Based on PubMed | How does multiple sclerosis cause difficulty swallowing (dysphagia), how common is it, and what evaluation and management options are recommended?

Multiple sclerosis (MS) can cause difficulty swallowing (dysphagia) by disrupting the brain and nerve pathways that coordinate the complex, automatic actions of the mouth, throat, and upper esophagus needed to safely move food and liquid into the stomach. ^[1] In MS, immune-mediated damage to myelin (the protective coating on nerve fibers) interferes with signal timing and muscle coordination; depending on where lesions occur, this can impair chewing, tongue control, the swallow reflex, and upper esophageal sphincter opening. ^[2] When these phases don’t work together, food or liquid may misroute toward the airway, causing coughing, choking, or aspiration, or may feel “stuck,” especially with thin liquids or mixed textures. ^[3]

How MS Leads to Dysphagia

• Central control of swallowing involves multiple brain regions and cranial nerves that must work “in fine balance” to coordinate mouth, throat, and esophageal muscles; neurological disorders such as MS can alter this balance and impair the swallow. ^[1]
• Demyelination in MS slows or blocks conduction along neural pathways, disrupting timing of the oral and pharyngeal swallow and sometimes causing upper esophageal sphincter dysfunction. ^[2]
• Resulting problems include delayed swallow initiation, weak tongue propulsion, poor airway closure, and cricopharyngeal muscle hyperactivity, any of which can increase the risk of aspiration (food or liquid entering the airway). ^[3]

How Common Is Dysphagia in MS?

• Dysphagia is relatively common in MS and becomes more frequent as disability increases; surveys in large MS cohorts have reported that around one‑third of individuals endorse swallowing problems, with higher rates in those with greater neurologic impairment. ^[4]
• Clinically, dysphagia may be underrecognized early and more obvious in advanced disease, so proactive screening is often recommended in those with symptoms such as coughing while eating, prolonged mealtimes, or recurrent chest infections. ^[5]

Why It Matters: Potential Complications

• Difficulty swallowing can lead to malnutrition, dehydration, and weight loss when eating and drinking become ineffective or unsafe. ^[6]
• Aspiration of food or liquid into the airway can introduce bacteria into the lungs and cause aspiration pneumonia, which can be serious if not recognized and managed. ^[7]
• In MS, recurrent infections and aspiration events can significantly impact quality of life and health, underscoring the value of early identification and management. ^[8]

Evaluation: What to Expect

A stepwise assessment helps define the pattern and severity of dysphagia and guides treatment.

• Clinical history and exam
  • Targeted questions about coughing/choking with meals, sensation of food sticking, changes with liquid vs. solid, weight loss, and recurrent chest infections, plus oral motor and cranial nerve exam. ^[1]
• Bedside swallow screening
  • Performed by a clinician or speech‑language pathologist (SLP) to observe safety and efficiency with different consistencies and to determine need for instrumental testing. ^[9]
• Instrumental studies (as indicated)
  • Videofluoroscopic Swallow Study (VFSS, “modified barium swallow”) or Fiberoptic Endoscopic Evaluation of Swallowing (FEES) to visualize bolus flow, airway protection, timing, and upper esophageal sphincter function, and to test postures or maneuvers in real time. ^[9]
• Functional scales and questionnaires
  • Standardized symptom tools can help track severity and treatment response over time in MS‑related dysphagia. ^[5]

Management Options

Treatment is individualized based on swallow phase(s) affected, severity, and patient goals, with most care coordinated by an SLP.

• Swallow therapy and techniques
  • Targeted exercises can strengthen or retrain the muscles involved in swallowing and improve timing and coordination; techniques may include effortful swallow, supraglottic swallow, Mendelsohn maneuver, and tongue‑base strengthening as tailored by an SLP. ^[9]
  • Postural adjustments and compensatory strategies (for example, chin tuck, head turn, smaller sips, double swallows) can help direct the bolus safely. ^[9]
• Diet modification
  • Adjusting texture and viscosity (thickening liquids, softer or pureed foods, avoiding mixed textures) can reduce aspiration risk and make swallowing more efficient, with periodic reassessment to avoid unnecessary restrictions. ^[9]
• Neuromodulatory and procedural options (selected cases)
  • For patients with upper esophageal sphincter hyperactivity, botulinum toxin injection into the cricopharyngeus has shown improvements in objective swallow measures in small MS cohorts. ^[10]
  • Pharyngeal electrical stimulation has demonstrated short‑term improvements in pilot studies of MS‑related dysphagia, suggesting a potential adjunct in specialized settings. ^[11]
• Medical and supportive care
  • Optimize overall MS care, manage reflux if present, and ensure adequate hydration and nutrition; consider supplements or high‑calorie options when intake is low. ^[9]
  • When swallowing remains unsafe and nutrition/hydration cannot be maintained, temporary or long‑term feeding tube placement may be recommended to reduce aspiration risk while supporting health. ^[12]
• Ongoing monitoring
  • Because dysphagia can fluctuate with MS activity and fatigue, regular follow‑up allows adjustments as strength and coordination change over time. ^[5]

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Quick Comparison: Evaluation and Management

Aspect	Purpose	Examples
Screening & history	Identify red flags and need for imaging	Coughing/choking, “food sticking,” weight loss, chest infections, oral motor exam. [1]
Instrumental testing	Visualize swallow, test strategies	VFSS or FEES to assess airway protection, timing, UES function. [9]
Therapy & techniques	Improve muscle function and safety	Swallow exercises, posture changes, safe‑swallow techniques. [9]
Diet changes	Reduce aspiration and effort	Thickened liquids, soft/pureed foods, avoid mixed textures. [9]
Procedures (selected)	Target specific dysfunction	Cricopharyngeal botulinum toxin for UES hyperactivity; pharyngeal electrical stimulation. [10] [11]
Escalation	Maintain nutrition when unsafe	Feeding tube if severe, persistent dysphagia. [12]

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Key Takeaways

• MS can cause dysphagia by disrupting the neural coordination of swallowing across the mouth, throat, and upper esophagus. ^[1]
• About one in three people with MS report swallowing difficulties, with higher rates as disability increases, so proactive screening is helpful. ^[4]
• Evaluation typically includes bedside assessment and, when needed, VFSS/FEES, followed by personalized therapy, diet strategies, and, in selected cases, procedural interventions; severe cases may require temporary or long‑term feeding support to stay safe and nourished. ^{[9] [10] [11] [12]}