Dysphagia: Causes, Symptoms & Treatment for Swallowing Difficulty

What Is Dysphagia and How Common Is It?

Dysphagia is the medical term for difficulty swallowing food, liquids, or saliva. It affects approximately 8-22% of adults over 50 years old, with prevalence rising to 50-75% in nursing home residents. Dysphagia can range from mild discomfort to complete inability to swallow, significantly impacting nutrition and quality of life.

Swallowing is a complex process that most people take for granted. It involves over 50 muscles and many nerves working together in a precisely coordinated sequence. When any part of this process is disrupted, dysphagia can occur. The condition may develop suddenly, such as after a stroke, or gradually worsen over time due to progressive neurological conditions or aging.

Understanding dysphagia requires recognizing that swallowing occurs in three distinct phases. The oral phase involves chewing food and forming it into a ball (bolus) that can be swallowed. The pharyngeal phase is the reflexive swallowing action where the food moves from the mouth through the throat while the airway is protected. The esophageal phase involves the food traveling down the esophagus to the stomach through wave-like muscle contractions called peristalsis.

Problems can occur at any of these phases, and the location of the difficulty helps determine the type of dysphagia and its likely causes. Oropharyngeal dysphagia affects the first two phases and is often related to neurological conditions, while esophageal dysphagia affects the final phase and is typically caused by structural or motility problems in the esophagus.

Who is most at risk for dysphagia?

While anyone can develop swallowing difficulties, certain groups face higher risk. Age is a significant factor, as the muscles involved in swallowing naturally weaken over time, a process called presbyphagia. People with neurological conditions such as stroke, Parkinson's disease, multiple sclerosis (MS), or amyotrophic lateral sclerosis (ALS) commonly experience dysphagia. Those who have undergone head and neck cancer treatment, particularly radiation therapy, are also at elevated risk.

Additionally, conditions affecting the esophagus such as gastroesophageal reflux disease (GERD), eosinophilic esophagitis, or esophageal cancer can lead to swallowing difficulties. Certain medications, particularly those that cause dry mouth, may also contribute to dysphagia symptoms.

What Are the Symptoms of Dysphagia?

Common symptoms of dysphagia include choking or coughing while eating, feeling that food is stuck in the throat or chest, needing multiple swallows to clear food, pain when swallowing, drooling, regurgitation, and unintentional weight loss. Symptoms vary depending on whether the problem is in the throat or esophagus.

The symptoms of dysphagia can vary significantly depending on the underlying cause and the phase of swallowing that is affected. Some people experience obvious difficulties that significantly impact their daily lives, while others may have subtle symptoms that develop gradually and are initially easy to overlook. Recognizing the full range of symptoms is important for early detection and treatment.

People with oropharyngeal dysphagia, which affects swallowing in the mouth and throat, typically experience difficulty initiating the swallow. They may cough or choke when trying to swallow, particularly with liquids, which are often harder to control than solid foods. Food may go "down the wrong pipe," entering the airway instead of the esophagus. This is called aspiration and can lead to frequent respiratory infections if it occurs regularly.

Esophageal dysphagia, affecting the food pipe, typically presents differently. People often describe feeling like food gets stuck behind the breastbone or in the chest. There may be a sensation of food not moving down properly, and regurgitation of undigested food can occur. Unlike oropharyngeal dysphagia, choking is less common because the initial swallowing reflex works normally.

Common signs to watch for

• Choking or coughing: During or immediately after eating or drinking
• Wet or gurgly voice: After swallowing, indicating residue in the throat
• Throat clearing: Frequent need to clear the throat during meals
• Food sticking sensation: Feeling that food is lodged in the throat or chest
• Multiple swallowing attempts: Needing to swallow several times to clear each bite
• Drooling: Difficulty controlling saliva, especially during meals
• Weight loss: Unintentional weight loss due to eating less or avoiding certain foods
• Heartburn or chest pain: Discomfort that may indicate esophageal problems
• Recurrent pneumonia: Lung infections caused by food or liquid entering the airways

Warning signs that need immediate attention

Some symptoms associated with swallowing problems require urgent medical evaluation. If you experience sudden onset of dysphagia along with slurred speech, facial drooping, or arm weakness, these could be signs of a stroke and require emergency care. Complete inability to swallow your own saliva, severe pain when swallowing, or difficulty breathing associated with swallowing problems also warrant immediate medical attention.

What Causes Difficulty Swallowing?

Dysphagia can be caused by neurological conditions (stroke, Parkinson's disease, MS, ALS, dementia), structural problems (tumors, strictures, Zenker's diverticulum), esophageal disorders (GERD, achalasia, eosinophilic esophagitis), muscle disorders, and aging-related changes. Identifying the cause is essential for effective treatment.

The causes of dysphagia are numerous and varied, reflecting the complexity of the swallowing mechanism. Understanding the underlying cause is crucial because treatment approaches differ significantly depending on what is causing the swallowing difficulty. Causes can be broadly categorized into neurological conditions, structural abnormalities, muscular disorders, and esophageal conditions.

Neurological causes are among the most common, particularly stroke, which can damage the brain areas controlling swallowing. Parkinson's disease affects swallowing through its impact on muscle coordination and timing. Multiple sclerosis can interrupt nerve signals to swallowing muscles. Amyotrophic lateral sclerosis (ALS) progressively weakens the muscles used for swallowing. Dementia can affect the cognitive aspects of eating and swallowing, leading people to forget to chew properly or hold food in their mouths without swallowing.

Structural causes involve physical changes that obstruct or narrow the swallowing pathway. Tumors in the mouth, throat, or esophagus can block the passage of food. Esophageal strictures, which are areas of narrowing, can develop from scarring due to chronic acid reflux or other injuries. Zenker's diverticulum is a pouch that forms at the junction of the throat and esophagus, where food can collect and cause regurgitation.

Esophageal conditions causing dysphagia

Several conditions specifically affecting the esophagus can lead to swallowing difficulties. Gastroesophageal reflux disease (GERD) can cause inflammation and scarring of the esophagus, leading to strictures. Achalasia is a rare condition where the muscles of the lower esophagus fail to relax properly, making it difficult for food to enter the stomach. Eosinophilic esophagitis is an allergic condition causing inflammation that can lead to food impaction.

Other esophageal causes include esophageal webs and rings, which are thin membranes of tissue that can partially block the esophagus, and esophageal motility disorders such as diffuse esophageal spasm, where abnormal contractions interfere with the normal movement of food.

Other contributing factors

• Dry mouth (xerostomia): Often caused by medications, radiation therapy, or Sjögren's syndrome
• Weakened jaw muscles: Affecting the ability to chew food properly
• Radiation therapy: Treatment to the head and neck can cause scarring and muscle damage
• Surgery: Operations on the throat, esophagus, or neck can affect swallowing
• Aging (presbyphagia): Natural weakening of swallowing muscles with age
• Medications: Some drugs can affect muscle function or cause dry mouth

What Can I Do to Help Myself with Swallowing Difficulties?

Self-care strategies for dysphagia include eating slowly, taking small bites, chewing thoroughly, sitting upright while eating, avoiding talking during meals, staying upright for 30 minutes after eating, and keeping the mouth clean. Texture modifications like softened foods or thickened liquids may also help.

While professional medical evaluation is important for persistent swallowing problems, there are many practical strategies you can use to make eating safer and more comfortable. These self-care measures can significantly reduce the risk of choking and aspiration while helping you maintain adequate nutrition. They are often used alongside medical treatment as part of a comprehensive management approach.

The way you eat matters as much as what you eat when managing dysphagia. Taking your time during meals is essential. Rushing increases the risk of food entering the airway. Plan meals when you won't feel hurried, and create a calm eating environment without distractions. Many people with swallowing difficulties find that eating smaller, more frequent meals is easier than three large meals.

Proper positioning during and after eating plays a crucial role in safe swallowing. Always sit fully upright, ideally at a 90-degree angle, when eating or drinking. This position uses gravity to help move food toward the stomach and reduces the risk of aspiration. Avoid reclining or lying down immediately after eating - remain upright for at least 30 minutes to allow food to move through the esophagus.

Practical eating tips

• Take small bites and sips: Smaller amounts are easier to control and swallow safely
• Chew thoroughly: Break food down completely before attempting to swallow
• Swallow before taking more: Clear your mouth completely before the next bite or sip
• Alternate food and drink: Taking a small sip of liquid between bites can help clear residue
• Avoid mixing textures: Foods that combine liquids and solids (like soup with chunks) can be difficult
• Keep your chin level or slightly tucked: Avoid tilting your head back to swallow
• Don't talk while eating: Speaking with food in your mouth increases aspiration risk
• Cough or clear your throat if needed: Don't suppress the urge to clear your airway

Maintaining oral hygiene

Good oral hygiene is particularly important for people with dysphagia. Bacteria from the mouth can cause serious lung infections if aspirated into the airways. Brush your teeth with fluoride toothpaste twice daily and clean between teeth with floss or interdental brushes. Rinse your mouth after meals to remove any food residue that may have collected in the cheeks or around the gums. If you have dry mouth, saliva substitutes or stimulating products can help.

When Should You See a Doctor for Swallowing Problems?

See a doctor if your swallowing difficulties are new and not from a cold, persist more than one month, cause unintentional weight loss, or don't improve with self-care. Seek emergency care for complete inability to swallow, severe breathing difficulties, sudden onset with stroke symptoms, or food stuck that won't pass.

While occasional minor swallowing discomfort is common and usually not serious, persistent or worsening symptoms warrant professional medical evaluation. Early diagnosis and treatment can prevent complications such as malnutrition, dehydration, and aspiration pneumonia. Knowing when to seek care versus when to try self-management strategies is an important part of managing your health.

You should schedule an appointment with your doctor if your swallowing problems are new and not related to a temporary illness like a cold or sore throat. Difficulties that persist for more than one month, regardless of whether they seem mild, should be evaluated. Unintentional weight loss is a particularly important warning sign, as it suggests the swallowing problems are significantly affecting your nutrition. If the self-care strategies described earlier don't seem to help, professional assessment is needed.

Preparing for your doctor's appointment

When you see your doctor about swallowing difficulties, being prepared can help ensure a thorough evaluation. Note when your symptoms started, whether they're constant or intermittent, and what makes them better or worse. Keep track of which foods or liquids cause the most difficulty. Document any associated symptoms such as heartburn, pain, regurgitation, or weight changes. Bring a list of all medications you take, as some can contribute to swallowing problems.

How Is Dysphagia Diagnosed?

Dysphagia is diagnosed through clinical evaluation, followed by tests such as videofluoroscopic swallowing study (barium swallow), endoscopy, esophageal manometry, and/or CT/MRI imaging. A speech-language pathologist often performs a bedside swallowing assessment to determine the safest foods and liquids.

Diagnosing dysphagia involves identifying not only that a swallowing problem exists but also its cause and severity. This typically requires a combination of clinical assessment and specialized tests. The diagnostic approach is tailored based on your symptoms, medical history, and which phase of swallowing appears to be affected.

Your initial evaluation will involve a detailed medical history and physical examination. The doctor will ask about your symptoms, when they started, and what types of foods or liquids cause problems. They will examine your mouth and throat and may ask you to swallow water while they observe. Based on this assessment, they will recommend appropriate diagnostic tests.

Examination of the mouth, throat, and esophagus

A physician can directly examine your mouth and throat, looking for any visible abnormalities, signs of weakness, or coordination problems. Endoscopy (also called upper GI endoscopy or esophagogastroduodenoscopy) allows the doctor to visualize the esophagus and stomach using a flexible tube with a camera. During this procedure, tissue samples (biopsies) can be taken to check for conditions such as inflammation, infection, or cancer.

X-ray and imaging studies

The videofluoroscopic swallowing study (VFSS), also known as a modified barium swallow, is considered the gold standard for evaluating oropharyngeal dysphagia. During this test, you swallow foods and liquids mixed with barium contrast while X-ray video records the swallowing process in real time. This allows clinicians to see exactly where problems occur and whether food or liquid enters the airway.

Esophageal X-ray with barium can show the shape and structure of the esophagus, revealing strictures, webs, rings, or areas of narrowing. The movement of barium through the esophagus also provides information about motility.

Specialized tests

Esophageal manometry measures pressure and muscle contractions throughout the esophagus. A thin tube with pressure sensors is passed through the nose into the esophagus while you swallow. This test is particularly useful for diagnosing motility disorders such as achalasia.

Fiberoptic endoscopic evaluation of swallowing (FEES) uses a flexible scope passed through the nose to directly visualize the throat during swallowing. It can be performed at the bedside and is useful for patients who cannot travel to radiology.

How Is Dysphagia Treated?

Dysphagia treatment depends on the underlying cause and may include swallowing therapy with a speech-language pathologist, dietary modifications (texture-modified foods, thickened liquids), medications, esophageal dilation for strictures, botulinum toxin injections, surgery, or in severe cases, alternative feeding methods like feeding tubes.

Treatment for dysphagia is highly individualized based on the cause, type, and severity of swallowing difficulties. The goal is to ensure safe and adequate nutrition while addressing the underlying problem when possible. Many people see significant improvement with appropriate treatment, though some conditions require ongoing management.

For oropharyngeal dysphagia, swallowing therapy with a speech-language pathologist (SLP) is often the cornerstone of treatment. The SLP can teach exercises to strengthen the muscles used for swallowing, techniques to improve coordination, and strategies to make swallowing safer. These might include specific head positions during swallowing, the "effortful swallow" technique, or the "Mendelsohn maneuver" to prolong the opening of the upper esophageal sphincter.

Advice from speech-language pathologists

A speech-language pathologist specializing in swallowing disorders can provide personalized guidance on which food and liquid consistencies are safest for you. They may recommend texture-modified diets ranging from pureed foods to soft and bite-sized, depending on your specific difficulties. Liquid consistency modifications, from thin to honey-thick or pudding-thick, may also be recommended to reduce aspiration risk.

Beyond dietary recommendations, the SLP will teach you specific swallowing techniques and exercises. These are tailored to your particular difficulties and may need to be practiced regularly to be effective. The goal is to improve your swallowing function over time while keeping you safe in the meantime.

Advice from dietitians

A registered dietitian can help ensure you're getting adequate nutrition despite dietary restrictions. They can suggest calorie-dense foods that are easy to swallow, recommend nutritional supplements if needed, and help you plan meals that are both safe and appetizing. Maintaining good nutrition is essential for healing and overall health.

Esophageal dilation

For esophageal strictures (areas of narrowing), dilation is often effective. During this procedure, performed during endoscopy, the doctor gently stretches the narrowed area using balloons or graduated dilators. Multiple dilation sessions may be needed, and in some cases, the procedure needs to be repeated periodically if the stricture recurs.

Surgery for Zenker's diverticulum

A Zenker's diverticulum is a pouch that forms at the junction of the throat and esophagus. Food can collect in this pouch and be regurgitated. Treatment typically involves surgery to either remove the pouch or create a wider opening between the pouch and esophagus so food drains more easily. This can often be done endoscopically rather than through an open surgical approach.

Alternative feeding when needed

In severe cases where oral feeding is unsafe or insufficient, alternative nutrition may be necessary. A nasogastric tube passes through the nose to the stomach and can provide nutrition temporarily. For longer-term needs, a gastrostomy tube (G-tube or PEG tube) is surgically placed directly through the abdominal wall into the stomach. These feeding methods can be used temporarily while treating the underlying condition or permanently if swallowing function cannot be adequately restored.

What Are the Complications of Untreated Dysphagia?

Untreated dysphagia can lead to aspiration pneumonia (lung infection from inhaled food or liquid), malnutrition, dehydration, weight loss, reduced quality of life, and social isolation. Aspiration pneumonia is particularly serious in elderly patients and those with weakened immune systems.

Understanding the potential complications of dysphagia underscores the importance of seeking evaluation and treatment. The most immediate concern is aspiration, where food, liquid, or saliva enters the airway instead of the esophagus. While healthy individuals can usually cough to clear aspirated material, people with weakened cough reflexes or immune systems are at risk for developing aspiration pneumonia, a serious lung infection.

Aspiration pneumonia is a significant cause of illness and death, particularly in elderly individuals and those in nursing homes. Signs include fever, cough with colored sputum, shortness of breath, and general decline. Recurrent pneumonias in someone with swallowing difficulties strongly suggest aspiration is occurring and underscore the need for swallowing assessment and treatment.

Malnutrition and dehydration develop when swallowing difficulties prevent adequate food and fluid intake. People may avoid eating because it's difficult, uncomfortable, or takes too long. They may restrict themselves to a limited range of "safe" foods, missing important nutrients. Weight loss, weakness, poor wound healing, and decreased immunity can result from inadequate nutrition.

The social and psychological impacts of dysphagia should not be underestimated. Eating is a social activity, and difficulty swallowing can lead people to avoid dining with others, declining invitations and becoming increasingly isolated. The anxiety about choking or embarrassment about eating difficulties can significantly affect quality of life and mental health.

What Should Caregivers Know About Dysphagia?

Caregivers should learn to recognize choking signs, understand recommended diet textures, know how to perform abdominal thrusts (Heimlich maneuver) for complete blockage, supervise meals when needed, ensure proper positioning during eating, and communicate with healthcare providers about any changes in swallowing ability.

Caring for someone with dysphagia can be challenging, but understanding the condition and knowing how to help can make a significant difference in safety and quality of life. As a caregiver, you play an essential role in ensuring mealtimes are safe and that the person maintains adequate nutrition.

Familiarize yourself with the specific dietary recommendations from the healthcare team. This includes knowing which food textures and liquid consistencies are appropriate and which should be avoided. Learn to prepare or modify foods according to these guidelines. Be consistent in following recommendations, as even occasional lapses can increase the risk of aspiration or choking.

Being prepared for emergencies

It's important to know how to respond if choking occurs. Learn to recognize the signs of choking, which include inability to speak or cough, clutching the throat, and turning blue. Know how to perform abdominal thrusts (Heimlich maneuver) for complete airway blockage. If the person can cough forcefully, encourage them to continue coughing to try to clear the blockage themselves.

Keep emergency contact numbers readily available and know when to call for emergency assistance. If someone cannot breathe, cannot cough effectively, or loses consciousness, call emergency services immediately while beginning first aid.

Frequently Asked Questions About Dysphagia