Dysphagia (swallowing problems)

What causes dysphagia?

Dysphagia is usually caused by another health condition, such as:

• a condition that affects the nervous system, such as a stroke, head injury, or dementia
• cancer, such as mouth cancer or oesophageal cancer
• gastro-oesophageal reflux disease (GORD), where stomach acid leaks back up into the oesophagus

Dysphagia can also occur in children as the result of a developmental or learning disability.

Dysphagia can be caused by problems with the:

• mouth or throat, known as oropharyngeal or "high" dysphagia
• oesophagus (the tube that carries food from your mouth to your stomach), known as oesophageal or "low" dysphagia

Read on to understand more about what can lead to this condition.

Causes of dysphagia

Swallowing is actually a fairly complex process, so there are many different reasons why dysphagia can develop.

Neurological causes

The nervous system is made up of the brain, nerves, and spinal cord. When this system is damaged, it can interfere with the nerves responsible for starting and controlling swallowing, and this can lead to dysphagia.

Some neurological causes of dysphagia include:

• a stroke
• neurological conditions that damage the brain and nervous system over time, including Parkinson's disease, multiple sclerosis, dementia, and motor neurone disease
• brain tumours
• myasthenia gravis, a rare condition that causes your muscles to become weak

Congenital and developmental conditions

The word "congenital" simply means something you were born with. Developmental conditions, on the other hand, affect the way you grow and develop over time.

Congenital or developmental conditions that may cause dysphagia include:

• learning disabilities, where learning, understanding, and communicating are difficult
• cerebral palsy, a group of neurological conditions that affect movement and coordination
• a cleft lip and palate, a common birth defect that results in a gap or split in the upper lip or roof of the mouth

Obstruction

Anything that blocks the throat or narrows the oesophagus (the tube carrying food from your mouth to your stomach) can make swallowing difficult.

Some causes of obstruction and narrowing include:

• mouth cancer or throat cancer, such as laryngeal cancer or oesophageal cancer (once these cancers are treated, the obstruction may no longer be a problem)
• pharyngeal (throat) pouches, also called Zenker diverticulum, where a large sac develops in the upper part of the oesophagus, making it harder to swallow both liquids and solids; this is a rare condition that mainly affects older people
• eosinophilic oesophagitis, where a type of white blood cell called an eosinophil builds up in the lining of the oesophagus as a reaction to certain foods, allergens, or acid reflux, damaging the lining and causing swallowing difficulties
• radiotherapy treatment, which can leave scar tissue that narrows the passage in your throat and oesophagus
• gastro-oesophageal reflux disease (GORD), where stomach acid causes scar tissue to form, narrowing your oesophagus
• infections, such as tuberculosis or thrush, which can lead to inflammation of the oesophagus (oesophagitis)

Muscular conditions

Any condition affecting the muscles that push food down the oesophagus and into the stomach can cause dysphagia, though this is uncommon.

There are 2 muscular conditions closely linked with dysphagia:

• scleroderma, where the immune system (the body's natural defence system) attacks healthy tissue, causing the throat and oesophagus muscles to stiffen
• achalasia, where the muscles in the oesophagus lose their ability to relax and open, so food or liquid cannot enter the stomach properly

Other causes

As people grow older, the muscles used for swallowing can naturally become weaker, which is likely why dysphagia is fairly common among elderly people. The good news is that treatment is available to help with this age related dysphagia.

Chronic obstructive pulmonary disease (COPD) is a group of lung conditions that make breathing in and out difficult, and these breathing problems can sometimes affect a person's ability to swallow as well.

Dysphagia can also sometimes develop as a complication following surgery on the head or neck.

Diagnosing dysphagia

See your GP if you’re having any difficulty swallowing. They’ll carry out an initial assessment and may refer you for further tests and treatment.

Tests will help determine whether your dysphagia is the result of a problem with your mouth or throat (oropharyngeal, or ‘high’ dysphagia), or your oesophagus, the tube that carries food from the mouth to the stomach (oesophageal, or ‘low’ dysphagia).

Diagnosing the specific type of dysphagia can make treatment more effective and reduce your chances of developing complications of dysphagia, such as choking or pneumonia.

Your GP will want to know:

• how long you’ve had dysphagia
• whether your symptoms come and go, or are getting worse
• whether dysphagia has affected your ability to swallow solids, liquids, or both
• whether you’ve lost weight

Specialist referral

Depending on the suspected cause, you may be referred for further tests with:

• an ear, nose and throat (ENT) specialist
• a speech and language therapist (SLT)
• a neurologist – a specialist in conditions that affect the brain, nerves, and spinal cord
• a gastroenterologist – a specialist in treating conditions of the gullet, stomach, and intestines
• a geriatrician – a specialist in the care of elderly people

Water swallow test

A water swallow test is usually carried out by a speech and language therapist, and can give a good initial assessment of your swallowing abilities. You’ll be given 150ml of water and asked to swallow it as quickly as possible.

The time it takes you to drink all of the water and the number of swallows required will be recorded. You may also be asked to swallow a soft piece of pudding or fruit.

Videofluoroscopy

A videofluoroscopy, or modified barium swallow, is one of the most effective ways of assessing your swallowing ability and finding exactly where the problem is.

An X-ray machine records a continuous moving X-ray on to video, allowing your swallowing problems to be studied in detail.

You’ll be asked to swallow different types of food and drink of different consistencies, mixed with a non-toxic liquid called barium that shows up on X-rays.

A videofluoroscopy usually takes about 30 minutes. You may feel sick after the test, and the barium may cause constipation. Your stools may also be white for a few days as the barium passes through your system.

Nasoendoscopy

A nasendoscopy, sometimes also known as fibreoptic endoscopic evaluation of swallowing (FEES), is a procedure that allows the nose and upper airways to be closely examined using a very small flexible tube known as an endoscope.

The endoscope is inserted into your nose so the specialist can look down on to your throat and upper airways. It has a light and camera at the end so images of the throat can be viewed on a television screen. This allows any blockages or problem areas to be identified.

FEES can also be used to test for oropharyngeal dysphagia after you’re asked to swallow a small amount of test liquid (usually coloured water or milk).

Before the procedure, you may have local anaesthetic spray into your nose, but because the camera doesn’t go as far as your throat, it doesn’t cause retching. The procedure is safe and usually only takes a few minutes.

Manometry and 24-hour pH study

Manometry is a procedure to assess the function of your oesophagus. It involves passing a small tube (catheter) with pressure sensors through your nose and into your oesophagus to monitor its function.

The test measures the pressures within your oesophagus when you swallow, which determines how well it’s working.

The 24-hour pH study involves inserting a tube into your oesophagus through your nose to measure the amount of acid that flows back from your stomach. This can help determine the cause of any swallowing difficulties.

Diagnostic gastroscopy

Diagnostic gastroscopy, also known as diagnostic endoscopy of the stomach, or oesophagogastroduodenoscopy (OGD), is an internal examination using an endoscope.

The endoscope is passed down your throat and into your oesophagus, and images of the inside of your body are transmitted to a television screen. It can often detect cancerous growths or scar tissue.

Read more about treating dysphagia.

Nutritional assessment

If dysphagia has affected your ability to eat, you may need a nutritional assessment to check that you’re not lacking nutrients (malnourished). This could involve:

• measuring your weight
• calculating your body mass index (BMI) to check whether you’re a healthy weight for your height
• carrying out blood tests

High (oropharyngeal) dysphagia

High dysphagia is swallowing difficulties caused by problems with the mouth or throat.

It can be difficult to treat if it’s caused by a condition that affects the nervous system. This is because these problems can’t usually be corrected using medication or surgery.

There are 3 main treatments for high dysphagia:

• swallowing therapy
• dietary changes
• feeding tubes

Treating dysphagia

Treatment usually depends on the cause and type of dysphagia. The type of dysphagia you have can usually be diagnosed after testing your swallowing ability and examining your oesophagus.

Many cases of dysphagia can be improved with treatment, but a cure isn’t always possible. Treatments for dysphagia include:

• speech and language therapy to learn new swallowing techniques
• changing the consistency of food and liquids to make them safer to swallow
• alternative forms of feeding, such as tube feeding through the nose or stomach
• surgery to widen the narrowing of the oesophagus by stretching it or inserting a plastic or metal tube (known as a stent)

Read more about diagnosing dysphagia and treating dysphagia.

Most swallowing problems can be treated, although the treatment you receive will depend on the type of dysphagia you have.

Treatment will depend on whether your swallowing problem is in the mouth or throat (oropharyngeal, or ‘high’ dysphagia), or in the oesophagus (oesophageal, or ‘low’ dysphagia).

The cause of dysphagia is also considered when deciding on treatment. In some cases, treating the underlying cause, such as mouth cancer or oesophageal cancer, can help relieve swallowing problems.

Treatment for dysphagia may be managed by a group of specialists known as a multidisciplinary team (MDT). Your MDT may include a speech and language therapist (SLT), a surgeon, and a dietitian.

Swallowing therapy

You may be referred to a speech and language therapist (SLT) for swallowing therapy if you have high dysphagia.

An SLT is a healthcare professional trained to work with people with feeding or swallowing difficulties.

SLTs use a range of techniques that can be tailored for your specific problem, such as teaching you swallowing exercises.

Dietary changes

You may be referred to a dietitian (specialist in nutrition) for advice about changes to your diet to make sure you receive a healthy, balanced diet.

An SLT can give you advice about softer foods and thickened fluids that you may find easier to swallow. They may also try to ensure you’re getting the support you need at meal times.

Feeding tubes

Feeding tubes can be used to provide nutrition while you’re recovering your ability to swallow. They may also be required in severe cases of dysphagia that put you at risk of malnutrition and dehydration.

A feeding tube can also make it easier for you to take the medication you may need for other conditions.

There are 2 types of feeding tubes:

• a nasogastric tube – a tube that is passed down your nose and into your stomach
• a percutaneous endoscopic gastrostomy (PEG) tube – a tube that is implanted directly into your stomach

Nasogastric tubes are designed for short-term use. The tube will need to be replaced and swapped to the other nostril after about a month. PEG tubes are designed for long-term use and last several months before they need to be replaced.

Most people with dysphagia prefer to use a PEG tube because it can be hidden under clothing. However, they carry a greater risk of complications compared with nasogastric tubes.

Minor complications of PEG tubes include tube displacement, skin infection, and a blocked or leaking tube. 2 major complications of PEG tubes are infection and internal bleeding.

Resuming normal feeding may be more difficult with a PEG tube compared with using a nasogastric tube. The convenience of PEG tubes can make people less willing to carry out swallowing exercises and dietary changes than those who use nasogastric tubes.

You should discuss the pros and cons of both types of feeding tubes with your treatment team.

Low (oesophageal) dysphagia

Low dysphagia is swallowing difficulties caused by problems with the oesophagus.

Medication

Depending on the cause of low dysphagia, it may be possible to treat it with medication. For example, proton pump inhibitors (PPIs) used to treat indigestion may improve symptoms caused by narrowing or scarring of the oesophagus.

Botulinum toxin

Botulinum toxin can sometimes be used to treat achalasia. This is a condition where the muscles in the oesophagus become too stiff to allow food and liquid to enter the stomach.

It can be used to paralyse the tightened muscles that prevent food from reaching the stomach. However, the effects only last for around 6 months.

Surgery

Other cases of low dysphagia can usually be treated with surgery.

Endoscopic dilatation

Endoscopic dilation is widely used to treat dysphagia caused by obstruction. It can also be used to stretch your oesophagus if it’s scarred.

Endoscopic dilatation will be carried out during an internal examination of your oesophagus (gastroscopy) using an endoscopy.

An endoscope is passed down your throat and into your oesophagus, and images of the inside of your body are transmitted to a television screen.

Using the image as guidance, a small balloon or a bougie (a thin, flexible medical instrument) is passed through the narrowed part of your oesophagus to widen it. If a balloon is used, it will be gradually inflated to widen your oesophagus before being deflated and removed.

You may be given a mild sedative before the procedure to relax you. There’s a small risk that the procedure could cause a tear or perforate your oesophagus.

Inserting a stent

If you have oesophageal cancer that can’t be removed, it’s usually recommended that you have a stent inserted instead of endoscopic dilatation. This is because, if you have cancer, there’s a higher risk of perforating your oesophagus if it’s stretched.

A stent (usually a metal mesh tube) is inserted into your oesophagus during an endoscopy or under X-ray guidance.

The stent then gradually expands to create a passage wide enough to allow food to pass through. You’ll need to follow a particular diet to keep the stent open without having blockages.

Congenital dysphagia

If your baby is born with difficulty swallowing (congenital dysphagia), their treatment will depend on the cause.

Cerebral palsy

Dysphagia caused by cerebral palsy can be treated with speech and language therapy. Your child will be taught how to swallow, how to adjust the type of food they eat, and how to use feeding tubes.

Cleft lip and palate

Cleft lip and palate is a facial birth defect that can cause dysphagia. It’s usually treated with surgery.

Narrowing of the oesophagus

Narrowing of the oesophagus may be treated with a type of surgery called dilatation to widen the oesophagus.

Gastro-oesophageal reflux disease (GORD)

Dysphagia caused by gastro-oesophageal reflux disease (GORD) can be treated using special thickened feeds instead of your usual breast or formula milk. Sometimes medication may also be used.

Breastfeeding or bottle feeding

If you’re having difficulty bottle feeding or breastfeeding your baby, see your midwife, health visitor or GP.

Coughing and choking

If you have dysphagia, there’s a risk of food, drink or saliva going down the ‘wrong way’. It can block your airway, making it difficult to breathe and causing you to cough or choke.

Read more information and advice about what to do if someone is choking.

If you have dysphagia, you may also develop a fear of choking. However, it’s very important you don’t avoid eating and drinking, as it could cause dehydration and malnutrition.

If you often choke on your food because of dysphagia, you may also be at an increased risk of developing a condition called aspiration pneumonia.

Aspiration pneumonia

Aspiration pneumonia is a chest infection that can develop after accidentally inhaling something, such as a small piece of food. It causes irritation in the lungs, or damages them. Older people are particularly at risk of developing aspiration pneumonia.

The symptoms of aspiration pneumonia include:

• a cough – this may be a dry cough, or you may produce phlegm that’s yellow, green, brown, or bloodstained
• a high temperature of 38C (100.4F) or over
• chest pain
• difficulty breathing – your breathing may be rapid and shallow and you may feel breathless, even at rest

Contact your treatment team immediately if you’re being treated for dysphagia and you develop these symptoms. If this isn’t possible, contact your local out-of-hours service or phone NHS 24 111 service.

Symptoms of aspiration pneumonia can range from mild to severe, and it is usually treated with antibiotics. Severe cases will require hospital admission and treatment with intravenous antibiotics (through a drip). Read more about treating pneumonia.

In particularly old or frail people, there’s a chance the infection could lead to their lungs becoming filled with fluid, preventing them working properly. This is known as acute respiratory distress syndrome (ARDS).

Your chances of developing pneumonia as a result of dysphagia are higher if you have a weakened immune system, chronic obstructive pulmonary disease (COPD), or if your oral and dental hygiene is poor.

Dysphagia in children

If children with long-term dysphagia aren’t eating enough, they may not get the essential nutrients they need for physical and mental development.

Children who have difficulty eating may also find meal times stressful, which may lead to behavioural problems.

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Dysphagia can sometimes lead to further problems. One of the most common is coughing or choking when food goes down the "wrong way" and blocks your airway.

If this happens often, you may start avoiding food and drink out of fear of choking, which can lead to malnutrition and dehydration.

Some people with dysphagia tend to develop chest infections, such as aspiration pneumonia, which need medical treatment.

Dysphagia can also affect your quality of life, as it may stop you enjoying meals and social occasions.

The main complication of dysphagia is coughing and choking, which can lead to pneumonia.