Understanding Dysphagia – More Than Just Difficulty Swallowing 

Dysphagia is a medical term that describes swallowing difficulty, and can range from mild sensations of food getting stuck in the throat to the complete inability to swallow and painful blockage. Dysphagia can be caused by various factors, including neurological and muscle disorders, structural anomalies, muscular problems (like amyotrophic lateral sclerosis), or conditions affecting the esophagus and throat.

There are two types of dysphagia known as Functional Dysphagia and Oropharyngeal Dysphagia. Functional Dysphagia is characterised by typical esophageal symptoms (including chest pain and heartburn), and Oropharyngeal Dysphagia is often the result of impaired muscle function, sensory changes or growths and obstructions in the mouth or throat.

Those who suffer from dysphagia can face significant challenges in their life, including nutritional challenges leading to malnutrition, aspiration risk (when food or liquid enters the lungs), as well as a decreased quality of life and potential for social isolation. 

Common Causes of Dysphagia 

Dysphagia occurs on a spectrum and can be a symptom of a number of different disorders or arise from several underlying causes. These causes can be categorized into three primary groups: neurological, structural, and muscular disorders. Each category encompasses various conditions that interfere with the normal swallowing process.

Neurological Disorders 

A neurological disorder is characterised by damage to the brain, spinal cord, or nerves that control the swallowing mechanism. Strokes are the most common causes of dysphagia in adults, with dysphagia affecting more than 50% of stroke survivors. Other common neurological disorders that cause dysphagia are Parkinson's Disease, Multiple Sclerosis (MS), Amyotrophic Lateral Sclerosis (ALS), Traumatic Brain Injury (TBI), and Cerebral Palsy.  

Structural Abnormalities 

Structural causes of dysphagia relate to physical abnormalities or obstructions in the throat or esophagus, and include:

• Esophageal Strictures: Narrowing of the esophagus due to inflammation, scarring, or tumors.

• Esophageal Webs: A thin membrane-like structure that grows across the inside of the upper esophagus.

• Tumors: Growths in the throat, esophagus, or surrounding areas.

• Diverticula: Pouches that form in the esophagus can trap food.

• Achalasia: When the lower esophageal sphincter fails to relax properly, preventing food from entering the stomach.

• Cricopharyngeal Dysfunction: The cricopharyngeus muscle fails to relax appropriately, causing a blockage during swallowing.

• Throat and Neck Surgery: Surgery in these areas can lead to scarring or altered anatomy that affects swallowing.

Muscular and Autoimmune Conditions 

Primarily involving conditions that weaken or impair the muscles and can include Dysferlinopathy (a genetic muscle conditions that causes muscle weakness and wasting), Myasthenia Gravis (dysphagia affects 15-40% of patients with this autoimmune disorder), Muscular Dystrophies (such as Duchenne wherein one third of young men suffering have reported swallowing difficulties), Polymyositis (an inflammatory muscle disease that causes the throat muscles to weaken) and Scleroderma (a connective tissue disorder that can affect the esophagus's muscularis layer and cause motility issues).

Warning Signs or Symptoms of Dysphagia You Shouldn’t Ignore 

Dysphagia can manifest through various warning signs and symptoms. Recognizing these symptoms early is crucial for preventing complications.

1. Pain When Swallowing (Odynophagia)

Individuals may feel an obstruction, or that food is getting stuck in their throat or chest when attempting to swallow. Swallowing may take longer than usual, and there may be a need to sip fluids or take smaller bites to aid the process without pain.

2. Frequent Choking or Coughing While Eating

Individuals with dysphagia may choke frequently on food or liquids, or cough during or after meals as they struggle to clear the airway. This can occur even with small bites or sips. 

3. Regurgitation

This symptom involves the involuntary return of food back into the mouth after swallowing. It may be associated with a feeling of nausea or a bitter taste due to stomach acid. Regurgitation can indicate underlying conditions such as gastroesophageal reflux disease (GERD), a condition wherein the stomach contents move up into the esophagus, or other esophageal disorders (such as achalasia, esophageal strictures and esophageal cancer).

4. Unexplained Weight Loss

Individuals may unintentionally lose weight due to difficulty eating and drinking. This weight loss can be gradual or sudden and may lead to reduced strength and overall health. Significant weight loss significantly impacts nutritional status and is a potential indicator of an underlying disease process.

5. Feeling of Food Sticking in the Throat or Chest

A persistent sensation that food is lodged in the throat or esophagus, even after swallowing, can point to structural issues or strictures in the esophagus that require further investigation.

6. Changes in Voice or Speech

Alterations in voice quality, such as sounding hoarse or having a wet-sounding voice after swallowing, may occur. This can be a sign of aspiration or improper swallowing mechanics and can reflect neurological involvement or changes in the larynx.

Risks & Complications of Dysphagia 

Dysphagia can lead to several serious risks and complications if not properly managed. The risk factors of dysphagia are generally characterised by the following: 

Malnutrition and Dehydration

Dysphagia can lead to reduced food intake and reduced consumption of essential nutrients, resulting in malnutrition. Malnutrition affects immune function, and causes poor recovery from illnesses or surgery. Individuals with dysphagia will also avoid fluids due to fear of choking or aspiration, leading to complications such as kidney problems, confusion, and increased risk of infection.

Aspiration Pneumonia

Aspiration occurs when food or liquid enters the airway and lungs instead of the esophagus, leading to inflammation and infection. Aspiration Pneumonia is a significant complication of dysphagia and can be life-threatening, particularly in the elderly or those with underlying health issues.

Weight Loss

Unintentional weight loss can occur due to insufficient intake of calories and nutrients. Severe weight loss can reduce muscle strength, impair overall health, and increase the risk of further complications.Social Isolation and Emotional Impact

Challenges associated with eating may lead individuals to avoid social situations, causing isolation and stress. Continuous social withdrawal can contribute to depression and anxiety, impacting mental well-being.

How Dysphagia is Diagnosed: Tests and Evaluations 

The diagnosis of dysphagia is multi-faceted and tailored to the individual’s symptoms and medical history. Diagnosing dysphagia involves a comprehensive evaluation based in research and support for dysphagia, and includes:

Medical History Assessment

• Gather a detailed patient history, including when the symptoms began, their severity, frequency, and any specific triggers (foods, liquids, or situations).

• Review medications that may be impacting swallowing.

• Ask about related symptoms such as pain while swallowing (odynophagia), frequent choking, coughing during meals, weight loss, and any gastrointestinal symptoms (such as heartburn or regurgitation).

Physical Examination

• A physical exam may include inspection of the throat, neck, and mouth for any visible abnormalities or signs of distress during swallowing.

• Neurological examinations can be used to assess motor function, coordination, and the presence of reflexes affecting swallowing.

• An informal assessment can be done to examine how the individual swallows different textures of food or liquids to identify difficulties.

Diagnostic Tests and Evaluations

• Barium Swallow Study (Modified Barium Swallow)

A radiologic imaging test that uses barium and X-rays to create images of your upper gastrointestinal (GI) tract. The aim is to visualize the swallowing process and identify abnormalities in the esophagus or throat.

• Endoscopy (Esophagogastroduodenoscopy or EGD)

An endoscopic procedure allowing direct visualization of the esophagus and surrounding tissues. Involves inserting a flexible tube with a camera (endoscope) through the mouth and down the throat to examine the esophagus and stomach. 

• Esophageal Manometry

An esophageal manometry can be used to see if the esophagus is contracting and relaxing properly. It measures the rhythmic muscle contractions (motility) of the esophagus and helps identify conditions such as achalasia or other motility disorders.

• Fiberoptic Endoscopic Evaluation of Swallowing (FEES)

Used to assess how you swallow, this test involves a thin, flexible tube with a camera being passed through the nose to visualize the throat while the patient swallows various textures of food. 

Treatment for Managing and Overcoming Dysphagia 

The treatment of dysphagia typically depends on its underlying cause. A multidisciplinary approach involving speech-language pathologists, dietitians, and physicians is often required for effective management. However, some more basic treatments are as follows:

Dietary and Texture Modifications

Facilitating the transition to food and drink that are softer or smoother consistencies can help encourage more consistent eating practices. This can mean including more pureed foods, soft foods and thickened food and drinks, which can help minimise the risk of aspiration and promote safe swallowing.

Eating Strategies 

Training on proper eating habits, such as taking smaller bites, chewing thoroughly, and using specific postures while eating (e.g., tilting the head forward) to enhance swallowing safety.

Swallowing Therapy and Exercises 

Customized exercises can strengthen the muscles involved in swallowing and improve coordination and control. The incorporation of Neuromuscular Electrical Stimulation (NMES) can be used to stimulate muscles in the throat, promoting better swallowing function.

Medications

Some medications may be helpful in managing specific causes or symptoms of dysphagia such as the utilisation of Proton Pump Inhibitors (PPIs) or identifying which medications cause dryness or sedation in the throat.

Surgical Interventions

In cases where dysphagia is caused by structural issues, surgical interventions may be necessary. This can include Esophageal Dilation (widening a narrowed esophagus to help relieve strictures), Tumor Resection (surgical removal), Fundoplication (often used for severe GERD), and Pharyngeal Pouch Surgery (for diverticula or pouches in the throat).

• Nutritional Assessment

An evaluation by a dietitian may be conducted to assess dietary adequacy and nutritional needs. This may result in the use of nutrition products, supplements or even enteral feeding (i.e. feeding tubes), as well as ongoing assessments to help track progress and make necessary adjustments.

Dysphagia Care: Research, Support, and Future Outlook 

Dysphagia is a complex condition with wide-ranging implications for those affected. Understanding the causes of dysphagia is crucial for diagnosis and treatment, and effective management is essential for maintaining health, well-being, and quality of life. 

A combination of dietary modifications (such as incorporating softer foods and thickeners), swallowing therapy, medications, and surgical interventions can help improve swallowing safety and enhance quality of life. Collaboration among healthcare professionals and caregivers is essential for effective dysphagia management and treatment. If symptoms of dysphagia arise, prompt diagnosis, evaluation and intervention are key to preventing complications and improving outcomes moving forward.

*If dysphagia is caused by gastroesophageal reflux disease (GERD) or esophagitis, PPIs may help reduce acid levels, decreasing inflammation and associated symptoms.

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