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Dysphagia
Overview
- What is dysphagia?
Dysphagia is the medical term used to describe difficulty swallowing. Dysphagia includes difficulty starting a swallow (called oropharyngeal dysphagia) and the sensation of food being stuck in the neck or chest (called esophageal dysphagia). This sensation is referring to something being stuck in the swallowing tube.
Oropharyngeal dysphagia can result from abnormal functioning of the nerves and muscles of the mouth, pharynx (back of the throat) and upper esophageal sphincter (muscle at the top end of the swallowing tube). Diseases that involve the swallowing tube (esophagus) can cause esophageal dysphagia. When a patient is being evaluated for dysphagia, it is important for the doctor to determine which type of dysphagia is more likely, oropharyngeal or esophageal, as different tests are ordered for each type.
Dysphagia needs to be distinguished from odynophagia, which is defined as pain during swallowing. This can arise from infection or inflammation in the esophagus. Dysphagia also needs to be distinguished from globus sensation - a constant sensation of something being stuck at the back of the throat, which does not typically make swallowing difficult. In contrast, dysphagia is a symptom that only occurs when attempting to swallow.
Causes
- What causes dysphagia?
Just as there are two types of dysphagia – oropharyngeal and esophageal dysphagia – there are similarly two broad groups of causes for dysphagia. Within each broad group, there are two subgroups of causes: neuromuscular (involving the nerve or muscle), and structural, where the esophagus is narrowed or compromised.
Oropharyngeal dysphagia: Neuromuscular causes (or reasons) are more often seen than structural reasons for this type of dysphagia. This is because the nerves controlling the muscles of the mouth, back of throat (pharynx) and top end of the esophagus (upper esophageal sphincter) have direct connections with the brain through cranial nerves, and can therefore be damaged in diseases involving the brain or cranial nerves.
Structural reasons for dysphagia include strictures (narrowed areas), or rarely tumors growing in the back of the throat.
Esophageal dysphagia: In this type of dysphagia, structural causes are far more frequent than disorders involving nerves or muscles (aka neuromuscular reasons). Therefore, narrowing in the esophagus from scarring due to acid reflux disease, inflammation of the lining of the esophagus (usually from acid reflux disease but occasionally from infections), tumors within the esophagus, compression of the esophagus from growths in the chest or sometimes even an enlarged heart can all cause dysphagia. In addition, a unique type of inflammation caused by a type of blood cell called eosinophils can cause dysphagia; this condition is called eosinophilic esophagitis.
Less common are disorders involving the nerves and muscle of the esophagus. The esophageal muscle can be weak and sometimes unable to generate adequate pressure during contraction. In extreme situations, the muscle generates no force and is unable to squeeze – this is sometimes called absent peristalsis and can be associated with dysphagia. Another disorder of the nerves and muscles is achalasia; a condition in which the muscle at the bottom end of the esophagus cannot relax during swallowing because of abnormal nerve control. The muscle in the body of the esophagus also does not squeeze normally in achalasia and becomes weak and stretched. When the nerves are abnormal to a lesser degree, spasm of the esophagus may result, which can also cause dysphagia.
Symptoms
- What are the symptoms of dysphagia?
Dysphagia is the sensation that food or liquids do not pass normally from the mouth to the stomach. Symptoms can vary depending on the location of the abnormality causing dysphagia. This may be accompanied with symptoms including:
- Needing increased effort to swallow food.
- Feeling as if food is stuck in the throat or chest.
- Increasing need to take sips of water with each swallow
- Drooling or spilling food from the mouth.
- Frequent heartburn.
- Acid backing up into the throat or the nasal passage.
- Pain or discomfort while swallowing.
- Gagging or coughing while swallowing.
- Hoarseness of voice
- Weight loss that happens without trying.
Diagnosis
- What are the tests that are done in patients with dysphagia?
Your healthcare provider will start with a careful history taking and physical exam, which can provide direction towards the cause of dysphagia in most patients. Tests performed on patients with dysphagia depend on whether the doctor thinks that the patient has oropharyngeal or esophageal dysphagia.
Some typical tests may include:
- Esophagram (barium swallow test): You will be given a solution to drink that shows your throat and esophagus clearly on X-rays. This video of the barium going down your esophagus can show if there are any tissue-changes or blockages.
- Esophagoduodenoscopy (EGD) or upper endoscopy: Your gastroenterologist introduces a camera down your throat that takes pictures of your throat, esophagus and stomach. It can show narrowing, tumors and conditions like Barrett’s esophagus. They may use a tool with the camera to remove tiny tissue samples that can be studied in a lab.
- Laryngoscopy: An ear, nose and throat doctor may place a small scope in your nose that allows them to examine your throat and voice box for irregularities, particularly during the workup for oropharyngeal dysphagia.
- Modified barium swallow: A speech and language pathologist (SLP) gives you liquids of different consistencies and foods with barium to swallow. They’ll tell you when to chew and swallow while a radiologist takes X-rays. This shows a real-time evaluation of your swallowing function.
- Fiberoptic endoscopic evaluation of swallowing (FEES): An SLP places a small camera into your nose that allows them to see your voice box and the top of your esophagus. Swallowing is monitored with different types of food and liquids.
- Esophageal manometry: This is an awake test. Your GI team passes a tube from your nose to your stomach. Once in place, they ask you to drink water. This probe then measures the strength and timing of muscle contractions of the esophagus during swallowing.
Treatment
- What is the treatment of dysphagia?
For the most part, the treatment of dysphagia depends on the cause. Treatment often involves making a change in the foods eaten or the consistency of food. The modified barium swallow may identify foods of certain consistencies that can be swallowed better than others. The test can also identify head and neck positions that facilitate swallowing.
Patients with narrowing of the esophagus benefit from stretching (dilating) the esophagus. Several techniques are available for dilation. Balloons can be passed through the endoscope and distended to stretch the narrowing, or dilators (long rubber or plastic cylinders of various sizes) can be passed through the mouth, sometimes over a guide wire. Since narrowing can be related to acid reflux disease or eosinophilic esophagitis, medical treatment is usually recommended. Patients with eosinophilic esophagitis are treated with acid lowering agents or steroid preparations that can be swallowed. Patients with reflux typically receive acid lowering agents only. Dilation is also affective but should be performed with caution to avoid deep tears; dilation is usually done when medical treatments do not improve dysphagia alone. It is important that medical treatments be continued even after dilation is completed in cases that the narrowing is due to eosinophilic esophagitis or reflux. When the narrowing is from inoperable cancer, wire or metal stents (thin expandable tubes) can be placed during endoscopy to keep the lumen of the esophagus open allowing food and liquid to pass through. Patients with achalasia improve when the muscle at the bottom end of the esophagus is disrupted, either with a large balloon (pneumatic dilation), during surgery or when endoscopic techniques are used to cut the lower esophageal sphincter muscle (per oral esophageal myotomy). Sometimes, botulinum toxin (BOTOX®) can be injected into the muscle at the bottom end of the esophagus to make it relax, but this treatment only results in short term improvement in achalasia.
- Can I expect my dysphagia to improve?
This depends on the cause of dysphagia. Dysphagia from strictures (narrowing) in the esophagus may improve very well with stretching of the esophagus but repeat endoscopic sessions for stretching may be necessary from time to time. Dysphagia from acid reflux disease, esophageal infections and eosinophilic esophagitis may resolve completely with medicines. Dysphagia from achalasia improves with either surgery or forceful dilation of the lower end of the esophagus, but the esophagus remains dilated. When the cause of dysphagia cannot be treated, alternative options include placing a metal or wire stent to keep the esophagus open, especially when the narrowing is due to a cancer.
With both types of dysphagia, if symptoms are present over a long period of time, patients may lose weight and become malnourished. Weight loss can be worse when the cause is cancer of the esophagus, or if there is a very tight narrowing or obstruction in the esophagus. Dehydration can occur if there is difficulty swallowing liquids. Sometimes, if esophageal blockage is nearly complete, it can be bypassed to avoid some of these problems, by placing a tube into the stomach for feeding (percutaneous gastrostomy tube). This is also sometimes performed in oropharyngeal dysphagia when the risk of food and liquids entering the lungs and causing pneumonia is high. Therefore, it is important that the cause of dysphagia is identified so that the right management can be started for it.
Author(s) and Publication Date(s)
C. Prakash Gyawali, MD, MRCP, FACG, Washington University School of Medicine, St. Louis, MO – Published November 2010.
Saad Javed, MD, Drexel University College of Medicine/Allegheny General Hospital, Pittsburgh, PA and Milli Gupta, MD, FRCPC, University of Calgary, Calgary, Alberta, Canada - Updated July 2026.