HARD TO SWALLOW?

Check out the many reasons for swallowing difficulties

Eating and drinking is a vital part of living. So, having difficulty swallowing food can make life difficult, leading to frustration, stress and even embarrassment. There are wide causes of swallowing problems, so this overview is a quick summary on the topic.

HOW DOES NORMAL SWALLOWING TAKES PLACE?

The easiest way to understand the problem is to firstly understand how normal swallowing takes place. In a simple progression of logic, things enter the mouth and in the context of solids, these need to be chewed up to the right consistency before the contents can be moved from the mouth to the throat. Once it is in the throat, there are a group of muscles that then squeeze from top to bottom to push the food into the oesophagus, which then takes the food down to the stomach. For all of this to work, the muscles need to be strong, the squeezing by the muscles needs to be co-ordinated, the brain and nervous system need to be working properly and the passageway from the mouth to the stomach needs to be clear of obstructions. So, with that in mind, let’s look at what can go wrong.

THE CAUSES OF SWALLOWING DIFFICULTY ARE QUITE VARIED.

In the elderly, the most common causes are neurological disorders such as stroke, Parkinson’s disease, and dementia. This particularly affects their ability to move food from the mouth to the throat. This can have serious consequences such as dehydration and malnutrition and it is possible for things to go down the wrong way into the lungs and then cause pneumonia. Such a problem is very distressing and may lead to depression.

In terms of the oesophagus, common causes of problems include motility disorders, side effects of medication, reflux and obstruction such as from a cancer. There are also rare situations such as having a pocket forming in the oesophagus, called a pouch, which catches the food as it tries to go down into the oesophagus.

SPECIALIST EXAMINATION AND TESTS TO FIND THE CAUSE.

With so many causes of problems, how do we start to try and work out the cause? Like all good medical assessments, we start with taking a history. The symptoms we are on the lookout for include food sticking in the throat, coughing or choking. If the patient can point to where they feel things are sticking, then we have a better guide to the level of the likely problem. If they are choking or coughing, then we are more focussed on the throat. The presence of pain with swallowing, is a serious concern and would be considered to be related to serious problems until proven otherwise.

Examination of those with swallowing problems has its limitations. A medical doctor can look inside the mouth and look for possible problems such as a

tongue tie, paralysed tongue, large tonsils or a weak palate. An ear nose and throat specialist can look down into the lower throat and around the voice box, but beyond that it comes down to special tests and investigations.

In terms of investigations, it will depend a bit on what is necessary. For example, if there is a suspicion of aspiration, then a speech pathologist can become involved to organise a special swallowing x-ray called a ‘modified barium swallow’. In other instances, referral may be required for an endoscopy. There are also special tests of the movement of the oesophagus that may be required too.

WAYS TO HELP MANAGE THIS CONDITION.

Just as the cause varies, so too does the management. The following are all possible necessities when it comes to managing this condition:

• Using medication to relieve acid reflux.

• Avoiding or minimising drugs that are sedatives, especially in those with dementia or who have had a stroke.

• Making dietary modification such as using a thickener to make liquids more solid.

• Speech therapy referral advice on manoeuvres to limit swallowing problems, especially when there is a weakness of part of the muscles of the swallowing system.

• Avoiding foods not suited for the patient, such as hard meat for those who wear dentures.

• Using oral moisturising agents, if the problem is a dry mouth.

• Some patients may need to be fed via a tube, if their swallowing problem is a significant one.

• If the cause is an obstruction, then this may require surgery and if it is a cancer, then other treatments may also be needed.

Dr David McIntosh is a Paediatric ENT Specialist with a particular interest in airway obstruction, facial and dental development and its relationship to ENT airway problems and middle ear disease. He also specialises in sinus disease and provides opinions on the benefit of revision of previous sinus operations. Dr McIntosh can be contacted via this website.