Dysphagia (swallowing problems)

Dysphagia is the medical term for swallowing difficulties. Some people with dysphagia find certain foods or liquids hard to swallow, while others can't swallow at all.

Other signs of dysphagia include:

• coughing or choking when eating or drinking
• bringing food back up, sometimes through the nose
• a sensation that food is stuck in your throat or chest
• persistent drooling of saliva

Over time, dysphagia can also cause symptoms such as weight loss and repeated chest infections.

You should see your doctor if you have swallowing difficulties.

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

Children can develop dysphagia too, as the result of a developmental or learning disability.

The trouble can come from 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

Treatment for dysphagia usually depends on its cause and type. Doctors can usually work out which type you have by testing your swallowing ability and examining your oesophagus.

Many cases of dysphagia can be improved with treatment, but a cure isn't always possible. The treatments 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)

Dysphagia can sometimes lead to other 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 because you're afraid of choking. That can lead to malnutrition and dehydration.

Some people with dysphagia tend to get chest infections, such as aspiration pneumonia, and these need medical treatment.

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

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

The nervous system is made up of the brain, nerves and spinal cord. If it is damaged, the nerves that start and control swallowing may not work properly, and that can lead to dysphagia.

Some neurological causes of dysphagia include:

• a stroke
• neurological conditions that cause damage to 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" means something you're born with. A developmental condition is one that affects the way you develop.

Some congenital or developmental conditions can cause dysphagia, or swallowing problems. They include:

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

Swallowing can become difficult when something blocks the throat or the oesophagus (the tube that carries food from your mouth to the stomach) becomes narrow.

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 an issue
• pharyngeal (throat) pouches, also known as Zenker diverticulum. A large sac develops in the upper part of the oesophagus, and this reduces the ability to swallow both liquids and solids. It's a rare condition that mainly affects older people
• eosinophilic oesophagitis. A type of white blood cell known as an eosinophil builds up in the lining of the oesophagus as the result of a reaction to foods, allergens, or acid reflux. The build-up damages the lining of the oesophagus and causes swallowing difficulties
• radiotherapy treatment, which can cause scar tissue that narrows the passageway in your throat and oesophagus
• gastro-oesophageal reflux disease (GORD), where stomach acid can cause scar tissue to develop and narrow your oesophagus
• infections, such as tuberculosis or thrush, which can lead to inflammation of the oesophagus (oesophagitis)

Any condition that affects the muscles used to push food down the oesophagus and into the stomach can cause dysphagia, though such conditions are rare.

There are 2 muscular conditions linked with dysphagia:

• scleroderma, where the immune system (the body's natural defence system) attacks healthy tissue, and this stiffens the muscles of the throat and oesophagus
• achalasia, where the muscles in the oesophagus lose their ability to relax and open, so food or liquid can't pass into the stomach

As you get older, the muscles you use for swallowing can become weaker. This may be why dysphagia, or swallowing problems, is fairly common in elderly people. There is treatment to help people with age-related dysphagia.

Chronic obstructive pulmonary disease (COPD) is a group of lung conditions that make it hard to breathe in and out properly. These breathing difficulties can sometimes affect your ability to swallow.

Dysphagia can also sometimes develop as a complication of head or neck surgery.

If you have any difficulty swallowing, see your doctor. They'll do an initial assessment and may send you for further tests and treatment.

The tests help find out whether your dysphagia comes from a problem in your mouth or throat (oropharyngeal, or "high" dysphagia), or in your oesophagus, the tube that carries food from the mouth to the stomach (oesophageal, or "low" dysphagia).

Finding the specific type of dysphagia can make treatment work better. It can also lower your chances of complications such as choking or pneumonia.

Your doctor 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

Depending on what your doctor thinks is causing the problem, you may be sent for further tests with one of these specialists:

• 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)

A speech and language therapist usually carries out the water swallow test, and it gives a good first picture of how well you can swallow. You'll be given 150ml of water and asked to swallow it as quickly as you can.

The therapist will record how long you take to finish all the water and how many swallows it takes. You may also be asked to swallow a soft piece of pudding or fruit.

A videofluoroscopy, also called a modified barium swallow, is one of the most effective ways of checking how well you swallow and finding exactly where the problem lies.

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

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

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

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

The endoscope goes into your nose, so the specialist can look down onto your throat and upper airways. It has a light and a camera at the end, and the images of your throat show up on a television screen. This helps to identify any blockages or problem areas.

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

Before the procedure, you may be given a local anaesthetic spray in your nose. The camera doesn't go as far as your throat, so it doesn't cause retching. The procedure is safe and usually takes only a few minutes.

Manometry is a test that checks how well your oesophagus is working. A doctor passes a small tube (a catheter) with pressure sensors through your nose and down into your oesophagus. The sensors measure the pressures inside it as you swallow, and that shows how well it's working.

The 24-hour pH study also uses a tube that goes in through your nose into your oesophagus. This one measures how much acid flows back up from your stomach. It can help find the cause of any swallowing difficulties.

Diagnostic gastroscopy is also called diagnostic endoscopy of the stomach, or oesophagogastroduodenoscopy (OGD). It's 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 sent to a television screen. It can often pick up cancerous growths or scar tissue.

Read more about treating dysphagia.

If dysphagia has made it hard for you to eat, you may need a nutritional assessment to check that you're getting enough nutrients (the term for not getting enough is malnourished). This could involve:

• measuring your weight
• calculating your body mass index (BMI) to see if your weight is healthy for your height
• carrying out blood tests

Most swallowing problems can be treated, though the treatment you get depends on the type of dysphagia you have.

Doctors first look at where the problem is. It may be in the mouth or throat (this is called oropharyngeal, or "high", dysphagia), or it may be in the oesophagus (oesophageal, or "low", dysphagia).

The cause of the dysphagia also matters when choosing a treatment. Sometimes the swallowing problem eases once the underlying cause, such as mouth cancer or oesophageal cancer, is treated.

Your care may be handled by a group of specialists called a multidisciplinary team (MDT). The team may include a speech and language therapist (SLT), a surgeon and a dietitian.

High dysphagia means trouble swallowing because of a problem in the mouth or throat.

It can be hard to treat when a condition affecting the nervous system is behind it. The reason is that these problems usually can't be corrected with medicine or surgery.

There are 3 main treatments for high dysphagia:

• swallowing therapy
• dietary changes
• feeding tubes

If you have high dysphagia, your doctor may refer you to a speech and language therapist (SLT) for swallowing therapy. An SLT is a trained health professional who works with people who have feeding or swallowing difficulties. They use several techniques and can adjust them to suit your particular problem, such as teaching you swallowing exercises.

Your doctor may refer you to a dietitian (a specialist in nutrition). They can advise you on changes to your diet so that you still get a healthy, balanced diet.

An SLT can suggest softer foods and thickened fluids that you may find easier to swallow. They may also try to make sure you get the support you need at meal times.

A feeding tube can give you nutrition while you're getting your ability to swallow back. In severe cases of dysphagia, where you are at risk of malnutrition and dehydration, you may need one. A feeding tube can also make it easier to take any medicine you need for other conditions.

There are 2 types of feeding tubes:

• a nasogastric tube, which is passed down your nose and into your stomach
• a percutaneous endoscopic gastrostomy (PEG) tube, which is placed directly into your stomach

Nasogastric tubes are meant for short-term use. After about a month, the tube needs to be replaced and moved to the other nostril. PEG tubes are meant for long-term use, and they last several months before they need replacing.

Most people with dysphagia prefer a PEG tube because it can be hidden under clothing. But PEG tubes carry a greater risk of complications than nasogastric tubes. The minor ones include the tube moving out of place, skin infection, and a blocked or leaking tube. The 2 major complications are infection and internal bleeding.

Going back to normal feeding may also be harder with a PEG tube than with a nasogastric tube. Because a PEG tube is so convenient, people who use one can be less willing to do swallowing exercises and make dietary changes than people who use a nasogastric tube.

You should talk through the pros and cons of both types of feeding tube with your treatment team.

Low dysphagia, also called oesophageal dysphagia, means trouble swallowing that comes from a problem with the oesophagus.

Whether medicine can treat low dysphagia depends on what is causing it. Proton pump inhibitors (PPIs) are normally used for indigestion, for example, but they may also improve symptoms caused by narrowing or scarring of the oesophagus.

Doctors can sometimes use botulinum toxin to treat achalasia. In this condition, the muscles in the oesophagus become too stiff, so food and liquid can't pass into the stomach.

The toxin paralyses the tightened muscles that stop food from reaching the stomach. The effect doesn't last long, though. It wears off after around 6 months.

In most other cases of low dysphagia, surgery can usually treat the problem.

Endoscopic dilatation is widely used to treat dysphagia (swallowing problems) caused by an obstruction. Doctors can also use it to stretch your oesophagus if it's scarred.

The procedure is done during an internal examination of your oesophagus, called a gastroscopy, using an endoscope. This is passed down your throat and into your oesophagus, and images of the inside of your body appear on a television screen.

With the help of those images, the doctor passes a small balloon or a bougie (a thin, flexible medical instrument) through the narrowed part of your oesophagus to widen it. A balloon is inflated gradually to widen the oesophagus, then deflated and removed.

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

If you have oesophageal cancer that can't be removed, doctors usually recommend a stent rather than endoscopic dilatation. The reason is that cancer raises the risk of perforating your oesophagus when it's stretched.

The stent is usually a tube made of metal mesh. It's put into your oesophagus during an endoscopy or under X-ray guidance.

Once it's in place, the stent slowly expands and opens up a passage wide enough for food to go through. You'll need to follow a particular diet, so that the stent stays open and doesn't get blocked.

If your baby is born with difficulty swallowing (congenital dysphagia), the treatment will depend on what is causing it.

Dysphagia, or swallowing trouble, that comes from cerebral palsy can be treated with speech and language therapy. Your child will be taught how to swallow, how to change the type of food they eat, and how to use feeding tubes.

Cleft lip and palate is a birth defect of the face, and it can cause dysphagia, which means trouble with swallowing. Doctors usually treat it with surgery.

If the oesophagus has become narrowed, doctors may treat it with a type of surgery called dilatation, which widens the oesophagus.

Swallowing problems (dysphagia) caused by gastro-oesophageal reflux disease (GORD) can be treated with special thickened feeds, which are given in place of your usual breast or formula milk. Sometimes medicine may be used as well.

If your baby is having trouble with bottle feeding or breastfeeding, see a doctor.

The main problem with dysphagia is that food or drink can make you cough and choke, and this can lead to pneumonia.

If you have dysphagia, food, drink or saliva can go down the "wrong way". It can block your airway, which makes it hard to breathe and makes you cough or choke.

You should read more information and advice about what to do if someone is choking.

Dysphagia can also leave you afraid of choking. But it's very important that you don't avoid eating and drinking, because that could lead to dehydration and malnutrition.

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

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

The symptoms of aspiration pneumonia include:

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

If you're being treated for dysphagia and you develop these symptoms, contact your treatment team immediately.

The symptoms can range from mild to severe, and the usual treatment is antibiotics. Severe cases need to be admitted to hospital and given intravenous antibiotics (through a drip).

In particularly old or frail people, there's a chance the infection could lead to the lungs filling with fluid, so they can't work 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 poor oral and dental hygiene.

Children with long-term dysphagia may not get the essential nutrients they need for physical and mental development if they aren't eating enough.

A child who has difficulty eating may also find meal times stressful, and this may lead to behavioural problems.

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