For most, swallowing is an automatic process that takes place countless times every day with little thought. However, the process of swallowing is actually an extremely complicated and coordinated process. Moving food from the mouth through the esophagus and down to the stomach involves about 50 pairs of muscles and many nerves working in concert.

Dysphagia is the medical term used to describe swallowing difficulties. Some people with dysphagia experience pain while swallowing, known as odynophagia. In particularly severe cases, a person with dysphagia may not be able to safely swallow solids, liquids, or even their own saliva. Some can’t swallow anything at all. It becomes a challenge to ingest enough calories and fluids to keep the body healthy and avoid medical problems including the danger of choking and aspiration.

At Yale Medicine, our Gastrointestinal Motility Program focuses on diagnosing and treating conditions that affect the digestive tract, including dysphagia, gastroesophageal reflux disease (GERD), gastroparesis (when the stomach can’t empty food properly), constipation, and fecal incontinence.

Our team includes gastroenterologists, surgeons, pathologists and radiologists who work together to manage even the most difficult-to-diagnose disorders. “We treat these as quality-of-life issues,” says Yale Medicine’s Amir Masoud, MD. “To help patients feel better is its own reward.”

Dysphagia, or difficulty swallowing, occurs on a continuum and can be a symptom of a number of different disorders. “It’s everything from trouble getting food down to the sensation that it feels wrong,” says Dr. Masoud.

Occasional problems with swallowing are not always concerning but, for cases that persist, there are often underlying causes including neurologic, congenital, developmental, obstructive, or muscular problems. One of the more common causes is GERD, where acid from the stomach can splash up into the esophagus and throat. In addition to typical “heartburn” that is associated with GERD, abnormalities in the way that the esophagus functions can also occur.

Dysphagia is most common in older adults. “As you get older, your muscles just don’t work as well,” Dr. Masoud says. Dementia and cognitive decline can also make it difficult to chew and swallow. While these pose a particular challenge, our team has extensive experience in managing and treating even the most difficult cases.

Generally, dysphagia falls into one of two categories:

Esophageal dysphagia happens when you have the sensation that food is stuck at the base of your throat or in your chest after you have started to swallow. Causes of this type of dysphagia include:

• Achalasia: Your lower esophageal muscle (sphincter) doesn’t relax enough to let food into your stomach, causing food to come back up into your throat.
• Esophageal spasm: Your esophagus doesn’t contract properly after you swallow.
• Esophageal stricture: A narrowed esophagus can trap large pieces of food. Narrowing is sometimes a result of tumors or scar tissue, which can be due to anything from GERD to radiation therapy. 
• Foreign bodies: Food or another object can partially block your throat or esophagus.
• Esophageal ring: A thin ring-like narrowing in the lower esophagus can intermittently create problems swallowing solid foods.
• Eosinophilic esophagitis: This occurs when chronic inflammation develops in the lining of the esophagus possibly due to a food allergy or acid reflux. This can alter the way that the esophagus functions or lead to rings or strictures.
• Scleroderma: This is an autoimmune disease that causes scar-like tissue to develop, leading to stiffening and hardening of tissues and loss of muscle function. As a result, your lower esophageal sphincter weakens, allowing acid to back up into the esophagus and cause heartburn, narrowing of the esophagus (stricturing), and weakness in the ability of the esophagus to pass food into the stomach.

Oropharyngeal dysphagia is characterized by difficulty initiating a swallow. You may gag, choke, cough, or have the feeling that the food or liquids are going down your windpipe or up your nose. Causes include:

• Neurological disorders: Multiple sclerosis, muscular dystrophy, Parkinson’s disease, and myasthenia gravis can all affect swallowing.
• Neurological damage: Stroke and brain or spinal cord injuries can cause tongue weakness or other problems.
• Pharyngeal (also known as Zenker’s) diverticula: This is when a small pouch forms and collects food particles in your throat, typically just above the esophagus.
• Cancer: Certain types of cancer and radiation treatment can cause swallowing problems. 

Symptoms of dysphagia can vary, but some include:

• An inability to swallow
• Pain with swallowing
• The sensation of food getting stuck in your throat or chest or behind your breastbone (sternum)
• Drooling
• Hoarseness
• Bringing food back up (regurgitation)
• Frequent heartburn
• Food or stomach acid coming back up into your throat
• Unexpected weight loss
• Coughing or gagging when swallowing

An upper endoscopy (inserting a thin scope with a light and camera at its tip down the throat and esophagus) is one of the most common diagnostic procedures for dysphagia. 

“We look at the inner wall of the esophagus—its lining—and we check for rings, masses, or strictures that can cause swallowing problems,” Dr. Masoud explains.

 Additionally, doctors may perform these tests:

• Esophagram: Also known as a “barium swallow,” this is an X-ray of the upper gastrointestinal tract.
• Esophageal manometry: Also known as a swallowing (pressure) test, this allows doctors to see patterns and types of swallowing abnormalities.
• pH and impedance testing: These types of tests are helpful in determining if there is any reflux into the esophagus (acid or non-acid).

We also work with speech-language pathologists, who might use tests that let them examine the stages of the swallowing process. These tests include:

• Flexible Endoscopic Evaluation of Swallowing with Sensory Testing (FEESST): This test uses a lighted fiber-optic tube, or endoscope, to view the mouth and throat and how it responds to stimuli, such as a puff of air, food or liquids.
• Videofluoroscopic Swallow Study (VFSS): A clinician films and records, via X-ray, the entire swallowing process as you consume several foods and liquids, along with the mineral barium to give better visibility of the digestive tract. 

Depending on your type of dysphagia, there are various treatment options. For those with esophageal dysphagia, treatment may include esophageal dilation—where doctors can open up a narrowed esophagus with a special balloon or dilators inserted through the esophagus.

For an esophageal tumor, achalasia or pharyngeal diverticula, surgery might be needed. For difficulty swallowing associated with GERD, prescription oral medications can reduce stomach acids and lead to symptom improvement. For conditions that get progressively worse, like MS or amyotrophic lateral sclerosis, a feeding tube in the stomach might ultimately be necessary.

Other treatments might include muscle exercises to strengthen weak facial muscles or improve coordination, or using different head and neck postures while eating. For example, a “chin tuck” involves tucking your chin so that food and liquids don’t enter the trachea when swallowing. An early step may involve making changes in food texture or size. This might involve putting food in a blender or adding special thickeners to liquids.

The specialists in our Gastrointestinal Motility Program not only treat patients with a wide variety of disorders that affect the digestive tract, but also conduct important, patient-focused research on reflux and swallowing disorders.

Doctors from all over the state refer patients to Yale Medicine, due to the wide array of state-of-the-art diagnostic and therapeutic tools. Our expertise for cases that are difficult to treat or diagnose is highly valued. We also can refer patients to our Speech & Swallow Program, which diagnoses and treats voice, airway, and swallowing disorders in children and adults.

“Being part of a world renowned academic center, we have a unique collection of experts from various fields, advanced training, and specialized diagnostic and therapeutic modalities,” Dr. Masoud says.