Difficult or Painful Swallowing? Dysphagia Can Be Treated

Occasional difficulty swallowing, such as when you eat too fast or don't chew your food well, usually isn't cause for concern. But if you regularly have difficulty swallowing, especially if accompanied by weight loss, regurgitation or vomiting, you should be evaluated by a doctor, says Nina Zhao, MD, MAEd, head and neck surgeon and dysphagia expert at University Hospitals ENT Institute.

What Causes Dysphagia?

The ability to swallow food and liquid is essential for survival. Although it may seem simple, swallowing is a complex process, requiring the coordination of many different muscles and nerves in the mouth and throat. When swallowing becomes difficult or painful, it’s called dysphagia.

Dysphagia can affect people of any age, but it’s most common in older adults. Difficulty swallowing affects up to 22 percent of people after age 50 and nearly 70 percent of elderly residents in long-term care facilities.

In addition to aging, dysphagia can be the result of any disease, disorder or injury that weakens the muscles and nerves used for swallowing. Some of the most common underlying medical conditions include:

• Neurological disorders such as multiple sclerosis, cerebral palsy, muscular dystrophy and Parkinson's disease 
• Stroke
• Narrowing of the esophagus due to scar tissue or tumors
• Brain or spinal cord injuries
• Gastroesophageal reflux disease (GERD) - Severe, chronic acid reflux that causes heartburn, chest pain and difficulty swallowing
• Achalasia - a condition in which the lower esophageal sphincter (muscle) doesn’t open properly to let food enter the stomach
• Eosinophilic esophagitis - an immune disease that causes inflammation and damage to the esophagus
• Esophageal cancer and some cancer treatments such as radiation therapy

Signs and Symptoms Associated with Dysphagia

Dysphagia can range from a mild inconvenience to a severe, even life-threating, medical condition. In addition to difficult or painful swallowing, symptoms may include:

• Choking, coughing or gagging when eating or drinking
• Excess saliva production and/or drooling
• Feeling like food is lodged in the throat
• Hoarseness
• Food or stomach acid backing up into the throat
• Frequent heartburn

In severe cases, dysphagia can lead to malnutrition, dehydration and weight loss. It can also cause aspiration pneumonia – a dangerous condition in which food or liquid enters the lungs instead of the stomach during attempts to swallow, causing lung inflammation and infection.

An Accurate Diagnosis is Essential

Swallowing problems can originate in the mouth, back of the throat, esophagus or the upper part of the stomach. It’s important to determine the source of the problem so an appropriate treatment plan can be developed.

“Your provider will first ask you for a description and history of your swallowing difficulties and perform a physical exam,” says Dr. Zhao. “If the cause of your swallowing problems cannot be determined by a physical exam and health history, the next step is to perform one or more diagnostic studies.”

Diagnostic tests to evaluate a swallowing problem may include:

• Modified Barium Swallow Study (MBSS). For this test, the patient drinks different types of barium solution under the direction of a speech language pathologist (SLP), a medical professional trained in evaluating swallowing. Using a special type of X-ray called fluoroscopy, the SLP can identify any abnormalities in the swallowing mechanism and assess the effectiveness of different strategies to improve swallowing function.
• Barium Esophagram. Also called a barium swallow, this test uses fluoroscopy to track how liquid moves through the esophagus and into the stomach and small intestine. It is performed by a radiologist and is often combined with a MBSS to help determine the location and origin of the dysphagia symptoms.
• Flexible Laryngoscopy. This procedure allows your doctor to visually examine the upper part of the throat using a small flexible tube (endoscope) that is passed through the nose. This test can identify abnormalities in the throat or voice box that might affect the ability to swallow.
• Fiberoptic Endoscopic Evaluation of Swallowing (FEES). This procedure is also performed with an SLP. Similar to the flexible laryngoscopy, a small endoscope is passed through the nose to visualize the throat. During the FEES, the patient is given various food consistencies and liquids mixed with food coloring or a dye. The clinician can observe the movement of the food and liquids as they are swallowed and determine if there are any abnormalities or difficulties in the swallowing process.
• Flexible Esophagoscopy. This procedure allows the doctor to visually examine the entire esophagus down to the stomach using a flexible endoscope. This can be completed through the nose with or without sedation, or through the mouth under sedation. This test can identify inflammation, infection, narrowing or abnormal growths that might affect the ability to swallow.

Based on the results of these tests, additional studies may be recommended. Most patients will require more than one study for an accurate diagnosis.

Customized Treatment Plans for Dysphagia

Once the cause and location of a swallowing problem is determined, a personalized treatment plan can be developed. If difficulty swallowing is the result an underlying medical condition, treatment will typically focus on addressing that. For example, if swallowing difficulties are associated with GERD, you may be prescribed oral medication to reduce stomach acid.

Additional treatment options may include:

• Lifestyle Changes. For occasional or minimal swallowing concerns, some simple lifestyle changes may be all that’s needed, including:
  • Eat smaller, more frequent meals and cut food into smaller pieces. Chew each bite slowly and thoroughly.
  • Try foods with different textures – if some cause more trouble than others, avoid those foods.
  • Limit or eliminate alcohol and caffeinated beverages. They can contribute to dry mouth which makes swallowing more difficult.
• Swallow Therapy. Most patients with dysphagia, regardless of the cause, will benefit from working with a speech language pathologist (SLP) – medical professionals with advanced training in the assessment and treatment of swallowing disorders. The SLP’s focus is to teach special exercises and techniques designed to improve swallow coordination.
• Minimally Invasive Procedures. Endoscopic procedures may be recommended to gently stretch and expand the esophagus if esophageal stricture (narrowing) or tightness of the sphincter muscle(s) is an issue. Sometimes the placement of a stent may also be necessary to keep the esophagus open – stents may be permanent or temporary. These are typically outpatient procedures done under local anesthetic.
• Surgery. Some swallowing problems will require surgery. For example, you might need surgery if dysphagia symptoms are the result of esophageal growths (bony or soft tissue), achalasia, esophageal cancer or GERD caused by a hiatal hernia.

  Related Links:

  University Hospitals has a multidisciplinary team dedicated to the diagnosis and treatment of dysphagia. Our team includes primary care providers, GI and ENT specialists, speech language pathologists and radiologists who work together to provide world-class, comprehensive dysphagia care, personalized to meet the unique needs of each patient.