Digestive Diseases: Swallowing Problems

The swallowing tract extends from the mouth to the stomach. The act of swallowing normally occurs in three phases. In the first phase, food or liquid is contained in the mouth by the tongue and palate (oral cavity). This phase is the only one we can control.

The second phase of swallowing begins when the brain makes the decision to swallow. At this point, a complex series of reflexes begin. The food is thrust from the oral cavity into the throat (pharynx). At the same time, two other events occur: A muscular valve at the bottom of the pharynx opens, allowing food to enter the swallowing tube (esophagus), and other muscles close the airway (trachea) to prevent food from entering the airways. This second phase of swallowing takes less than half a second.

The third phase of swallowing begins when food enters the esophagus. The esophagus, which is about nine inches long, is a muscular tube that produces waves of coordinated contractions (peristalsis). As the esophagus contracts, a muscular valve at the end of the esophagus opens and food is propelled into the stomach. The third phase of swallowing takes six to eight seconds to complete.

Thus, swallowing is a very complex act, requiring the normal function of the brain, several nerves and muscles, and two muscular valves, as well as an open, unconstricted esophagus.

A wide range of diseases can impair swallowing, including:

• Disturbances of the brain, such as Parkinson's disease, multiple sclerosis or ALS (amyotrophic lateral sclerosis, or Lou Gehrig's disease).
• Oral or pharynx muscle dysfunction (such as from a stroke).
• Loss of sphincter muscle relaxation (termed "achalasia").
• Esophageal narrowing (such as from acid reflux or tumors).

How Do I know If I Have a Swallowing Problem?

Normally, individuals rarely choke during a meal. Occasionally, food will stick in the esophagus for a few seconds (especially solid foods) but will pass spontaneously or can be washed down easily with liquids. However, there are a number of symptoms that require evaluation for a possible swallowing problem, including:

• Frequent choking on food.
• Hesitancy in food passage for more than a few seconds.
• Pain when swallowing.
• Recurring pneumonia (an indication that food may be going into the lungs rather than the esophagus).

Urgent evaluation by a doctor is required when food becomes lodged in the esophagus for more than 15 minutes and will not pass spontaneously or with liquids.

Some people are unaware that they have swallowing problems because they compensate unconsciously by choosing foods that are easier to eat, or they eat more slowly. They are at risk for choking or having large pieces of solid food lodge in the esophagus if they let down their guard.

How Are Swallowing Problems Diagnosed?

Your doctor will decide which phase of swallowing needs to be tested and order appropriate tests after asking questions to determine the details of your swallowing symptoms and previous medical problems, as well as performing an appropriate physical examination. Three tests are most commonly used to evaluate a swallowing problem:

• Cineradiography. An imaging test in which a movie camera is used to film the images of internal body structures. The patient swallows a barium preparation (liquid or other form that lights up under X-ray) and an X-ray machine with videotaping capability is used to view its movement through the esophagus. This is often performed under the guidance of a speech pathologist, an expert in swallowing as well as speech.
• Upper endoscopy: A flexible, narrow tube (endoscope) is passed into the esophagus and projects images of the inside of the pharynx and esophagus on a screen for evaluation.
• Manometry: This test measures the timing and strength of esophageal contractions and muscular valve relaxations

Among other tests that may be necessary, according to the specific needs of the individual, are an impedance test and a pH probe test (for acid reflux).