What is dysphagia?

When something goes wrong with the muscles that direct swallowing, it’s called dysphagia.

Dysphagia can lead to food or other material entering the airways or lungs by accident. This is called aspiration. Normally, a flap called the epiglottis blocks food particles and stomach contents from entering your lungs. Dysphagia can disrupt this process. Aspiration is serious because it can lead to pneumonia and other problems.

Problems with any of the phases of swallowing can cause dysphagia.

You normally swallow hundreds of times a day without even thinking about it. You swallow foods, liquids, and the normal saliva and mucus that your body makes.

When you swallow food, it passes through your mouth and into a part of your throat called the pharynx. From here, the food passes through a long tube (esophagus) before entering your stomach and the rest of your gastrointestinal tract. This requires a series of actions from the muscles along the path. It also requires coordination with the muscles of breathing. Breathing pauses when you swallow.

Swallowing is a very complex process. It needs the coordination of several nerves and muscle groups. Healthcare providers describe it in 3 phases:

• Oral preparatory phase. During this phase, you chew your food to a size, shape, and consistency that can be swallowed. This is called a bolus. The arch of your mouth and your tongue connect to prevent food or liquid entering the pharynx. Then, your tongue rises, squeezing the bolus back along the roof of your mouth and into your upper pharynx. You have some conscious control over these actions.

• Pharyngeal phase. Here, the muscles of your pharynx contract in sequence. This moves the bolus down toward the esophagus. At the same time, the esophageal sphincter relaxes. This is a tight ring of muscles at the entrance to the esophagus. This lets the bolus enter the esophagus.

• Esophageal phase. The muscles in your esophagus contract in sequence to move the bolus toward your stomach. The lower esophageal sphincter also relaxes. This is a tight ring of muscles at the bottom of the esophagus. This lets the bolus enter the stomach.

The last 2 phases are not under conscious control.

What causes dysphagia?

Several conditions can lead to swallowing problems. Some examples are:

• Stroke

• Dementia

• Head and neck cancer

• Head injury

• Conditions that lead to less saliva, such as Sjogren syndrome

• Progressive neurologic disorders, such as amyotrophic lateral sclerosis (ALS), Parkinson disease (PD), and multiple sclerosis (MS), and Alzheimer disease and related dementias

• Muscular dystrophies

• Blockage in the esophagus, such as from cancer or a history of intubation

• Motor problems of the esophagus

Trouble with different phases of swallowing may mean different sorts of medical problems. For example, decreased saliva is likely to cause a problem with the oral preparatory phase of swallowing. Parkinson disease might cause problems with the pharyngeal phase. A blockage in the esophagus would likely cause problems with the esophageal phase.

What are the symptoms of dysphagia?

Dysphagia and aspiration might cause some of these symptoms:

• Sense of food sticking in your throat or coming back into your mouth

• Choking

• Pain when swallowing

• Trouble starting a swallow

• Coughing or wheezing during or after swallowing

• Excess saliva

• Feeling congested after eating or drinking

• Having a “wet” sounding voice during or after eating or drinking

• Shortness of breath or fatigue while eating

• Repeated bouts of pneumonia

Your symptoms may partly depend on the phase of your swallow that is affected.

How is dysphagia diagnosed?

If you have symptoms of dysphagia or aspiration, you need to be checked right away. If you have a condition, such as stroke, that can cause trouble swallowing, you will need to be evaluated for dysphagia.

Diagnosis usually starts with a health history and evaluation. This is often done by a speech-language pathologist (SLP). The SLP may start by asking you about symptoms that might be related to dysphagia. They usually ask questions about the kinds of things that give you problems and about the timing of your symptoms.

The SLP will also look at your teeth, lips, jaws, tongue, and cheeks. You may need to move these areas in certain ways and make certain sounds. Your SLP may also check how you swallow different consistencies of liquids and foods. All of this is to help determine what phase of swallowing might be causing your problems. It can also give clues about the underlying cause for your dysphagia.

In some cases, you might need follow-up testing to find the source of your dysphagia. These tests can also help find the phase of swallowing that is causing the problems. These might include:

• Modified barium swallow study (MBSS) to show how food is traveling through your upper digestive system and where problems may exist

• Fiberoptic endoscopic evaluation of swallowing (FEES) instead of MBSS to determine how well you swallow

• Pharyngeal manometry if the origin of the dysphagia is still in question, to check the pressure inside your esophagus

How is dysphagia treated?

If possible, your medical team tries to address the underlying cause of dysphagia. In certain cases, you may need surgery to treat the root cause. You also may be able to take medicines to reduce the flow of saliva to address a cause of your dysphagia.

The symptoms of dysphagia also need to be managed. Depending on the specific type of your dysphagia, this might include:

• Changing your diet. This might mean eating soft, mashed, or blended foods, thickening liquids, taking small bites, and eating slowly

• Changing your position while eating. This might mean eating upright, tilting your head back, or bending your neck forward.

• Decreasing distractions during meals, and eating when you are most alert

• Practicing special exercises to strengthen your lips and tongue

• Learning special swallowing methods

As you recover, you might need to use fewer of these steps. Dysphagia after a stroke may greatly improve with time.

Some people are at high risk of aspiration even with these changes. If this is the case for you, you might need a feeding tube to prevent aspiration, at least temporarily.

What are possible complications of dysphagia?

A major complication of dysphagia is lung damage from aspiration.

Aspiration also increases your chance of getting pneumonia. This usually needs treatment with antibiotics. It can sometimes even cause death. With dysphagia, aspiration is always a risk.

Other possible complications include:

• Dehydration

• Poor nutrition and weight loss

• Increased risk of other illnesses

• Social isolation

Key points about dysphagia

• Swallowing is a complex process that involves the coordination of many muscles and nerves. Problems can happen with any of the 3 phases of swallowing.

• The healthcare team uses your symptoms, exams, and tests to help find the phase of swallowing that is causing your problems. This can aid in diagnosis and treatment.

• A speech-language pathologist will help assess and treat dysphagia.

• Complications of dysphagia include aspiration. This is when food or liquid enters your lungs by accident.

• Lifestyle changes, such as dietary changes, surgery, and sometimes medicines are used to treat dysphagia.

Next steps

Tips to help you get the most from a visit to your healthcare provider:

• Know the reason for your visit and what you want to happen.

• Before your visit, write down questions you want answered.

• Bring someone with you to help you ask questions and remember what your provider tells you.

• At the visit, write down the name of a new diagnosis, and any new medicines, treatments, or tests. Also write down any new instructions your provider gives you.

• Know why a new medicine or treatment is prescribed, and how it will help you. Also know what the side effects are.

• Ask if your condition can be treated in other ways.

• Know why a test or procedure is recommended and what the results could mean.

• Know what to expect if you do not take the medicine or have the test or procedure.

• If you have a follow-up appointment, write down the date, time, and purpose for that visit.

• Know how you can contact your healthcare provider if you have questions.