Trouble Swallowing (Dysphagia)
by Dr. Christopher Chang, last modified on
Dysphagia (also known as "trouble swallowing") is a common cause for a person to seek out medical attention. Watch a video on what a normal swallow looks like below. There are many ways one can go about describing dysphagia and how to go about evaluating this condition. One can talk about the 4 stages of swallowing (oral preparation, oral, pharyngeal, and esophageal) and the problems that can occur at each of these stages. However, a much simpler way of thinking about dysphagia is whether it is a "physical" problem or a "functional" problem and where does it occur.
A physical problem would be something like large tonsils preventing food from going past them easily. A functional problem would be a paralyzed tongue where the tongue itself is normal in appearance, but doesn't work right.
SO, given this information, one can proceed in a logical fashion to consider all the various causes of dysphagia and understand them without having a medical background. In terms of location, there really is only 3 levels: Mouth, Neck, and Chest.
Before going into abnormal swallowing issues, we need to first discuss what happens during a normal swallow. The green glob is food that is being swallowed.
- Image A: Food is being pushed into the back of the mouth.
- Image B: Food is entering the upper region of the voicebox. At this point, the epiglottis is being folded over the voicebox to protect the airway.
- Image C: Food is just entering the esophagus (swallowing tube) that leads down into the stomach.
- Image D: The upper esophageal sphincter opens up to allow food to enter into the esophagus.
- Image E: Food enters the esophagus and the sphincter closes up behind it to prevent regurgitation.
- Image F: Food is well on its way to the stomach.
Physical Problems Causing Dysphagia
Physical problems can be visualized either with the naked eye or using an instrument like a fiberoptic endoscope. In essence, physical problems can be seen (assuming a physician has the means of "getting" to the area of abnormality). Only a minority of functional problems (ie, muscle paralysis) can be directly visualized.
- Mouth Level: Cancer, benign tumor, Large Tonsils, etc. In toddlers, it could be due to anterior or posterior tongue tie.
- Neck Level: Cancer, benign tumor, pharyngeal pouch, Zenker's Diverticulum, lingual tonsil hypertrophy, reactive swelling from reflux, cervical spine bony spurs, infection, etc.
- Chest Level: Cancer, benign tumor, esophageal diverticulum, stricture, Schatzki's ring, hiatal hernia, etc.
Obviously, depending on the exact problem, there may be more symptoms than just "trouble swallowing" which may help a physician suspect a given diagnosis over another. Cancer hurts, so swallowing may cause an increase in pain (odynophagia). Pouches in the neck level would get food caught in them, so food regurgitation would be an additional symptom. For reflux, many people also complain of a constant mucus sensation in the throat with constant throat-clearing. Such typical additional symptoms are present for each of the other conditions mentioned.
Functional Problems Causing Dysphagia
Functional problems can NOT be visualized generally and require functional-type tests in order to discover the problem. Such tests may include Barium Swallow, Modified Barium Swallow, FEEST, 24 hour pH probe study, multichannel intra-luminal impedance testing, esophageal manometry/motility studies, etc. What test does one obtain? It really depends on the symptoms, but in the majority of cases, the barium swallow and the modified barium swallow are the most common initial tests to look for functional problems. Additionally, they are great tests for detecting physical problems as well.
- Mouth Level: Neurodegenerative disease (like bulbar ALS), paralysis of the palate/tongue, velopharyngeal insufficiency, etc.
- Neck Level: Neurodegenerative disease (like bulbar ALS), cricopharyngeal hypertrophy/spasm, superior laryngeal neuropathy, globus, glossopharyngeal/vagal nerve paralysis, vocal cord paralysis, lichen planus, scleroderma, etc.
- Chest Level: Esophageal dysmotility (fancy way of saying that the muscles are not squeezing in a coordinated fashion), achalasia, esophageal spasms, scleroderma, lichen planus, etc.
Just like for physical problems, additional symptoms may exist for each of these conditions beyond just trouble swallowing.
Who Do I Need to Make An Appt With???
Depending on the location, a gastroenterologist (GI physician) or an otolaryngologist (ENT physician) may be the first physician to evaluate you. If the problem is above the shoulders, see an ENT. If the problem is below the shoulders, see a GI doctor. Once a diagnosis is made, you may be subsequently referred to other specialists including a neurologist, oncologist, swallow therapist, or general surgeon.
Be prepared to undergo a multitude of tests as a diagnosis may not be able to be achieved at the first visit. At a minimum, endoscopy of some kind will be recommended and often, a barium swallow test. After these two basic tests, subsequent tests can go in a multitude of different directions including SELSAP.
Watch a video below illustrating a NORMAL swallow from both an endoscopic as well as x-ray viewpoints. Of note, the test being shown is called a modified barium swallow. If unable to view the video, try clicking here.
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