Melissa Conrad Stöppler, MD
Melissa Conrad Stöppler, MD, is a U.S. board-certified Anatomic Pathologist with subspecialty training in the fields of Experimental and Molecular Pathology. Dr. Stöppler's educational background includes a BA with Highest Distinction from the University of Virginia and an MD from the University of North Carolina. She completed residency training in Anatomic Pathology at Georgetown University followed by subspecialty fellowship training in molecular diagnostics and experimental pathology.
In this Article
- What is dysphagia?
- What causes dysphagia?
- Physical obstruction of the pharynx or esophagus
- Diseases of the brain
- Diseases of the smooth muscle of the esophagus
- Diseases of the skeletal muscle of the pharynx
- Miscellaneous diseases
- What are the symptoms of dysphagia?
- Swallowing related symptoms
- Non-swallowing related symptoms
- What is the differential diagnosis for dysphagia?
- How is dysphagia evaluated and the cause diagnosed?
- How is dysphagia treated?
- What is the prognosis for dysphagia?
- What does the future offer for dysphagia?
- Dysphagia At A Glance
- Find a local Gastroenterologist in your town
How is dysphagia treated?
The treatment of dysphagia varies and depends on the cause of the dysphagia. One option for supporting patients either transiently or long-term until the cause of the dysphagia resolves is a feeding tube. The tube for feeding may be passed nasally into the stomach or through the abdominal wall into the stomach or small intestine. Once oral feeding resumes, the tube can be removed.
Physical obstruction of the pharynx or esophagus
Treatment for obstruction of the pharynx or esophagus requires removal of the obstruction.
Tumors usually are removed surgically although occasionally they can be removed endoscopically, totally or partially. Radiation therapy and chemotherapy also may be used particularly for malignant tumors of the pharynx and its surrounding tissues. If malignant tumors of the esophagus cannot be easily removed or the tumor has spread and survival will be limited, swallowing can be improved by placing stents within the esophagus across the area of obstruction. Occasionally, obstructing tumors can be dilated the same way as strictures. (See below.)
Strictures and Schatzki's rings usually are treated with endoscopic dilation, a procedure in which the narrowed area is stretched either by a long, semi-rigid tube passed through the mouth or a balloon that is blown up inside the esophagus.
The most common infiltrating disease causing dysphagia is eosinophilic esophagitis which usually is successfully treated with swallowed corticosteroids. The role of food allergy as a cause of eosinophilic esophagitis is debated; however, there are reports of using elimination diets to identify specific foods that are associated with allergy. Elimination of these foods has been reported to prevent or reverse the infiltration of the esophagus with eosinophils, particularly in children.
Diverticuli of the pharynx and esophagus usually are treated surgically by excising them or by opening them up widely to the esophagus so that food does not collect in them. Occasionally they can be treated endoscopically. Cricopharyngeal bars are treated surgically by cutting the thickened muscle. Osteophytes also can be removed surgically.
Congenital abnormalities of the esophagus usually are treated surgically soon after birth so that oral feeding can resume.
Diseases of the brain
As previously discussed, strokes are the most common disease of the brain to cause dysphagia. Dysphagia usually is at its worst immediately after the stroke, and often the dysphagia improves with time and even may disappear. If it does not disappear, swallowing is evaluated, usually with a video swallowing study. The exact abnormality of function can be defined and different maneuvers can be tested to see if they can counter the effects of the dysfunction. For example, in some patients it is possible to prevent aspiration of food by turning the head to the side when swallowing or by drinking thickened liquids (since thin liquids is the food most likely to be aspirated).
Tumors of the brain can be removed surgically; however, it is unlikely that surgery will reverse the dysphagia. Parkinson's disease and multiple sclerosis can be treated with drugs and may be useful in patients with dysphagia.
Diseases of smooth muscle of the esophagus
Achalasia is treated like a stricture of the esophagus with dilation, usually with a balloon. A second option is surgical treatment in which the muscle of the lower esophageal sphincter is cut (a myotomy) in order to reduce the pressure and obstruction caused by the non-relaxing sphincter. Drugs that relax the sphincter usually have little or a transient effect and are useful only when achalasia is mild.
An option for individuals who are at high risk for surgery or balloon dilation is injection of botulinin toxin into the sphincter. The toxin damages the muscle of the sphincter and causes the pressure within the sphincter to decrease. The effects of botulinin toxin are transient, however, and repeated injections usually are necessary. It is best to treat achalasia early before the obstruction causes the esophagus to enlarge (dilate) which can lead to additional problems such as food collecting above the sphincter with regurgitation and aspiration.
In other spastic motility disorders, several drugs may be tried, including anti-cholinergic medications, peppermint, nitroglycerin, and calcium channel blockers, but the effectiveness of these drugs is not clear and studies with them are nonexistent or limited.
For patients with severe and uncontrollable symptoms of pain and/or dysphagia, a surgical procedure called a long myotomy occasionally is performed. A long myotomy is similar to the surgical treatment for achalasia but the cut in the muscle is extended up along the body of the esophagus for a variable distance in an attempt to reduce pressures and obstruction to the bolus.
There is no treatment for ineffective peristalsis, and individuals must change their eating habits. Fortunately, ineffective peristalsis infrequently causes severe dysphagia by itself. When moderate or severe dysphagia is associated with ineffective peristalsis it is important to be certain that there is no additional obstruction of the esophagus, for example, by a stricture due to GERD, that is adding to the effects of reduced muscle function and making dysphagia worse than the ineffective peristalsis alone. Most causes of obstruction can be treated.
Diseases of the skeletal muscle of the pharynx
There are effective drug therapies for polymyositis and myasthenia gravis that should also improve associated dysphagia. Treatment of the muscular dystrophies is primarily directed at preventing deformities of the joints that commonly occur and lead to immobility, but there are no therapies that affect the dysphagia. Corticosteroids and drugs that suppress immunity sometimes are used to treat some of the muscular dystrophies, but their effectiveness has not been demonstrated.
There is no treatment for the metabolic myopathies other than changes in lifestyle and diet.
Diseases that reduce the production of saliva can be treated with artificial saliva or over-the-counter and prescription drugs that stimulate the production of saliva.
There is no treatment for Alzheimer's disease.
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