Jay W. Marks, MD, is a board-certified internist and gastroenterologist. He graduated from Yale University School of Medicine and trained in internal medicine and gastroenterology at UCLA/Cedars-Sinai Medical Center in Los Angeles.
Melissa Conrad Stöppler, MD, is a U.S. board-certified Anatomic Pathologist with subspecialty training in the fields of Experimental and Molecular Pathology. Dr. Stöppler's educational background includes a BA with Highest Distinction from the University of Virginia and an MD from the University of North Carolina. She completed residency training in Anatomic Pathology at Georgetown University followed by subspecialty fellowship training in molecular diagnostics and experimental pathology.
The most common swallowing symptom of dysphagia is the sensation that swallowed food is sticking, either in the lower
neck or the chest.
If food sticks in the throat, there may be coughing or
choking with expectoration of the swallowed food.
If food enters the larynx,
more severe coughing and choking will be provoked.
If the soft palate is not
working and doesn't properly seal off the nasal passages, food—particularly
liquids--can regurgitate into the nose with the swallow. Sometimes, food may
come back up into the mouth immediately after being swallowed.
With neurological problems, there may be
difficulty initiating a swallow because food cannot be propelled by the
tongue into the throat.
Elderly individuals with dentures
may not chew their food well and therefore swallow large pieces of solid food
that get stuck.
What is dysphagia?
Dysphagia is the medical term for the symptom of difficulty
swallowing, derived from the Latin and Greek words meaning difficulty eating.
Mechanism of swallowing
Swallowing is a complex action.
Food is first chewed
well in the mouth and mixed with saliva.
The tongue then propels the chewed food
into the throat (pharynx).
The soft palate elevates to prevent the food from
entering the posterior end of the nasal passages, and the upper pharynx
contracts, pushing the food (referred to as a bolus) into the lower pharynx. At
the same time, the voice box (larynx) is pulled upwards by muscles in the neck,
and, as a result, the epiglottis bends downwards. This dual action closes off
the opening to the larynx and windpipe (trachea) and prevents passing food from
entering the larynx and trachea.
The contraction of the muscular pharynx
continues as a progressing, circumferential wave into the lower pharynx pushing
the food along.
A ring of muscle that encircles the upper end of the esophagus,
known as the upper esophageal sphincter, relaxes, allowing the wave of
contraction to push the food from the lower pharynx on into the esophagus. (When
there is no swallow, the muscle of the upper sphincter is continuously
contracted, closing off the esophagus from the pharynx and preventing anything
within the esophagus from regurgitating back up into the pharynx.)
The wave of
contraction, referred to as a peristaltic wave, progresses from the pharynx down
the entire length of the esophagus.
Shortly after the bolus enters the upper
esophagus, a specialized ring of muscle encircling the lower end of the
esophagus where it meets the stomach, known as the lower esophageal sphincter,
relaxes so that when it arrives the bolus can pass on into the stomach. (When
there is no swallow the muscle of the lower sphincter is continuously
contracted, closing off the esophagus from the stomach and preventing contents
of the stomach from regurgitating back up into the esophagus.)
After the bolus
passes, the lower sphincter tightens again to prevent contents of the stomach
from regurgitating back up into the esophagus. It remains tight until the next bolus comes along.
Considering the complexity of swallowing, it is no wonder that swallowing,
beginning with the contraction of the upper pharynx, has been "automated,"
meaning that no thought is required for swallowing once swallowing is initiated.
Swallowing is controlled by automatic reflexes that involve nerves within the
pharynx and esophagus as well as a swallowing center in the brain that is
connected to the pharynx and esophagus by nerves. (A reflex is a mechanism that
is used to control many organs. Reflexes require nerves within an organ such as
the esophagus to sense what is happening in that organ and to send the
information to other nerves in the wall of the organ or outside the organ. The
information is processed in these other nerves, and appropriate responses to
conditions in the organ are determined. Then, still other nerves send messages
from the processing nerves back to the organ to control the function of the
organ, for example, the contraction of the muscles of the organ. In the case of
swallowing, processing of reflexes primarily occurs in nerves within the wall of
the pharynx and esophagus as well as the brain.)
The complexity of swallowing also explains why there are so many causes of
dysphagia. Problems can occur with:
the conscious initiation of swallowing,
propulsion of food into the pharynx,
closing of the nasal passages or larynx,
opening of the upper or lower esophageal sphincters,
physical blockage to the
passage of food, and
transit of the bolus by peristalsis through the body of the
esophagus.
The problems may lie within the pharynx or esophagus, for example,
with the physical narrowing of the pharynx or esophagus. They also may be due to
diseases of the muscles or the nerves that control the muscles of the pharynx
and esophagus or damage to the swallowing center in the brain. Finally, the
pharynx and the upper third of the esophagus contain muscle that is the same as
the muscles that we use voluntarily (such as our arm muscles) called skeletal
muscle. The lower two-thirds of the esophagus is composed of a different type of
muscle known as smooth muscle. Thus, diseases that affect primarily skeletal
muscle or smooth muscle in the body can affect the pharynx and esophagus, adding
additional possibilities to the causes of dysphagia.
Odynophagia and globus sensation
There are two symptoms that are often
thought of as problems with swallowing (dysphagia) that probably are not. These
symptoms are odynophagia and globus sensation.
Odynophagia
Odynophagia means painful swallowing. Sometimes it is not easy for
individuals to distinguish between odynophagia and dysphagia. For example, food
that sticks in the esophagus often is painful. Is this dysphagia or odynophagia
or both? Technically it is dysphagia, but individuals may describe it as painful
swallowing (i.e., odynophagia). Moreover, patients with gastroesophageal reflux
disease (GERD) may describe dysphagia when what they really have is odynophagia.
The pain that they feel after swallowing resolves when the inflammation of GERD
is treated and disappears and is presumably due to pain caused by food passing
through the inflamed portion of the esophagus.
Odynophagia also may occur with
other conditions associated with inflammation of the esophagus, for example,
viral and fungal infections. It is important to distinguish between dysphagia
and odynophagia because the causes of each may be quite different.
Globus sensation
A globus sensation refers to a sensation that there is a lump in the throat.
The lump may be present continuously or only when swallowing. The causes of a
globus sensation are varied, and frequently no cause is found. Globus sensation
has been attributed variously to abnormal function of the nerves or muscles of
the pharynx and GERD. The globus sensation usually is described clearly by
individuals and infrequently causes confusion with true dysphagia.
What causes dysphagia?
As discussed previously, there are many causes of dysphagia. For convenience,
causes of dysphagia can be classified into two groups;
oropharyngeal (meaning
that the cause is a problem in the mouth or pharynx) and
esophageal.
Causes also
can be classified differently into several groups.
Physical obstruction of the pharynx or esophagus
Benign and malignant tumors of the pharynx and
esophagus. Most commonly these
tumors are malignant.
Tumors of the tissues surrounding the pharynx and esophagus. These tumors can
compress the pharynx and esophagus leading to obstruction. This is an unusual cause of dysphagia. An example would be
thyroid cancer.
Narrowing (strictures) of the esophagus. The strictures usually are due to
GERD and are located in the lower esophagus. These strictures are the result of ulcerations of the
esophagus that heal, with scarring as a result. Less common causes of strictures
include ingestion of acid or lye during attempts at
suicide, some pill medications that may stick in the
esophagus and cause ulceration and scarring, for example,
potassium chloride ( K-Dur, K-Lor, K-Tab, Kaon CL, Klorvess, Slow-K, Ten-K, Klotrix, K-Lyte CL),
doxycycline (Vibramycin, Oracea, Adoxa, Atridox and others),
quinidine (Quinidine
Gluconate, Quinidine Sulfate), biphosphonates used for treating
osteoporosis),
radiation therapy, and
infections of the lower esophagus, particularly in people with
AIDS.
Schatzki's rings. These rings are benign, very short narrowings (millimeters)
at the lower end of the esophagus. The cause of
Schatzki's rings is unknown though some
physicians believe they are caused by GERD.
Infiltrating diseases of the esophagus. The most common infiltrative disease
is a disease in which the wall of the esophagus fills with
eosinophils, a type of white blood cell involved in inflammation. This disease
is called eosinophilic esophagitis. The wall of the esophagus becomes stiff and cannot
stretch as the bolus of food passes. As a result, the bolus sticks.
Diverticuli (outpouchings) of the pharynx or esophagus. The diverticuli can
expand when it fills with swallowed food and can compress the pharynx or esophagus. The diverticuli can be
at the upper end of the esophagus (Zenker's diverticulum) or, less commonly, at the
middle or lower end of the esophagus.
Cricopharyngeal bars. These bars represent a part of the upper esophageal
sphincter that has hypertrophied, that is, expanded. The bar does not stretch normally as the
bolus passes. The cause of cricopharyngeal bars is unclear. Small bars that do not
interfere with swallowing are quite common.
Cervical osteophytes. Rarely,
arthritis of the neck results in an overgrowth
of bone that extends anteriorly out from a vertebra (an osteophyte). Since the vertebrae of the
neck lie immediately behind the lower pharynx and uppermost esophagus, the osteophyte
may impinge on the pharynx and esophagus.
Congenital abnormalities of the esophagus. These abnormalities are present
from birth and are almost always discovered in infants because of problems when oral feeding
begins.
GERD (gastroesophageal reflux disease) is a condition in which the acidified liquid
contents of the stomach backs up into the esophagus. The symptoms of uncomplicated GERD are heartburn,
regurgitation, and nausea. Effective treatment is available for most patients with GERD.
Diabetes mellitus is a chronic condition characterized by high levels of sugar (glucose) in the blood. The two types of diabetes are referred to as type 1 (insulin dependent) and type 2 (non-insulin dependent). Symptoms of diabetes include increased urine output, thirst, hunger, and fatigue. Treatment of diabetes depends on the type.
Sjögren's syndrome is an autoimmune disease involving the abnormal production of extra antibodies that attack the glands and connective tissue. Sjögren's syndrome with gland inflammation (resulting dry eyes and mouth, etc.) that is not associated with another connective tissue disease is referred to as primary Sjögren's syndrome. Sjögren's syndrome that is also associated with a connective tissue disease, such as rheumatoid arthritis, systemic lupus erythematosus, or scleroderma, is referred to as secondary Sjögren's syndrome. Though there is no cure for Sjögren's syndrome, the symptoms may be treated by using lubricating eye ointments, drinking plenty of water, humidifying the air, and using glycerin swabs. Medications are also available to treat dry eye and dry mouth.
A stroke results from impaired oxygen delivery to brain cells via the bloodstream. A stroke is also referred to as a CVA, or cerebrovascular incident. Symptoms of stroke include: sudden numbness or weakness of the face, arm or leg. Sudden confusion, trouble speaking or understanding. Sudden trouble seeing in one or both eyes, sudden trouble walking, dizziness, or loss of balance, and/or sudden severe headache with no known cause. A TIA, or transient ischemic attack is a short-lived temporary impairment of the brain caused by loss of blood supply. Stroke is a medical emergency.
Multiple sclerosis (MS) is a disease which progressively injures the nerves of the brain and spinal cord, reflected by alterations of virtually every sensory or motor function in the body. The cause of MS is primarily unknown. There are different types of MS including relapsing-remitting MS, primary-progressive MS, and secondary-progressive MS. Symptoms of MS rang from mild to severe and examples include visual disturbances, muscle weakness, spasm, and fatigue. Decreased concentration, memory loss, and impaired judgment. Treatment for MS is generally with medications.
There are four major types of thyroid cancer: papillary, follicular, medullary, and anaplastic thyroid cancer. Tumors on the thyroid are referred to as thyroid nodules. Symptoms of thyroid cancer include swollen lymph nodes, pain in the throat, difficulty swallowing, hoarseness, and a lump near the Adam's apple. Treatment usually involves chemotherapy, surgery, radioactive iodine, hormone treatment or external radiation and depends upon the type of thyroid cancer, the patient's age, the tumor size, and whether the cancer has metastasized.
Neck pain (cervical pain) may be caused by any number of disorders and diseases. Tenderness is another symptom of neck pain. Though treatment for neck pain really depends upon the cause, treatment typically may involve heat/ice application, traction, physical therapy, cortisone injection, topical anesthetic creams, and muscle relaxants.
Parkinson's disease is a slowly progressive neurologic disease characterized by a fixed inexpressive face, a tremor at rest, slowing of voluntary movements, a gait with short accelerating steps, peculiar posture and muscle weakness, caused by degeneration of an area of the brain called the basal ganglia, and by low production of the neurotransmitter dopamine. Most patients are over 50, but at least 10 percent are under 40.
Esophageal cancer is a disease in which malignant cells form in the esophagus. Risk factors of cancer of the esophagus include smoking, heavy alcohol use, Barrett's esophagus, being male and being over age 60. Severe weight loss, vomiting, hoarseness, coughing up blood, painful swallowing, and pain in the throat or back are symptoms. Treatment depends upon the size, location and staging of the cancer and the health of the patient.
Huntington's disease is the result of degeneration of neurons in areas of the brain. Huntington's disease is an inherited disorder. Early symptoms include mood swings, apathy, depression, and anger uncharacteristic of the individual. Judgement, memory, and other cognitive functions may become impaired. Presymptomatic testing is available for individuals who have a family history of Huntington's disease. Treatment includes medication and therapy for symptoms.
Scleroderma is an autoimmune disease of the connective tissue. It is characterized by the formation of scar tissue (fibrosis) in the skin and organs of the body, leading to thickness and firmness of involved areas. Scleroderma is also referred to as systemic sclerosis, and the cause is unknown. Treatment of scleroderma is directed toward the individual features that are most troubling to the patient.
Eosinophilic esophagitis is an inflammation of the esophagus. Eosinophilic esophagitis has many causes including acid reflux, heartburn, viruses, medications that become stuck in the esophagus, allergy, asthma, hay fever, allergic rhinitis, and atopic dermatitis. Eosinophilic esophagitis symptoms include difficulty swallowing food, abdominal pain, chest pain, and heartburn.
Barrett's esophagus occurs as a complication of chronic gastroesophageal reflux disease (GERD), primarily in white males. GERD refers to the reflux of acidic fluid from the stomach into the esophagus (the swallowing tube), and is classically associated with heartburn.
Myasthenia gravis, a chronic autoimmune neuromuscular disease. Varying degrees of weakness of the voluntary muscles of the body are the main characteristics. A defect in the transmission of nerve impulses ot the muscles is the cause of myasthenia gravis. Symptoms include weakness of th eye muscles, facial expression, and difficulty swallowing. Treatment of myasthenia gravis are medical therapies to control the symptoms of the disease.
Laryngitis is an inflammation of the voice box (vocal cords). The most common cause of acute laryngitis is infection, which inflames the vocal cords. Symptoms may vary from degree of laryngitis and age of the patient. Common symptoms include croup, hoarse cough, fever, cold, runny nose, dry cough, and loss of voice. Chronic laryngitis generally lasts more than three weeks. Causes other than infection include smoking, excess coughing, GERD, and more. Treatment depends on the cause of laryngitis.
Rabies is a potentially fatal viral infection. Rabies symptoms include fever, headache, myalgia, and can progress to more serious symptoms such as seizures, coma and death. The rabies vaccine (rabies treatment) should be administered immediately after the person or pet has been bitten.
Anaphylaxis is a serious allergic reaction that affects a number of different areas of the body at one time, and can be fatal. Causes of anaphylaxis can be food allergy, latex allergy, allergy to insect or but stings/bites, asthma, or other materials or conditions. Symptoms include flushing, itching, hives, anxiety, rapid or irregular pulse. Severe symptoms may be throat and tongue swelling, swallowing, and difficulty breathing. Some disorders appear similar to anaphylaxis such as fainting, panic attacks, blood clots in the lungs, heart attacks, and septic shock. If you think that you may be having an anaphylactic reaction, seek emergency care or call 911 immedately.
Polymyositis is a disease of the muscle featuring inflammation of the muscle fibers. It results in weakness of the muscles which can be severe and when associated with skin rash, is referred to as dermatomyositis. Although the cause of this disease is unknown, diagnosis includes physical examination of muscle strength, blood tests for muscle enzymes, electrical tests of muscle and nerves, and conformation by a muscle biopsy. Treatment of Polymyositis and Dermatomyositis includes high doses of cortisone-related medications, immune suppression, and physical therapy.
Achalasia is a disease of the esophagus that mainly affects young adults. Abnormal function of nerves and muscles of the esophagus causes difficulty swallowing and sometimes chest pain.
Amyotrophic lateral sclerosis (ALS, Lou Gehrig's disease) is a neurological disease that progresses rapidly. The disease attacks the nerve cells responsible for the control of voluntary muscles. Early symptoms include cramping, twitching, or stiffness of the muscles; slurred nasal speech; difficulty swallowing or chewing, and muscle weakness in an arm or leg. Currently, the cause of ALS is not known. ALS is a fatal disease. No cure has been found for ALS, however, the drug riluzole (Rilutek) is FDA approved, and this drug reduces the damage to motor neurons by decreasing the release of glutamate.
Digestion is the complex process of turning food you eat into the energy you need to survive. The digestive process also involves creating waste to be eliminated, and is made of a series of muscles that coordinate the movement of food.
Heartburn is a burning sensation experienced from acid reflux (GERD). Symptoms of heartburn include chest pain, burning in the throat, difficulty swallowing, the feeling of food sticking in the throat, and a burning feeling in the chest. Causes of heartburn include dietary habits, lifestyle habits, and medical causes. Treatments for heartburn include lifestyle changes, OTC medication, prescription medication, and surgery.
Schatzki (Schatzki's) ring, is a narrow ring of tissue located just above the junction of the esophagus and stomach. The cause of Schatzki ring is not clearly known, however, some doctors believe they are caused by long term acid reflux. The symptoms of a Schatzki ring is primarily poorly chewed food that stays in chunks becoming stuck in the esophagus. Diagnosis of Schatzki's ring is barium x-ray or endoscopy. Treatment is generally a procedure to stretch or fracture the rings.
Polio is caused by the poliovirus and is spread through person-to-person contact. In non-paralytic polio, patients experience mild flu-like symptoms such as fatigue, fever, headache, sore throat, and vomiting. In paralytic polio, symptoms include difficulty swallowing and breathing, headache, mood swings, muscle pains and spasms, and paralysis. There is no cure for polio, so treatment focuses on alleviating the symptoms. In 1955, a polio vaccine was developed.
Acid backing up into the larynx (voice box), it causes reflux laryngitis. Irritation of the lining of the esophagus, larynx, and throat can lead to esophagitis, sinusitis, strictures, hoarseness, throat clearing, swallowing problems, asthma, chronic cough, and more. Typical symptoms of reflux laryngitis include heartburn, hoarseness, or a sensation of a foreign body in the throat. Reflux laryngitis can be treated with OTC medication, prescription medication, and lifestyle changes.
Chagas disease is an infection caused by the T. cruzi parasite. Symptoms of Chagas disease include rash, swollen lymph nodes, fever, fatigue, nausea, vomiting, and the Romaña sign. An ELISA test is used to diagnose Chagas disease. Treatment depends upon the phase of the disease and the patient's age.
Cytomegalovirus (CMV) is a virus that is spread from person to person via spit, semen, vaginal secretions, urine, blood, sexual contact, breastfeeding, blood transfusions, organ transplants, and breast milk. Symptoms of CMV include fatigue, swollen glands, fever, and sore throat. You can take precautions to prevent CMV such as washing hands frequently and thoroughly, using condoms, if you work in day care centers wash hands thoroughly after contact with body secretions, and avoiding oral contact with objects covered in saliva. Individuals with HIV infection are at most risk of contracting CMV.
Irritable bowel syndrome (IBS) in children is a functional gastrointestinal disorder with symptoms of abdominal pain, bloating, diarrhea or constipation. The cause of IBS is unknown, however, certain foods, stress, anxiety, and depression may contribute to the symptoms of IBS. There is no cure for IBS in children; however, medications, dietary changes, and stress management may relieve symptoms.
Caring for a loved one or patient with Alzheimer's can become a difficult and overwhelming task at times. This guide helps caregivers of individual's with Alzheimer's deal with communicating, bathing, and dressing; as well as problem solving with incontinence, sleeping, wandering; and coping with difficulties Alzheimer's patients present.
Brain cell function requires a constant delivery of oxygen and glucose from the bloodstream. A stroke, or cerebrovascular accident (CVA), occurs when blood supply to part of the brain is disrupted, causing brain cells to die. Blood flow can be compromised by a variety of mechanisms.
Blockage of an artery
Narrowing of the small arteries within the brain can cause a lacunar stroke, (lacune
means "empty space"). Blockage of a single arteriole can affect a tiny area of brain causing that tissue to
die (infarct).
Hardening of the arteries (atherosclerosis) leading to the brain. There are four major blood vessels that supply the brain with blood.
The anterior circulation of the brain that controls most motor activity, sensation, thought, speech, and emotion is supplied by the carotid arteries.
The posterior circulation, which supplies the brainstem and the cer...