What is Dysphagia (Difficulty Swallowing)?
Dysphagia is a medical term for when someone has a hard time swallowing. This happens when the process of moving a liquid or solid from the mouth to the stomach takes longer than it should. Dysphagia can either suddenly appear or last for a long period, it might occur every now and then, or be a constant issue. It can be accompanied by a feeling of a lump in the throat. There are several reasons why this might happen, including problems with the throat or the esophagus, or a combination of both.
It occurs fairly often, especially in older people. This might be due to a physical blockage, a problem with how the muscles move, or because of issues that affect the body’s muscles and nerves, infections, or inflammation in the body. All of these could either cause dysphagia or contribute to it.
Understanding a patient’s past medical history and performing a physical check-up are essential steps in figuring out why someone has dysphagia. They often point the way to a diagnosis. However, further tests are usually done to be sure, including a test at the patient’s bedside, swallowing a special substance called barium while x-rays are taken, using a flexible tube with a camera to look inside (endoscopy), or testing the muscle activity in the esophagus. How dysphagia is treated depends on the cause, as well as any related conditions the patient might have.
There can be serious complications when someone has dysphagia. For example, they could accidentally inhale food or liquid into their lungs (aspiration), which could lead to pneumonia. They might also not get enough nutrients from their food, become chronically ill, or even die. When someone is in the hospital with dysphagia, they often have to stay there longer as they recover from it and any complications. Finally, people with dysphagia frequently report that their quality of life is diminished.
What Causes Dysphagia (Difficulty Swallowing)?
Dysphagia, or difficulty swallowing, can be sudden or ongoing, and can occur during different stages of the swallowing process. It can sometimes be accompanied by a painful swallowing sensation known as odynophagia, or the feeling of having something stuck in the throat, although this sensation is typically painless.
Oropharyngeal dysphagia is a type of swallowing difficulty that happens during the oropharyngeal phase of swallowing. This can be caused by structural or nerve problems. Some reasons include complications from neck surgery, illnesses that cause lumps or external pressure on the throat like Zenker’s diverticulum, esophageal webs, throat tumours and abscesses, goiters or an aortic aneurysm called dysphagia aortica.
Neuromuscular causes can include strokes, head injuries, diseases like multiple sclerosis, Parkinson’s, botulism, ALS, and supranuclear palsy, and muscle diseases like polymyositis and myopathies. Myasthenia gravis, a condition that affects the nerve junctions, can also lead to dysphagia.
Another type of swallowing difficulty is esophageal dysphagia, which is a result of the esophagus being blocked or the muscles not working properly. When there’s a blockage, one normally has trouble swallowing solids while muscle problems cause difficulty with both solids and liquids. This may be intermittent or continuous. Common causes of blockages are Schatzki ring, esophageal stricture or webs, esophageal carcinoma, and eosinophilic esophagitis. Motility disorders that could create issues swallowing include esophageal spasm, achalasia, ineffective esophageal motility, and systemic sclerosis.
Several rheumatologic disorders can also cause dysphagia, for instance, Sjögren syndrome can cause dry mouth and impact esophagus motility, while systemic sclerosis can affect the movement of the esophagus. Other conditions like rheumatoid arthritis, systemic lupus erythematosus, and mixed connective tissue diseases might also affect swallowing.
Medication can also contribute to dysphagia. Certain drugs can cause dry mouth or affect the esophagus’s ability to move, or cause inflammation of the esophagus as a side effect. Additionally, some might decrease the body’s natural defense against infections of the esophagus. Examples of such medications include but are not limited to antipsychotics, antidepressants, potassium supplements, anti-inflammatories, bisphosphonates, calcium channel blockers, nitrates, theophylline, alcohol, and opioids. It’s important to remember that opioids, in particular, might increase the risk of aspiration in patients with dysphagia by impacting the airway.
Risk Factors and Frequency for Dysphagia (Difficulty Swallowing)
Dysphagia, also known as difficulty swallowing, is a common problem that tends to become more prevalent as people get older. In fact, between 10% to 22% of Americans over the age of 50 experience dysphagia. This prevalence increases to 40% in those older than 60 years. Interestingly, some studies have discovered swallowing abnormalities in nearly 63% of elderly individuals who claimed they never had any issues with swallowing before.
The rates of dysphagia can also vary depending on where it is assessed. For example, between 14% to 18% of patients in hospitals and 30% to 60% of those living in senior care homes have reported symptoms. In intensive care units, the rates of dysphagia following the removal of a breathing tube can range from 3% to as high as 84%. This suggests that dysphagia is quite common in intensive care settings.
Underlying health conditions can also influence the rates of dysphagia. For example, stroke patients often experience issues with swallowing. The rates of dysphagia in this group can range from 19% to 81%, especially following a stroke affecting the brainstem or both side of the brain. As such, early detection of dysphagia in stroke patients is crucial to avoid complications and shorten hospital stays.
Interestingly, dysphagia can also be linked to specific medical conditions such as idiopathic achalasia, which often gets diagnosed at age 50 and affects men and women equally. Its incidence is about 0.3 to 1.6 cases per 100,000 adults annually. However, this figure climbs to about 17 cases per 100,000 each year in those over the age of 80.
Over the past decade, there’s been an increase in studies and publications regarding swallowing disorders, showing a growing interest in this health issue.
Signs and Symptoms of Dysphagia (Difficulty Swallowing)
Dysphagia, or difficulty swallowing, is a condition that has to be diagnosed correctly for effective treatment, thus necessitating a comprehensive patient history check and physical examination. These evaluations often provide clues that lead to the diagnosis.
The patient’s history should contain facts about the nature of the swallowing issues, the duration and progression, and whether the problem occurs with solids, liquids, or both. If the person experiences most issues swallowing solids, this could point to a blockage or a mechanical issue, like esophageal webs or rings. Alternatively, if the problems progress over time, it can signal a growing blockage or possibly cancer. Problems encountered when drinking fluids could imply an issue with the esophagus’s muscle movement, such as achalasia or systemic sclerosis. If these issues come and go, it could be due to an esophageal spasm.
When documenting the patient’s case history, pay attention to these details:
- The onset of issues
- Degree and timeline of symptoms
- Observed problems at the start of swallowing or a couple of seconds after
- Symptoms predominantly in the neck or chest
- Irritation with solids, fluids, or both
In addition to this, look out for the patient’s self-regulation on dietary patterns, like preferring softer food or liquids. Other accompanying symptoms like frequent coughing, choking, postnasal discharge, recurrent chest infections, functional declines, neurological deficits, weight loss, and emotional stress also need consideration.
Physical signs that might be spotted range from issues related to teeth and gums to local mucosal and neurological changes. A more pronounced difficulty at the onset of swallowing usually characterizes oropharyngeal dysphagia, while delay in discomfort a few seconds after swallowing might signify esophageal dysphagia.
Here are some symptoms indicative of oropharyngeal dysphagia:
- A delayed start of swallowing
- A cough while swallowing
- Nasal fluid ingress during swallowing
- The need to swallow multiple times to clear nasal secretions
- A lump in the throat feeling
And symptoms indicative of esophageal dysphagia include:
- The onset of symptoms few seconds after starting to swallow
- Undigested food coming back up
- Dysphagia is primarily felt within the chest
While oropharyngeal dysphagia is common amongst elderly people, those with histories of smoking or drinking alcohol, coupled with unexplained weight loss, it may suggest possible malignancy or cancer. Certain symptoms like undigested food coming back up, hoarseness of voice, halitosis, feelings of blockage in the throat, and instances of aspirations can indicate Zenker diverticulum. This condition, which involves a pocket being formed at the junction of the throat and esophagus, is thought to occur due to muscle weakness in the cricopharyngeal muscle.
Testing for Dysphagia (Difficulty Swallowing)
Diagnosing swallowing difficulties, also known as dysphagia, is usually based on the patient’s medical history and a physical examination. From here, doctors can determine if the patient has oropharyngeal dysphagia (which affects the throat) or esophageal dysphagia (which impacts the esophagus, or the food pipe).
In cases where the patient might have oropharyngeal dysphagia, a doctor might first conduct a clinical swallow evaluation by a speech pathologist or nurse. It’s important to note, however, that this test isn’t perfect – in fact, it could miss over half the patients with significant swallowing issues. Because of this, other screening tools are often also used to help detect problems, especially in older individuals. Still, many of these tests are not fully reliable and haven’t been officially validated.
Two other key tests are the videofluoroscopic swallow study (VFSS) and the fiberoptic endoscopic evaluation of swallowing (FEES). The VFSS test offers a two-dimensional view of how swallowing works, and while it’s a valuable tool, its reliability can vary. FEES, on the other hand, gives doctors a direct look at the swallowing process, but the test chosen largely depends on the patient’s condition. VFSS requires patients to sit upright and go to the radiology department, whereas FEES can be done right at the patient’s bedside.
If a patient with oropharyngeal dysphagia shows signs of cancer, like weight loss or bleeding, they may need additional evaluations, including a laryngoscopic examination. And if there are worries about a potential malignancy, a CT scan of the neck and head might be necessary.
For those with suspected esophageal dysphagia and no signs of oropharyngeal dysphagia, a gastroenterologist might conduct a barium video-esophagogram. This test is simple, cost-effective and can provide a lot of information about esophageal issues. While endoscopic procedures can offer more detailed insights, they also come with potential risks such as aspiration, especially in elderly patients.
In the end, which testing route is taken depends on the patient’s individual circumstances and the decisions made between them and their doctor. For some cases, a combination of approaches may be most effective. For example, many gastroenterologists recommend endoscopy as a starting test since many patients who had an esophagram end up needing an endoscopy later. In addition, some esophageal dysphagia patients may also require high-resolution esophageal manometry to assess other esophageal conditions.
Treatment Options for Dysphagia (Difficulty Swallowing)
Treating difficulty in swallowing, or dysphagia, involves customizing the treatment to the patient and the root cause of their condition. The goal is to prevent complications that could risk their life or health, such as pneumonia, dehydration, malnutrition or mental health issues that arise from difficulty eating. A team of experts, including doctors, nurses, speech therapists, dieticians, and caregivers, work together using a variety of strategies to improve swallowing and enhance the patient’s quality of life. This comprehensive management is particularly critical for older adults and patients with conditions like dementia, Alzheimer’s, stroke, and Parkinson’s disease.
It is important to acknowledge the psychological distress caused by dysphagia, such as depression, anxiety, fear and embarrassment. Patients and their caregivers need to be educated about coping strategies and social support. Techniques that train the patient to swallow differently can be helpful in preventing choking, although their effectiveness varies. Speech therapists often manage the rehabilitation process, which includes exercises and skills-based training.
Adjusting the patient’s diet can also help. This may involve altering the texture of food, increasing the thickness of liquids, or managing the timing and frequency meals, the size of food portions, and patient preferences. That said, there isn’t much evidence supporting diet modification in managing dysphagia, and the long-term effects are uncertain.
Other approaches include therapies to stimulate areas at the base of the tongue and soft palate, or using magnetic stimulation. These therapies may aid dysphagia caused by neurological disorders, but their usefulness for older adults is unknown. Electrical stimulation and traditional swallowing therapies could potentially help patients with stroke-induced dysphagia. Some patients may require a procedure to widen the upper esophageal sphincter.
For those with a muscular valve dysfunction in the throat (cricopharyngeal dysphagia) or a pouch in the throat (Zenker’s diverticulum), a procedure to cut or dilate the muscle can be considered. Certain medications can help treat swallowing difficulties related to myasthenia gravis. Benign esophageal strictures, or narrowings, can be treated by controlling acid reflux, endoscopic dilation, steroid injection, incision, or stent placement. Patients with tumors in the head and neck often require long-term swallowing rehabilitation. If swallowing difficulties persist after surgery, radiation therapy, or chemotherapy, a gastrostomy tube may be needed.
The cause of dysphagia due to irregular esophageal spasms is unclear, so treatment focuses on controlling symptoms. Options include various drugs, a specialized endoscopic procedure, botulinum toxin, and esophageal dilatation. Patients with a condition called scleroderma often have difficulty swallowing food and liquids. Current treatment options include drugs that stimulate gut motion and non-drug approaches such as acupuncture or electrical nerve stimulation.
People with a rare swallowing disorder called achalasia can be divided into 3 types, each requiring a different approach. Possible treatments include medications to relax the esophageal sphincter, botulinum toxin injection, or surgical/procedural interventions depending on the type of achalasia. However, each treatment approach has its risks and benefits.
What else can Dysphagia (Difficulty Swallowing) be?
Dysphagia, or difficulty swallowing, can be short-term or long-term and may affect different stages of the swallowing process. This condition can be caused by a variety of factors. Some of these causes could include:
- A non-cancerous narrowing of the esophagus
- A stroke
- Unusual contractions in the muscles of the esophagus
- Inflammation of the esophagus due to a specific type of white blood cell
- Cancer in the esophagus
- Thin layers of tissue or rings of extra tissue in the esophagus
- Repeated acid reflux from the stomach, also known as GERD
- A condition where the stomach bulges into the chest through an opening in the diaphragm, known as a hiatal hernia
- Multiple Sclerosis, a disease that affects the central nervous system
- Parkinson’s disease, a condition that affects the nerve cells in the brain
- Paterson-Kelly syndrome, a condition that involves anemia and difficulties swallowing
- A pouch that forms and collects food particles in your throat, known as a Zenker diverticulum
In children, there’s a unique form of dysphagia called dysphagia lusoria. It happens when the esophagus gets squeezed by a different growth or structure of a blood vessel. This typically involves an irregular right subclavian artery, which starts from the left side of the aorta, or a case in which there are two aortic arches.
What to expect with Dysphagia (Difficulty Swallowing)
The outlook for dysphagia, or difficulty swallowing, depends on what’s causing it. For instance, stroke patients who experience dysphagia usually see improvements gradually, between 3 weeks and 6 months, or possibly longer.
If dysphagia is caused by achalasia (a problem with the throat muscle) or a physical blockage, it may be resolved with surgery.
Possible Complications When Diagnosed with Dysphagia (Difficulty Swallowing)
Dysphagia, or difficulty swallowing, can greatly impact a person’s quality of life. It can lead to people feeling alone and embarrassed because they might cough or struggle to swallow when eating or drinking. Dysphagia also increases the chance of long-term lung infections and pneumonia due to accidentally inhaling food or drink. The condition can also result in dehydration and malnutrition. Furthermore, recovery after being injured or sick may take longer because of dysphagia.
Preventing Dysphagia (Difficulty Swallowing)
Patients experiencing swallowing difficulties should understand the root cause of their problem, along with any specific needs tied to that cause. However, these patients or the people caring for them should make sure to eat in a seated, upright position with the neck bent forward. This can make swallowing easier and reduce the chances of choking. If patients have a dry mouth, they may find relief with artificial saliva or moisturizing products. It’s also recommended that patients avoid talking while eating. To maintain adequate nutrition levels, high-calorie foods are suggested. Speech therapists can offer a variety of exercises to help improve swallowing ability.