Difficulty Swallowing (Dysphagia)

You may think that difficulty swallowing simply means food needs more chewing, or that food sticking can safely be managed by repeatedly washing it down. Dysphagia may arise from the mouth, throat, nervous system or oesophagus. It can lead to choking, aspiration, dehydration and weight loss, and adults with new dysphagia require prompt investigation.

Dysphagia means difficulty swallowing Dysphagia is the medical term for difficulty moving food, drink, saliva or medicines safely from the mouth to the stomach. You may experience difficulty starting a swallow, coughing or choking, food or drink coming through the nose, a wet or gurgly voice. Drooling, food sticking in the throat or chest, regurgitation, needing repeated swallows, taking much longer to eat, or avoiding particular textures. Over time, dysphagia can contribute to dehydration, weight loss and repeated chest infections. Swallowing involves several coordinated stages Swallowing requires coordination between the lips and jaw, the tongue, the throat, the airway protection structures, the oesophagus, nerves and muscles, and breathing. A disruption at one stage can produce a different pattern from a disruption elsewhere. This is why "food gets stuck" is not a diagnosis by itself. Oropharyngeal dysphagia affects the beginning of swallowing Oropharyngeal dysphagia involves difficulty moving food or drink from the mouth through the throat. Possible features include: Difficulty initiating the swallow. Coughing or choking immediately. Food or drink leaking from the mouth. Material coming through the nose. Drooling. A wet or gurgly voice. Repeated throat clearing. Breathlessness during meals. Food remaining in the mouth. Possible causes include stroke, neurological disease, muscle weakness, head or neck disease, structural abnormalities and treatment effects. The symptom pattern suggests the area requiring assessment but does not confirm the cause. Oesophageal dysphagia occurs after swallowing begins Oesophageal dysphagia involves difficulty moving swallowed material down the oesophagus. You may describe food sticking behind the breastbone, a delayed sensation after swallowing, food coming back up, chest discomfort during swallowing, difficulty mainly with solids, or difficulty with both solids and liquids. Possible causes include inflammation from reflux, scar related narrowing, a ring or web, eosinophilic oesophagitis, achalasia or another movement disorder, external compression, or oesophageal or stomach cancer. The place where you feel food sticking may not exactly identify where the problem is. Solids and liquids provide useful clues A clinician will ask whether difficulty occurs with solid food only, liquids only, both solids and liquids, pills, or particular textures. Difficulty that begins with solids can suggest narrowing. Difficulty with solids and liquids may point towards impaired movement or coordination. These are clues rather than rules. Symptoms may evolve, and several conditions can produce overlapping patterns. Choking and dysphagia are related but different Choking means the airway is partly or completely blocked. With mild choking, you may still be able to cough and speak. With severe choking, you may be unable to speak, cough effectively, breathe, or make sound. Severe choking is an immediate emergency. Call 999 and follow first aid instructions. NHS guidance advises back blows and abdominal thrusts for a conscious adult or child over one year when a severe obstruction persists. Dysphagia describes the underlying swallowing difficulty. It may cause repeated choking episodes but does not always cause a complete airway blockage. Aspiration means material enters the airway Aspiration occurs when food, drink, saliva or stomach contents enter the airway instead of travelling safely towards the stomach. Possible signs include coughing during or after eating, choking, a wet or gurgly voice, breathlessness during meals, recurrent chest infections, fever after a swallowing episode, or reduced oxygen levels in someone being monitored. Aspiration can contribute to pneumonia and other chest infections. The absence of dramatic choking does not by itself prove that swallowing is safe. Assessment may be needed when there are repeated chest infections, weight loss or other concerning features. Sudden dysphagia may be neurological A stroke or transient ischaemic attack can disrupt swallowing. Call 999 when sudden swallowing difficulty occurs with facial drooping, arm weakness, new numbness on one side, slurred or confused speech, sudden visual loss, severe new balance difficulty, or reduced consciousness. Time critical stroke treatment should not be delayed while trying food or drink. Do not give food, drink or oral medicine to someone with suspected stroke until swallowing safety has been assessed. Reflux can inflame or narrow the oesophagus Repeated acid exposure may inflame the oesophagus. Healing after inflammation can sometimes produce a stricture, which is a narrowed segment. Possible features include heartburn, painful swallowing, solid food sticking, regurgitation, and gradual progression. Do not assume that dysphagia is simply another reflux symptom. New food sticking needs prompt investigation. Achalasia and eosinophilic oesophagitis affect oesophageal movement Achalasia is a rare disorder in which the oesophagus does not move food normally and the muscular ring at its lower end does not relax appropriately. It may cause difficulty with solids and liquids, regurgitation, food sticking, chest discomfort, night time coughing, and weight loss. Eosinophilic oesophagitis is an inflammatory condition affecting the oesophageal lining, causing solid food moving slowly, intermittent food sticking, chest discomfort, reflux like symptoms, and sometimes complete food bolus obstruction. It is diagnosed through endoscopy and biopsies rather than symptoms alone. Do not begin a highly restrictive elimination diet without specialist and dietetic advice. Medicines may contribute in different ways Some medicines may reduce alertness, affect muscle coordination, cause dry mouth, irritate the oesophagus, or be difficult to swallow because of their size or shape. Tell your clinician about every medicine and whether difficulty is limited to pills or also affects food and drink. Do not crush, split or open tablets or capsules without pharmacist advice. Some modified release, enteric coated or hazardous medicines become unsafe or ineffective when altered. Dysphagia can reduce nutrition and hydration Possible consequences include weight loss, dehydration, weakness, constipation, reduced medicine intake, longer and more tiring meals, avoidance of social eating, and malnutrition. Tell the clinician whether your clothes have become looser, meals take much longer, you avoid certain textures, you drink less, urine has become darker or less frequent, tablets are being missed, or you repeatedly develop chest infections. A dietitian may help maintain nutrition while swallowing is investigated. Adults with dysphagia need urgent investigation Current NICE guidance recommends a suspected cancer pathway referral for adults with dysphagia to assess for oesophageal or stomach cancer. There is no adult age threshold attached to dysphagia in this recommendation. This does not mean that cancer is the most likely cause. It means that an important cause must be excluded promptly. Continue to report worsening symptoms while waiting for assessment. A food bolus can become completely stuck A food bolus obstruction occurs when swallowed food blocks the oesophagus. Possible signs include sudden food sticking, inability to swallow further food or drink, regurgitation, chest or throat discomfort, drooling, or inability to swallow saliva. Do not continue eating or repeatedly force down water or more food. If you cannot swallow your saliva, are drooling continuously or have severe pain, seek urgent emergency assessment. If breathing is affected, call 999 immediately. Your clinician asks where the process fails Questions may include: When the problem began. Whether it started suddenly or gradually. Whether it is worsening. Whether starting the swallow is difficult. Whether you cough immediately. Whether food sticks after it has been swallowed. Whether solids, liquids or pills are affected. Whether swallowing is painful. Whether food returns through the mouth or nose. Whether you have lost weight. Whether you have had chest infections. Whether there is heartburn. Whether you have had stroke or neurological symptoms. Which medicines you take. How symptoms affect eating and drinking is as important as the word "dysphagia". Speech and language therapists assess swallowing A speech and language therapist has specialist expertise in communication and swallowing. Assessment may consider posture, alertness, mouth and tongue movement, cough strength, voice quality, different food and fluid textures, strategies that improve safety, and whether instrumental testing is required. The therapist may provide an eating and drinking care plan. Speech and language therapy does not replace gastroenterology or ear, nose and throat assessment when structural disease is possible. Different tests answer different questions Possible investigations include upper gastrointestinal endoscopy, biopsy, a contrast swallow X ray, videofluoroscopic swallowing assessment, fibreoptic endoscopic evaluation of swallowing, oesophageal manometry, acid monitoring, CT or other imaging, and neurological tests. An endoscopy examines the oesophagus and stomach with a flexible camera. A swallowing study examines how material moves through the mouth and throat. Manometry assesses pressure and movement within the oesophagus. Not everyone requires every test. Follow an individual eating and drinking plan After assessment, recommendations may include upright positioning, a slower pace, smaller mouthfuls, particular swallowing techniques, altered food textures, thickened or modified fluids, adapted utensils, supervision or assistance, mouth care, alternative medicine formulations, or tube feeding in selected situations. Do not thicken drinks or restrict textures indefinitely without an individual assessment. Modified diets can reduce enjoyment, fluid intake and nutrition when used unnecessarily. If you already have a swallowing plan, follow the specified textures and contact the team when your ability changes.

Swallowing is a sequence rather than one action. A safe assessment asks whether there is an immediate airway blockage, whether it is difficult to start the swallow, whether food or drink enters the airway, whether material sticks after the swallow begins, whether solids, liquids or both are affected, whether nutrition or hydration is being affected, and what condition is disrupting the swallowing sequence.