Certainly if you've worked much with the elderly, or as a nursing assistant in a nursing home, you've worked with those who have struggled to swallow. We refer to this as dysphagia in medicine. It's common to those who have suffered a stroke, who have Parkinson's disease, or even dementia. There are also adults who have some level of dysphagia because they suffer with gastroesophageal reflux disease. They may even have allergies that cause their throat to tighten up a bit, making it harder to swallow. This past year though, I've had more clients share, without any of these concerns, that they too have found the occasional struggle to swallow. Let's take a look at why this might happen and what you might do about this concern.
Interestingly, there are many who do experience difficulty with swallowing and instead of seeking care with a clinician, they simply adapt their eating patterns. If they do seek care, most causes are found to be non-eventful, or benign, and ultimately resolve on their own. Certainly, this can be indication of progressing neurological disease, and the risk here is aspiration pneumonia and malnourishment. In these individuals, prompt diagnosis is important, but what if you are in every other way healthy and have no reason to think you should struggle to swallow?
Oropharyngeal dysphagia is most commonly related to chronic neurologic conditions, particularly Parkinson' disease, stroke, and dementia. This is not part of normal aging (Cho et al., 2015), and it may be the first symptom of a neuromuscular disorder, such as amyotrophic lateral sclerosis or myasthenia gravis (Sherer et al., 2005 & Traynor et al., 2000). Of course, we would want to evaluate the integrity of one's teeth, their dentures, dry mouth, or side effects of medication that can make it more challenging to swallow, as well as consider tardive dyskinesia which can occur secondary to many anti-psychotic medications, particularly after long-term use. Even younger children can experience these side effects. The commonly used anti-nausea medication, Zofran, often prescribed in pregnancy can also cause tardive dyskinesia. Chronic cough can occur from ACE inhibitors, a specific type of medication used for elevated blood pressure. Structural abnormalities may also be present, such as tumors, or even chronic infections, even from yeast or herpes. This can even occur from an enlarged thyroid, or goiter, or issues in the cervical spine.
GERD is a pretty common reason that many fail to consider. Again, even functional disorders can occur or allergic reactions, both of which are often fairly common and under-recognized. Functional esophageal disorders would include irritable bowel syndrome, which is super common, and to some degree related to abnormalities in the gut-brain interaction and central nervous system processing. People with these symptoms are often hyper-vigilant about minor symptoms or hypersensitive to even physiologic amounts of acid (Drossman, 2016). This is more often the case in those who have intermittent problems and don't typically report them to their clinician or in those who have extensive evaluations but no cause is identified.
Less commonly, we can see obstructive lesions and motility disorders. Alcohol can create decreased tone in the lower esophageal sphincter, as can benzo-diazepines, caffeine, nitrates, tricyclic antidepressants, and calcium channel blockers used for hypertensive medications. No joke, I cared for a woman in a Good Samaritan clinic who didn't have healthcare, and she had a chicken bone stuck in her throat for more than a year!
What's the First Step in Figuring Out the Why?
Your clinician will first attempt to discern between oropharyngeal and esophageal pathology, based on your symptoms. So, is this an air tube issue, or a food tube issue. They will then perform a physical exam, and from there may suggest specific testing or management to guide, rule out or confirm diagnosis.
What happens when you swallow? Does it make you cough? This suggests the problem is esophageal. If you have trouble initiating a swallow, or you choke or cough, or even regurgitate your food or water, then this suggests oropharyngeal dysphagia. Your clinician will also want to know how long this has been happening and if it is getting worse. Is this acute, maybe from new medications your are taking, an infection, or maybe a chicken bone! If it comes and goes though, then we think medications, even opioids, or potentially a motility disorder, or inconsistent denture use. If it is progressing and getting worse, then we increase our concern for malignancy. Sometimes individuals will avoid going out to eat or isolate themselves because they are having so much difficult swallowing.
Do you have trouble chewing your food? We call this bruxism in medicine, which may result from TMJ arthritis or pain disorders. Poor dentures is often involved in these scenarios, or dental disease. Weakness with chewing though is suggestive of myasthenia gravis, giant cell arteritis, or myopathy.
What gets stuck? Is it solids only or both liquids and solids? If both, then a motility disorder is suggested in the esophagus. If only liquids, then an oropharyngeal pathology is a bit more suggestive. If solids only, then a mechanical obstruction or intrinsic issue, such as a stricture or web or tumor. Weight loss with these symptoms is especially concerning, and may relate to neoplasia or advancing disease.
We also want to know about medications. Opioids can cause these symptoms, as can NSAIDs, and a number of others. Asthma may be related, and environmental allergies, even food allergies. If any of these latter ones correlate then eosinophilic esophagitis is likely involved and a random biopsy is recommended through esophago-gastroduodenoscopy.
Oropharyngeal Dysphagia
Individuals who report choking, coughing, drooling, nasal regurgitation, difficulty initiating a swallow, or needing repeated swallows to clear food from the mouth more likely have oropharyngeal dysphagia. If there is hoarseness or other voice changes, a "wet" voice, then this too is consistent with oropharyngeal dysphagia. Most often they can identify their symptoms to their throat and neck, but keep in mind that in at least one-third of cases, symptoms in the throat or neck are caused by lesions in the distal esophagus but because of overlapping sensory innervation, the actual level of obstruction and where this is perceived can be a little misguided (Ashraf et al., 2017). These individuals are served well by collaborating with a speech and language pathologist.
Esophageal Dysfunction
These individuals do not have difficulty initiating a swallow. They are more likely to report feeling like something is stuck in their throat after they swallow. They may have lesions that progress, which will be felt more often with solid foods, although if the issue is more about motility dysfunction, this will be felt with both solids and liquids. If testing is appropriate, this is often initiated with a barium EGD. This is more cost-effective than the barium esophagography.
Odynophagia
Painful swallowing, as one experiences with strep throat, is typically infectious. This may be viral esophagitis or esophageal candidiasis as well. If there is regurgitation of undigested food, particularly at night, this is more often a diagnosis of achalasia or Zenker diverticulum.
Weight loss and rapidly progressive symptoms, especially in an older adult, should have a comprehensive and expedited evaluation.
When one experiences difficulty swallowing and this is their only symptom, then this isn't typically very emergent. If younger than 50 years, then this is pretty low risk, and more likely related to reflux. We will likely offer strategies for reducing dyspepsia first, conventionally with a PPI or in a holistic practice, we'll address diet and offer botanicals that are soothing (Liu et al., 2018). My preference is Licorice Root, but as DGL to eliminate risk for elevating blood pressure.
If hoarseness or cough provoked by swallowing sips of water is present, then malignancy or other obstructive lesions need to be ruled out.
Family practice providers can collaborate with otorhinolaryngologists or a speech-language pathologist in gathering further imaging and swallowing studies. Depending on your practitioner, their skill and experience, and your local resources, the specific screening tools and healthcare practitioners working together may differ. Those with GERD symptoms though, esophagitis, or peptic strictures are often helped by acid suppression therapy, for about 8 to 12 weeks. When symptoms are more in line with eosinophilic esophagitis, then acid reduction is also helpful, but we would also want to assure we eliminate the trigger.
Amitriptyline 25mg or Imipramine 50mg a day has shown to be helpful for dyspepsia, and cognitive behavioral therapy in those with functional dyspepsia may also be helpful. We love the MRT testing and LEAP therapy.
References
Ashraf, H. H., Palmer, J., & Dalton, H. R. (2017). Can patients determine the level of their dysphagia? World Journal of Gastroenterology, 23(6), 1038-1043.
Cho, S. Y., Choung, R. S., & Saito, Y. A. (2015). Prevalence and risk factors for dysphagia: a USA community study. Neurogastroenterology Motility, 27(2), 212-219.
Drossman, D. A. (2016). Functional gastrointestinal disorders: history, pathophysiology, clinical features and Rome IV. Gastroenterology, 150(6), 1262-1279.
Liu, L. W. C., Andrews, C. N., & Armstrong, D. (2018). Clinical practice guidelines for the assessment of uninvestigated esophageal dysphagia. Journal of Canadian Association Gastroenterology, 1(1), 5-19.
Scherer, K., Bedlack, R. S., & Simel, D. L. (2005). Does this patient have myasthenia gravis? JAMA, 293(15), 19-6-1914.
Traynor, B. J., Codd, M. B., & Corr, B. (2000). Clinical features of amyotrophic lateral sclerosis according to the El Escorial and Airlie House diagnostic criteria: a population-based study. Archives of Neurology, 57(8), 1171-1176.
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