It’s a very common symptom affecting 22% of people aged over 50 and almost all people older than 80. You may have heard the term “dysphagia” which means difficulty in swallowing.
The severity of dysphagia can vary from being fairly temporary and a minor nuisance to the absolute inability to swallow, with risk of inhaling food and fluid and consequent life-threatening chest infections.
It’s important to seek urgent medical attention if you feel your swallow is so bad that you are unable to maintain hydration or nutrition. If it’s a very sudden occurrence, I recommend you visit your local Accident and Emergency department in the first instance.
The most important cause to exclude is a cancerous growth in the swallowing apparatus or on the nerves that supply the swallow muscles. Often there is a gradual history with severe weight loss and other “alarm” symptoms such as a constant throat or ear pain, or a new neck lump.
This is a relatively common cause of dysphagia. The ring like cricopharyngeus muscle separates the throat muscles from that of the gullet. This can be thickened or spasmodic, causing hold-up of food or fluid. In some patients it may lead to an inability to burp! It is usually due to chronic gastric acid reflux (or GORD) and other causes of prolonged gullet inflammation.
If left untreated, a block in the upper gullet leads to a pressure rise, forcing an outpouching of the throat lining through a small defect in the muscle above the cricopharyngeus. This creates a pharyngeal pouch, in which food material may be trapped. Occasionally undigested food from the pouch regurgitates into the throat and risks entering the airway, manifest as choking and recurrent chest infections. Sometimes a pharyngeal pouch can harbour a cancerous lesion.
If acid reflux and other causes of inflammation in the oesophagus (or gullet) are left unchecked, then over time a circular scar or stricture forms, narrowing it.
A stricture is a relatively common side effect of radiotherapy for cancer and can occur many years after the treatment ended.
The act of swallowing comprises a complex coordination of certain muscle groups that are all supplied by named nerves. Dysphagia commonly presents as one of the symptoms of a neurological condition such as stroke, multiple sclerosis or Parkinson’s disease. A telling symptom is that fluid ingestion is disproportionately affected in comparison to swallowing solids
Surrounding structures may indent the swallowing apparatus. Conditions such as a protuberant bony spine (from arthritis) or an enlarged thyroid gland or rarely an abnormally coursing major blood vessel can cause dysphagia.
This extremely common symptom deserves its own section. Please read on!
To start with, I will perform a comprehensive head and neck and neurological examination.
As part of this, I will perform an endoscopic assessment of the throat and upper oesophagus in the clinic. This involves passing a fine lubricated camera through your nose, into the throat. This will additionally visualise the voice box and the upper gullet.
I may request a barium swallow test or a specialist swallow assessment such a video swallow or flexible endoscopic evaluation of swallowing (FEES). These last two tests carefully evaluate the mechanics of your swallow and demonstrate whether any food or fluid goes down the wrong way into the windpipe. They are particularly useful in diagnosing and managing neurological swallowing problems.
You may also need a CT scan of the neck and chest and occasionally an MRI scan of the brain to identify any worrying obstructing cause or exclude central neurological conditions.
Sometimes I may need to perform an examination of your throat and gullet under general anaesthetic, during which time any suspicious lesions will be biopsied and other therapeutic interventions performed.
Treatment is aimed to cure the existing problem; to prevent/ or treat other exacerbating conditions such as acid reflux or chronic infections and to rehabilitate your swallow.
Complex swallowing disorders require a collaborative input from speech and swallow specialists, who will help to “retrain” the swallow by exercising and strengthening the tongue and swallow muscles. This helps to channel food correctly down the gullet and away from the voice box and windpipe.
Sometimes a neurological condition impairs the mobility of one or more vocal cords in the voice box, which therefore doesn’t close when you swallow; causing aspiration. This can be remedied by a procedure that moves the cord to the midline. This improves the voice and cough and therefore the ability to clear away food that tries to enter the airway.
Cricopharyngeal muscle thickening or excessive spasm may be relaxed by injecting botulinum toxin (Botox) into the muscle and a gentle stretch of the muscle under general anaesthesia. For severe cases, a permanent surgical solution includes division of the muscle using laser through the mouth, or via an open neck approach.
This can also be treated through the mouth in most cases via a stapling or laser procedure, but extremely large pouches may require a neck operation.
Narrowing from scar can be treated via a procedure through the mouth that involves a gentle dilatation with a balloon and sometimes the addition of Botox. It may need to be repeated a few times before the narrowing remains permanently open.
I’ve deliberately left discussion about globus pharyngeus towards the end of this section, because although this condition is the commonest swallowing problem seen by ENT surgeons, other more serious problems with the swallow need to be excluded first.
Globus pharyngeus isn’t really a diagnosis. It’s a term that is commonly used to describe a feeling of a lump or pressure in the throat. It can occur on either side of the neck, but is often central. It doesn’t impair swallow and indeed is often only felt with a “dry” swallow. There are usually no other worrying symptoms such as a painful swallow or a neck lump.
Hopefully you will be reassured after I have performed a full and comprehensive head and neck examination including endoscopic assessment of the upper swallowing pipe.
The cause of a “globus” sensation is thought to originate from irritation of the muscular junction between the throat and oesophagus; namely the cricopharyngeus muscle. There are numerous associated conditions such as gastric acid reflux, post nasal drip, irritant chemicals including smoking, neck trauma and grumbling infections such as thrush, that I will look for and treat if necessary. An acutely stressful event such as a bereavement is also very common trigger.
Most patients are reassured following a negative clinical and radiological assessment.
Symptoms often improve with lifestyle modifications such as increasing water intake and following an anti-reflux diet. Medication may be directed to reducing gastric acid reflux and reducing the sensitivity of your throat lining.
Occasionally, an examination of your upper swallowing passages under anaesthesia may be required to exclude anything more worrying; the resulting stretch of the swallowing muscles often relieves the sensation.