in the esophagus or “sticking” on the way down to the stomach
• Odynophagia — pain when swallowing, which can occur in the throat or chest and can mimic heartburn or even heart-related symptoms
• Coughing during or right after swallowing can be due to food getting into the throat too early, parts of food left behind in the throat after swallowing or food coming back up. Because people swallow throughout the day, the connection of coughing to swallowing is not always obvious.
• Choking — coughing triggered by the feeling of food or liquid sticking in the throat or esophagus, or entering airways. Some people describe it as food “going down the wrong pipe.” If food or saliva gets into the airways, it can lead to a type of inflammation called aspiration pneumonia. People with impaired thinking or sensation due to a neurologic condition are at higher risk for aspiration pneumonia.
• Regurgitation — return of food or liquid to the mouth or throat (normal swallowing moves food and liquid in one direction). Unlike vomiting, regurgitation happens without retching, nausea or engaging stomach muscles. The taste of fluid entering the mouth or throat is significant — if it tastes like the food you swallowed, it usually indicates a swallowing disorder; if it tastes sour or bitter, that means it came back from the stomach, which could be a symptom of gastroesophageal reflux disease (GERD).
• Nasal regurgitation is when swallowed food or fluid backtracks and enters the nose. This happens when the nasopharynx does not close properly, and it may indicate a problem with the nerves that empower muscles of the soft palate or throat.

While the above symptoms often happen during or after swallowing, some signs of dysphagia can appear independently of eating, drinking or swallowing. Talk to your doctor if you’ve been experiencing:

• Persistent sore throat
• Hoarseness
• Shortness of breath
• Chest pain or discomfort
• Trouble forming food and liquid into a soft ball (bolus) in the mouth
• A need for extra time to chew or move food or liquid in the mouth
• Trouble pushing food or liquid to the back of the mouth
• Reflux or heartburn sensations
• Vomiting

Types and Causes of Swallowing Disorders

There are many reasons why swallowing may become difficult.  

Problems with Motility

Esophageal motility is the movement of food through the esophagus. Normally, coordinated muscle contractions in the esophagus move the swallowed food toward the stomach in one direction. At the top and bottom ends of the esophagus are rings of muscles called sphincters that allow the food to enter and exit the esophagus.

If the muscles stop working together or if one of them stops working at all, food can fail to pass into the stomach. This can happen due to issues with the muscles or the nerves that supply the muscles. Events such as previous surgery on the esophagus or having a breathing tube can often lead to difficulties swallowing, but in many cases, the exact cause is unknown.

Problems with mobility in the esophagus include:

• Achalasia — loss of function in the ring of muscle between the lower end of the esophagus and stomach, called the lower esophageal sphincter
• Distal esophageal spasm — disordered muscle contractions in the lower part of the esophagus, which can cause food to come back up into the throat
• Jackhammer esophagus — unusually strong contractions of the muscles in the esophagus that can cause severe chest pain during swallowing

There are also other types of motility problems in the esophagus, such as the lower esophageal sphincter being too tight or too loose. If the sphincter is too loose, it can allow the stomach contents to enter back into the esophagus – a condition known as gastroesophageal reflux disease (GERD).

Structural Abnormalities

The esophagus is a mostly straight, tube-like structure. If it becomes narrowed or develops pockets, this can lead to swallowing problems. Some people are born with anatomical features that make them prone to swallowing disorders. But more often, structural changes develop over time. They include:

• Esophageal stenosis and strictures — narrowing of the esophagus due to thickening of the esophageal walls, growth of tumors and other reasons
• Esophageal diverticulum — a pocket-like pouch that can form in the lining of the esophagus and trap swallowed food. Zenker’s diverticulum is one form of it.  
• Esophageal cancer and benign tumors in the esophagus

Neurologic Problems

Neurogenic dysphagia is swallowing problems related to the nerves governing function of the mouth, throat and esophagus.

A person experiencing nasal regurgitation is likely to have some form of neurologic disease, and coughing during swallowing is another sign that the dysphagia could be due to a nerve problem. In some cases, if you have these symptoms, your doctor will want to evaluate you to rule out systemic (all-over) nerve disease.

Swallowing issues can accompany conditions associated with muscle weakness or poor coordination such as:

• Stroke
• Amyotrophic lateral sclerosis (ALS)
• Traumatic or surgical damage to nerves in the head and neck
• Myasthenia gravis 
• Polymyositis 
• Parkinson’s disease

Hyperthyroidism and hypothyroidism can also affect nerve function related to swallowing.

Allergies That Affect Swallowing — Eosinophilic Esophagitis

Eosinophilic esophagitis is a chronic condition that can cause swallowing difficulties in infants, children and adults.

An allergic reaction to a food or other environmental factor can trigger inflammation of the esophagus. Over time, the esophagus may tighten and develop abscesses or constricting rings of tissue that can become blocked by swallowed food (impaction), which can cause a medical emergency.

Diagnosing Swallowing Disorders

To diagnose a swallowing disorder, your doctor will start by performing a thorough physical exam and asking you about your symptoms and medical history. As you describe your swallowing difficulties, focus on (or write down beforehand):

• When you have symptoms
• Where in the mouth, throat, neck or chest you feel that food is getting stuck
• Whether particular foods trigger your symptoms or make them worse
• When you think the swallowing problems started
• Any other new symptoms or health concerns you are having, even if they seem unrelated

In addition to examining the inside of your mouth and throat, your doctor may recommend one or more of the following tests to confirm the diagnosis and the cause of your swallowing problems.

• Fiberoptic endoscopic evaluation of swallowing (FEES test) to observe how you swallow — a flexible scope is inserted through the nose
• Videofluoroscopic swallow study (VFSS), as well as a barium swallow (esophagram), to take X-rays or record how your organs and muscles work together when you swallow
• Pharyngoscopy to look for structural, nerve, muscle or other problems in the throat by using fiber optics or a thin tube with a camera (an endoscope)
• Upper endoscopy to look into the esophagus using an endoscope, which can help identify areas of inflammation, narrowing or other abnormalities
• 24-hour pH impedance testing or wireless pH testing to evaluate acid reflux activity by using a thin, acid-sensitive probe in the esophagus
• Esophageal manometry to evaluate the changes in pressure that happen when you swallow, which helps assess muscle function in the esophagus

If you are a patient in a hospital when your swallowing problems start, a speech-language pathologist will evaluate your swallowing by performing a bedside swallow exam. It involves a physical exam of your mouth, testing of swallowing reflexes and swallowing test liquids of various thickness.

Dysphagia Treatment

In some cases, it is possible to remove the cause of a swallowing disorder, such as by relaxing an esophageal sphincter that is too tight. If treating the cause is not possible, then dysphagia treatment focuses on making swallowing safer and on easing the discomfort. Depending on your diagnosis, your doctor may recommend medications, swallowing therapy, surgery, changing your diet or other treatments.

Medications for Swallowing Disorders  

Medications can be effective in relieving specific swallowing symptoms or treating an underlying cause such as an infection or a neurologic condition:

• Botulinum toxin injections and other types of muscle relaxers to relax certain muscles in the esophagus
• Proton pump inhibitors and other medications to treat GERD
• Antibiotics to treat infection
• Corticosteroids to treat dysphagia due to an allergic reaction
• Other medications to help minimize symptoms of a neurologic disorder

Swallowing Retraining Therapy

Swallowing therapy focuses on retraining muscles to improve swallowing and to reduce the risk of choking and aspiration. The therapy is performed by speech-language pathologists – specialists trained in swallowing assessments and rehabilitation therapy.

Swallowing exercises include but are not limited to:

• Larynx closure exercises to strengthen the muscles of the larynx
• Tongue strengthening exercises to improve tongue strength and mobility
• Lip closure exercises to increase lip strength and mobility

Swallowing retraining can be especially helpful for people with dysphagia caused by neurological disorders, as well as those who’ve had surgery on the throat muscles.

Surgery and Other Procedures for Swallowing Problems

Because the organs involved in swallowing are close to the mouth, swallowing problems can often be addressed with an endoscope (a lighted flexible tube) inserted through the mouth. With the endoscopic approach, no incisions are made. However, in some cases, it may be necessary to cut through the skin to treat the cause of a swallowing problem.

Procedures for swallowing disorders include:

• Peroral endoscopic myotomy (POEM) to treat achalasia by cutting a tight ring of muscle to loosen it
• Diverticulectomy to remove a diverticulum in the esophagus. Sometimes, doctors also need to cut muscles in the esophagus (myotomy).
• Esophageal stent placement to insert a tube inside a narrowed esophagus to keep it open
• Dilation to gently stretch the narrowed areas in the esophagus
• Surgery to remove a tumor or another growth blocking the esophagus

Diet Modification and Behavioral Changes

If removing the swallowing problem is not possible, changing what and how you eat can help make swallowing safer and more comfortable. Your speech-language pathologist may recommend:

• Eliminating foods that cause swallowing problems or changing their consistency — for example, by blending fruit into smoothies instead of eating it whole
• Changing the posture or position of your head when you swallow
• Using special techniques to keep food moving if it feels stuck

Enteral Feeding (Feeding Tube)

Sometimes, a swallowing disorder may be so severe that it prevents eating enough to maintain weight. Feeding tubes can provide a way for nutrition to bypass the problem area and decrease the risk of coughing and choking. Your doctor may recommend enteral feeding if you have lost a substantial amount of weight or if you keep getting aspiration pneumonia due to the swallowing disorder.

There are several types of feeding tubes based on how they provide nutrition and where in the body they are inserted. Your care team will determine which type of tube is the most appropriate.

A feeding tube does not need to be permanent. As your ability to swallow and absorb nutrients improves, the tube may be removed.