M. Louay Omran, M.D.
Dr. Omran is Assistant Professor in the Division
of Geriatrics at Saint Louis University School of Medicine.
Dysphagia, or difficulty in swallowing, is not a disease in
itself but a condition that can be brought on by many different causes
because swallowing is a delicate process, easily disturbed. Some causes
are minor and quickly treatable; others are serious, even
Although it can be as difficult to find the right treatment for
dysphagia, as it is to define a precise cause, good treatments do exist
for most forms of this condition. Unfortunately, as a recent European
study has confirmed, dysphagia often goes undetected and either
untreated or undertreated.
How Swallowing Works
dysphagia, it is helpful to start by understanding how we swallow. The
swallowing process is surprisingly intricate, involving both conscious
and unconscious actions carried out by more than 40 pairs of muscles
that must be finely coordinated. Doctors divide the swallowing process
into three phases -- oral, oropharyngeal and esophageal. Dysphagia
occurs when something interferes with either the second or third phase.1
The Three Stages of Swallowing
In the oral phase, we
take food or drink into our mouths and then push it into the back of the
mouth toward the upper part of the throat, through which we both breathe
In the oropharyngeal phase, the food or drink moves down the throat as
various muscles briefly shut off breathing, direct the food or drink
away from the breathing tube that leads to the lungs and guide it into
the esophagus and stomach.2
The esophageal phase starts when the food or drink encounters a sort of
one-way valve called the upper esophageal sphincter (UES). After passing
through the UES, the food or drink travels down the esophagus to another
valve, the lower esophageal sphincter (LES). Swallowing is complete when
the LES relaxes, allowing the food or drink to fall into the stomach.3
Causes of Dysphagia
There are two main
subcategories of dysphagia: oropharyngeal dysphagia, which causes a
swallowing problem before the food or drink reaches the upper esophagus
and esophageal dysphagia, when the problem arises afterwards. As the
chart below illustrates, they usually have different causes.
In young people, the most common causes of dysphagia are inflammatory
muscle disease and two kinds of obstructions, known as webs and rings,
that can form in the esophagus.
In older persons, oropharyngeal dysphagia is usually caused by central
nervous system problems such as stroke,
dysphagia is usually caused by
reflux esophagitis motility
disorders (abnormal coordination of contractions) and the presence of
Reflux esophagitis is a condition in which acid travels the wrong way up
from the stomach through the LES and into the esophagus. This acid
damages the esophagus's lining and, over time, repeated episodes can
lead to a narrowing of the esophagus and dysphagia. It can also cause a
condition known as "Barrett's esophagus," which can be a precursor of
cancer. (The risk of esophageal cancer increases with age. Other risk
factors include alcohol and tobacco abuse; and injury from radiation
therapy, ingestion of chemicals, or other cause.)
Another possible cause of dysphagia is achalasia, which is the inability
of the LES to relax and allow food or drink to pass through to the
Table 1. Common
Causes of Dysphagia
or neck cancer
- Zenker diverticulum
- Cervical osteophytes
- Post-surgical/radiation stenosis (narrowing)
- Infections (tonsilar enlargement/abscess)
- Caustic esophagitis
- Myasthenia Gravis
- Eaton-Lambert Syndrome
- Myotonic dystrophy
- Occulopharyngeal dystrophy
- Thyroid myopathy (hyper or hypo
- Steroid myopathy
Esophageal Sphincter (UES)
- Hypertensive UES
- Abnormal relaxation of the UES
- Abnormal opening of the UES
Obstructive Lesion within the Esophagus
- Benign tumors
- Malignant tumors
- Foreign bodies
Obstructive Lesion Outside the Esophagus
- Mediastinal mass
- Aberrant subclavius
- Tortuous aorta
- Enlarged right atrium
- Diffuse esophageal spasm
esophageal sphincter hypertension
- Chagas Disease
- Diabetes mellitus
- Radiation esophagitis
The most common
symptom of oropharyngeal dysphagia is difficulty in swallowing liquids.4,5
Sufferers complain of food "sticking" in the throat. This happens
immediately after swallowing and may be accompanied by coughing, choking
or nasal regurgitation. When these symptoms occur suddenly, the cause
may be a stroke; if they come on more gradually, the cause may be a head
or neck tumor.
Those with esophageal dysphagia typically feel pain or discomfort lower
down in the upper chest area,6 particularly shortly after
Angina-like chest pain after swallowing is usually caused either by
esophageal spasm or gastro-esophageal reflux. A painful sensation that
lasts for the few seconds during which the food is traveling down the
esophagus usually points to esophagitis, an inflammation caused by
infections, chemical burn or the lodging of pills. Regurgitation of food
shortly after eating and bad breath are signs of a disease called Zenker's diverticulum, an abnormal pouch in the esophagus in which food
gets stuck. Dysphagia accompanied by weight loss may mean the presence
When solid food dysphagia comes and goes, the usual cause is
non-cancerous rings (especially in the lower esophagus). Dysphagia that
grows worse and worse, on the other hand, is more typically caused by
cancer, esophageal spasm or achalasia (failure of the LES to relax and
allow food or drink to pass through to the stomach).7
It is important not to confuse true dysphagia with the purely sensory
condition known as "globus hystericus." People suffering with this
condition have a feeling of fullness in the throat that may be relieved
by eating; their swallowing, however, remains unimpaired. The cause of
globus hystericus is not known.8,9,10
Tests for Dysphagia
Suppose you go to the
doctor with symptoms of dysphagia. After taking a detailed history and
doing a physical examination, your doctor should have a good idea about
the type and location of the dysphagia. Usually, the next step is to
confirm this with one of the following tests: Video Fluoroscopic
Swallowing Study (VFSS), Video Endoscopic Swallowing Study (VESS),
barium-contrast esophagogram, upper endoscopy or manometry.
Video Fluoroscopic Swallowing
This technique, also known as "modified barium swallow", is the best
method for detecting oropharyngeal dysphagia.11 The patient
is asked to swallow a variety of food items of different consistencies
that are coated with barium. A video recording is then made, showing how
the food moves through the different stages of the swallowing process.
Video Endoscopic Swallowing
VESS allows the doctor to examine the esophagus through a
fiberoptic scope inserted in the nose.12 This test is one of
several that are substituted when VFSS is unavailable or, for one reason
or another, can not be done.13,14,16
Barium-contrast esophagogram is the usual first choice if
esophageal dysphagia is suspected. The patient is asked to drink liquid
barium so that pictures can be taken of mechanical obstructions such as
rings and webs. This test can also reveal signs of esophageal spasm17
Esophagoscopy, in which the doctor uses a device called an
endoscope to look inside the esophagus, is superior to the barium
swallow test for identifying and evaluating GERD. It can also be used to
provide treatments, such as the insertion of pneumatic balloons or
dilators; obtaining a biopsy or tissue sample; and removing foreign
This test uses an instrument that measures pressure to
identify patterns of muscle contraction that point to various causes of
Many causes of oropharyngeal dysphagia are quite treatable.
These include thyroid disease and myasthenia gravis, a disease where
nerve signals don't reach the muscle. Dysphagia caused by tumors or
other structural lesions can be corrected with surgery.
A number of therapy techniques are available that directly address the
swallowing problems. These include changing the diet (such as eating
thickened liquids or thin liquids, depending on the type of dysphagia),
swallowing exercises, changes in body posture, strengthening exercises
Some kinds of esophageal dysphagia can be treated with
drugs such as cisapride or domperidone. Another approach is to use
dilating devices, such as an inflatable balloon, to widen the esophagus.
When the cause is reflux esophagitis, the first treatment is anti-reflux
therapy such as proton pump inhibitors and cisapride or domperidone, or,
if these fail, dilation. Infections should be treated with the
appropriate drugs. Tumors are usually treated with surgery.
Surgery is often the best treatment for achalasia. If the patient is a
poor operative risk, nitrates and/or calcium channel blockers are used
instead. If these are unsuccessful, doctors may try dilating the
esophagus. Other options include injecting the esophagus with botulinium
toxin which paralyzes the nerve.
Difficult to diagnose, it is easy to understand why a
complicated condition like dysphagia often goes undetected and
untreated. Because there are so many possible causes, it can be even
more difficult to pinpoint the exact problem and to find the right
treatment. This does not mean, however, that you should ignore symptoms
of dysphagia. Most types of dysphagia can be treated and cured, in some
cases very easily.
1. Dantas RO, Kern MK, Massey BT, et al. Effects of swallowed bolus
variables on oral and pharyngeal phases of swallowing. Am J Physiol
1990;258(5 pt 1):G675-81.
2. Miller AJ. Deglutition. Physiological Reviews 1982;62:129-84.
3. Castell DO. Dysphagia: a general approach to the patient. In: Gelfand
DW, Richter JE, eds. Dysphagia: diagnosis and treatment. New York:
4. Castell DO, Donner MW. Evaluation of dysphagia: a careful history is
crucial. Dysphagia 1987;2 (2):65-71.
5. Hendrix TR. Art and science of history taking in patients with
difficulty swallowing. Dysphagia 1993;8:69.
6. Wilcox CM, Alexander LN, Clark WS. Localization of an obstructing
esophageal lesion. Is the patient accurate? Dig Dis Sci 1995;40:2192-6.
7. Barloon TJ, Bergus GR, Lu CC. Diagnostic imaging in the evaluation of
dysphagia. Am Fam Phys 1996;53(2):535-46.
8. Cook IJ. Globus-real or imagined? Gullet 1991;1:68-73.
9. Sonies BC. Clinical examination of motor and sensory function of the
adult oral cavity. Dysphagia 1987;1:178.
10. Leder SB. Gag reflex and dysphagia. Head Neck 1996;138-141.
11. Ekberg O, Nylander G. Cineradiography of the pharyngeal stage of
deglutition in 250 patients with dysphagia. Br J Radio 1982;55
12. Bastian RW. Videoendoscopic evaluation of patients with dysphagia:
An adjunct to the modified barium swallow. Otolaryngo Head Neck Surg
13. McConell FMS, Cerenko D, Harsh T, et al. Evaluation of pharyngeal
dysfunction with manofluorography. Dysphagia 1988; 2: 187-95.
14. Stone M, Shawker TH. An ultrasound examination of the tongue
movement during swallowing. Dysphagia 1986; 1: 78-83.
15. Nilson H, Ekberg O, Olsson R, et al. Quantitive assessment of oral
and pharyngeal function in Parkinson's disease. Dysphagia 1996;11:
16. Silver KH, Van Nostrand. Scintigraphic detection of salivary
aspiration: description of a new diagnostic technique and case reports.
Dysphagia 1992; 7:45-9.
17. Ott DJ, Gelfand DW, Wu WC, et al. Radiological evaluation of
18. Singer J, Heiken JP. Diagnostic imaging of the esophagus. In
Cummings CW, et al (eds): Otolaryngology-Head and Neck surgery, ed2. St.
Louis, Mosby, 1993.
19. Ellis HF Jr, Olsen MA. Achalasia of the Esophagus. Philadelphia, WB
20. Webb WA, McDaniels L, Jones L. Endoscopic evaluation of dysphagia in
two hundred and ninety-three patients with benign disease. Surg Gynecol
Obstet 1984;158 (2):152-6.
21. Parkman HP, Maurer AH, Caroline DF, et al. Optimal evaluation of
patients with non-obstructive dysphagia. Manometry, scintegraphy, or
videoesophagography? Dig Dis Sci 1996;41 (7):1355-68.
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