Oropharyngeal dysphagia: swallowing problems in the mouth and throat

Swallowing is a coordinated action involving the mouth, throat and gullet. The NHS defines dysphagia as having problems swallowing, and notes that some people have trouble with certain foods or drinks while others cannot swallow at all. A North and East Devon NHS primary care pathway separates two patterns: oropharyngeal dysphagia, also known as high dysphagia, which is difficulty in initiating a swallow, and oesophageal or low dysphagia, which is the sensation that food or liquid is hindered on its way from the mouth to the stomach.

This page concerns the first pattern. The distinction matters because the likely causes, the specialist involved and the urgency of investigation differ.

The NHS lists coughing or choking when eating or drinking, bringing food back up sometimes through the nose, a feeling that food is stuck in the throat or chest, and a gurgly, wet-sounding voice when eating or drinking. You may also drool and have problems chewing. The Devon pathway adds nasal speech, a diminished cough reflex, food dribbling from the mouth, and recurrent chest infections among the accompanying features of oropharyngeal dysphagia.

Coughing is not always present. The pathway notes that food, drink or saliva can enter the airway silently, which is why repeated chest infections or unexplained weight loss should prompt an assessment even without obvious choking.

• Coughing or choking during or soon after eating or drinking.

• A wet, gurgly or croaky voice after swallowing.

• Food or fluid coming back up, sometimes through the nose.

• Drooling, difficulty chewing, or taking a long time to finish meals.

• Weight loss, dehydration or repeated chest infections.

The NHS says you may be more likely to have dysphagia if you take some medicines such as antipsychotics, have a learning disability, have acid reflux, have breathing problems such as COPD, have a condition affecting the nervous system or brain such as cerebral palsy, stroke, dementia or multiple sclerosis, or have cancer such as mouth or oesophageal cancer.

The Devon pathway lists causes of oropharyngeal dysphagia in two groups: mechanical or obstructive causes such as infections, an enlarged thyroid, enlarged lymph nodes, a pharyngeal pouch (Zenker's diverticulum) and head and neck malignancy; and neuromuscular disease, including bulbar palsy such as motor neurone disease, Parkinson's disease, myasthenia gravis and stroke.

It also lists associated features that point to a neurological cause, for example weakness down one side after an earlier stroke, drooping eyelids or features of Parkinson's disease.

The NHS says your GP will examine you and may refer you to a specialist for further tests. The Devon pathway describes the key aim of the history and examination as deciding whether the dysphagia is oropharyngeal or oesophageal, by asking about the timing, types of food that cause trouble and whether symptoms are progressive or intermittent. It says problems with liquids suggest an oropharyngeal cause.

Red flags are important. The pathway notes that dysphagia is a symptom highly predictive of cancer in primary care populations and that an urgent two-week-wait referral is indicated when dysphagia is of short duration, worse for solids than liquids, progressive or associated with weight loss. Most oropharyngeal causes are referred to ENT, with referral to neurology if a neurological cause is suspected and to a speech and language therapist where appropriate.

Treatment depends on the cause and severity. The NHS lists medicines to treat acid reflux, swallowing therapy with a speech and language therapist, changes to what you eat and drink such as softer foods and thickener in drinks, special spoons, plates and cups, feeding tubes through the nose or into the stomach, and surgery or injections for some oesophageal causes. If the cause is a short-term condition such as reflux the problem may improve on its own, but longer-term causes may need specialist treatment to make eating and drinking as safe as possible.

Practical measures at home usually come from the speech and language therapist after assessment. Do not change food textures or thicken drinks on your own, because the right consistency depends on what the assessment shows.

The NHS advises an urgent GP appointment or NHS 111 if you, your child or someone you care for has difficulty swallowing, coughs or chokes while eating or drinking, feels something is stuck after eating, keeps bringing food or milk back up, has a wet gurgly voice after eating, is short of breath after eating or drinking, or gets lots of chest infections. In children, crying a lot or arching the back when feeding is also on the NHS list.

If someone is choking and cannot breathe or speak, or is struggling to breathe, call 999.

On the NHS, swallowing assessment is delivered by speech and language therapy services, often alongside ENT, gastroenterology or neurology, and dietitians. Some independent speech and language therapists see adults privately, but if there are red flags such as weight loss or progressive symptoms the urgent cancer pathway through the GP applies in either route.