Swallowing Difficulty

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How do I know if I have dysphagia (difficulty swallowing)?

Patients may experience dysphagia, or difficulty swallowing, in different ways. These include:

• Sensation that food gets stuck or held up in the throat or chest during the attempted swallow

• Discomfort or pain in the throat or chest as the food is swallowed

• Sensation that food or drink is slow or hindered passing down the throat and/or chest

• Need to chew very carefully, eat very slowly, or sip on water to ‘flush’ the food down

• Need to repetitively swallow to get food past the throat

• Inability or difficulty in initiating the swallow after food has been chewed in the mouth

• Sensation that food or drink ‘goes down the wrong way’ when swallowing, sometimes making the patient cough

• Swallowed food coming back out the nose

 

All of the above symptoms are always abnormal, and indicate a problem with the swallowing mechanism. As such if any of these symptoms are present they warrant evaluation by a gastroenterologist who specialises in swallowing disorders.

 

Are there other symptoms that occur in patients with dysphagia, or difficulty swallowing?

Yes, difficulty swallowing may or may not be accompanied by the following symptoms, and the presence and severity of these associated symptoms can often provide a clue as to the underlying cause:

• Regurgitation (effortlessly bringing up swallowed food or fluid; NB: this is different to vomiting)

• Chest pain

• Weight loss

 

Is dysphagia dangerous?

The prognosis for dysphagia is entirely dependent on the underlying cause – ranging from very dangerous conditions (e.g. cancer) to completely benign conditions that can be treated simply during a regular endoscopy procedure. This makes it imperative that a thorough evaluation by a specialist gastroenterologist whenever a person is experiencing difficulty swallowing.

 

Apart from the troublesome symptoms, the main adverse consequence dysphagia (difficulty swallowing) can cause when severe is impaired nutrition, due to the patient’s inability to swallow sufficient food.

 

What causes difficulty swallowing (dysphagia)

Broadly, dysphagia can be divided by location affected (pharynx vs. oesophagus) and the type of disorder (structural vs. motor).

 

Location

Dysphagia may be divided into disorders of the 

• Pharynx (throat), or 

• Oesophagus (food pipe or gullet). 

 

It is important to note that where the patient perceives the problem (i.e., throat or chest) cannot be used to determine the true location of the problem, as sometimes oesophageal disorders may be referred to the throat.

 

Type of Disorder

Dysphagia may also be broadly subdivided into:

• Structural conditions (anatomical abnormalities in the upper gastrointestinal tract which physically impede the transit of swallowed food and/or fluid), or 

• Motor or motility disorders (disorders affecting the muscles and/or nerves involved with the swallowing)

 

What conditions cause dysphagia (difficulty swallowing)?

There are many conditions that can cause dysphagia. Some of the more common ones are listed below, divided by location and type of disorder.

 

Structural oesophageal disorders

• Oesophageal cancer

• Oesophageal stricture due to acid reflux, radiotherapy to chest, ingestion of caustic substances, or prior surgery of the upper gastrointestinal tract

• Eosinophilic oesophagitis

 

Motility disorders of the oesophagus

• Achalasia

• Scleroderma

• Oesophageal spasm

 

Structural pharyngeal disorders

• Cervical oesophageal web

• Throat cancer

• Pharyngeal stricture due to radiotherapy to throat, or prior surgery to the neck

• Zenker’s diverticulum or other pharyngeal pouch

 

Motor disorders of the pharynx

• Stroke

• Neurological disorders, e.g. Parkinson’s disease, myasthenia gravis

• Muscle inflammation, e.g. myositis

 

The list above is not exhaustive and many other possibilities exist.

 

 

How is the cause of dysphagia (difficulty swallowing) diagnosed?

The first step is thorough history-taking (asking questions about your symptoms). A skilled specialist with expertise in this area can in the majority of the cases narrow down the likely cause of dysphagia by careful questioning of your symptoms.

 

History-taking is usually complemented by one or more investigations, to conclusively make a diagnosis.

 

What tests or investigations are required to diagnose the cause of difficulty swallowing?

In the past, swallowing disorders were difficult to manage because of poor diagnostic tools. However, the last decade or more has seen significant advances in the technologies used to diagnose the cause of dysphagia. This means that now, a clear diagnosis can be made in the majority of such patients.

 

The tests include one or more of:

• Endoscopy: This is usually the first test undertaken to diagnose dysphagia. Under sedation, a camera is inserted through the patient’s mouth to view the pharynx (throat), oesophagus and stomach. Endoscopy is a good test to rule out cancer, and for identifying structural disorders of the oesophagus and pharynx. At endoscopy, biopsies of the oesophagus should be taken to rule out microscopic inflammatory disorders of the oesophagus which can cause dysphagia.

• Oesophageal Manometry: If endoscopy is normal, and especially where a motility disorder of the oesophagus is suspected, the test of choice is oesophageal manometry. This is the gold standard for the diagnosis of oesophageal motility disorders. 

• Barium swallow: An x-ray test where barium is swallowed and x-rays taken to identify how well the barium passes through while swallowing. It is not as accurate as manometry for diagnosis of oesophageal motor function (motility), but sometimes provides complementary information. It also provides information about the structure of the oesophagus, but in general is not as good as endoscopy in this regard.

• Modified barium swallow (video fluoroscopic swallow study): Similar to the barium swallow, but focusing exclusively on the pharynx (throat). This is performed by a speech pathologist. It is the test of choice to diagnose motor disorders of the pharynx.

 

 

What are the treatments available for difficulty swallowing (dysphagia)?

There is no one size fits all treatment for dysphagia. The treatment is tailored to the specific diagnosis, which makes it vital that a correct diagnosis is made. The good news is that nowadays with improvement in diagnostic modalities, a clear diagnosis can be made in the majority of patients, and effective therapy is also available for the majority of conditions that cause dysphagia. Broadly, some of the potential treatment options include:

• Medications

• Oesophageal dilatation via endoscopy

• Other endoscopic therapies, including injections

• Surgery

• Dietary modifications

• Swallow therapy (exercises)

 

 

Who do I see for help with difficulty swallowing (dysphagia) in Sydney?

You need to see a gastroenterologist who specialises in swallowing and is experienced in diagnosing and treating any of the potential conditions that are causing your symptoms. Contact A/Prof Santosh Sanagapalli to arrange a consultation and assessment today.