Difficulty in swallowing food or drink is termed dysphagia. People with dysphagia get the feeling that food is getting stuck somewhere between the throat and the stomach. It is different from the feeling of having a lump in the throat which is called globus sensation.

The digestive tract is a continuous tube from the mouth to the anus. The food taken in through the mouth gets swallowed at the pharynx or the throat. From the throat it travels down the esophagus to reach the stomach where the main digestion of food takes place. It is in the esophagus that the food seems to be getting stuck, when people have dysphagia.

Complications: Pneumonia is a serious complication which may develop in people with dysphagia resulting from aspiration of food, drink or saliva into the respiratory canal. When aspiration is a frequent occurrence, it may result in a chronic form of lung disease. Weight loss and malnourishment are very common in people with dysphagia.

Causes

Swallowing is a process involving the synchronized activity of several muscles and nerves in the mouth, throat and esophagus. It is the brain which controls the sequential contractions and relaxations of these muscles, effectively forcing the food down, starting from the mouth. Muscles and nerves have to work in tandem to bring about the contractions as well as the relaxation which should follow it. Dysphagia can be caused by any of the following reasons.

• Neurological disorders
• Muscular dysfunction
• Disorders causing disruption in the esophageal movement
• Blockage in the esophagus

People who have disorders affecting the brain or the nervous system usually have difficulty in swallowing food and drink. Amyotrophic lateral sclerosis or ALS in short, and multiple sclerosis, are two of the abnormal conditions affecting the nervous system which cause dysphagia in addition to various other difficulties. Those who have Parkinson’s disease or those who have suffered damage to the brain due to stroke, also have varying degrees of difficulty in swallowing food.

Muscle weakness due to inherited conditions like muscular dystrophy, autoimmune diseases like myasthenia gravis, or a connective tissue disease called dermatomyositis which affect the skin and the muscles, may cause dysphagia.

Any abnormal growth in the esophagus, including esophageal cancer, can cause difficulty in swallowing due to physical obstruction to the movement of food. Esophageal scarring caused by chronic gastro esophageal reflux disease (GERD) or by the ingestion of corrosive substances like acid may precipitate dysphagia. Compression on the esophagus by a large bulge or aneurysm of the aorta arising from the heart, tumors in the chest or by the abnormal enlargement of the thyroid gland also may offer obstruction to the smooth movement of food.

Achalasia is an abnormal condition in which the normal peristaltic movements of the esophagus become irregular or slow down considerably and the lower esophageal sphincter does not relax to allow the passage of food into the stomach. Dysphagia may be caused by this disorder of the esophagus, or by a similar motility disorder caused by systemic sclerosis.

Often dysphagia causes only minor discomfort, especially when it is caused by a chronic condition such as GERD or acid reflux disease. But some cases of dysphagia require immediate medical attention, particularly when there are other symptoms present. Some such warning signs are given below.

Warning signs: When people have the following symptoms accompanied by difficulty of swallowing, they should seek urgent medical care.

• Absolute inability to swallow. Drooling may be present as even saliva cannot be swallowed.
• Odynophagia or pain at the time of swallowing.
• Swallowing difficulty due to a newly developed nerve weakness.
• Coughing or choking on food and drink.
• Severe weight loss due to insufficient intake of food

When to see a doctor: The presence of any of the above warning signs, except weight loss, indicates an urgent need for medical intervention. Those who have no warning signs along with dysphagia, and those with only the symptom of weight loss, need to consult a doctor within a few days.

When a person visits a doctor with dysphagia, a thorough medical examination is conducted to detect the possible reasons for the condition. A detailed description of the symptoms, as well as the previous medical history of the patient, is also necessary to assess the condition and to determine what further investigations are required.

The doctor may want to know minute details about the way the patient eats and drinks; whether there is drooling or uncontrollable spilling of food, or whether coughing and choking while eating, or frequent incidents of food spilling from the nose, are present. Doctor may also ask if the person is having difficulty in swallowing either food or drink or both. Motility disorder of the esophagus is the usual cause if the patient has difficulty with both solids and liquids.

If the dysphagia had started with solids and have gradually worsened into difficulty with liquids also, it may be due to a growing tumor in the esophagus.

If there is drooling or spilling of food from the mouth while eating, or food particles coming out through the nose, the dysphagia may be due to a muscular or neurologic disorder.

The physical examination involves the not only the examination of mouth, throat, neck and such other parts directly involved in swallowing, but the general physical condition of the patient also, with special focus on the muscular and neurologic functions.

• Strength of facial muscles including that of mouth and eyes
• Presence of tremors during activity or at rest
• gait and balance while walking
• The capacity to perform actions like counting or blinking eyes which are repetitive in nature
• Bulging of the neck due to enlargement of thyroid gland or tumors
• Wasting away of muscles, fasciculation or twitching of muscles under the skin
• Changes in the texture of skin, thickening of finger tips, presence of rash etc.

Testing: Doctors may want to do some investigative tests to determine the exact cause of dysphagia.

If there is almost total or absolute blockage, an emergency endoscopic evaluation, with a flexible viewing tube or endoscope inserted into the esophagus, is done to detect the cause of the blockage.

If the blockage is partial, usually a radio opaque imaging test is done first. The test involves the ingestion of radio -opaque barium liquid followed by x-ray imaging. The patient may also be given barium liquid mixed with food particles for swallowing. If there is any evidence of a physical blockage in the esophagus, endoscopic examination may follow to ascertain the nature of block; it may be scarring, presence of cross webs or rings in the esophagus or esophageal cancer or other benign growths.

When no physical blockage is detected in the barium swallow test, the possibility of esophageal motility disorder is investigated. The patient is given a narrow tube embedded with several tiny pressure sensors and while it is being swallowed, the contractions and relaxations of the esophagus are detected. From the data provided by the pressure sensors, it is possible to determine motility disorders of the esophagus and the inability of the lower esophagus to relax to help the food move into the stomach.

Treatment

The treatment of dysphagia is effective when the cause of the condition can be treated. Eating very small manageable amount of food with each bite and chewing it thoroughly may help relieve the symptoms when the cause cannot be cured, as in the case of Parkinson’s disease. Certain measures prescribed by rehabilitation specialists such as tongue exercises, re-training of the muscles involved in swallowing, altering the position of head while eating etc. may help people who have had a stroke, to achieve better control and ease of swallowing.

A feeding tube which is fixed on the abdomen and opening into either the stomach or into the small intestine may be necessary for people who have a high chance of aspiration of food or choking while eating through the mouth.

Essentials for Older People

With aging, the general motor function declines due to the degeneration of muscles and slower neurotransmission in the nerves. This affects the muscles and nerves of the face, neck and mouth too. The various components of the process of eating food, such as chewing, turning the food around in the mouth with the tongue for effective mixing with saliva and swallowing down the throat, require the precise coordination of muscles and nerves in the tongue, mouth, throat, jaws and neck. As people age, the strength of muscles decrease and coordinated movements slow down. It may cause their swallowing of larger particles of food, increasing the chances of choking on the food. The dentures more frequently used by older people also contribute to their difficulty in manipulating the food in the mouth.

Muscular and neurologic disorders are most often caused by other age-related disorders such as Parkinson’s disease, stroke or diabetes. Certain drugs used in the treatment of many other disorders such as diuretics or anticholinergics adversely affect the production of saliva. Chemotherapy as well as radiotherapy employed in the treatment of cancer, which also results in the reduced secretion of saliva, can precipitate or worsen dysphagia. Hyposalivation greatly impairs the capacity to swallow, as saliva has the important function of wetting the food and lubricating the throat for smooth movement of food.

The treatment and management of dysphagia in older people may involve specialists from several medical fields such as gastroenterology, rehabilitative medicine, prosthetic dentistry etc., in addition to the general physicians treating them.

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