Dysphagia
Basics
The medical term for swallowing difficulties is dysphagia Figure 01.
Swallowing requires normal function and coordination of the brain, nerves, muscles, teeth, and salivary glands. The swallowing process begins in the mouth and ends when food or liquids arrive in the stomach; dysphagia may result from conditions that affect at any point along this path.
Figure 01. Anatomy of the digestive system
Dysphagia is a common symptom in the general population, but dysphagia is most common among older adults.
Although anyone can experience dysphagia, the condition is most common in older adults. Up to 40% of nursing home residents are affected by the condition.
All cases of dysphagia warrant medical attention.
Dysphagia always requires medical attention, even if the symptoms are mild. Dysphagia can be an early warning symptom of a serious underlying condition. Furthermore, untreated swallowing disorders can lead to complications, including weight loss, malnutrition, dehydration, choking, a type of pneumonia caused by inhalation of food liquid, gases, dust, or fungi (aspiration pneumonia), and even death.
The diagnosis and treatment of dysphagia usually involves a team of health care professionals.
Several different types of doctors may help evaluate and treat dysphagia, including a primary care doctor, an otolaryngologist who is an ear, nose, and throat (ENT) doctor, a radiologist, a doctor who specializes in digestive conditions (gastroenterologist), and a rehabilitation specialist. The team usually also includes other health care professionals with specific expertise, such as speech-language pathologists, swallowing therapists, physical or occupational therapists, and dietitians.
Because dysphagia can be caused by numerous underlying conditions, the treatment is tailored to the specific cause of dysphagia. Treatment may include drug therapy, swallowing rehabilitation, surgery, or some combination of these measures.
Causes
There are two broad types of swallowing difficulties: one type affects the mouth and upper throat (oropharyngeal dysphagia), and the other type affects the esophagus (esophageal dysphagia) [Figure 1].
Oropharyngeal dysphagia refers to swallowing difficulties that affect the mouth and/or the upper throat (pharynx). In contrast, esophageal dysphagia refers to swallowing difficulties that affect the tube (esophagus) that connects the pharynx to the stomach. These two types of dysphagia can usually be distinguished based on a person's medical history (specific symptoms), the specific signs noted during a physical examination, and the results of diagnostic tests.
There are many causes of both oropharyngeal dysphagia and esophageal dysphagia Table 01.
Dysphagia is actually a symptom of an underlying condition. Because swallowing requires the healthy function of many different oral structures, muscles, and nerves, a wide range of different medical and dental conditions can cause dysphagia. Overall, oropharyngeal dysphagia is more common than esophageal dysphagia.
Table 1. Common Causes of Dysphagia
| Oropharyngeal dysphagia |
| Stroke |
| Parkinson's disease |
| Muscular dystrophy |
| Tumors of the mouth or pharynx |
| Drug-induced dry mouth (xerostomia) |
| Radiation-induced dry mouth (xerostomia) |
| Chemotherapy-induced inflammation of the mucosa of the mouth, ranging from redness to severe ulceration (mucositis). |
| Esophageal dysphagia |
| Inability to produce involuntary, wave-like contractions of esophagus (peristalsis), a condition know as achalasia |
| Esophageal spasms that block food and liquid instead of propelling them downward toward stomach (diffuse esophageal spasms) |
| Scleroderma: an autoimmune disease that can cause the weakening of tissues in the esophagus |
| Age-related changes of motor function of esophagus |
| Tumors of the esophagus |
| Regions of narrowing (strictures) |
| Lower esophageal ring that causes narrowing (Schatzki's ring) |
| Pill-induced inflammation of the esophagus (pill esophagitis) |
| Esophagitis induced by gastroesophageal reflux disease (GERD) |
| Functional (psychogenic) dysphagia: difficulty swallowing when no physical abnormalities are present; can be caused by stress |
Stroke is the most common cause of oropharyngeal dysphagia.
Dysphagia can result from strokes that affect the area of the brain that controls motor actions (the cortex), and from strokes that affect the area of the brain that houses the swallowing center (the brain stem). About half of all stroke victims experience some degree of dysphagia in the post-stroke period, but in most of these cases, normal or near-normal swallowing function returns within one week.
Esophageal dysphagia is most often due to actual blockages within the esophagus that are referred to as structural disorders. The disorders mechanically block food and liquid from moving towards the stomach.
The most common structural problems are esophageal cancer, strictures, and lower esophageal rings (Schatzki's rings).
The conditions like achalasia or scleroderma can impair the normal, wave-like contractions of the esophagus (peristalsis) that propel food toward the stomach. Spasms of the esophagus can also interfere with peristalsis.
Swallowing disorders in children are most commonly caused by structural conditions present at birth, and by disorders involving both the muscles and the nerves(neuromuscular conditions) such as muscular dystrophy.
Many factors may contribute to dysphagia in older adults.
Advancing age can be associated with poorly understood, age-related changes of esophageal motility. Many older adults also have dental problems and a generalized loss of muscle strength, and they may take a variety of drugs to treat specific medical conditions. All of these factors can contribute to dysphagia.
Symptoms
Oropharyngeal and esophageal dysphagia typically produce different types of symptoms Table 02.
Table 2. Possible Signs of Swallowing Difficulties
| Difficulty chewing |
| Difficulty initiating swallowing |
| Difficulty moving food or liquid from the mouth into the throat |
| Sensation that food is getting stuck in the mouth, throat, or esophagus |
| Persistent sensation of a "lump" in the throat |
| Frequent need to clear the throat |
| Generalized mouth or throat pain |
| Pain during swallowing |
| Drooling |
| Coughing or choking when eating |
| Bad breath |
| Reflux of food or liquid into the throat, mouth, or nose |
| Change in voice (nasal voice or hoarseness) |
| Difficulty speaking |
| Hiccups |
| Dry mouth and/or throat |
| Weight loss |
| Heartburn |
| Chest pain |
| Ear pain |
| Frequent respiratory tract infections |
| Pneumonia |
Inability to swallow solids, liquids, or both can provide clues about the underlying cause of dysphagia.
The consistency of food associated with dysphagia often provides clues about the underlying cause. People with oropharyngeal dysphagia often have more difficulty swallowing liquids, while people with structural causes of dysphagia often have more difficulty swallowing solids. If the person’s esophagus has difficulty producing the contractions to move food down to the stomach often he or she may have difficulty swallowing either solids or liquids.
Long-standing dysphagia can lead to complications; it is important to be alert for symptoms of these complications.
Longstanding dysphagia carries risks of malnutrition, dehydration, and movement of food or liquid into the airway (aspiration).
Adults must be alert for the symptoms of swallowing difficulties in infants and children.
Infants and children with dysphagia may have residual food or liquid in their mouths after eating, may turn their heads or make exaggerated facial expressions when attempting to eat, or may vomit. They may also cough or choke if food or liquid enters the airway. However, aspiration occurs without obvious symptoms in about 70% of children. Frequent upper respiratory tract infections or pneumonia in an infant or child may be the first indication of aspiration.
Risk Factors
Gastroesophageal reflux disease (GERD) increases the risk of inflammation of the esophagus (esophagitis), esophageal strictures, and esophageal cancer, all of which can cause swallowing difficulties.
The chronic acid reflux of gastroesophageal reflux disease (GERD) often damages the esophageal lining. Inflammation of the esophagus (esophagitis) can cause dysphagia and pain during swallowing (odynophagia); over time, esophagitis can lead to narrowing (strictures) of the esophagus, and even esophageal cancer. Esophagitis, strictures, and esophageal cancer can all interfere with swallowing.
Many drugs prescribed for various medical conditions may be associated with dysphagia.
Dysphagia is a potential side effect of many drugs used to treat medical conditions. These drugs include central nervous system depressants (such as drugs used to treat anxiety or trouble sleeping), antipsychotics (used to treat psychosis), corticosteroids (a group of anti-inflammatory drugs that includes prednisone and is used to treat many diseases), lipid-lowering drugs (for people with high cholesterol), colchicines (used to treat gout and other medical conditions), aminoglycosides (a group of antibiotics), anticonvulsants (used to treat seizure disorders), and antihistamines (for allergies).
Certain drugs can actually produce a chemical inflammation if they stay in contact with the esophageal lining for long periods of time. This inflammation is called pill esophagitis, and it can cause dysphagia.
Certain antibiotics can cause pill esophagitis, such as tetracycline, doxycycline, and minocycline, as well as other drugs such as potassium chloride, iron supplements, vitamin C, and quinidine. Aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs such as ibuprofen), zidovudine, and alendronate are also thought to cause to this burn.
Certain hereditary conditions are associated with dysphagia.
Hereditary conditions such as muscular dystrophy can lead to dysphagia because these patients lack the muscle control necessary for normal swallowing.
Diagnosis
The medical term for swallowing difficulties is dysphagia Figure 01.
Swallowing requires normal function and coordination of the brain, nerves, muscles, teeth, and salivary glands. The swallowing process begins in the mouth and ends when food or liquids arrive in the stomach; dysphagia may result from conditions that affect at any point along this path.Figure 01. Anatomy of the digestive system
Dysphagia is a common symptom in the general population, but dysphagia is most common among older adults.
Although anyone can experience dysphagia, the condition is most common in older adults. Up to 40% of nursing home residents are affected by the condition.
All cases of dysphagia warrant medical attention.
Dysphagia always requires medical attention, even if the symptoms are mild. Dysphagia can be an early warning symptom of a serious underlying condition. Furthermore, untreated swallowing disorders can lead to complications, including weight loss, malnutrition, dehydration, choking, a type of pneumonia caused by inhalation of food liquid, gases, dust, or fungi (aspiration pneumonia), and even death.
The diagnosis and treatment of dysphagia usually involves a team of health care professionals.
Several different types of doctors may help evaluate and treat dysphagia, including a primary care doctor, an otolaryngologist who is an ear, nose, and throat (ENT) doctor, a radiologist, a doctor who specializes in digestive conditions (gastroenterologist), and a rehabilitation specialist. The team usually also includes other health care professionals with specific expertise, such as speech-language pathologists, swallowing therapists, physical or occupational therapists, and dietitians.
Because dysphagia can be caused by numerous underlying conditions, the treatment is tailored to the specific cause of dysphagia. Treatment may include drug therapy, swallowing rehabilitation, surgery, or some combination of these measures.
There are two broad types of swallowing difficulties: one type affects the mouth and upper throat (oropharyngeal dysphagia), and the other type affects the esophagus (esophageal dysphagia) Figure 01.
Oropharyngeal dysphagia refers to swallowing difficulties that affect the mouth and/or the upper throat (pharynx). In contrast, esophageal dysphagia refers to swallowing difficulties that affect the tube (esophagus) that connects the pharynx to the stomach. These two types of dysphagia can usually be distinguished based on a person's medical history (specific symptoms), the specific signs noted during a physical examination, and the results of diagnostic tests.
There are many causes of both oropharyngeal dysphagia and esophageal dysphagia Table 01.
Dysphagia is actually a symptom of an underlying condition. Because swallowing requires the healthy function of many different oral structures, muscles, and nerves, a wide range of different medical and dental conditions can cause dysphagia. Overall, oropharyngeal dysphagia is more common than esophageal dysphagia.
Table 1. Common Causes of Dysphagia
| Oropharyngeal dysphagia |
| Stroke |
| Parkinson's disease |
| Muscular dystrophy |
| Tumors of the mouth or pharynx |
| Drug-induced dry mouth (xerostomia) |
| Radiation-induced dry mouth (xerostomia) |
| Chemotherapy-induced inflammation of the mucosa of the mouth, ranging from redness to severe ulceration (mucositis). |
| Esophageal dysphagia |
| Inability to produce involuntary, wave-like contractions of esophagus (peristalsis), a condition know as achalasia |
| Esophageal spasms that block food and liquid instead of propelling them downward toward stomach (diffuse esophageal spasms) |
| Scleroderma: an autoimmune disease that can cause the weakening of tissues in the esophagus |
| Age-related changes of motor function of esophagus |
| Tumors of the esophagus |
| Regions of narrowing (strictures) |
| Lower esophageal ring that causes narrowing (Schatzki's ring) |
| Pill-induced inflammation of the esophagus (pill esophagitis) |
| Esophagitis induced by gastroesophageal reflux disease (GERD) |
| Functional (psychogenic) dysphagia: difficulty swallowing when no physical abnormalities are present; can be caused by stress |
Stroke is the most common cause of oropharyngeal dysphagia.
Dysphagia can result from strokes that affect the area of the brain that controls motor actions (the cortex), and from strokes that affect the area of the brain that houses the swallowing center (the brain stem). About half of all stroke victims experience some degree of dysphagia in the post-stroke period, but in most of these cases, normal or near-normal swallowing function returns within one week.
Esophageal dysphagia is most often due to actual blockages within the esophagus that are referred to as structural disorders. The disorders mechanically block food and liquid from moving towards the stomach.
The most common structural problems are esophageal cancer, strictures, and lower esophageal rings (Schatzki's rings).
The conditions like achalasia or scleroderma can impair the normal, wave-like contractions of the esophagus (peristalsis) that propel food toward the stomach. Spasms of the esophagus can also interfere with peristalsis.
Swallowing disorders in children are most commonly caused by structural conditions present at birth, and by disorders involving both the muscles and the nerves(neuromuscular conditions) such as muscular dystrophy.
Many factors may contribute to dysphagia in older adults.
Advancing age can be associated with poorly understood, age-related changes of esophageal motility. Many older adults also have dental problems and a generalized loss of muscle strength, and they may take a variety of drugs to treat specific medical conditions. All of these factors can contribute to dysphagia.
Oropharyngeal and esophageal dysphagia typically produce different types of symptoms Table 02.
Table 2. Possible Signs of Swallowing Difficulties
| Difficulty chewing |
| Difficulty initiating swallowing |
| Difficulty moving food or liquid from the mouth into the throat |
| Sensation that food is getting stuck in the mouth, throat, or esophagus |
| Persistent sensation of a "lump" in the throat |
| Frequent need to clear the throat |
| Generalized mouth or throat pain |
| Pain during swallowing |
| Drooling |
| Coughing or choking when eating |
| Bad breath |
| Reflux of food or liquid into the throat, mouth, or nose |
| Change in voice (nasal voice or hoarseness) |
| Difficulty speaking |
| Hiccups |
| Dry mouth and/or throat |
| Weight loss |
| Heartburn |
| Chest pain |
| Ear pain |
| Frequent respiratory tract infections |
| Pneumonia |
Inability to swallow solids, liquids, or both can provide clues about the underlying cause of dysphagia.
The consistency of food associated with dysphagia often provides clues about the underlying cause. People with oropharyngeal dysphagia often have more difficulty swallowing liquids, while people with structural causes of dysphagia often have more difficulty swallowing solids. If the person’s esophagus has difficulty producing the contractions to move food down to the stomach often he or she may have difficulty swallowing either solids or liquids.
Long-standing dysphagia can lead to complications; it is important to be alert for symptoms of these complications.
Longstanding dysphagia carries risks of malnutrition, dehydration, and movement of food or liquid into the airway (aspiration).
Adults must be alert for the symptoms of swallowing difficulties in infants and children.
Infants and children with dysphagia may have residual food or liquid in their mouths after eating, may turn their heads or make exaggerated facial expressions when attempting to eat, or may vomit. They may also cough or choke if food or liquid enters the airway. However, aspiration occurs without obvious symptoms in about 70% of children. Frequent upper respiratory tract infections or pneumonia in an infant or child may be the first indication of aspiration.
Gastroesophageal reflux disease (GERD) increases the risk of inflammation of the esophagus (esophagitis), esophageal strictures, and esophageal cancer, all of which can cause swallowing difficulties.
The chronic acid reflux of gastroesophageal reflux disease (GERD) often damages the esophageal lining. Inflammation of the esophagus (esophagitis) can cause dysphagia and pain during swallowing (odynophagia); over time, esophagitis can lead to narrowing (strictures) of the esophagus, and even esophageal cancer. Esophagitis, strictures, and esophageal cancer can all interfere with swallowing.
Many drugs prescribed for various medical conditions may be associated with dysphagia.
Dysphagia is a potential side effect of many drugs used to treat medical conditions. These drugs include central nervous system depressants (such as drugs used to treat anxiety or trouble sleeping), antipsychotics (used to treat psychosis), corticosteroids (a group of anti-inflammatory drugs that includes prednisone and is used to treat many diseases), lipid-lowering drugs (for people with high cholesterol), colchicines (used to treat gout and other medical conditions), aminoglycosides (a group of antibiotics), anticonvulsants (used to treat seizure disorders), and antihistamines (for allergies).
Certain drugs can actually produce a chemical inflammation if they stay in contact with the esophageal lining for long periods of time. This inflammation is called pill esophagitis, and it can cause dysphagia.
Certain antibiotics can cause pill esophagitis, such as tetracycline, doxycycline, and minocycline, as well as other drugs such as potassium chloride, iron supplements, vitamin C, and quinidine. Aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs such as ibuprofen), zidovudine, and alendronate are also thought to cause to this burn.
Certain hereditary conditions are associated with dysphagia.
Hereditary conditions such as muscular dystrophy can lead to dysphagia because these patients lack the muscle control necessary for normal swallowing.
The diagnosis of dysphagia begins with a medical history.
A detailed medical history is essential for the diagnosis of dysphagia. In about 85% of people who consult a doctor for dysphagia, the medical history strongly hints at the underlying cause of dysphagia.
A head and neck exam can help confirm the presence of dysphagia and provide clues about the underlying cause.
During a head and neck exam, a doctor examines the lining of the mouth, the tongue, the roof of the mouth (palate), the teeth, the throat (pharynx), the voice box (larynx), the nose, and the neck. The doctor will test reflexes, motor function, muscle strength, and sensation, and check for symptoms such as collection of secretions and abnormal movement of the vocal cords.
In some cases, a general physical exam is necessary to determine the cause of dysphagia.
Many body-wide (systemic) conditions can affect swallowing. A general physical exam may detect signs and symptoms of neuromuscular disease, endocrine disorders, cancer, or autoimmune disease.
Although many tests are available for confirming dysphagia and identifying the underlying cause, doctors choose specific tests based on the most likely diagnosis Table 03.
A few tests will often confirm dysphagia and reveal the underlying cause. In some cases, a doctor may order additional tests if preliminary tests do not provide enough information.
Table 3. Tests Used to Diagnose Swallowing Difficulties
| Test | What it can detect |
|---|---|
| Barium swallow test and videofluoroscopy | Can show structural abnormalities of the esophagus and/or throat. Videofluroscopy can visualize the act of swallowing and aspiration |
| Fiberoptic endocscopy | May reveal inflammation of the esophagus, tumors, webs, rings, narrowing (strictures), pouches (diverticula) |
| Manometry | Can determine how well the esophagus is moving food down to the stomach (esophageal motility) |
| Ultrasound | Can detect swallowing problems in infants and children and certain causes of esophageal dysphagia in adults |
| Continuous pH monitoring | For detecting acid reflux, which may be associated with dysphagia |
| Bolus (esophageal transit) scintigraphy | Checks for entry of swallowed material into the airway (aspiration)? |
| Computed tomography (CT) and magnetic resonance imaging (MRI) | Looks for structures that compress the esophagus |
The barium swallow test and videofluoroscopy are the most sensitive tests for detecting structural abnormalities.
During the barium swallow test and videofluoroscopy (also called the videofluoroscopic swallow study [VFSS]), a person is asked to swallow barium in various forms ranging from liquid to semisolid to solid. During the barium swallow test (most useful for evaluating esophageal dysphagia), individual x-rays are taken. During videofluoroscopy (most useful for evaluating oropharyngeal dysphagia), serial x-rays are taken and then analyzed in slow motion.
Because the x-rays show the mouth, throat, and esophagus as the barium moves from the mouth to the stomach, these tests are very sensitive for detecting structural causes of dysphagia, such as tumors, webs, strictures, rings, diverticula (the outward pouching of the wall of an organ or structure), and compression of the esophagus by external structures. The tests may also reveal impaired function of the esophagus and of the lower esophageal sphincter (LES). However, these tests are not very useful for detecting minor inflammation of the esophagus.
Fiberoptic endoscopy is the most sensitive test for detecting inflammation of the esophagus (esophagitis). It is also very useful in detecting structural abnormalities of the inner lining of the esophagus, stomach and the first part of the small bowel (duodenum).
During fiberoptic endoscopy, a thin, lighted tube is advanced through the mouth or nose, and the pharynx, esophagus, and stomach are viewed directly. This test is very helpful for detecting esophagitis. Furthermore, during this test, small samples of secretions, tissue, and cells can be collected for later laboratory analysis, and trapped foreign bodies can be retrieved through the endoscope.
Manometry is very sensitive for detecting problems with esophageal movement (motility).
During manometry, a pressure sensor is advanced into the pharynx and esophagus in order to detect abnormal contractile pressures during rest and swallowing. Manometry is useful for diagnosing conditions that affect how well the esophagus is able to contract and transport food, such as achalasia and diffuse esophageal spasms. This test can be performed during videofluoroscopy.
Ultrasound is useful for identifying swallowing problems in infants and children, and certain causes of esophageal dysphagia in adults.
In infants and children, an ultrasound probe applied to the cheek and upper neck can be used to view the action of the tongue and larynx during sucking and swallowing. In adults, the probe can be advanced into the esophagus and used to check for abnormal structures that are hidden within the esophageal wall.
Continuous pH monitoring is useful for determining if acid reflux is associated with dysphagia.
During continuous pH monitoring, a pH sensor is placed in the esophagus and used to record the pH (degree of acidity) over a 24-hour time period. The person may be asked to keep a diary noting the time when dysphagia occurs; later comparison of the diary and pH results may reveal that dysphagia and acid reflux occur at the same time.
A test called bolus scintigraphy is useful for measuring esophageal transit (the time taken by the food to traverse the esophagus) and detecting aspiration.
During bolus scintigraphy, a person is asked to swallow liquid that has been labeled with a radioactive material. The amounts of radioactive material in the esophagus and other structures can be measured over time. The test is very sensitive for detecting the entry of swallowed material into the airway (aspiration), but it is not routinely used during the evaluation of dysphagia.
Computed tomography (CT) and magnetic resonance imaging (MRI) scans may be useful for identifying structures that compress the esophagus. The scans are painless, and offer more complete structural detail.
Blood tests can help identify certain causes of dysphagia.
Blood tests may be used to measure levels of thyroid-stimulating hormone, vitamin B12, and creatinine kinase. Blood tests may also reveal substances that signal the presence of myasthenia gravis, a neuromuscular disorder that can cause dysphagia.
Functional dysphagia is not usually diagnosed until all other types of dysphagia have been ruled out.
In rare cases, a person may have a sensation of a lump in the throat (called globus sensation) or a sensation of poor movement of swallowed food, but physical exams and diagnostic tests do not reveal any abnormality. This form of dysphagia is called functional (or psychogenic) dysphagia, and is usually diagnosed when careful testing reveals no physiologic or anatomic cause for the symptoms. Functional dysphagia can be caused by stress, and is often seen in conjunction with fainting, nausea, and fatigue.
Following a few simple steps can help prevent irritation of the esophagus due to damage from swallowed pills (pill esophagitis).
Pill esophagitis can usually be prevented by drinking 4 ounces of water, taking the pill with six to eight ounces of water, and then drinking another 4 ounces of water. Furthermore, pills should be taken at least 2 hours before going to bed and while sitting up or standing.
Treatment of gastroesophageal reflux disease (GERD) may help prevent complications that lead to dysphagia.
Gastroesophageal reflux disease (GERD) can cause esophagitis, strictures, and in severe cases, may even contribute to esophageal cancer, and all of these complications can impair swallowing. Successful treatment of GERD can halt ongoing injury of the esophagus, and may even reverse this injury in some cases. A doctor may recommend periodic screening endoscopy for people with moderate or severe GERD because they have an increased risk for complications.
Minimize the risk factors for esophageal cancer.
Smoking and consuming large amounts of alcohol have been shown to increase a person's risk of esophageal cancer. Quitting smoking and restricting alcohol intake to light or moderate amounts may reduce this risk.
Supervise young children and “child-proof” your home.
Because young children often place objects in their mouths, it is important to supervise them at all times and to ensure that they won't come in contact with dangerous items, such as small objects and cleaning solutions. A pediatrician can outline steps for “child-proofing” your home.
Prevention and Screening
Following a few simple steps can help prevent irritation of the esophagus due to damage from swallowed pills (pill esophagitis).
Pill esophagitis can usually be prevented by drinking 4 ounces of water, taking the pill with six to eight ounces of water, and then drinking another 4 ounces of water. Furthermore, pills should be taken at least 2 hours before going to bed and while sitting up or standing.
Treatment of gastroesophageal reflux disease (GERD) may help prevent complications that lead to dysphagia.
Gastroesophageal reflux disease (GERD) can cause esophagitis, strictures, and in severe cases, may even contribute to esophageal cancer, and all of these complications can impair swallowing. Successful treatment of GERD can halt ongoing injury of the esophagus, and may even reverse this injury in some cases. A doctor may recommend periodic screening endoscopy for people with moderate or severe GERD because they have an increased risk for complications.
Minimize the risk factors for esophageal cancer.
Smoking and consuming large amounts of alcohol have been shown to increase a person's risk of esophageal cancer. Quitting smoking and restricting alcohol intake to light or moderate amounts may reduce this risk.
Supervise young children and “child-proof” your home.
Because young children often place objects in their mouths, it is important to supervise them at all times and to ensure that they won't come in contact with dangerous items, such as small objects and cleaning solutions. A pediatrician can outline steps for “child-proofing” your home.
Treatment
If a person is having difficulty breathing, is choking, or has stopped breathing, call for emergency help immediately. Perform first aid for choking and cardiopulmonary resuscitation (CPR) if necessary.
In some people with dysphagia, food “going down the wrong pipe” (aspiration of swallowed material) can lead to choking and even complete airway obstruction. If a person begins choking or has difficulty breathing, it is important to call for emergency medical help immediately. Emergency phone numbers should be posted clearly near all telephones.
If a person is choking, perform first aid for choking; if a person stops breathing, perform cardiopulmonary resuscitation (CPR). Local hospitals and clinics often provide classes in these potentially life-saving skills, so that bystanders can be prepared for emergencies. This preparation is particularly important for family members, friends, and coworkers of people who have dysphagia.
All cases of dysphagia warrant medical attention.
The following measures can be undertaken only after dysphagia has been medically evaluated and its cause has been determined.
Eliminate alcohol and dietary sources of caffeine.
In some people, foods and beverages containing caffeine (coffee, tea, chocolate, and colas) and alcohol make swallowing difficulties worse. Eliminating these substances from the diet may relieve dysphagia.
Adjust eating habits to accommodate swallowing limitations.
Measures that can minimize dysphagia include changing postures, removing distractions, using special swallowing maneuvers, eating more slowly, taking smaller mouthfuls of food, and using special utensils and prosthetics. A doctor and a swallowing therapist can outline the best measures for each person's specific type of dysphagia.
Adjust meal composition to accommodate swallowing limitations.
Dysphagia may cause difficulty swallowing solids, liquids, or both solid and liquids. Choosing foods of specific consistencies may help alleviate different types of dysphagia. Solid foods can often be pureed in a blender or food processor. Adjusting the temperature, taste, and texture of foods may also help minimize dysphagia. Doctors, swallowing therapists, and dietitians can often provide helpful tips for meal preparation.
Choose appetizing foods that are dense in calories.
Moderate and severe dysphagia can lead to weight loss and malnutrition. Selecting appetizing foods and foods that contain many calories in small portions can improve a person's motivation for eating and help ensure that they consume sufficient calories and nutrients. A nutritionist can help you to calculate the required calories and suggest different menus.
If dry mouth (xerostomia) is causing dysphagia, try chewing gum, sucking on lozenges, or using a homemade artificial saliva solution.
In some cases of xerostomia (dry mouth), saliva secretion can be promoted by chewing gum or sucking on sour lozenges. If the salivary glands cannot secrete saliva, a homemade artificial saliva solution can be made by adding 1 teaspoon of baking soda and 1 teaspoon of salt to a quart of water.
Your doctor is the best source of information on the drug treatment choices available to you.
Esophageal tumors may be treated with a variety of different therapies.
Treatment options for esophageal tumors depend on whether they are benign or malignant. Benign tumors can be removed either surgically or endoscopically. Treatment of malignant tumors depends on how advanced they are. If a tumor is malignant (esophageal cancer), treatment may include radiation therapy and chemotherapy. Tumors that block the esophagus may also be treated with electrocoagulation (the application of electric current to a tumor in an attempt to dissolve it) or laser therapy.
Dilatation may alleviate esophageal dysphagia caused by strictures, lower esophageal rings (Schatzki's rings), and achalasia. Dilatation refers to gradual mechanical stretching of constricted areas of the esophagus.
Dilatation is usually performed during several sessions spaced out over weeks or months. Cylindrical dilators (also called bougies and the process bougienage) made of plastic or filled with mercury are advanced into the esophagus, where they exert outward pressure on the constriction. This pressure stretches the tissue; over time, successively larger dilators can be used to further stretch the constriction. Dilatation is most commonly used to treat esophageal dysphagia caused by strictures, lower esophageal rings (Schatzki's rings), and achalasia. Dilatation carries a small risk of complications such as esophageal tears; a person considering dilatation should discuss these possible complications with a doctor before the procedure.
Balloon dilatation can alleviate dysphagia caused by achalasia and lower esophageal rings (Schatzki's rings).
Balloon dilatation (also called pneumatic dilatation) is done to widen the constricted region of the esophagus. This type of dilatation is usually completed in a single session. A doctor advances a deflated balloon type instrument to the narrowed region and then inflates it. This action mechanically ruptures the fibers of the constriction. Balloon dilatation is most often used to stretch the lower esophageal sphincter (LES) in people with achalasia, and to stretch lower esophageal rings (Schatzki's rings). Balloon dilatation carries a small risk of complications such as esophageal tears and bleeding; a person considering dilatation should discuss these possible complications with a doctor before the procedure. Furthermore, this type of dilatation can lead to reflux in a small percentage of people.
Injection of botulinum toxin (Botox) is a new treatment for certain causes of esophageal dysphagia.
Injections of botulinum toxin (Botox) can prevent certain nerve cells from triggering muscle contraction. The treatment allows muscles or sphincters to relax. Botulinum toxin injections are being used to alleviate dysphagia caused by esophageal conditions such as achalasia.
Several measures can alleviate dysphagia that is caused by drugs.
If a specific drug is causing dysphagia, the drug may be tapered to a lower dose or discontinued completely, or another drug with similar function may be substituted.
Swallowing therapy (swallowing rehabilitation) can maximize swallowing function and develop compensatory skills.
Swallowing therapy helps a person retrain the muscles involved in swallowing and learn strategies for working around any residual dysphagia. During swallowing therapy, a person may be taught any of the following measures:
Swallowing strategies for neurologic causes of dysphagia often include eating smaller and more frequent meals, drinking through a straw; avoiding distractions, taking smaller bites of food, eating more slowly, tucking the head during swallowing and swallowing twice, and choosing softer foods that have a high caloric content and foods that have appealing tastes, smells, and textures.
Functional dysphagia may be treated with psychiatric therapies.
If tests fail to detect any anatomic or physiologic cause for dysphagia, the dysphagia may be classified as functional (psychogenic) dysphagia. A doctor may recommend psychotherapy and psychoactive drugs for the treatment of functional dysphagia.
If dysphagia causes saliva to pool, an aspirator can be used to periodically suction saliva from the mouth.
Customized oral devices can reduce dysphagia caused by structural conditions.
Speech-language pathologists, swallowing therapists, and rehabilitation specialists can design and construct oral devices to counter specific structural problem. These devices include prosthodontic appliances, obturators, and palatal lifts.
Special feeding implements and devices can alleviate dysphagia.
Dysphagia caused by overactive sphincters can be treated with myotomy. Myotomy refers to direct cutting of the muscle fibers of a sphincter.
Achalasia can be treated by myotomy of the lower esophageal sphincter (LES); similarly, overactivity of the cricopharyngeus muscle (the upper esophageal sphincter [UES]) can also be treated by myotomy. Although this surgical procedure once required an open incision of the chest or abdominal wall, myotomy can now be performed laparoscopically, through tiny incisions made in the skin. Tiny instruments, cameras, and lights allow the surgeons to operate on the area without opening up the abdominal cavity. The camera projects the images onto a video monitor, and the instruments, located on the ends of very long, skinny tubes, are controlled at the top of the handle.
Diverticula (the outward pouching of a wall of an organ or structure) that cause symptoms can be surgically corrected.
Surgery may be used to completely remove or to decrease the size of esophageal tumors.
Antireflux surgery can halt esophageal injury in people with severe gastroesophageal reflux disease (GERD).
If gastroesophageal reflux disease (GERD) does not respond to medical treatment, antireflux surgery (also called fundoplication) may be used to halt acid reflux.
Several surgical procedures can help minimize and prevent aspiration (entry of food or liquid into the airway).
These procedures include tracheotomy (creation of an opening in the airway), vocal cord medialization (surgery to improve the closing action of the vocal cords), and separation of the larynx and trachea; these three procedure result in loss of voice, but they can be reversed at a later time if dysphagia resolves. Surgical removal of the larynx (laryngectomy) can also stop aspiration, but this procedure results in permanent loss of voice.
Several surgical procedures can provide alternate routes for nutrition.
If dysphagia is markedly interfering with calorie and nutrient intake, and if it poses a serious risk for choking, surgical procedures can be used to permit feeding by placing food directly into the stomach or intestine using a feeding tube (enteral feeding), or intravenous feeding (parenteral feeding).
The ducts of salivary glands can be surgically relocated if a person is having trouble controlling secretions.
Any sudden deterioration of stable dysphagia needs immediate medical attention.
If the patient is unable to swallow saliva immediate medical attention is warranted.
The prognosis of dysphagia depends on the underlying cause.
The underlying cause of dysphagia usually determines if dysphagia will improve, remain stable, or worsen. A doctor can outline the typical prognosis for a specific type of dysphagia. However, even for specific causes of dysphagia, many individual factors can affect the course of the condition.
For dysphagia caused by neurologic conditions, dysphagia that occurs suddenly is likely to improve over time, whereas dysphagia that develops gradually often worsens over time.
Dysphagia caused by stroke usually improves. In contrast, dysphagia caused by neuromuscular disorders often worsens.
Conditions that require dilatation or botulinum toxin injection may require additional treatments.
Although dilatation and botulinum toxin injections promptly relieve some types of dysphagia, the effect of treatment may decrease over time, and additional treatment sessions may be needed.
Regular medical exams are necessary to monitor the degree of dysphagia and to assess the effects of treatment.
During regular medical exams, a doctor can determine if dysphagia is improving, remaining stable, or progressing. Exams are also useful for assessing the effects (and any side effects) of treatment, for checking weight and nutritional status, and for planning additional treatment measures.
Certain conditions that cause esophageal dysphagia require follow-up, because these conditions increase the risk of esophageal cancer.
Some conditions, such as achalasia and gastroesophageal reflux disease (GERD), are associated with an increased risk of esophageal cancer. These conditions may warrant regular medical exams and specific screening tests.