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Dysphagia - A Guide

Dysphagia is a medical term that is used to refer to difficulties with swallowing. Some people with dysphagia have problems swallowing certain foods or liquids, while others are completely unable to swallow.

Introduction
Symptoms of dysphagia
Causes of dysphagia
Diagnosing dysphagia
Treating dysphagia
Complications of dysphagia

Introduction

Dysphagia usually arises as a complication of another health condition, such as a stroke, throat and mouth cancer or gastro-oesophageal reflux disease (GORD), which is a condition where stomach acid leaks back up into the oesophagus. The oesophagus is the tube that runs from your stomach to your throat.

Types of dysphagia

There are two types of dysphagia:

  • Oropharyngeal or high dysphagia. This is where the difficulties in swallowing are due to problems with the mouth or throat.
  • Esophageal or low dysphagia. This is where the difficulties in swallowing are due to problems with the oesophagus.

Low dysphagia is often caused by a blockage in or irritation to the oesophagus, and can often be treated using surgery.

High dysphagia is often caused by underlying problems with the nerves and muscles that help control the swallowing process. High dysphagia can be more challenging to treat than low dysphagia.

How common is dysphagia?

Dysphagia can be a common condition among people with certain related health conditions. It is estimated that 30-40% of elderly people staying in nursing homes have some degree of dysphagia.

Dysphagia is also a common complication of strokes, occurring in an estimated one in every two cases.

Prognosis

Aside from the obvious risk of malnutrition and dehydration, difficulties with the swallowing reflex mean that there is a chance that small particles of food can drop down into the lungs. That can trigger a serious and possibly fatal lung infection (aspiration pneumonia). See the Complications section for more information about aspiration pneumonia.

The recommended treatment for dysphagia will depend on the underlying cause of the condition. However, some possible treatments include:

  • physical therapy,
  • diet modification,
  • surgery, and
  • the use of feeding tubes.

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Symptoms of dysphagia

The symptoms of dysphagia include:

  • not being able to swallow,
  • pain while swallowing,
  • bringing food back up,
  • coughing or choking when eating,
  • coughing or gagging when swallowing,
  • a sensation that food is stuck in your throat or chest,
  • unexplained weight loss, and
  • developing repeated and frequent lung infections (pneumonia).

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Causes of dysphagia

Understanding how swallowing works is useful in understanding more about the causes of dysphagia. Although swallowing is often taken for granted, it is a very complicated process that involves over 50 pairs of muscles and thousands of nerves.

There are three stages to swallowing:

  • Stage one During the first stage of swallowing, your tongue moves the food around your mouth so that it can be chewed. Chewing helps to break food down into smaller chunks, while mixing it with saliva. Saliva makes the food moist and easier to swallow.
  • Stage two Your tongue pushes food or liquid to the back of your mouth. The nervous system triggers the swallowing reflex, activating the muscles that push the food down your throat towards your oesophagus (tube running from the throat to the stomach). During this phase, the larynx (voice box) closes in order to prevent any food or liquid from entering your lungs.
  • Stage three Food or liquid enters your oesophagus. In a healthy person, muscles quickly move the food or liquid through the oesophagus and into the stomach.

Dysphagia can result from anything that affects any of the nerves, muscles or passageways that are used during the swallowing process.

Neurological causes

Brain damage and damage to the nervous system can interfere with the nerves that are responsible for triggering and regulating the swallowing reflex. This can lead to dysphagia.

Some neurological causes of dysphagia include:

  • stroke,
  • cerebral palsy,
  • Parkinson’s disease,
  • multiple sclerosis, and
  • motor neurone disease.

Obstruction

Health conditions that cause an obstruction in or a narrowing of the throat and oesophagus can make swallowing difficult. Some causes of obstruction and narrowing include:

  • mouth or lung cancer,
  • cleft lip and palate,
  • radiotherapy (radiation can cause the development of scar tissue, which can narrow the passageway in your throat and oesophagus),
  • gastro-oesophageal reflux disease (GORD) (stomach acid can cause scar tissue to develop), and
  • infections, such as tuberculosis or herpes simplex, that lead to the inflammation of the oesophagus (esophagitis).

Muscular conditions

Any health condition that affects the muscles that are used to push food down through the oesophagus and into the stomach can cause dysphagia. Two examples of muscular conditions that are associated with dysphagia are:

  • Scleroderma. The immune system attacks healthy tissue, leading to a stiffening of the throat and oesophagus muscles.
  • Achalasia. The muscles in the oesophagus become too stiff to allow food or liquid to enter the stomach.

As a natural consequence of ageing, the muscles that are used in swallowing can become weaker. This may explain why dysphagia is a relatively widespread condition among elderly people. Dysphagia should not simply be accepted as part of growing older, because treatment is available to help those with age-related dysphagia.

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Diagnosing dysphagia

In diagnosing dysphagia, the aim is to determine the exact location of your swallowing problem (whether you have ‘high’ or ‘low’ dysphagia) and to assess how your ability to swallow has been affected.

There are a number of ways that this can be done, which are explained below.

Recent medical history

Your GP will ask you some questions about your dysphagia symptoms, such as how long you have been experiencing dysphagia for, whether or not dysphagia has affected your ability to swallow solids, liquids or both, and whether you have lost any weight.

Water-swallow test

Your GP may carry out a water-swallow test, which can provide 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 GP will record how long it takes you to drink all the water and the number of swallows that were required.

Your GP may also carry out a variation of the water-swallow test, where you will be asked to swallow a soft piece of pudding or fruit.

Barium swallow test

If your GP suspects that you have dysphagia, they may refer you to an ears, nose and throat (ENT) clinic for further testing.

The barium swallow test is one of the most effective ways of assessing a person’s swallowing, and locating exactly where the problems are occurring. The test can often identify blockages or problems with the muscles that are 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 for testing purposes because it shows up on an X-ray.

During the barium swallow test, a special video camera will be used to record you swallowing (or trying to swallow) the barium solution. The footage will be studied to check for problems.

Endoscopy

An endoscopy is a test that uses a small, flexible camera called an endoscope. The endoscope will be passed down your throat and into your oesophagus. The endoscope can often detect the presence of cancerous tumours, or scar tissue that has been caused by gastro-oesophageal reflux disease (GORD).

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Treating dysphagia

It can be difficult to achieve a complete cure for high dysphagia because the underlying neurological problems cannot usually be corrected using medication or surgery.

The exception to this is dysphagia caused by Parkinson’s disease. While Parkinson’s disease cannot be cured, the symptoms of dysphagia can be controlled using medication.

Excluding dysphagia that is caused by Parkinson’s disease, there are three main treatment options for ‘high’ dysphagia:

  • Swallowing therapy, where a speech and language therapist (SLT) will teach you to ‘relearn’ how to swallow, or find a new way of swallowing.
  • Dietary changes, such as eating softer foods.
  • Feeding tubes, which can be used to provide nutrition while you are trying to recover your ability to swallow.

Swallowing therapy

Your SLT may be able to teach you exercises that can stimulate the nerves that are used to trigger your swallowing reflex, and strengthen the muscles that are used during swallowing.

There are also a number of physical techniques that can be used to make swallowing easier. For example, some people find that ducking their chin forward when swallowing helps to prevent any food from entering their airways.

Dietary changes

You may be referred to a nutritionist, who will advise you about making changes to your diet, such as incorporating food and liquids that are easier to swallow while ensuring that you receive a healthy, balanced diet.

Mashed potatoes are a good source of carbohydrates. Scrambled eggs and cheese are high in protein and calcium.



Feeding tubes

Feeding tubes may be required in severe cases of dysphagia that put you at risk of malnutrition and dehydration.

There are two types of feeding tubes:

  • Nasogastric tube, a tube that is passed down your nose and into your stomach, and
  • Percutaneous endoscopic gastrostomy (PEG) tube, a tube that is surgically implanted directly into your stomach, which passes through a small incision on the surface of your stomach, or abdomen.

Nasogastric tubes are designed for short-term use and last for 10-28 days before they need to be replaced.

PEG tubes are designed for long-term use and last for up to 2-3 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 do carry a greater risk of complications than nasogastric tubes.

Minor complications of PEG tubes include:

  • tube displacement,
  • skin infection,
  • tube blockage, and
  • tube leakage.

Major complications of PEG tubes include:

  • internal bleeding, and
  • infection.

There is also some evidence that people who use PEG tubes find it more difficult to resume normal feeding compared with those who use nasogastric tubes. This could be because the added convenience offered by PEG tubes means that people are less willing to participate in swallowing exercises and dietary changes than people who use nasogastric tubes.

You should discuss the advantages and disadvantages of both feeding systems with your treatment team.

Treating esophageal or ‘low’ dysphagia

Cases of low dysphagia can usually be treated using surgery.

Dilation is a widely used technique in cases of obstruction. It involves placing a small balloon inside your oesophagus. The balloon is inflated, which gradually widens your oesophagus, and then the balloon is deflated and removed.

Botulinum toxin
Botulinum toxin can be used to treat achalasia (a type of dysphagia 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 minute doses. The toxin can be used to paralyse the over-stiff muscles that are preventing food from reaching the stomach.

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Complications of dysphagia

Aspiration pneumonia is a lung infection that is triggered when a small piece of food enters the lungs.

People with oropharyngeal or ‘high’ dysphagia are particularly vulnerable to aspiration pneumonia because their impaired swallowing reflexes mean that their larynx does not close during swallowing, so their lungs are not protected.

The symptoms of aspiration pneumonia include:

  • fever,
  • fatigue,
  • chest pain,
  • shortness of breath,
  • blue skin (cyanosis), due to a lack of oxygen, and
  • wheezing.

You may also have a cough that sometimes produces foul-smelling phlegm and may contain traces of blood and pus.

You should immediately contact your care team if you are currently being treated for dysphagia and you develop these symptoms. If this is not possible, contact your local out-of-hours service or call 111.

The symptoms of aspiration pneumonia can range from mild to severe. Severe cases will require admission to hospital and treatment with intravenous antibiotics.

In particularly vulnerable or 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).



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