Learning Center: SWALLOWING

TYPES OF SWALLOWING DIFFICULTY

Dysphagia is first sorted by where the problem is. Where it is often points to what is causing it and which tests are most useful.

Oropharyngeal dysphagia

Oropharyngeal dysphagia is a problem getting food or liquid out of the mouth and through the throat. Typical symptoms are coughing or choking while eating or drinking, a wet or gurgly voice after swallowing, food sticking in the throat or neck, food or liquid coming out of the nose, needing several swallows for one bite, and repeated chest infections. Common causes include:

• Neurologic disease. Stroke is the most commonly reported cause of swallowing problems in US adults [1, 3]. In Parkinson disease, about one third of patients report swallowing trouble, but objective testing finds it in about 4 out of 5. Many patients do not notice the problem or mention it unless asked [4]. ALS, multiple sclerosis, dementia and myasthenia gravis are other neurologic causes.

• Head and neck cancer and its treatment. A tumor of the mouth, throat or voice box, surgery to remove it, and radiation can all affect swallowing. These are covered in their own sections below.

• Structural problems. These include Zenker's diverticulum, a tight or poorly opening upper esophageal sphincter (cricopharyngeal dysfunction), bone spurs on the front of the neck vertebrae, and narrowing (stenosis) after surgery or radiation.

• Vocal cord weakness or paralysis, which reduces the ability to close the airway and to cough out what goes the wrong way.

• Aging. Normal aging slows the swallow and weakens the muscles somewhat (sometimes called presbyphagia). Aging alone usually does not cause aspiration, but it leaves less reserve when illness or medication is added.

Esophageal dysphagia

Esophageal dysphagia is a feeling that food sticks or hangs up after it has been swallowed, usually behind the breastbone or at the base of the neck. Trouble with solid food only suggests a narrowing. Trouble with both solids and liquids from the start suggests a problem with how the esophagus moves (a motility disorder). Common causes include:

• Strictures and rings. Scarring from long-standing acid reflux, rings in the lower esophagus, and webs.

• Eosinophilic esophagitis (EoE). A chronic allergic or immune inflammation of the esophagus that is increasing in frequency. It often causes solid food to stick and is a common reason for food to get stuck in younger adults. It is diagnosed with endoscopy and biopsies and treated with acid-suppressing medicine, swallowed topical steroids, diet changes, a biologic medicine, or dilation [5].

• Achalasia. A motility disorder in which the esophagus does not push food down normally and the lower esophageal sphincter does not relax. It causes trouble with solids and liquids, regurgitation, and sometimes chest pain and weight loss [6].

• Reflux and other motility disorders, medication injury (pills that lodge in the esophagus), and pressure from outside the esophagus.

• Cancer of the esophagus. This is less common, but steadily worsening trouble with solid food, especially with weight loss, needs prompt evaluation.

Symptoms that need prompt attention

• Swallowing trouble that is getting steadily worse, or unexplained weight loss.

• Food that gets completely stuck and does not pass (this is an urgent problem).

• Coughing or choking with meals, or repeated pneumonia.

• Hoarseness, a lump in the neck, ear pain with swallowing, or coughing up blood, especially in people who smoke or drink alcohol.

EVALUATION OF SWALLOWING PROBLEMS (DYSPHAGIA)

Evaluation starts with the history: what is hard to swallow (liquids, solids or both), where it seems to stick, how long it has been going on, whether it is getting worse, and whether there has been coughing with meals, pneumonia or weight loss. The examination includes the mouth, the neck and the nerves of the face and throat. A flexible laryngoscope passed through the nose lets the surgeon see the throat, the voice box and how the vocal cords move. The tests below are then chosen based on whether the problem appears to be in the throat or in the esophagus. See also swallow evaluations, modified barium swallow study, barium swallow study and EGD on the Diagnostics pages.

Questionnaires

The Eating Assessment Tool (EAT-10) is a 10-question form that patients fill out themselves. Scores range from 0 to 40 [16]. In a meta-analysis of 7 studies with 1,064 people, a score of 3 or more identified dysphagia found on an instrumental study with a sensitivity of 85% and a specificity of 82% [17]. The EAT-10 is a screening tool and a way to follow symptoms over time. It does not replace a swallow study.

Bedside swallow screening

Bedside screening usually involves watching a person drink water, and sometimes other consistencies, for signs of trouble such as coughing or a wet voice. These screens are quick and widely used, especially after a stroke. A 2021 Cochrane review found that no single bedside screening tool had both high and precisely measured sensitivity and specificity in a well-designed study [18]. Because aspiration can be silent, a normal bedside screen does not rule it out. When aspiration is suspected, an instrumental test is needed.

Modified barium swallow study (videofluoroscopic swallow study)

In a modified barium swallow study (MBSS), the patient swallows liquids and foods of different textures mixed with barium while a speech-language pathologist and radiologist record a moving x-ray. The study shows all phases of the swallow, including the moment of the swallow itself, the opening of the upper esophageal sphincter, and whether material enters the airway. It also lets the team test strategies, such as tucking the chin, turning the head, or changing food texture, to see what makes swallowing safer. The radiation dose is small.

Flexible endoscopic evaluation of swallowing (FEES)

In FEES, a thin flexible scope is passed through the nose to look down on the throat and voice box while the patient eats and drinks foods dyed for visibility. It needs no radiation and can be done at the bedside or in the office. It gives a direct view of the throat lining, secretions and vocal cord movement. The view is briefly blocked at the moment of the swallow (called "white-out"), so events during the swallow are inferred from what is seen before and after.

The two tests are complementary. A meta-analysis of 6 studies comparing them in adults found that FEES was somewhat more sensitive than videofluoroscopy for aspiration (88% vs 77%), penetration (97% vs 83%) and residue (97% vs 80%), with similar specificity (93% to 98%). The authors noted that better studies are needed to settle which is more accurate [19]. In practice, the choice depends on the question being asked, the patient's condition, and local expertise.

Penetration-Aspiration Scale

Both studies are often scored with the Penetration-Aspiration Scale, an 8-point scale based on how deep material goes into the airway and whether it is cleared. A score of 1 means nothing entered the airway. Higher scores mean deeper entry, and a score of 8 means silent aspiration below the vocal cords that is not coughed out [20].

Tests for esophageal dysphagia

• Upper endoscopy (EGD). A flexible scope is passed through the mouth into the esophagus and stomach under sedation. It can find strictures, rings, inflammation, eosinophilic esophagitis and tumors, take biopsies, and stretch (dilate) a narrowing in the same session. It is generally the first test for esophageal dysphagia [21].

• Barium swallow (esophagram). X-ray pictures are taken while the patient swallows barium, sometimes with a barium tablet or marshmallow to find subtle narrowing. It shows the shape of the esophagus, a Zenker's diverticulum, rings and strictures, and some motility problems, but it cannot take a biopsy.

• High-resolution manometry. A thin catheter with pressure sensors is passed through the nose into the esophagus to measure the strength and coordination of the esophageal muscles and the sphincters. It is the key test for achalasia and other motility disorders [6].

ZENKER’S DIVERTICULUM (HYPOPHARYNGEAL DIVERTICULUM)

A Zenker's diverticulum is a pouch that forms in the back wall of the lower throat, just above the upper esophageal sphincter. It develops at a naturally weak spot in the muscle wall (Killian's triangle). The underlying problem is thought to be a cricopharyngeus muscle that does not open fully, which raises pressure in the throat with each swallow and slowly pushes the lining out through the weak area. Food and liquid collect in the pouch instead of passing into the esophagus.

Who gets it and symptoms

Zenker's diverticulum is a condition of older adults. In a nationwide study from Finland, the yearly incidence was 2.9 per 100,000 people, higher in men than in women. Fewer than 4 in 10 patients had surgery; many with mild symptoms were watched [22]. Typical symptoms are trouble swallowing that slowly gets worse, a gurgling sound in the neck, regurgitation of undigested food (sometimes hours after eating or onto the pillow at night), bad breath, coughing, and weight loss. Food that spills from the pouch into the airway can cause aspiration pneumonia. The diagnosis is usually made with a barium swallow, which shows the pouch clearly.

Treatment

Treatment is offered when symptoms bother the patient or cause weight loss or aspiration. Small pouches with few symptoms can be watched. All the operations aim to do two things: divide the tight cricopharyngeus muscle (cricopharyngeal myotomy) and get rid of the pouch, either by removing it or by joining it to the esophagus so that it drains.

• Open (transcervical) surgery. Through an incision in the neck, the surgeon divides the cricopharyngeus and removes the pouch (diverticulectomy) or tacks it up so that it drains (diverticulopexy). This approach gives durable results and works for pouches of any size, but it needs a neck incision and usually a hospital stay.

• Rigid endoscopic surgery. Under general anesthesia, a rigid scope is placed through the mouth, and the wall between the pouch and the esophagus (which contains the cricopharyngeus) is divided with a stapler or a laser. There is no neck incision, recovery is usually quick, and eating starts soon after. It requires enough neck extension and mouth opening to place the scope, and very small pouches can be hard to treat this way.

• Flexible endoscopic septotomy. Using a flexible scope, usually by a gastroenterologist, the wall between the pouch and the esophagus is divided. In a meta-analysis of 20 studies with 813 patients, success was 91%, complications 11%, and recurrence 11% [23].

• Zenker's peroral endoscopic myotomy (Z-POEM) and related "tunneling" techniques. The endoscopist makes a tunnel under the lining and divides the muscle completely inside it. A 2025 meta-analysis of 9 studies with 759 patients found higher clinical success with tunneling techniques than with standard flexible septotomy (risk ratio 1.15), a trend toward fewer recurrences, and similar complication rates [24].

Comparing the approaches

No randomized trials compare these operations, so comparisons rest on cohort studies. A 2021 network meta-analysis of 9 studies and 903 patients found that open surgery had a lower chance of persistent or recurrent symptoms than endoscopic laser treatment (odds ratio 0.20), and that the laser and stapler techniques performed similarly [25]. Endoscopic approaches generally mean a shorter operation and hospital stay and a faster return to eating, and when symptoms come back, the procedure can usually be repeated. In practice, the choice depends on the size of the pouch, the patient's anatomy and overall health, and the patient's priorities. See also swallowing treatments.

VOCAL CORD WEAKNESS AND SWALLOWING

The vocal cords (vocal folds) do more than make the voice. They are the last line of defense for the airway: they close tightly during the swallow, and they close and then open forcefully to produce a strong cough that clears anything that goes the wrong way. Each vocal cord is moved by the recurrent laryngeal nerve on that side, which branches from the vagus nerve. The left recurrent laryngeal nerve loops down into the chest before coming back up to the voice box, so it can be injured by problems or surgery in the chest as well as the neck.

Causes

Common causes of vocal cord paralysis or weakness (paresis) include surgery on the thyroid, neck, chest, heart or spine; tumors of the thyroid, lung, chest or skull base that press on or invade the nerve; stroke and other neurologic disease; and viral injury. Sometimes no cause is found. After thyroid surgery, a systematic review of 27 studies and 25,000 patients found an average rate of temporary nerve weakness of 9.8% and of permanent weakness of 2.3%, with rates depending on how carefully the vocal cords were examined [26]. See also the Learning Center page on thyroid tumors.

Effect on swallowing

When one vocal cord does not move, a gap remains between the cords during the swallow, and the cough is weak and breathy. Liquids, especially thin ones, are most likely to slip into the airway. Hoarseness and a breathy, weak voice are usually the first symptoms. In a study of 64 adults with one immobile vocal cord who had videofluoroscopy, 31% showed penetration and 23% showed aspiration. This was true whether or not the paralysis came from surgery [27]. If the nerve injury is high in the neck, near the skull base, the throat muscles and their sensation on that side are often affected too, and swallowing problems tend to be worse.

Treatment

• Swallowing therapy and strategies. A speech-language pathologist can teach techniques such as turning the head toward the weak side, tucking the chin, and taking small sips, which often reduce aspiration right away. Thickened liquids are sometimes used for a time.

• Injection laryngoplasty. A filler material is injected next to the weak vocal cord to move it toward the middle so that the cords can meet. It can be done in the office or the operating room. Many fillers are temporary, lasting a few months, which makes injection useful while waiting to see if the nerve recovers.

• Medialization thyroplasty. Through a small neck incision, a permanent implant is placed beside the vocal cord to hold it in a better position. It is often combined with other procedures to improve closure further. It is used when recovery is not expected.

• Nerve reinnervation. In selected patients, a nearby nerve is connected to the nerve of the voice box to restore muscle tone. It mainly helps the voice, and it takes months to work.

How much these procedures help swallowing

The evidence is mixed. Voice and cough usually improve after medialization, but swallowing gains are less consistent. A systematic review of 9 prospective studies with 157 patients found that 7 studies showed a clinically meaningful improvement in swallowing after injection or thyroplasty, but only 4 found a statistically significant change, and the studies had important risks of bias [28]. In the videofluoroscopy study above, the median Penetration-Aspiration Scale score improved only slightly after medialization (from 4 to 3), and the change was not statistically significant [27]. A 2026 Japanese insurance database study found fewer pneumonias after laryngoplasty than before it in the same patients, but when treated patients were compared with matched untreated patients, there was no reduction. The authors concluded that no definite answer was possible [29]. Medialization improves the closure of the cords, but it does not restore lost sensation or weak throat muscles, which helps explain why some patients still aspirate. Swallowing therapy is therefore often continued after the procedure. See also the Learning Center page on voice.

Swallowing difficulty after cancer treatment

Link to the American Head and Neck Society site with information on swallowing problems after treatment for cancer.

Swallowing after cancer treatment depends on the site and size of the tumor and on how it was treated. Radiation and chemoradiation are covered above. This section covers surgery, how swallowing is measured, and long-term care.

Surgery

Removing a tumor of the tongue, floor of mouth, throat or voice box removes or scars tissue that is needed for swallowing. The effect depends mostly on how much of the tongue base, palate, throat wall or larynx is removed. When a large area is removed, it is often rebuilt with tissue moved from another part of the body (a flap), which restores bulk and closes the wound but does not move or feel like the original tissue. Swallowing therapy usually starts soon after surgery, and many patients regain an oral diet.

For small cancers of the oropharynx (the tonsil and base of tongue), transoral robotic surgery (TORS), done through the mouth without a neck incision, is an alternative to radiation. The ORATOR trial randomly assigned 68 patients with early oropharyngeal cancer to radiation or to TORS with neck dissection. At one year, swallowing scores on the MD Anderson Dysphagia Inventory were slightly better after radiation (86.9 vs 80.1), but the difference was smaller than what is considered clinically meaningful. Radiation caused more hearing loss and tinnitus, and surgery caused more trismus (limited mouth opening) [30]. At five years, swallowing scores had converged and were not significantly different. Dry mouth was worse after radiation and pain was worse after surgery, and survival was excellent and similar in both groups [31]. The trial was small, and many surgery patients also needed radiation after surgery, but it supports offering patients both options. See also the Learning Center pages on oropharynx, larynx and hypopharynx cancers.

Measuring swallowing

The MD Anderson Dysphagia Inventory (MDADI) is a 20-question survey of how swallowing affects daily life for patients with head and neck cancer. Scores range from 20 to 100, and higher is better [32]. It is the main patient-reported measure used in trials such as DARS and ORATOR. It is used along with swallow studies, which measure what the swallow actually does.

Long-term care and treatment of late problems

The American Cancer Society's survivorship guideline for head and neck cancer recommends that survivors be checked for swallowing problems and aspiration at follow-up visits and referred to a speech-language pathologist when problems appear [33]. Steps that help include:

• Ongoing swallowing therapy and exercises, including a home program after treatment ends.

• Dilation of a stricture or narrowing in the throat or upper esophagus, often repeated. About 1 in 10 patients develop a stricture within two years of treatment [8].

• Treatment of dry mouth, dental problems and trismus, which make chewing and swallowing harder.

• Prompt attention to new or worsening swallowing trouble, pneumonia or weight loss, which can signal late radiation effects or, less often, a return of the cancer.

Summary

• Dysphagia is common, especially in older adults and after stroke, neurologic disease and head and neck cancer treatment, and it raises the risk of pneumonia, malnutrition and death [1, 2, 3].

• Problems in the throat and problems in the esophagus have different causes and need different tests. A bedside screen cannot rule out aspiration. A modified barium swallow and FEES are complementary tests for the throat, and endoscopy, barium swallow and manometry are used for the esophagus [18, 19, 21].

• Radiation and chemoradiation often affect swallowing, sometimes years later. Radiation planning that spares the swallowing muscles improves swallowing, and staying on an oral diet and doing swallowing exercises are linked to better results [8, 9, 10, 12].

• Zenker's diverticulum can be treated through the neck or through the mouth with good results. Open surgery is somewhat more durable, and endoscopic approaches are quicker to recover from [23, 24, 25].

• A paralyzed vocal cord leads to penetration or aspiration in about a third of patients. Medialization improves the voice and helps the swallow in many patients, but the evidence for swallowing benefit is limited [27, 28].

• After head and neck cancer treatment, swallowing should be followed over the long term, and new trouble swallowing deserves prompt evaluation [9, 33].

Related Learning Center pages

Voice · Radiation therapy · G-tube placement · Oropharynx cancer · Larynx cancer · Hypopharynx cancer · Thyroid tumors · Throat Learning Center

References

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