Swallowing difficulties - dysphagia - what does it really mean?

Dysphagia means that a person finds it difficult to eat, chew, swallow and to transport the food from the mouth down to the stomach. The medical term dysphagia comes from the Greek ’dys’ meaning reduced or impaired, and ’fagein’ meaning to eat. [1] Dysphagia can occur in one or more of the levels in the swallowing process and is thus divided into different types. Dysphagia can strike at any time in life: from a newborn baby to adolescence, middle age, or when we become old. Here is a guide through the different types of dysphagia.
 

In Sweden, dysphagia affects 1 million people per year to one degree or another. You can add to that approximately 1 million people who have either not had optimal treatment - or even none at all, but that have a chronic dysphagia from earlier in their lives. Totally then, it is estimated that 2 million people in Sweden suffer from dysphagia. Because our knowledge of dysphagia is incomplete, the numbers of unrecognised cases may be higher. This makes dysphagia one of the most prevalent dysfunctions that we have, but one of those that we talk the least about.
 

For those not personally affected, dysphagia is often unnoticed, but for those affected it can be an everyday fight for life. Problems in swallowing can be a major issue when you think that a normal person swallows 600 times every 24 hours, of which 350 occur during the day, 200 during mealtimes and 50 times during sleep [6].

In the section ”Dysphagia -  different causes” we describe in more detail how the usual symptoms show themselves, and how those who are suffering can get help.

 

4 different phases in the swallowing process - and 4 different types of dysphagia

In the same way as the swallowing process can be divided into four different phases, so can the different types of dysphagia - swallowing difficulties. These are the four vital stages:
 

  1. Pre-oral phase - when the food is transferred from plate to mouth.
  2. Oral phase - when the food is chewed and processed in the mouth: also called ’mouth phase’.
  3. Pharyngeal phase - when the bolus passes the front palate (anterior palatal arch) and the pharynx: also called ’pharynx phase’.
  4. Esophagal phase - when the food is transported through the esophagus: also called ’esophagus phase’
     

Below we go into more detail on each of these different phases in the reverse of the natural order shown above: beginning with the esophagal phase, and working our way upwards to the pre-oral phase.

 

4. Esophagal dysphagia

This is what we call the swallowing problem that affects the esophagus’ function. Esophagal dysphagia can be further divided into two subgroups:
 

a) Intermittent esophagal dysphagia - the problem comes and goes

This is the most common type of dysphagia - one in ten people (approx. 1 million in Sweden) that are otherwise-healthy have hiatus hernia which causes this type of dysphagia. [5]

It is common that those that suffer from a hiatus hernia experience some of the following symptoms, either during, or shortly after, swallowing. The problem comes and goes to start with, but after a while becomes more persistent. A full list of the usual symptoms is shown under hiatus hernia
 

  • Acidic indigestion, reflux, heartburn.
  • Persistent cough.
  • A feeling of a lump in the neck or throat.
  • A blocked feeling in the chest.
  • Difficulty in swallowing solid food e.g. chicken, dry meat, rice or soft dry bread.
  • Food stuck in the throat, and misdirected swallowing more often than normal.
  • A feeling of ’being full’ earlier than usual.
  • Frothy, thick, or profuse saliva that can be difficult to swallow away, which often leads to a need to attempt to swallow more often.
     

If untreated, symptoms can worsen with time, and more symptoms can occur, creating problems in everyday living. From an initial position that the problem comes and goes, it can worsen until it is experienced at almost every mealtime. For this reason it is extremely important to get started with treatment as early as possible.

Read more under hiatus hernia about the usual symptoms, why your body reacts as it does.

Note! If you find that it is always difficult to swallow food pieces above a certain size, and if you have had repeated pneumonia, read the section on achalasia cardiae
 

b) Constant esophagal dysphagia - always a block in the chest

With constant dysphagia there is always a block in the chest with food morsels you try to swallow that are larger than a certain size. This can be caused by some form of narrowing of the esophagus caused for example by scar tissue, or by pockets along the oesophagus, or by a tumour.

Achalasia cardiae – is a rare type of constant oesophagal dysphagia whose symptoms can sometimes be similar to hiatus hernia. The differences however are several: for example a person with achalasia cardiae will have constant difficulties in swallowing food, experience rapid weight loss, be victim to repeated pneumonias, but will not experience acidic reflux or heartburn.


Read more on the differences under achalasia cardiae
 

If you suspect some form of constant esophagal dysphagia you should immediately ask for a referral to an Ear, Nose and Throat (ENT) doctor, a surgeon or a gastroenterologist.
 

Causes of esophagal dysphagia

So, in conclusion, there are several different causes to esophageal dysphagia: hiatus hernia, achalasia cardiae, tumors or narrowing of the esophagus, abnormality or deformity, or scleroderma.

 

3. Pharyngeal dysphagia – food lodges in the airway or nose

It is typical for this type of dysphagia that food ’goes down the wrong way’ into the airways because of misdirected swallowing; and that the patient’s voice sounds odd as a result. This can be caused by reduced feeling or muscle strength to close the epiglottis to protect the airway during swallowing. Morsels of food can also remain in the pharynx after swallowing, and later work their way up into the nose. Misdirected swallowing can also be caused by a muscular inability to be able to open the upper mouth of the esophagus, or a lack of strength to transport the bolus through the pharynx to the esophagus.
 

Causes of pharyngeal dysphagia

Various reasons for this type of dysphagia can be: stroke or some type of neurological disease like Parkinson’s, MS, or ALS. Pharyngeal dysphagia can also occur after radiation injuries, whiplash injuries or a conditioned reflex.

 

2. Oral dysphagia - difficulties in chewing and swallowing

This type of dysphagia means that you find it hard to chew, mix the food with saliva in your mouth, to transport the food backwards towards your pharynx, and that sometimes it can remain in your mouth because the swallow reflex has not cut in. Here, the affected areas are primarily the oral cavity including the lips’, cheeks’ and tongue’s functions, together with the swallow reflex from the anterior palate.
 

Causes of oral dysphagia

Various reasons for this type of dysphagia can be: stroke, Down syndrome, cleft palate, Parkinson’s disease, ALS, MS, Sjögrens syndrome, dryness in the mouth, medicine-induced dryness in the mouth, tumors, radiation injuries, extreme anxiety, poor bite, bad teeth, poor jaw function, senility or conditioned reflex.

 

1. Pre-oral dysphagia – food from the plate into the mouth

This form of dysphagia is concerned with the problems in being able to transport food from your plate to your mouth yourself. For example, after a stroke which has caused paralysis in one arm, an inability to hold the head and body in balance in an upright position, difficulties in focusing and seeing the food, and also tiredness and a lack of initiative can all be a problem.

 

Causes of pre-oral dysphagia

Various reasons for this type of dysphagia can be: stroke, with paralysis in an arm or leg which can cause poor posture or difficulties in sitting up straight, cerebral palsy, Parkinson’s disease, ALS, multiple sclerosis, paralysis caused by injury, age-related weakness, senility, dementia or Alzheimer’s disease.

To be able to look after yourself, and transport your own food from your plate to mouth has a huge effect on your mealtime experience and quality of life. Look here at an eating aid.

 

Swallowing problems can have serious medical consequences

To be able to express our emotions facially, eat, suck, swallow, breathe and talk are abilities that we take for granted - until the day someone close to us loses those functions. Only then do we realise that problems in the mouth, pharynx and esophagus affect our most fundamental and important life functions that are crucial for our well-being.

The oral cavity plays a central role in an individual’s development, and we must stimulate and use the involuntary musculature that is involved when we eat, suck, chew, swallow, breathe and talk. Injuries or impairment in this area can lead to changes in the normal pattern of swallowing, which in their turn can create alarming new symptoms with grave medical consequences.

An impaired swallowing capacity, where muscles in the face, mouth, and throat are dramatically weakened, can lead to secondary difficulties. Poor facial development can lead to speech-, sucking-, and chewing difficulties, deformed appearance, breathing problems, sleep apnoea and bite- and jaw impairment.
 

Reduced life quality - the victims suffer in silence

Food and drink are almost always involved when we meet with friends, family, colleagues at work, business partners or when we celebrate events. This means that people with swallowing difficulties - dysphagia – are often embarrassed, hold themselves back, or simply don’t participate.

Dysphagia has a negative effect on both healing and rehabilitation, which is strongly correlated to extended care periods, more complicated care interventions, reduced quality of life and great personal suffering for those that are affected, and those close to them. Dysphagia meets WHO’s criteria for being a handicap and means, for those who are affected by it, a hidden physical, psychological and social suffering.
 

Limited understanding from those close by

Depending upon what caused the swallowing difficulties, it can be more or less difficult for relatives and friends to accept the problem and see how they can best support the sufferer. If you are affected, it is common to be met with scepticism, fear and lack of understanding because most people are not acquainted with dysphagia and lack knowledge about it. Unfortunately for many, it can be that when they seek help from healthcare professionals they are misunderstood until they come in contact with a specialist.

If you are otherwise fit but, for example, suffer from a hiatus hernia, it can be difficult for those around you to understand that this is a huge problem in your daily life. Often, you may be told by others, and you might believe yourself, that it’s all in your head - which is completely wrong. This is something that we want to change, together with those that are suffering. We’ll do this by spreading knowledge on what dysphagia is, explaining the causes behind the dysfunction and showing how, nowadays, this can be treated.

 

Text by: Dr. Mary Hägg, Doctor of Medicine, Post-doctoral researcher at Uppsala University specialising in orofacial medicine, Head of Department at the Speech and Swallowing Faculty: Ear, Nose and Throat Clinic at Hudiksvall Hospital, Sweden. Registered Dentist. In cooperation with MYoroface.

October 2016

(Translation from the original Swedish text by T.W.Morris, MYoroface)


Reference sources  

 

  1. Svensson, P. (2008) I Hartelius, L., Nettelbladt, U. & Hammarberg, B. (red.). Logopedi. Lund: Studentlitteratur.
    (English translation: ”Speech therapy”).
     

  2. Logemann, J.A. (ProEd) (1998). Evaluation and treatment of swallowing disorders. (2nd ed) Austin, Texas: San Diego College
     

  3. O'Neill, P.A. (2000). Swallowing and prevention of complications. British medical bulletin, 56(2), 457-65.
     

  4. Tibbling-Grahn L, broschyr 03 Svenska Dysfagiförbundet, Stoppar maten upp i bröstet när du äter? Mellangärdesbråck – En vanlig matstrupssjukdom i alla åldrar., (pdf).
    (English translation: ”Does food get stuck in your chest when you eat? Hiatus hernia – A common sickness in people of all ages”).
     

  5. Kjellén G, Tibbling L. Manometric oesophageal function, acid perfusion test and symptomatology in a 55-year-old general population. Clinical Physiology. 1981; 1:405-15
     

  6. Ekberg O, (2011), Röntgendiagnostiska avdelningen, Universitetssjukhuset MAS, Malmö, Normal sväljning inclusive anatomi och fysiologi, (pdf). Hämtad 2015-12-05, kl 15.00,
    http://media1.dysfagi.se/2011/06/svaljningssvarigheter.pdf
    (English translation:” Normal swallowing including anatomy and physiology”).
     

  7. 1177.se, (2016), Muskler och senor, Hämtad 2016-09-20, kl 13.45,
    http://www.1177.se/Gavleborg/Tema/Kroppen/Rorelseapparaten/Muskler-och-senor/
    (English translation:”Muscles and sinews”).

 

 

 

    

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