Difficulty Swallowing
Difficulty swallowing is the medical term dysphagia. In ENT practice, this often means a sensation that food is sticking high in the throat or not passing smoothly at the start of the swallow.
This page is mainly about swallowing problems felt high in the throat. Symptoms felt lower down in the chest are more often related to the food pipe and may fall more within gastroenterology, although the location can sometimes be misleading.
I have seen many patients with this symptom. It can be uncomfortable and worrying, but the causes vary widely. Some are relatively minor and treatable, while others need more detailed assessment. The key is to work out whether the problem is in the throat itself, at the top of the food pipe, or lower down.
What do patients usually mean by difficulty swallowing?
Patients describe this in different ways. Common descriptions include:
food sticking high in the throat
needing repeated swallows to clear food
needing a drink to wash food down
coughing or choking when eating or drinking
tablets seeming to get stuck
discomfort when swallowing
regurgitation of food or liquid back into the throat or nose
Some people mainly struggle with solids. Others notice difficulty with both food and drink. Some have a constant problem, while for others it fluctuates.
What can cause food to feel stuck high in the throat?
There is no single cause. Common possibilities include(but not limited to):
Cricopharyngeal spasm or dysfunction
The cricopharyngeus is the ring of muscle at the top of the food pipe. If it does not relax properly, food can build up in the throat before it passes down.
Oesophageal dysmotility
Sometimes the swallowing problem is actually lower down in the food pipe, but the sensation is felt higher in the throat. Oesophageal dysmotility means the muscles and nerves of the food pipe are not moving food along normally.
Reflux
Reflux can irritate the throat and upper swallowing passage, leading to inflammation, sensitivity, throat clearing, or a feeling that swallowing is not quite right.
Stress and muscle tension
Stress should not be used as a shortcut diagnosis, but it can worsen throat muscle tension and make an already sensitive swallow feel more noticeable.
Pharyngeal pouch
A pharyngeal pouch is a pocket that forms just above the entrance to the food pipe. It is seen most often in older patients. It can collect food and cause sticking, regurgitation, coughing, gurgling in the throat, bad breath, and sometimes recurrent chest infections if food or fluid goes down the wrong way.
Vocal cord palsy
If one vocal cord is not moving properly, swallowing can be affected as well as the voice. Some patients notice coughing on liquids, choking, or a weak cough.
Neurological or systemic causes
Swallowing relies on precise coordination between muscles and nerves. Conditions such as stroke, Parkinson’s disease, multiple sclerosis, motor neurone disease, myasthenia gravis, or inflammatory muscle disease can affect that coordination.
When might it be cancer?
This is one of the first things patients worry about.
Difficulty swallowing can occasionally be caused by cancer, but the pattern matters. A mild intermittent sensation of food sticking high in the throat is very different from a swallowing problem that is steadily getting worse.
The concern is greater when swallowing difficulty is associated with red flags.
What are the red flags?
Red flags include:
progressive swallowing difficulty
pain on swallowing
unexplained weight loss
a neck lump
coughing or spitting blood
one-sided throat pain
ear pain without an obvious ear cause
repeated choking or chest infections
difficulty swallowing both liquids and solids
symptoms that are steadily worsening rather than fluctuating
These symptoms do not automatically mean cancer, but they do mean proper assessment is important.
How is it investigated?
The first step is a careful history. I want to know where the problem is felt, whether it affects solids or liquids, whether there is coughing or choking, whether there are reflux symptoms, whether the voice has changed, and whether there are any red flags.
I then examine the mouth, throat, and neck, and in most cases I perform a flexible nasendoscopy in clinic. This is a thin flexible camera passed gently through the nose so I can examine the back of the nose, throat, and voice box.
For many patients, this is the most useful first ENT investigation. It helps assess inflammation, pooling of saliva, vocal cord movement problems, structural abnormalities, or signs that something more serious needs to be excluded.
Depending on the history, further investigations may include:
FEES, which is a fibreoptic endoscopic evaluation of swallowing
videofluoroscopy or a video swallow study
barium swallow in selected cases
gastroscopy
reflux assessment
CT or MRI scanning where needed
panendoscopy under general anaesthetic
referral to gastroenterology if the problem appears to be lower down in the food pipe
Speech and language therapy is often an important part of both assessment and treatment.
What is a panendoscopy?
A panendoscopy is a more detailed examination of the throat, voice box, and upper food pipe performed under general anaesthetic. Rigid instruments are passed through the mouth so the area can be examined more closely than is possible in clinic.
It is not needed for everyone. It is usually reserved for selected cases where there is an abnormal finding, concern about a hidden lesion, ongoing symptoms that need a closer look, or a need to take biopsies.
When might gastroenterology be involved?
Although this page focuses on swallowing problems felt high in the throat, some patients turn out to have a problem lower down in the food pipe. Oesophageal dysmotility, narrowing, inflammation, or other oesophageal conditions can all cause symptoms that seem to be felt in the throat.
That is why some patients need gastroenterology assessment, particularly if the history suggests a lower swallowing problem, if a gastroscopy is needed, or if oesophageal motility testing may be helpful.
What treatments help?
Treatment depends on the cause.
Reassurance, swallowing therapy and reflux treatment
In many patients, the most important first step is understanding what is actually causing the symptom. Reassurance matters, but so does making the right diagnosis.
Speech and language therapy is often very helpful, both for assessment and for practical swallowing advice. This may include swallowing strategies, posture advice, exercises, and diet modification where needed.
If reflux is contributing, treatment may include lifestyle advice, alginates, and in selected patients acid-suppressing medication.
Targeted treatment for structural or muscle problems
Some patients have a more specific problem such as cricopharyngeal dysfunction, a pharyngeal pouch, or another narrowing at the top of the food pipe.
Most patients with cricopharyngeal dysfunction do not need major treatment. In milder cases, swallowing advice, speech and language therapy, and sometimes treatment of associated reflux may be enough. Selected patients may benefit from procedures such as balloon dilatation or, more rarely, surgery.
If a pharyngeal pouch is causing significant symptoms, treatment may involve a surgical procedure.
Treatment of underlying medical causes
If swallowing difficulty is related to oesophageal dysmotility, vocal cord palsy, a neurological condition, or a wider medical problem, treatment needs to focus on the underlying cause as well as swallowing safety.
Some of these conditions can be difficult to treat completely, and in those situations the aim is often to improve symptoms, maintain nutrition, and reduce the risk of choking or chest infections. Gastroenterology input may also be needed where the problem appears to be lower down in the food pipe.
When should urgent medical advice be sought?
Urgent assessment is sensible if swallowing becomes rapidly worse, if you cannot swallow fluids, if you are losing weight, if there is pain on swallowing, if there is bleeding, or if breathing is affected.
How I approach this in clinic
When I assess a patient with difficulty swallowing, my first aim is to work out whether this is truly a throat problem or whether the sensation is being referred from lower down.
The second is to identify whether the issue is structural, muscular, neurological, inflammatory, or functional. For some patients the main problem is cricopharyngeal dysfunction. For others it is reflux, vocal cord movement, muscle tension, pharyngeal pouch, or a problem lower down in the food pipe.
The best results usually come from making the right diagnosis early, rather than trying to force every swallowing symptom into one explanation.
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Disclaimer
This page is intended as general information only. It does not replace a consultation, examination, or individual medical advice.