Difficulty swallowing: why it happens, which cases are urgent, and which doctor to see

Swallowing is a chain of movements that starts in the mouth and ends in the stomach. The tongue pushes the food back, the throat muscles carry it to the top of the oesophagus, and the oesophagus contracts in waves to take it down to the stomach. MSD Manuals defines difficulty swallowing as an obstruction to the passage of liquids, solids or both from the throat to the stomach, and separates it from the feeling of a lump in the throat (globus): with globus it feels as though something is in the throat, but food goes down easily. If food goes down easily and there is only the feeling of a lump, our page on the feeling of a lump in the throat will suit you better.

The first task is to tell whether the situation is urgent. With a sore throat, the NHS recommends calling for emergency help straight away if there is difficulty breathing or not being able to swallow at all, drooling because you cannot swallow, a high-pitched sound when breathing in (stridor), or severe symptoms getting worse quickly; in Turkey this means 112. The threshold is the same with a dental abscess: if breathing, speaking or swallowing has become difficult, if there is a lot of swelling in the mouth, if the eye has swollen or vision has been affected, go to A&E. For pus collecting around the tonsil (a peritonsillar abscess), the NHS's signs are a severe sore throat getting worse quickly, swelling inside the mouth and throat, difficulty speaking, not being able to swallow, difficulty breathing and not being able to open the mouth.

Swelling of the epiglottis (epiglottitis) is the most insidious picture on this list. The NHS describes it as an emergency in which the flap that closes off the windpipe when you swallow swells and can block the airway, needing treatment in hospital straight away. The symptoms develop quickly: a very severe sore throat, a high temperature, a muffled voice, painful and difficult swallowing, drooling, and noisy breathing that eases when leaning forwards. The NHS writes that you should sit upright until help arrives, because lying down can make the symptoms worse.

Difficulty swallowing that comes from a tooth mostly appears when an infection spreading from the lower molars passes under the jaw and into the deep spaces of the neck. In this situation, difficulty swallowing can be a sign that the infection is getting close to the airway. In a study at the University of Cologne of 499 patients operated on for severe neck infections of dental origin, advanced methods to secure the airway during anaesthesia were needed more often in those with difficulty swallowing and shortness of breath; shortness of breath was found to be linked to admission to intensive care, and in 4 patients (0.8%) an airway had to be opened directly through the neck. We have explained how this picture progresses on our page about infection spreading in the face.

If there are no urgent signs, the second question is where the difficulty lies. MSD distinguishes two types. In difficulty swallowing that comes from the mouth and throat, the person struggles to start swallowing, liquid comes back through the nose, and they cough or choke when swallowing; saliva and food can escape from the mouth. This type is mostly seen in nerve and muscle diseases such as stroke, Parkinson's disease, multiple sclerosis, motor neurone disease or myasthenia gravis. In difficulty swallowing that comes from the oesophagus, on the other hand, the food gets stuck in the chest after it has been swallowed. The cause is either a movement disorder of the oesophagus or a mechanical obstruction such as a narrowing, a ring or a tumour.

Your own observation tells the doctor a great deal. MSD writes that difficulty only with solid food suggests a mechanical obstruction, while difficulty with both solids and liquids says nothing on its own. Difficulty that comes and goes suggests a ring in the oesophagus or a muscle spasm; difficulty that progresses from solids to liquids over months or years, with food coming back up at night, suggests achalasia, a disease in which the muscle cannot relax. Difficulty swallowing that progresses quickly, is constant and comes with no other nerve finding, on the other hand, brings to mind a blockage in the oesophagus, possibly cancer. When a person points to the lower chest as the place where food gets stuck, this usually shows the right place; the level of the neck is less reliable.

Food getting stuck is a separate emergency heading. MSD writes that the commonest cause of objects stuck in the oesophagus is large pieces of poorly chewed meat, and that fish bones can get stuck too. If the person can swallow liquids, or at least their saliva, the blockage is partial and counted as less urgent. If they cannot even swallow their saliva and are constantly bringing it up, the blockage is complete and needs removing by endoscopy straight away; MSD states that a firmly stuck piece of food left for more than about 24 hours creates a risk of damage to and perforation of the oesophageal wall. Genuine shortness of breath, wheezing or a high-pitched breathing sound, on the other hand, suggests the object is in the airway: in this case, 112.

The mouth is also the first link in swallowing, and here the teeth and saliva matter. Saliva softens the food and helps it slide; the NHS writes that a dry mouth can come about with medicines, dehydration, mouth breathing, anxiety and cancer treatment, and that you should see a GP if a dry mouth is making it difficult to speak or eat. A systematic review bringing together 15 studies in people over 65 living in the community found that having few teeth left, a lack of pairs of opposing teeth that meet, a dry mouth and weakness of the tongue and lip muscles were consistently linked to difficulty swallowing. Most of these studies are observational; they do not prove that tooth loss on its own causes difficulty swallowing, but they show that an examination of the mouth should not be skipped in an older person with difficulty swallowing.

There is a reason not to put off difficulty swallowing that progresses slowly. MSD writes that everyone with difficulty swallowing should have an upper endoscopy to rule out cancer. NICE, England's national health guidance body, also recommends that people with difficulty swallowing are put on the fast referral pathway for suspected oesophageal cancer. This does not mean that all difficulty swallowing is cancer; MSD's list also includes benign causes such as narrowing due to reflux, oesophageal rings and allergic inflammation of the oesophagus (eosinophilic oesophagitis). But the distinction can only be made with an endoscopy.

Neither list is for making a diagnosis; they are for seeing how quickly you need to act. The pictures in the first list should also be shown to a doctor, but they can usually be assessed within days. If any item from the second list applies, do not wait.

The sequence deliberately starts with the airway, then moves down to where the difficulty is and what is causing it.

1. 1

   The airway and urgent signs

   If there is difficulty breathing, a high-pitched breathing sound, drooling, not being able to swallow at all, swelling in the mouth or neck that is growing fast, or not being able to open the mouth, call 112 straight away. Do not lie down; sit leaning forwards or upright. Do not drive yourself.

2. 2

   Food stuck

   If the person cannot cough, speak or breathe, this is choking: call 112 and give first aid. If breathing is easy but the food has stayed stuck in the chest and even saliva will not go down, go to A&E the same day.

3. 3

   Examination of the mouth and throat

   With difficulty swallowing that comes with a high temperature and pain, the doctor examines the tonsils, the back of the throat, the floor of the mouth and the teeth, and looks for swelling and tenderness in the neck. If the source is a tooth, this shows up with an examination of the mouth and an X-ray. If a deep neck infection is suspected, a CT scan is done.

4. 4

   A detailed history

   MSD writes that the doctor asks how long the difficulty has been going on, whether it started suddenly, whether it is with solids, liquids or both, whether food comes back through the nose, whether saliva or food escapes, whether food gets stuck and whether there is coughing while eating. Muscle weakness, tiring quickly, tremor, and balance and speech problems are also asked about. Make a note of these beforehand.

5. 5

   Endoscopy and other investigations

   MSD writes that everyone with difficulty swallowing should have an upper endoscopy, and that samples should be taken during it for allergic inflammation of the oesophagus. If an endoscopy cannot be done or no cause is found, a barium swallow X-ray is done, and if that is normal too, tests of oesophageal movement. With difficulty that comes from the mouth and throat, investigations in which swallowing is watched on video or with a thin camera are used.

6. 6

   Treatment aimed at the cause

   The NHS writes that treatment varies with the cause and severity: reflux medicines, swallowing exercises with a speech and language therapist, soft foods and changing drinks with thickeners, special spoons and cups, procedures to widen the oesophagus, injections to relax the muscles and, in severe cases, a feeding tube.

7. 7

   Assessing the mouth, teeth and dentures

   Especially in older people, missing teeth, a loose denture and a dry mouth can make it harder to prepare the food for swallowing. Adding a dental examination to the swallowing assessment can bring to light a factor that can be corrected.

The same symptom can come from very different places. The following are the sources met most often, and the clue particular to each.

The following are the wrong decisions commonly seen with this picture, and what they cost.

How long difficulty swallowing lasts depends entirely on the cause. The course below summarises the usual progress of the pictures met most often; your doctor's plan takes priority.

1. Throat infection

   The NHS states that tonsillitis usually passes in 3–4 days, and recommends seeing a GP if symptoms have not gone in 1 week. During this time, plenty of fluids and soft food make swallowing easier.

2. Infection of dental origin

   Once the source tooth has been treated or extracted and the pus drained, the swelling and painful swallowing ease within days. With a deep neck infection, treatment continues in hospital.

3. Reflux and narrowing

   The NHS writes that difficulty swallowing caused by reflux can clear up with treatment. If there is a narrowing, an endoscopic widening procedure may be needed.

4. Stroke and nerve diseases

   Swallowing therapy, texture-modified food and changes of position are a long-term process. A speech and language therapist reassesses how safe swallowing is at regular intervals.

5. Long-lasting difficulty swallowing

   The NHS writes that weight loss, dehydration and repeated chest infections can develop over time. Weighing yourself regularly and planning your diet with a dietitian reduce these risks.

We do not give figures here, because the scope varies a great deal depending on where the cause lies. The items that determine the scope:

An emergency

Infections threatening the airway and food that is stuck need treatment in hospital, with surgery or emergency endoscopy if needed.

Diagnostic investigations

Upper endoscopy and biopsy, a barium X-ray, tests of oesophageal movement and swallowing studies are added according to the cause.

Long-term treatment

With difficulty swallowing due to nerve and muscle diseases, swallowing therapy, a dietitian and special nutrition products are spread over time.

Mouth and dental treatment

If the source is a dental infection, dental treatment; if missing teeth or a denture that does not fit play a part, a denture or dental plan is discussed separately.