Difficulty in Swallowing (Dysphagia) Causes and Treatment

Difficulty in swallowing is a common symptom but can be the presenting feature of carcinoma of the pharynx and therefore requires investigation.

Pharyngeal pouch can cause difficulty in swallowing

A pharyngeal pouch is a herniation of mucosa through the fibres of the inferior pharyngeal constrictor muscle (cricopharyngeus) . An area of weakness known as Killian's dehiscence allows a pulsion diverticulum to form. This will collect food which may regurgitate into the mouth or even down to the lungs at night with secondary pneumonia.

Diagnosis is made radiologically and treatment is surgical, either via an external approach through the neck where the pouch is excised or more commonly endoscopically with stapling of the gaping wall.


Foreign bodies can cause difficulty on swallowing

Foreign bodies in the pharynx can be divided into three general categories: soft food bolus, coins (smooth), bones (sharp). Soft food bolus can be initially treated conservatively with muscle relaxants for 24 hours. Impacted coins should be removed at the earliest opportunity but sharp objects require emergency removal to avoid perforation of the muscle wall. If the patient perceives the foreign body to be to one side, then it should be above cricopharyngeus, the constrictor muscle and an ENT examination will locate it; common areas are the tonsillar fossae, base of tongue, posterior pharyngeal wall and valleculae. Radiology will identify coins, and it can be a clinical decision to see whether a coin will pass down to the stomach, in which case no further treatment is required as it will exit naturally.

Fish can be divided into those with a bony skeleton (teleosts) and those with a cartilaginous skeleton (elasmobranchs), and therefore radiology may only be useful in some cases. Radiology can also identify air in the cervical oesophagus indicating a radiolucent foreign body lying distally.

Globus Pharyngeus

This is not a true dysphagia. It is a condition with classic symptoms of an intermittent sensation of a lump in the throat. This is perceived to be in the midline at the level of the cricoid cartilage and is worse when swallowing saliva; indeed it often disappears when ingesting food or liquids. ENT examination is usually clear and normal laryngeal mobility can be felt when gently rocking the larynx across the postcricoid tissues. A contrast swallow will show not only the structures below the pharynx but also assess the swallowing dynamically. Any suspicious area will require an endoscopy with biopsy.