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Swallowing Disorders 

Introduction

Swallowing is a complex process.  Swallowing, termed deglutition, allows you to pass food and liquids from your mouth to your stomach for digestion.  Swallowing difficulties, termed dysphagia, can occur for several reasons.  Certain medical conditions, neurological conditions, or structural deformities can cause dysphagia.

Treatment for dysphagia varies from individual to individual.  It depends on the cause and severity of the swallowing disorder.  Treatments may include treating the underlying medical condition, rehabilitation, and changes in food preparation.

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Anatomy
Swallowing involves three steps that move food and liquid from your mouth to your stomach.  First, when you eat, you chew food with your teeth to break it down into pieces small enough to swallow.  Your tongue moves the food around in your mouth while you chew.  Saliva glands and mucous glands in your mouth secrete fluids to help moisten the food in preparation for swallowing.  Food that is ready to be swallowed is called a bolus.  When you drink liquids, your tongue forms a cup and moves the liquid to the back of your mouth.
 
Second, as your tongue moves a bolus to the back of your mouth, the swallowing reflex is triggered.  The timing of the swallowing sequence is determined by your vagus nerve.  When signaled, your tongue raises against the palate at the top of your mouth, and the bolus moves into the oropharynx, the first part of the pharynx.  Your pharynx is a passageway that contains the respiratory and digestive tracts.
 
Finally, muscle contractions, called peristalsis, move the bolus from the oropharynx to the esophagus.  During this process, your epiglottis covers the larynx (voice box) to prevent the bolus from entering the larynx or trachea (windpipe) when you swallow.  This prevents food or liquid from entering your lungs.  This is also why you cannot talk or breathe while you swallow.
 
Your esophagus is a tube that moves food from your throat to your stomach.  Muscles in the esophagus wall squeeze the food toward your stomach.  A ring of muscles is located at the bottom of the esophagus.  It is called the lower esophageal sphincter (LES).  The LES relaxes to allow food to enter the stomach.  The LES closes tightly after the food enters.  This prevents stomach contents and acids from returning to the esophagus. 
 
The stomach produces acids to break down food for digestion.  The stomach secretes mucus to protect the lining of the stomach from the acids.  The esophagus does not secrete mucus and is not protected from stomach acids. 

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Causes
Swallowing difficulties, termed dysphagia, can occur for several reasons.  They can result from problems with any part of the swallowing process.  Common causes of dysphagia include problems related to the mouth or throat (pharynx) and the esophagus. 
 
Problems related to the mouth or throat can be caused by obstructions, conditions that block the passage of food or liquids.  Obstruction can result from medical conditions including tumors, cervical spine disease, Zenker’s diverticulum, and esophageal webs.  Emotional or anxiety disorders can also cause pseudo-obstructions.
Problems with the mouth can also include structural malformations, including those that people are born with.  This includes cleft palate and deformities caused by mouth cancer or severe burns.  It may also include very poor jaw or tooth alignment that affects chewing.
 
Nerve and muscle disorders associated with the mouth and throat can interfere with the swallowing reflex.  Some neurological conditions can affect nerve signals, messages sent between the brain and the digestive system, and disrupt the swallowing process.  Such medical conditions include traumatic brain injury, stroke, Parkinson’s Disease, Huntington’s Disease, Multiple Sclerosis, Amyotrophic Lateral Sclerosis (ALS, also called Lou Gehrig’s Disease), Myasthenia Gravis, Muscular Dystrophy, Polymyositis, and infections, such as Polio or Syphilis.
 
Esophageal problems may be related to obstructions or nerve and muscle impairment.  Tumors, foreign material, Schatzki’s Ring, or strictures can cause the esophagus to narrow.  Strictures are obstructions from inflammation, scarring, or external pressure.  Strictures can result from radiation, chemicals, medications or ulcers. 
 
Nerve and muscle disorders of the esophagus can interfere with the movement of food from the throat to the stomach.  Such neurological conditions include Achalasia, GERD, Hiatal Hernia, Diffuse Esophageal Spasm, Symptomatic Esophageal Peristalsis (Nutcracker Esophagus), and Scleroderma.  

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Symptoms
Swallowing difficulties can present several different types of symptoms depending on the source of the problem.  Some people with neurological conditions may have difficulty aligning their jaws to bite, closing their lips, chewing, and moving their tongue to maneuver food to the back of their mouth.  Food and liquid may dribble out of the mouth or remain in the mouth after attempting to swallow.  Food and liquid may accumulate in the space between the teeth and gums or the teeth and the cheeks.  Further, the epiglottis may fail to completely cover the trachea during swallowing and food or liquid may enter the trachea.  This can cause coughing and choking.  Aspiration occurs if the food or liquid is not removed with coughing or choking, but instead enters the lungs.  Aspiration can lead to infection, including pneumonia.
 
Medical conditions associated with the esophagus can make it feel like food is stuck in your throat.  You may regurgitate food, meaning have food return to your mouth after you swallow it.  You may experience pain, pressure, burning or heaviness in your chest or neck. 

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Diagnosis
Your doctor will review your medical history and conduct a medical examination to start to determine the cause of your swallowing difficulty.  You should tell your doctor about your symptoms, medications, and medical conditions.  Your doctor may conduct tests and imaging studies to help determine the cause and extent of your swallowing difficulty and to rule out conditions with similar symptoms.  Common tests include an esophageal manometry and pH testing.  Common imaging studies include a chest X-ray, barium swallow, and endoscopy.  Your doctor may also order tests called swallowing studies that provide information about your swallow pattern.
 
An esophageal manometry measures the muscle function in the esophagus and the LES.  A thin tube will be placed in your esophagus through your nose or mouth.  During the test you will be asked to swallow your saliva and to swallow liquids.  The tube has sensors that detect the pressure in various parts of the esophagus.  As the esophagus muscles contract and squeeze the tube, the pressures are transmitted and recorded in a computer.
 
PH Monitoring determines how much stomach acid backs up into the esophagus and how long it stays there.  It also measures the strength of your stomach acid.  This test may take place over a period of time, such as 24 hours.  Your doctor will place a very thin tube through your nose and into your esophagus.  This device will measure your stomach acid levels as you go about your regular activities.  A newer version of pH Monitoring uses a tiny capsule that is placed in the esophagus.  The capsule measures pH levels and transmits the results by radio wave to a receiver that you wear on a belt.  After about 48 hours the capsule passes harmlessly through your digestive tract.
 
Your doctor may take a chest X-ray to check for infection associated with aspiration.  An X-ray is a painless procedure.  It simply requires that you remain very still while the pictures are taken.
 
A barium swallow, also called an upper gastrointestinal (GI) series, provides a set of X-rays showing the esophagus, stomach, and small intestine.  Before the X-rays are taken, barium, a chalky substance, is swallowed.  The barium provides an image of the upper GI structures on the X-ray images.  A barium swallow is commonly used to determine the cause of pain, swallowing problems, blood stained vomit, and unexplained weight loss.  A barium swallow is a procedure that does not require sedation or anesthesia.
 
An upper GI endoscopy is a procedure that uses an endoscope to view the esophagus, stomach, and upper duodenum, the first part of the small intestine.  This test is also called an esophagogastroduodenoscopy (EGD).  An endoscope is a long thin tube with a light and a viewing instrument that sends images to monitor.  The endoscope allows a doctor to examine the inside of the upper gastrointestinal tract for bleeding, tumors, polyps, and other abnormal conditions.  A tissue sample or biopsy can be taken with the endoscope.  It is also used to treat bleeding.  You will receive a medication to relax you prior to the test.
 
There are several types of swallowing studies.  A videofluoroscopy or modified barium swallow are most frequently used.  Usually, a speech language pathologist or an occupational therapist administers the test.  For the test, you will drink barium solution of various thicknesses while video X-rays are taken.  The barium highlights the path of the bolus as the swallowing process takes place.  A videofluoroscopy can show if the bolus is successfully swallowed or if aspiration occurs.

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Treatment
Treatment for swallowing difficulties is very individualized.  Treatment depends on the cause, severity, and extent of your condition.  Some underlying causes of swallowing problems can be diagnosed and treated with medications and sometimes surgery.  Rehabilitation, such as oral motor exercises and swallowing techniques, can be helpful for people with neurological disorders.  Additionally, changes in diet or food preparation can help.  Changing the consistency or temperature of foods can make them easier to swallow.  Further, occupational therapists can prescribe adaptive eating equipment to help with feeding and swallowing.

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Prevention
Prevention of swallowing difficulties depends on the cause of the problem.  Your doctor will provide you with instructions specific to you.  If you are being treated for a medical condition, you should make and keep all of your doctor appointments.

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Am I at Risk

Risk factors may increase your likelihood of experiencing swallowing difficulties.  People with all of the risk factors may never develop swallowing problems; however, the chance of developing the condition increases with the more risk factors you have.  You should tell your doctor about your risk factors and discuss your concerns.


Risk factors for swallowing difficulties:


_____ Neurological conditions that affect the mouth or throat can cause swallowing difficulties.  These conditions include traumatic brain injury, stroke, Parkinson’s Disease, Huntington’s Disease, Multiple Sclerosis, Amyotrophic Lateral Sclerosis (ALS, also called Lou Gehrig’s Disease), Myasthenia Gravis, Muscular Dystrophy, Polymyositis, and infections, such as Polio or Syphilis.
_____ Medical conditions can cause obstruction.  Such medical conditions include tumors, cervical spine disease, Zenker’s diverticulum, esophageal webs, and emotional or anxiety disorders.
_____ Esophageal obstructions can disrupt or block the flow of food and liquids to the stomach.  This can result from narrowing of the esophagus.  Conditions that can cause the esophagus to narrow include tumors, foreign material, Schatzki’s Ring, or strictures
_____ Smoking and Gastroesophageal Reflux Disease (GERD) are risk factors for the development of esophageal cancer.
_____       Esophageal neurological or muscular conditions can affect the flow of food and liquids to the stomach.  Examples of such conditions include Achalasia, GERD, Hiatal Hernia, Diffuse Esophageal Spasm, Symptomatic Esophageal Peristalsis (Nutcracker Esophagus), and Scleroderma. 
_____ If you have a cleft palate, you may experience difficulty swallowing.

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Complications
Complications from dysphagia include aspiration, dehydration, and malnutrition.  Aspiration is concerning because it can lead to lung infections, including pneumonia.  Dehydration and malnutrition may occur if a person is not able to consume enough food or liquids.  In some cases, tube feedings may be necessary.

Poor swallowing can cause choking if food or liquid “goes down the wrong windpipe.”  If food becomes lodged, the Heimlich maneuver may need to be performed.  If efforts do not remove the food from the airway, someone should call the emergency medical services in your area, usually 911.  The emergency medical personnel may need to establish an alternative airway to allow the person to breathe.  Choking can be serious and life threatening.  If untreated, it can cause blockage of the airway and even death.

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Advancements
Researchers are studying ways to improve detection of swallowing disorders.  Researchers are also focusing on why some treatments for dysphagia work for some people and not for others.

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This information is intended for educational and informational purposes only. It should not be used in place of an individual consultation or examination or replace the advice of your health care professional and should not be relied upon to determine diagnosis or course of treatment.

The iHealthSpot patient education library was written collaboratively by the iHealthSpot editorial team which includes Senior Medical Authors Dr. Mary Car-Blanchard, OTD/OTR/L and Valerie K. Clark, and the following editorial advisors: Steve Meadows, MD, Ernie F. Soto, DDS, Ronald J. Glatzer, MD, Jonathan Rosenberg, MD, Christopher M. Nolte, MD, David Applebaum, MD, Jonathan M. Tarrash, MD, and Paula Soto, RN/BSN. This content complies with the HONcode standard for trustworthy health information. The library commenced development on September 1, 2005 with the latest update/addition on April 13th, 2016. For information on iHealthSpot’s other services including medical website design, visit www.iHealthSpot.com.