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Trouble Swallowing / Difficulty Swallowing

Definition :
You might take swallowing for granted — you take a bite of food, chew and swallow. Most people don't think much more about it. But for some people, difficulty swallowing makes every meal a challenge.

Occasional difficulty swallowing (dysphagia) usually isn't cause for concern, and may simply occur when you eat too fast or don't chew your food well enough. But persistent difficulty swallowing may indicate a serious medical condition requiring treatment.

Difficulty swallowing may mean it take more time and effort to move food or liquid from your mouth to your stomach. Difficulty swallowing also may be associated with pain. In some cases, you may not be able to swallow at all.

Difficulty swallowing can occur at any age, but is most common in older adults. The causes of swallowing difficulties vary, and treatments depend upon the cause. In many cases, the condition can be partially or completely corrected.

Causes :
When you swallow, your tongue pushes food to the back of your throat. Muscle contractions quickly move food through your pharynx, the area that extends from the back of your throat to the top of your esophagus. Next, the food moves past your windpipe (trachea) and into your esophagus, the tube that connects your throat to your stomach.

Circular bands of muscles (sphincters) at the top and bottom of your esophagus open every time you swallow to let food pass, then quickly close. The lower sphincter allows food to enter your stomach and keeps stomach acid from coming up into your esophagus. Muscles in the wall of your esophagus help push food

toward your stomach in a coordinated process (peristalsis).

Dysphagia occurs when there's a problem with any part of the swallowing process.

A number of conditions can interfere with swallowing, and they generally fall into one of several main categories.

Esophageal dysphagia
This is the most common type of swallowing difficulties. It refers to the sensation of food sticking or getting hung up in the base of your throat or chest. Common causes of esophageal dysphagia include :

  • Achalasia. This occurs when your lower esophageal muscle (sphincter) doesn't relax properly to let food enter your stomach. Muscles in the wall of your esophagus are often weak as well. This can cause regurgitation of food not yet mixed with stomach contents, sometimes causing you to bring food back up into your throat.
  • Aging. With age, your esophagus tends to lose some of the muscle strength and coordination needed to push food into your stomach.
  • Diffuse spasm. This condition produces multiple, high-pressure, poorly coordinated contractions of your esophagus usually after you swallow. Diffuse spasm is a rare disorder that affects the smooth (involuntary) muscles in the walls of your lower esophagus. The contractions often occur intermittently, becoming more severe over a period of years.
  • Esophageal stricture. Narrowing of your esophagus (stricture) causes large chunks of food to get caught. Narrowing may result from the formation of scar tissue, often caused by gastroesophageal reflux disease (GERD), or from tumors.
  • Esophageal tumors. Difficulty swallowing tends to get progressively worse over several months when esophageal tumors are present.
  • Foreign bodies. Sometimes, food, such as a large piece of meat, or another object can become lodged in your throat or esophagus. Older adults with dentures and people who have difficulty chewing their food properly are at risk of obstruction of the throat or esophagus. Children are prone to swallowing pins, coins, pieces of toys, or other small objects that can become stuck. If an obstruction causes an inability to swallow or interferes with breathing, call for emergency help or go to the nearest emergency department immediately.
  • Gastroesophageal reflux disease (GERD). Damage to esophageal tissues from stomach acid backing up (refluxing) into your esophagus can lead to spasm or scarring and narrowing of your lower esophagus, making swallowing difficult. Long-term GERD can sometimes lead to Barrett's esophagus, a condition in which the color and composition of the cells lining your lower esophagus change because of repeated exposure to stomach acid. Having Barrett's esophagus increases your risk of esophageal cancer.
  • Pharyngeal diverticula. A small pouch forms and collects food particles in your throat, often just above your esophagus, leading to difficulty swallowing, gurgling sounds, bad breath and repeated throat clearing or coughing. This disorder is more common as you age.
  • Scleroderma. This disease is characterized by an overgrowth of scar-like tissue, causing stiffening and hardening of tissues. It can weaken your lower esophageal sphincter, allowing acid to reflux into your esophagus and causing symptoms and complications similar to those of GERD.

Oropharyngeal dysphagia
Certain neuromuscular problems can weaken your throat muscles, making it difficult to move food from your mouth into your throat and esophagus (pharyngeal paralysis). You may choke or cough when you attempt to swallow, or have the sensation of food or fluids going down your windpipe (trachea) or up your nose. This may lead to pneumonia. Causes of oropharyngeal dysphagia include:

  • Neurological disorders. Certain disorders, such as post-polio syndrome, multiple sclerosis, muscular dystrophy and Parkinson's disease, may first be noticed because of oropharyngeal dysphagia.
  • Neurological damage. Sudden neurological damage, such as from a stroke or brain or spinal cord injury, can cause difficulty swallowing or an inability to swallow.

Dysphagia in infants and children
Common causes of swallowing difficulties in infants and children include :

  • Developmental problems due to premature birth or low birth weight
  • Nervous system disorders, such as cerebral palsy or meningitis
  • Cleft lip or palate

Unexplained dysphagia
Some people experience dysphagia that has no anatomical cause. Unexplained swallowing difficulties include :

  • Difficulty taking oral medications. Some people can't seem to swallow pills or tablets, even though they have no other difficulty swallowing.
  • Lump in your throat (globus). Some people feel the sensation of a foreign body or lump in their throats when, in reality, no foreign body or lump exists. Stress or excitement may worsen this sensation. Oftentimes, resolving the stress alleviates the problem. Actual difficulty swallowing usually isn't present.

Risk Factor :
Due to natural aging and normal wear and tear on the esophagus, older adults are at higher risk of swallowing difficulties. Babies born prematurely are more prone to developmental problems, including gastrointestinal disorders that may cause difficulty swallowing. People with neurological or nervous system disorders are more likely to experience difficulty swallowing.

When to seek medical advice :
If an obstruction causes an inability to swallow or interferes with breathing, call for emergency help or go to the nearest emergency department immediately.

Slight or occasional difficulty swallowing usually isn't cause for concern. But difficulty swallowing can indicate a serious medical problem, such as esophageal cancer. See your doctor if you regularly have difficulty swallowing. Your doctor will likely perform a physical examination to determine the cause of your swallowing problem. Depending on the cause, your doctor may refer you to an ear, nose and throat specialist (otolaryngologist), a doctor specialized in treating disorders of the esophagus (gastroenterologist) or an expert in diseases of the nervous system (neurologist).

If you suspect that your child has trouble swallowing, contact your child's doctor. He or she may refer you and your child to a doctor who specializes in treating children with feeding and swallowing disorders (speech pathologist).

Symptoms :
Signs and symptoms sometimes associated with dysphagia may include :
  • Pain while swallowing (odynophagia)
  • Not being able to swallow at all
  • Choking or coughing while eating
  • Sensation of food getting stuck in your throat or chest, or behind your breastbone (sternum)
  • Pressure or pain in your chest
  • Bringing food back up (regurgitation)
  • Frequent heartburn
  • Food or stomach acid backing up into your throat
  • Gurgling sound in your throat
  • Unexpected weight loss

In infants and children, signs and symptoms of swallowing difficulties may include :

  • Lack of attention during feeding or meals
  • Tensing of the body during feeding
  • Refusing to eat foods of different textures
  • Lengthy feeding or eating times (30 minutes or longer)
  • Food or liquid leaking from the mouth
  • Coughing or gagging during feeding or meals
  • Spitting up or vomiting during feeding or meals
  • Inability to coordinate breathing with eating and drinking
  • Poor weight gain or growth

Diagnosis :
Your doctor may use a variety of tests to determine the cause of swallowing difficulties. These may include :

  • Barium X-ray. For this test, you drink a barium solution. The barium coats the inside of your esophagus, allowing it to show up better on X-rays. Your doctor can then see changes in the shape of your esophagus and can assess the muscular activity. Your doctor may also have you swallow solid food or a pill coated with barium to watch the muscles in your throat as you swallow or to look for subtle blockages in your esophagus that the liquid barium solution may not identify.
  • Endoscopy. A thin, flexible, lighted instrument (endoscope) is passed down your throat so that your doctor can view your esophagus.
  • Esophageal muscle test. In this test, called manometry (muh-NOM-uh-tre), a small tube is inserted into your esophagus and connected to a pressure recorder. This allows measurement of the muscle contractions of your esophagus as you swallow.

Complications :
Dysphagia can make it difficult for you to take in enough food and fluids to stay adequately nourished. People with difficulty swallowing are at risk of malnutrition and dehydration. If food or liquid enters your airway (aspiration) as you attempt to swallow, respiratory problems or infections can occur, such as frequent bouts of pneumonia or upper respiratory infections.

Treatment for swallowing difficulties is often tailored to the particular type or cause of your swallowing disorder :

  • Oropharyngeal dysphagia. For oropharyngeal dysphagia, your doctor will most likely refer you to a throat specialist or neurologist for further diagnostic testing and to a speech or swallowing specialist for therapy. Certain exercises may help coordinate your swallowing muscles or restimulate the nerves that trigger the swallowing reflex. You may also learn simple ways to place food in your mouth or to position your body and head to help you swallow successfully.
  • Esophageal dysphagia. For a tight esophageal sphincter (achalasia) or an esophageal stricture, your doctor may use an endoscope with a special balloon attached to gently stretch and expand the width of your esophagus (dilatation). For an esophageal tumor or pharyngeal diverticula, you may need surgery to clear your esophageal path. Difficulty swallowing associated with GERD can be treated with prescription oral medications to reduce stomach acid after a stricture is dilated. You may need to take these medications for an extended period of time. If you have esophageal spasm but your esophagus appears normal and without GERD, you may be treated with medications to relax your esophagus and reduce discomfort.
  • Severe dysphagia. If difficulty swallowing prevents you from eating and drinking enough to maintain a healthy weight and avoid dehydration, your doctor may recommend special liquid diets. In severe cases of dysphagia, you may need a feeding tube to bypass the part of your swallowing mechanism that isn't working normally.

Although swallowing difficulties can't be prevented when the cause is neurological damage or disorders, you can reduce your risk of occasional difficulty swallowing by eating slowly and chewing your food well. Early detection and effective treatment of GERD can lower your risk of developing dysphagia associated with an esophageal stricture.

Please be aware that this information is provided to supplement the care provided by your physician. It is neither intended nor implied to be a substitute for professional medical advice. CALL YOUR HEALTHCARE PROVIDER IMMEDIATELY IF YOU THINK YOU MAY HAVE A MEDICAL EMERGENCY. Always seek the advice of your physician or other qualified health provider prior to starting any new treatment or with any questions you may have regarding a medical condition.
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