Dysphagia: what causes swallowing difficulties?

Problems with swallowing, known as dysphagia, often cause issues with eating and talking, and needs assessment and treatment. 

What is dysphagia?

Dysphagia is the term given to difficulties with swallowing. It can mean you’re unable to swallow foods or liquids easily and may choke when trying to swallow. Dysphagia is usually caused by problems with your mouth or throat, or by problems with your gullet (oesophagus).

What types of dysphagia are there?

There are two types of dysphagia that affect different stages of the swallowing process.

The act of swallowing occurs in four phases: oral preparatory, oral, pharyngeal and oesophageal. Dysphagia that affects the first three phases is called oropharyngeal dysphagia. When dysphagia affects the final stage, it is called oesophageal dysphagia.

Oropharyngeal dysphagia

Also known as high dysphagia, oropharyngeal dysphagia is caused by problems with your mouth or weakening of your throat muscles. Weakened muscles or a nerve disorder make it difficult to swallow without gagging or choking.

This type of dysphagia can be caused by a range of conditions, many of which primarily affect the nervous system, including:

• Multiple sclerosis
• Nerve damage as a result of surgery or radiation therapy
• Parkinson’s disease
• Post-polio syndrome

Oropharyngeal dysphagia can also be caused by head or neck cancer, or by oesophageal cancer. In some cases, it can be caused by a rare condition called Zenker's diverticulum or a pharyngeal pouch, where food collects in a bulge in your throat (pharynx), causing an obstruction. 

Oesophageal dysphagia

Oesophageal dysphagia feels as though you have something caught in your throat. It can be caused by several things, including:

• Foreign bodies stuck in your throat or oesophagus
• Narrowing of your oesophagus as a result of scarring or growths
• Narrowing or swelling of your oesophagus caused by gastro-oesophageal reflux disease (GERD) or inflammation
• Scar tissues as a result of radiation treatment or chronic (long-term) inflammation
• Spasms in your lower oesophagus
• The formation of oesophageal rings or webs that narrow the oesophagus and cause tightness 

What are the symptoms of dysphagia?

There are several symptoms of dysphagia, which can differ depending on which type you have.

Symptoms of oropharyngeal dysphagia

As well as having to clear your throat often, you may experience coughing or choking when you swallow. Food getting stuck in the throat can lead to:

• Drooling
• Frequent swallowing
• Liquids coming out of your nose
• Pain swallowing
• Taking a long time to chew your food
• Trouble breathing while eating

If you have difficulty swallowing your meals, you may lose interest in food, which can cause weight loss, dehydration and malnutrition.

Symptoms of oesophageal dysphagia

You may experience pain in your chest when you swallow and feel as if food is getting stuck. Other symptoms include:

• Coughing in the night that causes you to wake up
• Lack of interest in food
• Signs of dehydration and malnutrition
• Vomiting after swallowing food
• Weight loss

When should you see a doctor about dysphagia?

If you only have occasional dysphagia, it may help to eat more slowly to ensure that your food is properly chewed before swallowing.

If you have persistent dysphagia, you should make an appointment with your GP to have it investigated.

How is dysphagia diagnosed?

Your GP will ask questions about your symptoms and how they affect you. Depending on your initial assessment, you may be referred for tests and treatment with a speech and language therapist (SLT), a neurologist (a doctor specialising in treating the brain and nervous system) or a gastroenterologist (a doctor specialising in treating the gut).

Tests can include:

• Barium swallow test
• Fibreoptic endoscopic evaluation of swallowing (FEES) — a camera used to check your throat and upper airways
• Videofluoroscopy — X-rays showing your swallowing in real-time

Testing will show which type of dysphagia you have. You may also be referred for other tests if it is likely that your dysphagia is being caused by an underlying health condition.

How is dysphagia treated?

Treatment of dysphagia will depend on the type of dysphagia you’re diagnosed with. If dysphagia is caused by an underlying illness, treating this illness will relieve the issues with swallowing.

Treatments for oropharyngeal dysphagia

This type of dysphagia can be hard to treat as it’s often caused by a condition that affects your nervous system. It therefore can’t usually be treated with medication or surgery. Instead, three main treatments are used to help make eating and drinking as safe as possible:

• Dietary changes — softer foods and thicker fluids are often advised
• Feeding tubes — used for severe cases in the short term (nasogastric tubes) or long term (percutaneous endoscopic gastronomy tube)
• Swallowing therapy — exercises to help you recover or improve your swallowing ability

Treatments for oesophageal dysphagia

The cause of your dysphagia will determine the best course of treatment. Options include:

• Botulinum toxin treatment to help temporarily paralyse and consequently relax tightened muscles — this treatment can last up to six months
• Endoscopic dilation to stretch your oesophagus if it is obstructed or scarred
• Medication — available for certain types of oesophageal dysphagia eg if your dysphagia is caused by scarring of your oesophagus, proton pump inhibitors (PPIs) may help to reduce chronic indigestion that can cause scarring 
• Stent insertion — usually used for dysphagia caused by oesophageal cancer that can’t be removed
• Surgery — depending on the underlying cause of your dysphagia, surgery may be an effective solution