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Frequent Choking? Difficulty Swallowing?

Updated: Mar 11

It's interesting to me how often clients will have these sort of annoying little ticks, annoying to them of course - not me, and they aren't really motivated to seek evaluation. They simply tolerate them or just assume it's something a bit peculiar about them, their norm. Lewis Capaldi more recently shared in his documentary that he suffered from Tourettes for years and it was exceedingly disruptive before he sought diagnosis. We grow tolerance and maybe we avoid, but #dysphagia, or having difficulty swallowing, is one of those sort of ignored or under-appreciated not-so-little annoyances.


Dysphagia is common and underreported. The reasons could be many, from esophageal lesions to gastroesophageal reflux or esophagitis triggered by food allergens (Wilkinson, et al., 2021). An enlarged thyroid may be to blame or potentially, a stroke, Parkinson disease, or dementia. Many frail, older adults with progressive neurologic disease have significant but unrecognized dysphagia, which significantly increases their risk of aspiration pneumonia and malnourishment. I even had a client many years ago who I was seeing in a free clinic, who shared she had a chicken bone stuck in her throat and it had been there for over a year. X-ray confirmed. How does that even happen, right? Increasingly, opioid-induced esophageal dysfunction is being diagnosed as well.



Swallowing involves a number of voluntary and involuntary neuromuscular contractions that coordinate to permit breathing and swallowing through the same anatomic pathway. We typically try to identify if this is a oropharyngeal or esophageal issue, meaning it could be more about chewing and initiating the swallow, or more an issue in the lower esophageal sphincter and distal esophagus into the stomach.


Lower oropharyngeal dysphagia is more commonly related to chronic neurologic conditions such as Parkinson's disease, stroke, or dementia but this isn't a normal part of aging (Wilkinson, et al. 2021). It can also be the first symptom of neuromuscular disorders such as ALS (amyotophic lateral sclerosis) or myasthenia gravis. Many times it is as simple as not chewing effectively, an issue with dentures or having a dry mouth. It may even be a side effect of medications. Tardive dyskinesia can also cause difficulty swallowing, which relates to long-term antipsychotic medications. Chronic coughs related to a particular blood pressure medication can also interfere with swallowing. Tumors, infections with yeast or herpes, even a goiter can interfere with normal swallowing.


There are some medications that can directly irritate the esophagitis, such as vitamin C, bisphosphonates, ferrous sulfate, NSAIDs, potassium chloride, quinidine, and tetracyclines (Wilkinson et al., 2021). Alcohol, caffeine, benzodiazepines, some antidepressants, and some blood pressure medications can decrease the tone of the lower esophageal sphincter which allows stomach acid to come back into the esophagus and create inflammation. The reasons really are many, and much of this can be corrected.


Esophagogastroduodenoscopy


Not just one of the more fun medical words to try and pronounce, it is also the diagnostic recommendation for the initial evaluation of difficulty swallowing when the history suggests it may be from a functional cause. Esophageal cancer should be ruled out, as well as other serious conditions, but these do have a low prevalence. It might be that the clinician offers acid-suppression therapy for a few weeks but if that doesn't resolve in four-to-six weeks, then further evaluation should be persued as esophageal cancer can progress rapidly.


More Common Causes of Dysphagia


Gastroesophageal reflux disease (GERD) is one of the more common reasons clients will complain of difficulty swallowing. They will experience some submucosal inflammation and potentially even delayed motility or in more severe cases, experience erosive esophagitis and stricture. When this occurs because of allergy, progressive fibrosis, esophageal rings and furrows, and dysmotility can result so again, delaying care is ill-advised.


Like irritable bowel syndrome or functional dyspepsia, gut-brain interaction and central nervous system processing is thought to be an underlying cause (Wilkinson, et al., 2021). These individuals may be super aware even with fairly minor symptoms or hypersensitive to even normal levels of stomach acid. While many are cognizant of difficulty swallowing, more often clients will complain of chest pain and heartburn. When client's experience a functional dyspepsia, it's more that they can initiate the swallow, but they may report food getting stuck after swallowing.


Our investigation though into the history of discomfort can be helpful in better understanding the diagnosis of dysphagia. Simply asking about swallowing can tell us a lot. Does swallowing cause them to cough? Does it feel like food is stuck? If so, where? Do they choke? Do they regurgitate at all and if so, where do they notice this? How long has this been happening and is it getting worse? Do you hesitate to go out and eat because of it? Are the symptoms constant or intermittent? Do you have trouble chewing your food or weakness in chewing? Is there difficulty with fluids as well as solids? Are there any other symptoms, such as bad breath or weight loss? Do they have asthma or are they taking any medications?


Clients may share that they drool, have nasal regurgitation, difficulty initiating a swallow or they choke when they do. They may explain that they need to repeat their swallows to clear the food from their mouth, and even have hoarseness and other voice changes, including a "wet" voice. When the issue is more esophageal then they won't typically have issues with their swallow, but they'll report food getting stuck after swallowing. They may have obstructive lesions and this is often progressive. When swallowing is painful, it is more often infectious. If clients have trouble swallowing even with sipping water, hoarseness, or especially weight loss then referral to an #otorhinolaryngologist should be extended.


Approach to Treatment


This is largely determined by the cause of the difficulty in swallowing, but mindful eating might be part of the management. Avoiding triggering foods, chewing carefully, cutting food into smaller pieces, drinking more fluids to dilute food boluses, and eating slower can help. It may be that individuals require muscular reconditioning exercises to strengthen the jaw, lips, and tongue, or to learn compensatory self-swallow techniques. Drinking more water when taking pills can help with pill esophagitis.


Treating #GERD or identifying a goiter are all helpful approaches. Tricyclic anti-depressants can be helpful when the issue is more related to a visceral hypersensitivity or hyper-vigilance, similar to sensory disorders. We typically treat this with amitriptyline 25mg daily, or imipramine 50mg daily. Cognitive behavioral therapy can also be helpful.


References

Wilkinson, J. M., Codipilly, D. C., & Wilfahrt, R. P. (2021). Dysphagia: Evaluation and collaborative management. Am Fam Physician, 103(2), 97-106.

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