Dysphagia: Causes, symptoms, treatment of constant difficulty in swallowing
Most of us would have occasionally had difficulty in swallowing or would have choked on food but for some people, it is a daily challenge to swallow sometimes even their own saliva. In medical term, it is known as Dysphagia and here are its causes, symptoms and treatment
Did you know that on an average, a human being swallows 600 times a day? Most of us would have occasionally had difficulty in swallowing or would have choked on food but for some people, it is a daily challenge to swallow food and liquids and sometimes even their own saliva.
In medical term, this constant difficulty in swallowing is known as Dysphagia where “Dys” stands for “difficult” and “phagia” means eating.
In an interview with HT Lifestyle, Lajja Shah, Consultant Speech and Swallow Therapist at Sir HN Reliance Foundation Hospital, revealed that Dysphagia can be attributed to many reasons:
1. Structural abnormality - There is an alteration in the structure of mouth , pharynx , larynx and oesophagus (food pipe). Such alteration is seen in cases such as e.g. head and neck surgeries, presence of tumours, birth defects such as cleft palate.
2. Neurologic problem - The brain has different areas that are in-charge for different functions such as walking, talking and also swallowing . If there is damage to the swallowing centre in the brain, it can lead to mild to severe degree of swallowing difficulties. This is noticed in cases such as stroke, Parkinson's Disease, brain injury.
3. Age Related - As we age, swallowing mechanism changes (Presbyphagia) and makes the experience of eating different for many elderly people. Even in patients with dementia, Dysphagia is seen in later stages of the disease which further impacts the patient’s quality of life.
Dr Aditi Sinha, Consultant ENT and Head Neck Surgeon at Masina Hospital, shared, “Dysphagia is the medical word for difficulty in swallowing. This symptom is usually due to a problem of the food pipe (oesophagus). Less commonly, a problem at the back of the mouth, or something pressing on the oesophagus, can cause this complaint.” According to her, there are many possible causes of Dyspahia and broadly they can be divided into problems starting at the top of the swallowing process (in the mouth and back of the throat) and those caused by problems lower down in the food pipe (oesophagus). These include -
1. Oropharyngeal causes: These are the causes which are problems high up in the swallowing process just below the mouth.
• Neurological problems
Difficulty swallowing as a result of these conditions can be common in elderly people, in some disabled people and in people who have had strokes. Examples of these neurological conditions include:
a) Cerebral palsy
b) Severe learning disability
e) Motor neuron disease
f) Multiple sclerosis
g) Parkinson's disease
h) Myasthenia gravis
However, in these situations Dysphagia would not be the first symptom to develop and various other symptoms would usually also be present.
For short periods of time, severe infections can cause difficulty in swallowing. For example, very swollen tonsils (acute tonsillitis or tonsillar abscess) or very swollen neck lymph nodes.
• Tumours and swellings
Tumours or swellings which press on the oropharynx can cause problems swallowing. This includes cancers of the mouth and throat, lumps or cancer of the thyroid gland, or cancers which cause swelling of the lymph nodes in the neck.
• Pharyngeal pouch
A pharyngeal pouch is an uncommon condition where a dead end pouch (diverticulum) forms coming off the lowest part of the throat (the lower pharynx). Most occur in people over the age of 70. It may not cause any symptoms but can cause symptoms such as dysphagia, a sense of a lump in the neck, food regurgitation, cough and bad breath.
• Breathing problems
Conditions causing difficulty breathing, particularly chronic obstructive pulmonary disease (COPD) can have a knock-on effect on swallowing.
• Globus sensation
This is not a true cause of dysphagia. Globus sensation is the term used when a person has the "feeling of a lump" in the back of their throat when actually there is no lump present when the throat is examined. Some people with this condition may have a feeling or perception of difficulty swallowing. However, in this condition there is no true dysphagia, as you can eat and drink normally. Many people with globus sensation notice the symptoms most when they are swallowing their saliva.
2. Oesophageal causes of Dysphagia
• Stricture due to severe oesophagitis
Oesophagitis means inflammation of the lining of the food pipe. Most cases of oesophagitis are due to acid reflux. The acid irritates the inside lining of the lower oesophagus to cause swelling. Gastro-esophageal reflux disease (GERD) is a general term which describes the range of situations - acid reflux, with or without oesophagitis and symptoms. A complication of severe long-standing oesophagitis is scarring and narrowing (a stricture) of the lower oesophagus.
• Eosinophilic oesophagitis: due to food allergies
• Oesophageal cancer
Most cases occur in people over the age of 55, although younger people are sometimes affected. Those diagnosed at an early stage have the best chance of a cure. Dysphagia is often the first symptom and is caused by the cancer growing and narrowing the passage in the oesophagus.
• Strictures due to other causes
Although oesophagitis and cancer are the most common causes of oesophageal narrowings (strictures) there are various other causes - for example, following surgery or radiotherapy to the oesophagus. Various medicines can irritate the oesophagus and cause a stricture. Accidentally drinking bleach, acid or other chemicals can cause damage, scarring and strictures.
• Oesophageal webs and rings
These are abnormal non-cancerous overgrowths (extensions) of normal oesophageal tissue. They are uncommon. Their cause is not clear although oesophageal webs sometimes develop in people who have iron-deficiency anaemia.
Achalasia is a condition that affects both the muscles and the nerves that control the muscles of the oesophagus. This makes it difficult for you to swallow food properly. It mainly affects adults aged between 20-40 years. In most cases, no underlying cause can be found.
• Muscle disorders: Examples include scleroderma and myositis.
• Pressure from outside the oesophagus
Pressure from structures next to the oesophagus can sometimes affect the function of the oesophagus to cause dysphagia. For example, cancer of the thyroid, lung, stomach or spine, or a large aortic aneurysm may press on the oesophagus. Again, other symptoms would normally have developed before the dysphagia.
Lajja Shah listed some common symptoms of Dysphagia as:
1. Food getting stuck in your throat and requires extra effort and time to gulp it down
2. Coughing during or immediately after swallowing
3. Food coming back from nose or mouth
4. Pain while swallowing
5. Choking sensation while swallowing
She said, “If you experience the above frequently, it is better to get yourself checked. Swallowing Disorders when mild, can impact your experience of eating or some food consistencies may be difficult to swallow compared to others eg- taking pills can be hard for some people. Swallowing Disorders when severe , can lead to aspiration (food can enter the lungs via air pipe) , Malnutrition and several other health complications. People with severe Dysphagia may need to be dependent on tube feeding.”
Echoing that the severity of dysphagia can vary, Dr Aditi Sinha highlighted, “When mild, it can mean a feeling of food just taking longer to pass through the oesophagus and it can be painless. Liquids may well cause no problem. When severe, it can mean both solids and liquids do not pass at all down the oesophagus and may cause you to vomit back (regurgitate) food and drink. When moderate, it can be somewhere in between these extremes. Symptoms that may occur at the same time as dysphagia are regurgitation of food, vomiting, coughing, choking and pain on swallowing, weight loss.”
She added, “Difficulty swallowing may make it difficult to take in enough food and/or drink, resulting in malnutrition or lack of fluid in the body (dehydration). It may make it difficult to take necessary medication, which may go on to cause further medical problems. It leads to a risk of food 'going down the wrong way' (aspiration) towards the lungs instead of the stomach. This can cause choking or lung infections.”
Diagnosis and treatment:
Lajja Shah opined, “Early Diagnosis of Dysphagia can lead to good treatment outcomes and prevent health complications. Swallowing Therapists along with ENT surgeon, Radiologist or Gastrointestinal physician do specialised tests, to diagnose type and severity of dysphagia. Dysphagia is treated by a swallowing therapist using strengthening exercises, electrical stimulation and dietary-postural changes.”
Asserting that diagnosis depends on the possible causes of the difficulty swallowing (dysphagia), which may be determined by a doctor talking to you (your history) and a detailed physical examination, Dr Aditi Sinha pointed out that two of the most common tests done when someone has dysphagia are endoscopy and barium swallow.
1. Endoscopy - This is a test where the doctor looks into the upper part of your gut (the upper gastrointestinal tract). An endoscope is a thin, flexible telescope. It is about as thick as a little finger. The endoscope is passed through the mouth, into the oesophagus and down towards the stomach and duodenum. The tip of the endoscope contains a light and a tiny video camera so the operator can see inside your oesophagus and stomach. The endoscope also has a side channel to take biopsies.
2. Barium swallow - This is a test that helps to look for problems in the oesophagus. The oesophagus and other parts of the gut do not show up very well on ordinary X-ray pictures. However, if you drink a white liquid that contains a chemical called barium sulfate, the outline of the upper parts of the gut (oesophagus, stomach and small intestines) shows up clearly on X-ray pictures.
Talking about other tests, she revealed that the following tests may be considered:
• Oesophageal manometry - this is a test where a pressure-sensitive tube is passed via your nose or mouth into your oesophagus to measure the pressure of the muscle contractions in the oesophagus.
•Videofluoroscopy - this is a bit like a barium swallow. Different drinks and foods are mixed with barium and you are asked to do various things like swallow, move your head, etc, after drinking or eating the mixture. X-ray pictures are taken and your swallowing can be examined.
•pH monitoring - during this test, a thin tube is passed through your nose or mouth and into your oesophagus. A monitor that is attached to the tube can measure the pH (acid level) in your oesophagus.
•Routine Blood tests
Dr Aditi Sinha shared that the treatment will depend on the cause of the dysphagia and which part of the body is affected:
• Medications - May be prescribed to treat an underlying condition that is responsible for dysphagia.
• Therapy - Many people need therapy to strengthen their muscles and improve swallowing. Exercises can boost coordination and build tone in the muscles of the face to manage dysphagia. Finding easier ways to eat (like turning the head a certain way or altering food and drink) may also help. Speech therapy often focuses on techniques to facilitate swallowing, and it can teach people with dysphagia how to continue to eat and swallow despite any physical limitations. In the most severe cases, a feeding tube is necessary to ensure nourishment when a person can no longer chew and swallow independently.
• Surgery - Surgery may be required to fix abnormalities of the throat or esophagus to make difficult swallowing a little easier.
• Diet for Dysphagia - Some people with dysphagia find that dietary changes improve their symptoms. They may have to eat foods that are soft and moist, or carefully dice, mince, mash, or puree foods that aren’t. Thickening agents can minimize swallowing issues for people who have trouble with thin liquids.
Insisting that getting rid of distractions during mealtime and eating when you’re most alert can also help, she added some tips for finding help for Dysphagia:
• You should report any degree of dysphagia to your doctor - no matter how mild. Dysphagia is a symptom that always needs to be explained and diagnosed correctly.
• If you have trouble swallowing, you should talk to your doctor. Dysphagia is often a complex condition to treat. Swallowing is an intricate process that involves many muscles and nerves in the body.
• If untreated, dysphagia can recur, become more complex and difficult to treat.
• To help with your swallowing issues, you may need to see one or more of these specialists - Otolaryngologist (ENT Specialist), Neurologist, Gastroenterologist, Speech-language pathologist, Dietician.