Management of dysphagia follows the cause and the level at which the swallow fails. Two goals run through both levels: restore the safe passage of food and fluid, and prevent the complications — above all aspiration and malnutrition — that make dysphagia dangerous.
Oropharyngeal dysphagia
Treatment of oropharyngeal dysphagia aims to improve the movement of food and drink and to prevent aspiration, and identifying the risk of aspiration is the key decision. Several measures are simple and can start at once: fixing dental problems gives a patient the teeth to chew with; modifying the texture of foods and drinks, most often thickening thin fluids and choosing softer foods, and reducing the size of each bolus make swallowing safer; and postural changes during swallowing help some patients. Swallowing therapy with a specialist adds behavioral maneuvers and strengthening exercises and can improve a failing swallow. Nutrition and hydration need active monitoring, because a patient who eats less, or drinks only thickened fluids, can become dehydrated or malnourished.
If oral intake cannot be made safe, feeding is supported through a fine-bore nasogastric tube in the short term and a gastrostomy for longer use. Gastrostomy feeding improves nutritional status compared with nasogastric feeding, but a mortality benefit over nasogastric feeding is not established: in dysphagic stroke patients, randomised evidence has not confirmed that gastrostomy feeding lowers the risk of death. The underlying disease is treated in parallel — the dysphagia of Parkinson’s disease or myasthenia gravis, for example, responds to treatment of the neurological or neuromuscular disease itself. Surgery aimed at the sphincter, such as cricopharyngeal myotomy, helps some patients but remains controversial, whereas surgery for a Zenker’s diverticulum is well established.
Esophageal dysphagia
Esophageal dysphagia is relieved by correcting the specific obstruction or motility problem. When food is acutely impacted, the bolus is removed endoscopically; pushing it down risks perforation and should be avoided. The cause then guides treatment.
- Peptic stricture — the scar of long-standing reflux. Endoscopic dilation, usually with a bougie, is the first step, combined with a high dose of a proton-pump inhibitor to heal the esophagitis and reduce the need for repeat dilation.
- Schatzki’s ring — a mucosal ring at the gastroesophageal junction. A single large bougie, or a balloon, is used to fracture the ring rather than merely stretch it, with acid suppression afterwards.
- Eosinophilic esophagitis — allergen-driven inflammation. Treatment combines acid suppression, swallowed topical corticosteroids, and dietary elimination guided by the allergens identified, with dilation reserved for the rings and strictures it can leave behind.
- Achalasia — failure of the lower esophageal sphincter to relax, with loss of peristalsis. Treatment lowers the sphincter pressure: pneumatic dilation, laparoscopic Heller myotomy, or peroral endoscopic myotomy (POEM). Botulinum toxin injection is reserved for patients who cannot tolerate those procedures, because its effect lasts only months and it makes later surgery harder.
The complications are the reason dysphagia is treated at all. Aspiration can cause pneumonia, and reduced intake can cause weight loss, malnutrition and dehydration; long-standing obstruction can leave the esophagus dilated and the patient dependent on a restricted diet. Preventing these is as much a part of management as relieving the obstruction itself.