Swallowing problems is the general term for difficulty, a sticking sensation or pain while moving food, drink or saliva from the mouth to the stomach. Known medically as dysphagia, the condition can stem from many causes, ranging from a simple throat infection to neurological diseases and narrowing of the esophagus. Identifying the cause correctly matters both for maintaining nutrition and for preventing food from entering the lungs.
What Are Swallowing Problems?
Swallowing is a complex process that requires dozens of muscles in the mouth, throat (pharynx), voice box (larynx) and esophagus to work in harmony within seconds. It takes place in three phases:
- Oral phase: Food is chewed, mixed with saliva, shaped into a small mass (bolus) by the tongue and pushed toward the throat. This phase is voluntary.
- Pharyngeal phase: The swallowing reflex starts; the soft palate closes off the nasal cavity, while the epiglottis and vocal cords seal the windpipe. The bolus passes through the muscular ring at the entrance of the esophagus.
- Esophageal phase: Wave-like contractions of the esophagus carry food to the stomach in about 8 to 10 seconds.
A problem in any of these phases leads to difficulty swallowing. If the problem is in the mouth and throat, it is called oropharyngeal dysphagia; if it is in the esophagus, esophageal dysphagia. Pain on swallowing is called odynophagia and may accompany dysphagia. A constant lump sensation in the throat that is unrelated to eating (globus) is a different condition from true swallowing difficulty.
Difficulty swallowing can occur at any age but becomes much more common later in life. People who have had a stroke, those with neurological diseases such as Parkinson’s, and patients who have received radiation therapy to the head and neck are at particular risk. Because these problems often develop slowly, people may change their eating habits without realizing it: preferring soft foods, washing down every bite with water or taking longer to finish meals. These adaptations can keep the problem unnoticed for a long time.
Causes of Swallowing Problems
Mouth and Throat (Oropharyngeal) Causes
In this group, the problem usually lies in moving the bolus into the throat and triggering the swallowing reflex. The main causes are:
- Stroke and brain injuries
- Nerve and muscle diseases such as Parkinson’s disease, multiple sclerosis, ALS and myasthenia gravis
- Failure of the muscle at the entrance of the esophagus to relax properly (cricopharyngeal dysfunction)
- A pouch forming where the throat meets the esophagus (Zenker’s diverticulum)
- Tumors of the mouth, tongue, throat and larynx, and changes after surgery or radiation therapy to this area
- Tonsillitis, peritonsillar abscess and sores inside the mouth
- Severe dry mouth and poorly fitting dentures
Esophageal Causes
In this group, the bolus gets stuck behind the breastbone after it has been swallowed. Causes include:
- Reflux-related narrowing (stricture): Long-term acid exposure can create scar tissue and narrowing in the esophagus.
- Eosinophilic esophagitis: An allergy-related inflammation of the esophagus and a common cause of recurrent food sticking, especially in young men.
- Achalasia: The muscle at the lower end of the esophagus fails to relax, and esophageal movements are impaired.
- Esophageal spasm: Irregular, strong contractions cause chest pain and a sticking sensation.
- Rings and webs: Thin, ring-shaped narrowings in the lower esophagus (Schatzki ring).
- Tumors and external pressure: Esophageal tumors or pressure from nearby structures, such as a large goiter.
- Connective tissue diseases: Conditions such as scleroderma can affect the esophageal muscles.
Certain medications can also cause swallowing problems. Some antibiotics, painkillers and iron pills taken with little water or while lying down can injure the esophagus. Sedatives and drugs that cause dry mouth can weaken the swallowing reflex and make food harder to move along. That is why all medications should be shared with the doctor during evaluation.
In children, swallowed foreign objects, congenital structural abnormalities and developmental problems are the main concerns.
Symptoms of Swallowing Problems
Symptoms provide important clues about where the problem is. With mouth and throat causes, complaints appear as soon as swallowing begins, whereas with esophageal causes, food sticks in the chest a few seconds later. Common symptoms include:
- Trouble starting a swallow, holding food in the mouth for a long time
- Coughing or choking while eating or drinking
- Liquids coming back through the nose
- A wet, gurgly voice after swallowing
- A feeling of food sticking in the throat or behind the breastbone
- Pain when swallowing
- Undigested food coming back up, bad breath
- Longer mealtimes, avoiding certain foods
- Unintended weight loss and recurrent chest infections
Difficulty that starts with solid foods and gradually extends to liquids suggests a progressive narrowing of the esophagus. Trouble with both solids and liquids from the start is more typical of esophageal motility disorders such as achalasia. In some patients, food enters the windpipe without any symptoms because the cough reflex is weak; this is called silent aspiration.
How Are Swallowing Problems Diagnosed?
Evaluation begins with detailed questions: how long the difficulty has lasted, whether it occurs with solids, liquids or both, whether the sticking is felt in the throat or the chest, and whether there is weight loss or other illness. This is followed by an examination of the mouth, throat, larynx and neck, including tongue movement, the soft palate and the vocal cords. Patients traveling from abroad are encouraged to bring previous endoscopy or imaging reports and a list of all current medications.
FEES (Fiberoptic Endoscopic Evaluation of Swallowing)
FEES is a method commonly used in ENT practice to assess swallowing. A thin, flexible endoscope is passed through the nose to view the throat and larynx, and the path of the bolus is watched as the patient swallows foods and drinks of different textures, usually colored. This shows whether food remains in the throat or enters the windpipe. It involves no radiation and can be done at the bedside when needed.
Imaging and Other Tests
- Barium swallow: X-ray images are taken while the patient swallows a barium liquid that shows up on X-ray, revealing narrowing, pouches (diverticula), rings and motility problems in the esophagus.
- Videofluoroscopic swallow study: All phases of swallowing are recorded on moving X-ray images using barium foods of different textures.
- Upper gastrointestinal endoscopy: The lining of the esophagus and stomach is examined, a biopsy can be taken, and a narrowing can be widened in the same session.
- Esophageal manometry: Measures the strength and coordination of esophageal muscle contractions; it is important in diagnosing achalasia.
- Imaging: Neck and chest CT scans may be requested if a tumor or external pressure is suspected.
Treatment of Swallowing Problems
Treatment depends entirely on the underlying cause and often requires an ENT specialist, gastroenterologist, neurologist, speech-language pathologist and dietitian working together.
Swallowing Therapy and Diet Changes
Swallowing therapy is the foundation of treatment for oropharyngeal dysphagia. Under the guidance of a speech-language pathologist, exercises strengthen the tongue, lips and throat muscles. Head positions, such as tucking the chin toward the chest while eating, and special swallowing maneuvers are taught to reduce the risk of food entering the windpipe.
Thickening liquids, pureeing foods, taking small bites and eating while sitting upright are also recommended. For patients who cannot eat enough by mouth, a temporary tube from the nose to the stomach, or for longer-term needs a feeding tube placed through the abdominal wall into the stomach (PEG), may be used.
Practical Tips at Home
Small adjustments in daily life can improve both safety and enjoyment of meals:
- Eat in a quiet setting without distractions such as television
- Avoid talking while eating or eating in a hurry; make sure each bite is swallowed before taking the next
- Be careful with dry, crumbly and sticky foods such as dry bread, rice and nuts
- Stay sitting upright for at least 30 minutes after eating
- Swallow tablets with plenty of water while upright; if tablets are hard to swallow, ask the doctor about a liquid or other form
- Keep up regular oral care, which helps lower the risk of chest infection if food goes down the wrong way
Medication
Acid-reducing medication is used for reflux-related difficulty; for eosinophilic esophagitis, these drugs or swallowed corticosteroid preparations; and for infections, appropriate antibiotics or antifungals. In neurological diseases such as myasthenia gravis, treating the underlying disease also improves swallowing.
Endoscopic and Surgical Treatments
- Dilation: For reflux strictures, rings and some scar-related narrowings, the narrowed area is widened with a balloon or dilators during endoscopy.
- Achalasia treatment: The muscle that fails to relax is treated with balloon dilation, or cut with laparoscopic Heller myotomy or the endoscopic POEM technique; botulinum toxin may be used in selected patients.
- Zenker’s diverticulum and cricopharyngeal problems: The wall between the pouch and the esophagus can be divided endoscopically through the mouth; open surgery from the neck is used when needed.
- Stent: In narrowing caused by a tumor, a stent may be placed in the esophagus to ease swallowing.
For tumors, treatment follows a multidisciplinary plan that may include surgery, radiation therapy and drug therapy.
Possible Risks and Important Considerations
Untreated difficulty swallowing can lead to malnutrition, dehydration and weight loss. Food or liquid entering the windpipe can cause recurrent aspiration pneumonia, which can have serious consequences, especially in older adults and after a stroke. Difficulty eating can also lead to social withdrawal and a lower quality of life.
When to Seek Emergency Care
Go to the emergency department without delay if:
- Food is stuck and will not pass, and even saliva cannot be swallowed
- Swallowing difficulty comes with shortness of breath, noisy breathing or bluish skin
- A button battery, magnet or sharp object has been swallowed, especially by a child
- There is severe chest pain on swallowing or vomiting of blood
- High fever comes with neck swelling, inability to open the mouth and drooling
- Swallowing difficulty starts suddenly together with facial drooping, slurred speech or weakness in an arm or leg
Even when not an emergency, worsening difficulty swallowing, unintended weight loss, accompanying hoarseness, or new complaints in people who smoke or drink alcohol should be evaluated soon.
Swallowing Problems: Frequently Asked Questions
Which doctor should I see for difficulty swallowing?
If the sticking is felt at the level of the throat, or if voice or cough complaints are also present, an ENT specialist can perform the first evaluation. If the sticking is felt in the chest, a gastroenterology evaluation is also needed. In many patients, both specialties work together.
Is a lump in the throat the same as difficulty swallowing?
Not always. A lump sensation unrelated to eating, which may even ease while swallowing or during meals, is usually called globus and can be linked to reflux, muscle tension or stress. An examination is still needed to distinguish it from true swallowing difficulty.
Is difficulty swallowing normal in old age?
Swallowing muscles may slow down slightly with age, but significant difficulty is not considered a natural part of aging. New coughing during meals or weight loss in older adults should always be investigated.
Why are thickened liquids recommended?
Thin liquids move very quickly through the throat, so in patients with a delayed swallowing reflex the risk of them entering the windpipe is high. Thickened liquids move more slowly, giving the swallowing reflex time to kick in.
Can swallowing problems resolve completely?
This depends on the cause. With infections, reflux strictures or rings, treatment can bring marked improvement. After a stroke, many patients recover over time with therapy, while some may need long-term dietary adjustments.
Conclusion
Op. Dr. Tayfun Demirel, ENT specialist, evaluates patients with difficulty swallowing at the practice in Ataşehir, Istanbul, through a detailed ear, nose and throat examination and endoscopic methods. The evaluation determines whether the problem lies in the mouth and throat or in the esophagus, and when needed, an individual treatment plan is created in collaboration with other specialties. Please contact the clinic to book an appointment. This article is for informational purposes only; an in-person examination is required for diagnosis and treatment.
