Dysphagia
Introduction
Dysphagia is a medical term for difficulty with swallowing. Some people with dysphagia have problems swallowing certain foods or liquids, while others cannot swallow at all.
Dysphagia is usually caused by another health condition, such as:
Dysphagia can also occur in children as a result of a developmental or learning disability.
See Dysphagia - causes for more information.
Dysphagia can be common in people with certain health conditions, such as those above. It can be either a short- or long-term condition.
Types of dysphagia
There are two types of dysphagia:
- swallowing difficulties caused by problems with the mouth or throat (oropharyngeal or high dysphagia)
- swallowing difficulties caused by problems with the oesophagus (oesophageal or low dysphagia)
Outlook
Dysphagia can lead to:
Some people with dysphagia have a tendency to develop chest infections, such as aspiration pneumonia, which may require medical treatment. This is more likely to occur in people with medical conditions.
See Dysphagia - complications for more information about aspiration pneumonia.
Dysphagia can also affect a person’s quality of life because it may prevent them from enjoying meals and social occasions.
Depending on the cause of dysphagia, there are several treatments, including:
- speech and language therapy to learn new swallowing techniques
- changing the consistency of food and drinks to make them safer to swallow
- alternative forms of feeding, such as tube feeding through the nose or stomach, if swallowing is unsafe
- treating the narrowing of the oesophagus by stretching or inserting a metal tube
See Dysphagia - treatment for more information about the different treatment options available.
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Symptoms
The symptoms of dysphagia include:
- coughing or choking when eating or drinking
- not being able to swallow
- pain when swallowing
- bringing food back up, sometimes through the nose
- a sensation that food is stuck in the throat or chest
Longer-term symptoms may include:
- unexplained weight loss
- developing repeated and frequent chest infections
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Causes
We usually take swallowing for granted, but it is a very complicated process that involves around 50 pairs of muscles and many nerves.
Dysphagia, the medical name for difficulty with swallowing, can be caused by anything that affects any of the nerves, muscles or passageways used during swallowing.
Some causes of dysphagia are explained below.
Neurological causes
The word neurological refers to the nervous system. This is made up of the brain, nerves and spinal cord.
Damage to the nervous system can interfere with the nerves responsible for starting and controlling swallowing. This can lead to dysphagia.
Some neurological causes of dysphagia include:
Congenital and developmental conditions
Congenital means something you are born with. Developmental conditions affect the way you develop.
Congenital or developmental conditions that may cause dysphagia in children include:
- learning disabilities - where your child finds learning, understanding and communicating difficult
- cerebral palsy - a group of neurological conditions that affect a child's movement and co-ordination
Obstruction
Health conditions that cause an obstruction in the throat or a narrowing of the oesophagus can make swallowing difficult. The oesophagus is the tube that carries food from the mouth to the stomach.
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
- radiotherapy treatment, where doses of high-energy radiation are used to destroy cancer cells - it can cause scar tissue, which narrows the passageway in your throat and oesophagus
- gastro-oesophageal reflux disease (GORD), a condition where stomach acid leaks back up into the oesophagus - the acid can cause scar tissue to develop, narrowing your oesophagus
- infections, such as tuberculosis or thrush, which can lead to the inflammation of the oesophagus, known as oesophagitis
Muscular conditions
Any condition that affects the muscles used to push food down the oesophagus and into the stomach can cause dysphagia. However, such conditions are very rare.
Two muscular conditions associated with dysphagia are:
- scleroderma - where the immune system (the body’s natural defence system) attacks healthy tissue, leading to a stiffening of the throat and oesophagus muscles
- achalasia - where the muscles in the oesophagus become too stiff to allow food or liquid to enter the stomach
Other causes
As you get older, the muscles that are used to swallow can become weaker. This may explain why dysphagia is relatively common in elderly people. However, dysphagia should not simply be accepted as part of the ageing process and treatment is available to help people with age-related dysphagia.
Chronic obstructive pulmonary disease (COPD) is a collection of lung diseases that make it difficult to breathe in and out properly. Breathing difficulties can sometimes affect your ability to swallow.
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Diagnosis
See your GP if you are having difficulty swallowing. They will carry out an initial assessment and may refer you to another healthcare professional for further tests and treatment.
The aim of diagnosing dysphagia is to:
- determine whether it is due to a problem with the mouth or throat (called oropharyngeal or high dysphagia), or the oesophagus (the tube that carries food from the mouth to the stomach, called oesophageal or low dysphagia)
- assess how your ability to swallow has been affected
- maintain your levels of food and fluids
- minimise the risks associated with dysphagia, such as choking, poor nutrition and chest infections
Recent medical history
Your GP will ask you some questions about your dysphagia symptoms, such as:
- how long you have 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 have lost any weight
Referral to a specialist
Depending on the suspected cause of your dysphagia, your GP may refer you for further tests with:
- an ear, nose and throat (ENT) specialist
- a speech and language therapist (SLT)
- a neurologist - a specialist in treating conditions that affect the brain, nerves and spinal cord
- a gastroenterologist - a specialist in treating conditions of the stomach and intestines
Some further tests that you may have are explained below.
Water swallow test
A water swallow test can give a good initial assessment of your swallowing abilities. You will be given 150ml of water and asked to swallow it as quickly as possible. Your specialist will record how long it takes you to drink all the water and the number of swallows required.
You may also be asked to carry out a variation of the water swallow test that involves swallowing a soft piece of pudding or fruit.
Barium swallow test
The barium swallow test is one of the most effective ways of assessing your swallowing ability and finding exactly where the problems are occurring. The test can often identify blockages or problems with the muscles used during swallowing.
As part of the test, you will be asked to drink some barium solution. Barium is a non-toxic chemical that is widely used in tests because it shows up clearly on an X-ray. Once the barium moves down into your upper digestive system, a series of X-rays will be taken to identify any problems.
Diagnostic gastroscopy
Diagnostic gastroscopy is also known as diagnostic endoscopy of the stomach or OGD (which stands for oesophagogastroduodenoscopy). It is an internal examination using an endoscope. An endoscope is a long, thin, flexible tube that has a light source and a camera at one end.
The endoscope will be passed down your throat and into your oesophagus. Images of the inside of your body will then be shown on a television screen.
The endoscope can often detect the presence of cancerous growths or scar tissue caused by gastro-oesophageal reflux disease (GORD), a condition where stomach acid leaks back up into the oesophagus.
An endoscopy can also be used to provide treatment, such as stretching your oesophagus using a balloon or a bougie (thin, flexible medical instrument). The procedure can also be used to insert metal stents. See Dysphagia - treatment for more information about these treatments. The treatment used will depend on what is causing the narrowing of your oesophagus.
Nutritional assessment
If dysphagia has affected your ability to eat, you may need a nutritional assessment to check that you are not lacking nutrients (malnourished). This could involve:
- measuring your weight
- calculating your body mass index (BMI) to check that you are a healthy weight for your height
- carrying out blood tests
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Treatment
Treatment for dysphagia will depend on:
- whether the difficulty with swallowing occurs in the mouth or throat (called oropharyngeal or high dysphagia), or in the oesophagus (the tube that carries food from the mouth to the stomach, known as oesophageal or low dysphagia)
- the cause of your dysphagia (see Dysphagia - causes for more information)
High (oropharyngeal) dysphagia
High dysphagia is where swallowing difficulties are caused by problems with the mouth or throat.
High dysphagia can be difficult to treat if the problems are due to a condition that affects the nervous system. This is because these problems cannot usually be corrected using medication or surgery.
The exception is dysphagia caused by Parkinson’s disease, a long-term condition that affects the way the brain co-ordinates body movements, or myasthenia gravis, a long-term condition that affects the muscles used in swallowing. It may be possible to control the symptoms of dysphagia caused by these conditions using medication.
Research has been carried out into the medication used to treat dysphagia in Parkinson’s disease. So far, this has had mixed results, and larger studies are needed to determine whether this treatment is successful. See Parkinson’s disease - treatment and Myasthenia gravis - treatment for more information about the medicines used to treat these conditions.
There are three main treatment options for high dysphagia:
- swallowing therapy
- dietary changes
- feeding tubes
These treatment options are described below.
Swallowing therapy
If you have high dysphagia, you may be referred to a speech and language therapist (SLT) for swallowing therapy. An SLT is a healthcare professional who has been trained to work with people with feeding or swallowing difficulties.
SLTs use a range of techniques that can be tailored for your specific problem. Only use the techniques that your SLT teaches you as not every technique will be suitable or effective. For example, some techniques may be difficult or less effective in people with a neurological condition.
Dietary changes
You may be referred to a dietitian for advice about changing your diet. A dietitian is a healthcare professional who specialises in nutrition. They can advise you about making dietary changes as well as ensuring that you receive a healthy, balanced diet. For example, softer foods may be easier to eat and thickened fluids may be easier to drink.
An SLT may also speak to members of your family or your carers to make sure you are getting the support that you need at meal times. They may also try to increase your confidence with eating, for example by helping you overcome a fear of choking when you eat.
Feeding tubes
Feeding tubes can be used to provide nutrition while you are recovering your ability to swallow. They may also be required in severe cases of dysphagia that put you at risk of malnutrition and dehydration (when you are not getting enough nutrients or fluid).
There are two types of feeding tubes:
- a tube that is passed down your nose and into your stomach (nasogastric tubes)
- a tube that is surgically implanted directly into your stomach (percutaneous endoscopic gastrostomy, or PEG, tubes)
Nasogastric tubes are designed for short-term use and may be considered if you are likely to need a feeding tube for up to six weeks. The tube will need to be replaced and swapped to the other nostril after four to six weeks. PEG tubes are designed for long-term use and last for around two years before they need to be replaced.
Most people with dysphagia prefer to use a PEG tube because the equipment can be easily hidden under clothing. However, PEG tubes carry a greater risk of complications compared to nasogastric tubes.
Minor complications of PEG tubes include:
- tube displacement
- skin infection
- tube blockage
- tube leakage
Major complications of PEG tubes include:
- internal bleeding
- infection
People who use PEG tubes may also find it more difficult to resume normal feeding compared with those who use nasogastric tubes. This may be because the convenience of PEG tubes means people who use them are less willing to carry out swallowing exercises and dietary changes compared to people who use nasogastric tubes.
Discuss the advantages and disadvantages of both feeding tubes with your treatment team.
Low (oesophageal) dysphagia
Low dysphagia is where swallowing difficulties are due to problems with the oesophagus.
Medication
Depending on the cause of low dysphagia, it may be possible to treat it with medication. For example, proton pump inhibitors (PPIs), which are used to treat indigestion, may improve symptoms caused by narrowing or scarring of the oesophagus.
Botulinum toxin
Botulinum toxin can be used to treat achalasia. This is a condition where the muscles in the oesophagus become too stiff to allow food and liquid to enter the stomach.
Botulinum toxin is a powerful poison that is safe to use in very small doses. The toxin can be used to paralyse the overly stiff muscles that are preventing food from reaching the stomach. However, the effects only last for around six months.
Surgery
Other cases of low dysphagia can usually be treated with surgery.
Endoscopic dilatation
Endoscopic dilation is widely used to treat dysphagia caused by obstruction. It can also be carried out to stretch your oesophagus if it is scarred.
Endoscopic dilatation will be carried out during a diagnostic gastroscopy, also known as OGD (which stands for oesophagogastroduodenoscopy). OGD is an internal examination using an endoscope. An endoscope is a long, thin, flexible tube that has a light source and a camera at one end.
During the procedure, the endoscope is passed down your throat and into your oesophagus. Images of the inside of your body are shown on a television screen. Using the image as guidance, a small balloon or a bougie (a thin, flexible medical instrument) is passed through the narrowed area of your oesophagus to widen it. If a balloon is used, it is inflated to gradually widen your oesophagus before being deflated and removed.
You may be given a mild sedative before the procedure to relax you. There is a small risk that the procedure could cause a tear or perforation to your oesophagus.
Stent insertion
If you have oesophageal cancer that cannot be removed by surgery, it is usually recommended that you have stent insertion instead of endoscopic dilatation. This is because if you have cancer, there is a higher risk of perforating your oesophagus if it is stretched.
Stent insertion involves inserting a metal mesh tube, called a stent, into your oesophagus. The procedure can be performed during OGD (see above) or under X-ray guidance.
After it is inserted, the stent gradually expands in the tumour. This creates a passage that is big enough to allow food to pass through your narrowed oesophagus. To keep the stent open without blockages, you will need to follow a particular diet. You will be advised about this, but it is likely to include sloppy or soft food and fizzy drinks.
Congenital dysphagia
If your baby is born with difficulty swallowing, known as congenital dysphagia, their treatment will depend on the cause.
Dysphagia caused by cerebral palsy
Cerebral palsy is a condition that affects a child's movement and co-ordination. It can be treated with speech and language therapy (SLT) to teach your child how to swallow, adjusting the type of food they eat and using feeding tubes.
Cleft lip and palate
Cleft lip and palate is a facial birth defect that can cause dysphagia. It is usually treated with surgery.
Dysphagia caused by narrowing of the oesophagus
This may be treated with a type of surgery called dilatation to widen the oesophagus.
Dysphagia caused by gastro-oesophageal reflux disease (GORD)
Dysphagia caused by GORD can be treated by using special thickened feeds instead of your usual breast or formula milk, and sometimes with medication.
Breastfeeding or bottle feeding
If you are having difficulty bottle feeding or breastfeeding your baby:
- See your midwife, health visitor or GP.
- Call the National Breastfeeding Helpline on 0300 100 0212.
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Complications
The main complication of dysphagia is coughing and choking, which can lead to aspiration pneumonia.
Coughing and choking
If you have dysphagia, there is a risk of food, drink or saliva going down the "wrong way". It can block your airway, making it difficult to breathe and causing you to cough or choke.
Something that goes down the wrong way can enter your lungs, which may cause a chest infection such as aspiration pneumonia.
Aspiration pneumonia
Aspiration pneumonia is a chest infection that is caused by breathing in a small piece of food or a harmful substance, such as smoke. The object or substance that is inhaled causes irritation in the lungs or damages them.
The symptoms of aspiration pneumonia include:
- a cough - this may be a dry cough or you may produce phlegm that is yellow, green, brown or blood-stained
- a high temperature of 38C (100.4F) or over
- chest pain
- difficulty breathing - your breathing may be rapid and shallow and you may feel breathless even when you are resting
If you are being treated for dysphagia and you develop these symptoms, immediately contact the healthcare professionals who are treating you. If this is not possible, contact your local out-of-hours service or call NHS Direct on 0845 4647.
The symptoms of aspiration pneumonia can range from mild to severe and are usually treated with antibiotics. Severe cases will require hospital admission and treatment with antibiotics through a drip.
See the topic about Pneumonia - treatment for more information about this condition.
In particularly frail people, there is a chance that the infection could lead to their lungs becoming filled with fluid, preventing them from working properly. This is known as acute respiratory distress syndrome (ARDS).
See the topic about Respiratory distress syndrome for more information about ARDS.
Dysphagia in children
If children with long-term dysphagia are not eating enough, they may not get the essential nutrients they need. This could affect their brain development.
Children who have difficulty eating may also find meal times stressful, which may lead to behavioural problems.
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