Dysphagia (swallowing problems)
Swallowing looks like a simple movement, but it is fast, coordinated work by the tongue, soft palate, throat, voice box and oesophagus: in little more than a…
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On this page
- The rule this page starts with
- What exactly you feel, and what it gets confused with
- Choking and food going the wrong way
- When to call an ambulance, and when to be seen today
- When the swallow itself fails: nerves, muscles and mouth
- When something is blocking the oesophagus
- What happens at the appointment
- How to eat and drink while you wait for the appointment
- Online consultation
Swallowing looks like a simple movement, but it is fast, coordinated work by the tongue, soft palate, throat, voice box and oesophagus: in little more than a second a mouthful has to go into the oesophagus without a single drop entering the airway. That mechanism can fail at any point, which is why "it is hard to swallow" describes very different things. This subject has one rule that matters more than everything else, so it comes first.
The rule this page starts with
If solid food has become harder to swallow, if that started recently and above all if it is getting worse week by week, it needs investigating without waiting. This is exactly how cancer of the oesophagus behaves, and cancer of the junction where the oesophagus meets the stomach: first meat, bread and dry potato stick; then you chew longer and help things down with a drink; later even soft food will not pass. The channel narrows gradually, and the person changes their habits at the same pace — cuts things smaller, chooses soup, is last to finish at the table. From the outside it does not look like illness, and time slips away.
The urgency is not there to frighten anyone. Oesophageal cancer found early is curable; found when even water will not go down, it is a very different conversation. Between those two states there are usually months rather than years.
All the more reason not to put it off if the difficulty comes with any of this:
- you are losing weight without trying;
- blood tests have shown anaemia, or you have become pale and breathless on stairs;
- your voice has gone hoarse and is not recovering;
- swallowing is not only difficult but painful, or there is pain behind the breastbone;
- you have passed black tarry stools or vomited blood;
- you are over fifty, you smoke or used to, and you have had heartburn for years.
None of this means the worst has already happened. It means an examination and a gastroscopy are needed in the next few days, not "when there is time".
What exactly you feel, and what it gets confused with
A doctor needs to separate two sensations that are described in similar words but point to different conditions and different tests.
Food genuinely sticks. You swallow a mouthful and it stops, in the throat or behind the breastbone. You have to wait, take a drink, make several empty swallows, and sometimes the mouthful comes back up. Until that clears, the next mouthful cannot go down. Note two things: the level at which it stops, and what sticks — only solids, or water too. Those answers narrow the range of causes considerably.
A lump in the throat that does not stop you swallowing. A feeling of tightness or of something being there is present all the time, yet food and drink pass normally, and it is most noticeable when you swallow on an empty throat. This is a separate condition, linked to reflux, to tension in the neck muscles and to anxiety, and on its own it does not point to a tumour: here swallowing is not impaired, the sensation is. There is still a limit, though. If the lump is always on the same side, if it comes with weight loss, hoarseness or earache, or if it has not settled in weeks, get it looked at.
There is a third case as well: pain on swallowing without anything sticking. That more often means inflammation, from an ordinary throat infection to oesophagitis.
Choking and food going the wrong way
The second group of complaints is not about narrowing but about safety. When the fault happens at the very start of the swallow, food and liquid go into the airway instead of the oesophagus:
- coughing and choking while eating or drinking, especially on thin liquids;
- after a few mouthfuls the voice sounds wet and gurgly;
- food or drink comes back through the nose;
- saliva escapes from the mouth, food is left in the cheek;
- bouts of coughing at night when lying down.
This is how aspiration pneumonia develops: a lung infection caused by food that has gone into the lungs. It is the commonest serious consequence of a swallowing problem. It matters especially after a stroke, where swallowing is affected in the first days in a great many people and does not recover in all of them, and in Parkinson's disease, where it worsens slowly and unnoticed by the person themselves. Both can have silent aspiration: food enters the airway and there is no cough at all, because the protective reflex has weakened. So the thing to watch here is not coughing but other signals — repeated "colds with a temperature", a cough that never finishes, weakness, refusing food, weight loss. If such a person develops a temperature and a cough, they need a doctor the same day, and the doctor must be told that swallowing is a problem.
When to call an ambulance, and when to be seen today
Call an ambulance on the single European number 112 if:
- a piece of food has blocked the airway: the person cannot speak, breathe or cough, clutches at their throat, turns blue. Minutes count here, and while help is on the way first aid for choking is given;
- swallowing has gone suddenly, together with a drooping face, weakness in an arm or slurred speech — that is a stroke;
- the tongue, lips or throat are swelling as you watch, the voice has gone and breathing is hard — that is an allergic swelling;
- in someone with myasthenia the weakness is spreading and reaching swallowing and breathing;
- a child has suddenly stopped swallowing and is drooling — not even swallowing their own saliva, refusing to drink, sitting leaning forward, breathing noisily. That is how a stuck foreign body and swelling in the throat present, and waiting until morning is not an option. If there is the slightest chance the child has swallowed a flat button battery from a remote control or a toy, say so straight away: a battery lodged in the oesophagus burns through the wall within hours.
Be seen the same day if:
- you cannot swallow even water or saliva and have to spit;
- a mouthful has stuck and has not passed in several hours, with pain behind the breastbone;
- you have not been drinking for more than a day: dry tongue, little urine, weakness, dizziness;
- a temperature and a cough have appeared in someone who chokes at meals.
When the swallow itself fails: nerves, muscles and mouth
Here the mechanism of the swallow is broken, which is why there is choking and why liquids are harder than solids.
- Stroke is the commonest cause of swallowing problems that come on suddenly.
- Parkinson's disease and other conditions with slowly increasing stiffness.
- Motor neurone disease: swallowing and speech deteriorate together, the tongue weakens and wastes, and weakness in the hands and muscle twitching are added.
- Myasthenia, with one very characteristic feature: swallowing is noticeably harder late in the day and towards the end of a meal than in the morning and in the first spoonfuls. A drooping eyelid and double vision usually go with it.
- Multiple sclerosis, advanced dementia, the after-effects of a head injury, cerebral palsy.
Anything that stops a mouthful being prepared belongs here too. A dry mouth makes swallowing hard in itself — from medicines, from dehydration, after radiotherapy to the head and neck, in diseases of the salivary glands. A badly fitting denture, or a missing one, makes chewing impossible. And some drugs interfere with swallowing directly: antipsychotics and medicines with anticholinergic effects.
When something is blocking the oesophagus
Here it is the other way round: liquids go down and solids stick.
- Cancer of the oesophagus or of its junction with the stomach — the reason the first section exists.
- A narrowing after reflux. Years of heartburn leave a ring of scar in the lower oesophagus. Watch for the trap: heartburn often eases at that point, and the person thinks things are improving when in fact the channel has narrowed.
- Achalasia: the lower valve of the oesophagus stops opening on time. It is unlike the rest — both food and water pass badly, what has been eaten sits in the oesophagus for a long time and comes back undigested, especially on lying down, hence the night-time cough and the wet pillow. It runs for years and slowly leads to weight loss.
- Oesophagitis: from reflux, from an allergic condition of the oesophagus (in young people it often begins with a piece of meat stuck fast), or from a fungal infection when immunity is low.
- Damage from a tablet. Tetracyclines, anti-inflammatory painkillers, bisphosphonates and potassium supplements can burn the wall of the oesophagus if they are taken lying down and with almost no water.
- Pressure from outside: a large goitre, enlarged glands in the chest, changes in the spine.
What happens at the appointment
The doctor will ask when it started, what sticks and at what level, whether it has got worse, what you weighed six months ago, whether you have had heartburn, what medicines you take and whether you smoke; they will look at your mouth and neck, listen to your lungs, assess your voice and watch you swallow a few spoonfuls of water. Where solids stick, the first test is usually a gastroscopy: the oesophagus and stomach are looked at through a thin tube, a sample of tissue is taken at the same time, and sometimes a narrowing is stretched. Where there is choking, the swallow itself is studied, with an X-ray test using contrast or with an endoscope while the person eats. If achalasia is suspected the pressure inside the oesophagus is measured, and a blood test for anaemia is added.
How to eat and drink while you wait for the appointment
This is not treatment. It is how to avoid harming yourself during the days when the cause is being worked out.
- Eat sitting up with a straight back, and stay upright for half an hour afterwards.
- Make food smaller: meat and vegetables down to a soft or pureed texture. Leave out anything dry, crumbly or stringy — toast, loose rice, tough meat, skins.
- Eat slowly, in small mouthfuls, chewing thoroughly, and do not talk with your mouth full. Turn the television off: swallowing needs attention.
- Do not wash solid food down with large gulps. It does push the mouthful along, but that is exactly how it ends up in the airway. Drink separately and in small sips.
- If you choke on liquids, tell your doctor: thickening them is sometimes advised, but the texture and the method are chosen by a specialist, not tried at random.
- Take tablets sitting up with a full glass of water, and do not lie down straight afterwards. Before crushing or splitting a tablet, ask your doctor or pharmacist: some medicines stop working that way and others irritate the oesophagus.
- Write your weight down once a week, and note what stuck and when. At the appointment that piece of paper says more than memory does.
- Do not try to push a stuck mouthful down with bread or a lot of water, and do not make yourself sick. Do not smoke or drink alcohol with meals.
Online consultation
What decides matters here is not examination but conversation: what sticks, where, since when, and what else has appeared alongside. That is what an Oladoctor doctor can establish online, and quickly. They will tell you whether a gastroscopy is needed and how urgently, which tests to ask for and in what order, go through any reports you already have and through your medicines, because sometimes the cause is there, and explain how to eat and drink safely until you are seen. And if what you describe looks like a narrowing that is progressing, like aspiration, or like the start of a neurological illness, you will be told plainly and given a deadline for being seen.
This material is for information only and does not replace medical advice.
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