Swallowing System
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Swallowing System
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Jose Vega MD, PhD, is a board-certified neurologist and published researcher specializing in stroke.
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Alali D, Ballard K, Bogaardt H. Treatment effects for dysphagia in adults with multiple sclerosis: A systematic review. Dysphagia . 2016 Oct;31(5):610-8.
Lembo AJ. (2017). Oropharyngeal dysphagia. Talley NJ, ed. UpToDate. Waltham, MA: UpToDate Inc.
What Your Body Does When You Swallow Your Food
Anatomy and Function of the Medulla Oblongata
Subtle Signs of Brainstem Lesions in MS
Your Brain Is the Most Complex Organ of Your Body
Dysphagia and Swallowing Problems: What You Need to Know
The Cranial Nerves Supply Your Face and More
Five Lip Exercises for Dysphagia Therapy
The Many Symptoms of Multiple Sclerosis
What Is a Small Vessel or Subcortical Stroke?
What to Know About a Stroke of the Medulla Oblongata
What to Know About Craial Nerve 7 (Facial Nerve)
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Ⓒ 2022 Dotdash Media, Inc. — All rights reserved
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Nicholas R. Metrus, MD, is board-certified in neurology and neuro-oncology. He currently works at the Glasser Brain Tumor Center with Atlantic Health System in Summit, New Jersey.
Although it may seem like a pretty simple function, swallowing is one of the most complicated tasks that your body performs. The process requires delicate coordination between your brain and certain nerves and muscles, and issues with swallowing can have a major effect on your overall quality of life.
Swallowing occurs in three sequential phases , all requiring the careful coordination of muscles in the mouth, pharynx (your throat), larynx (your voice box), and esophagus (the tube that carries food from your throat to your stomach). These muscles are all under the control of a group of nerves called your cranial nerves.
The cranial nerves are 12 pairs of nerves that emerge from the brainstem, located at the base of your brain. Your cranial nerves control functions such as smelling, tasting, swallowing, seeing, moving your face and eyes, and shrugging your shoulders. Several of the cranial nerves are involved with controlling the coordination and movements involved in chewing and swallowing. 1
The following cranial nerves are involved in swallowing:
In turn, cranial nerves are controlled by “processing centers” in the brain where information related to swallowing is processed. These centers include areas located in the cerebral cortex, the medulla oblongata , and the cranial nerve nuclei.
The voluntary initiation of swallowing takes place in special areas of the cerebral cortex of the brain called the precentral gyrus (also called the primary motor area), posterior-inferior gyrus, and the frontal gyrus. Information from these areas converges in the swallowing center in the medulla, which is part of the brainstem.
Apart from the brain, nerve signals originating in the mouth receive input about the food we are chewing. Several sensory nerves in the mouth, pharynx, and larynx bring information to the brain that allows us to know what type of material is in the mouth and throat. 2 For instance, they "tell" the brain about the size, temperature, and texture of food.
This information is sent to the sensory cortex of the brain, and eventually the medulla, which uses the sensory information to direct the efforts of the muscles of chewing.
The act of chewing changes the food into a softer and more slippery food bolus that is suitable and safe for swallowing. As the swallowing reflex advances through its different phases, the nerves involved in swallowing trigger the reflexive closing of the larynx and the epiglottis. This closing off of the "windpipe" prevents food and liquid particles from entering the lungs.
If the windpipe does not properly close off, or if swallowing is not well coordinated, problems such as choking can occur. Another complication of swallowing problems, aspiration pneumonia, can happen if food enters the lungs. 3 This may happen as a result of a stroke or other neurological disorders. Lastly, malnutrition and dehydration may occur as a result of swallowing difficulties.
As you can see, there are multiple areas of the central nervous system which, if affected by a stroke or another neurological condition like multiple sclerosis, Parkinson's disease , or dementia , could disrupt the ability to swallow. 3
Even more so, the medulla is a relatively small area of the brainstem that contains multiple structures that are critical in carrying out the swallowing reflex—so strokes that involve the medulla are especially likely to cause swallowing problems. In fact, people with medullary strokes may require temporary or permanent feeding tube placement to prevent choking and aspiration pneumonia . 4
Guidelines published in 2019 by the American Heart Association (AHA) for treatment of patients with stroke recommend early screening for dysphagia (trouble swallowing) to prevent potential aspiration and avoid related illness. The AHA also recommends feeding tubes for patients with dysphagia for at least the few days immediately following a stroke as doctors continue to check for problems with swallowing. 5
While living with swallowing problems certainly adds a complication to your life, know that there are well-designed techniques that can help you or your loved one safely adapt to these difficulties. For instance, a speech and swallow therapist can help you make adjustments to the types of food and liquids that you consume in order to make it easier for you to safely swallow.
In addition, swallowing exercises like the supraglottic swallow or Mendelsohn's maneuver can help strengthen your muscles involved in swallowing. 6 These oral movement exercises and other strategies like using a cup, straw, or spoon can further be helpful.
Lamantia AS, Moody SA, Maynard TM, et al. Hard to swallow: developmental biological insights into pediatric dysphagia . Dev Biol . 2016;409(2):329-42. doi:10.1016/j.ydbio.2015.09.024
Haggard P, De Boer L. Oral somatosensory awareness . Neurosci Biobehav Rev . 2014;47:469-84. doi:10.1016/j.neubiorev.2014.09.015
U.S. Department of Health and Human Services, National Institutes of Health, National Institute on Deafness and Other Communication Disorders. Dysphagia .
American Speech-Language-Hearing Association. Adult dysphagia . (no date).
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When it comes to staying healthy and providing your body with the necessary nutrients and vitamins needed, you probably haven’t given too much thought to the actual act of swallowing.
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But delivering food and fluids from your mouth to your digestive system is a complex task. The act of swallowing involves many different nerves and muscles that work to take food into your mouth, prepare and chew food, and then move it from your mouth to your stomach through your esophagus.
Any disruption can lead to serious complications. Issues with difficulty swallowing, also called dysphagia , can have different causes and different impacts on your overall health. If you encounter these issues, it’s important to understand what’s happening and to separate fact from fiction to best know how to treat it.
We spoke with gastroenterologist Alison Schneider, MD to help dispel myths around these swallowing issues.
Dysphagia is a general medical term used which means “difficulty with swallowing” and it can happen in one of a few different locations. “When we approach a patient who has difficulty swallowing or getting food down, we have to start by exploring where it’s happening,” says Dr. Schneider.
There are different areas dysphagia can happen, as there are three stages to swallowing. These include:
The symptoms can also vary, including:
As far as causes of dysphagia, there are several different factors to look at when trying to pinpoint what’s going on.
Your doctor will look for cues in how you describe symptoms and determine a possible cause, says Dr. Schneider.
One main factor is how you react to swallowing solid foods versus liquids. “When a patient complains of difficulty swallowing solid foods, we think maybe this is more of a mechanical issue or an obstruction in the esophagus, such as an esophageal ring, stricture from scarring related to acid reflux, or even esophageal cancer,” Dr. Schneider says.
“On the other hand,” she continues, “if symptoms occur with both solid foods and liquids, the cause may be the muscles and nerves used for swallowing that make the esophagus have muscular or peristaltic contractions. We often group these conditions into motility disorders of the esophagus.”
Difficulty in your mouth (like tongue weakness) or your throat could be due to muscle weakness after a stroke. Neurological and muscular issues like multiple sclerosis , amyotrophic lateral sclerosis ( ALS ) and muscular dystrophy can also contribute to issues with swallowing. And, as Dr. Schneider points out, obstruction, including tumors or swollen glands, could be the culprit.
Like many medical conditions, it’s important to dispel myths surrounding dysphagia to maximize diagnosis and treatment. The more you understand the condition, the easier it can be to get the proper medical help.
While a stroke is a common cause of dysphagia, there are plenty of other reasons the condition may develop. “As far as neuromuscular reasons go, Parkinson’s disease, ALS and many other neurological conditions can be associated with difficulty swallowing. These conditions are often evaluated by speech-language pathologists who evaluate and treat these types of swallowing disorders ” notes Dr. Schneider. “And, additionally, there are those structural issues, too, like tumors.”
While altering your diet can lead to a lot of positive changes for your health, it can’t fully alleviate dysphagia. “There are dietary changes that help you manage symptoms, but those changes won’t treat the underlying condition,” says Dr. Schneider.
“Your stomach acids aren’t supposed to touch your esophageal lining for prolonged periods,” explains Dr. Schneider, “so when we talk about acid reflux , it has to do with your lower esophageal sphincter is opening and closing more than it should.”
While the acid can certainly cause discomfort and certain symptoms, including heartburn and even difficulty swallowing, it may not always be causing the symptom itself. Conditions such as esophageal strictures and tumors might be to blame. “The source of the issue can be discovered via an endoscopy, a procedure gastroenterology specialists perform that can directly look at the organs of a patient with a specialized camera and to look for these concerning conditions,“ says Dr. Schneider.
There are several treatments available when it comes to taking care of dysphagia. If you have dysphagia as the result of a stroke or neuromuscular issue, there are therapy exercises that can strengthen the affected muscles.
“Patients can work with speech pathologists who can recommend exercises to strengthen weak facial muscles and improve swallowing coordination,” Dr. Schneider says. Learning how to clear your throat or change your body position to avoid choking can also help.
“There are also some electrical stimulation techniques that can be used to help patients, to help them learn ways to improve neuromuscular stimulation,” she adds.
Surgical and endoscopic treatments are also available, according to Dr. Schneider, though they vary depending on the situation. Whether it’s removing a tumor or installing stents in your esophagus (similar to heart stents). These techniques can greatly aid those with symptoms of dysphagia.
The bottom line, Dr. Schneider says, is to make sure you notify your healthcare provider as soon as you notice something’s wrong. “If you’re having any difficulty with swallowing, like symptoms of choking, coughing or feeling like food is sticking from time to time, do not ignore the symptom.”
Early detection is the key to early treatment: “Difficulty swallowing should not be ignored because we want to make sure we’re not missing anything very serious,” Dr. Schneider advises. “And we don’t want any undiagnosed disease to progress to the point we may have difficulty with management in the future.”
Cleveland Clinic is a non-profit academic medical center. Advertising on our site helps support our mission. We do not endorse non-Cleveland Clinic products or services. Policy
Difficulty with swallowing can have a large impact on your health, so it’s important to separate fact from fiction when seeking treatment. Our expert dispels common myths.
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Difficulty swallowing (dysphagia) affects your quality of
life and your health. The ability to safely swallow is vital for adequate
nutrition and hydration, and it prevents foods and liquids from entering your
lungs, where they can cause pneumonia.
Swallowing is a complex process that requires multiple muscles to work together. When you swallow:
A problem in one or more of these areas can make it difficult or painful to swallow.
The term dysphagia refers to difficulty swallowing. It is used regarding a variety of swallowing disorders. Not all swallowing problems are dysphagia — it is normal to have occasional difficulty swallowing certain foods or liquids, such as when taking large bites of food. However, ongoing difficulty swallowing could be a cause for concern.
Depending on which part of the swallowing process is affected, dysphagia can be described as:
Swallowing disorders cause a variety of symptoms that include:
While the above symptoms often happen during or after swallowing, some signs of dysphagia can appear independently of eating, drinking or swallowing. Talk to your doctor if you’ve been experiencing:
There are many reasons why swallowing may become difficult.
Esophageal motility is the movement of food through the esophagus. Normally, coordinated muscle contractions in the esophagus move the swallowed food toward the stomach in one direction. At the top and bottom ends of the esophagus are rings of muscles called sphincters that allow the food to enter and exit the esophagus.
If the muscles stop working toget
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