I have an elderly gentleman friend who experiences a strange problem -- he chokes on food, coughs up phlegm, and then usually vomits. I have encouraged him to take smaller bites, chew them very well and slow down with his eating process. He insists this is an allergy, but one of his granddaughters has a similar problem -- her age is 20 -- and has had her esophagus stretched. Any information you could provide would be helpful.

L.C.

Allergy is one possible explanation, but it would be far down on my list of possible diagnoses. There are many other explanations for his problem, and some of these possibilities are quite dangerous. In other words, the swallowing difficulty you describe may be a sign of a serious medical condition.

The act of swallowing is actually quite complex. First of all, there is the act of "bolus formation." "Bolus" is the medical term for a wad of well-chewed food. Bolus formation requires efficient chewing, coordination of the tongue, lips and cheek (to keep the food in the front part of the oral cavity, and to move it around to the teeth) and adequate saliva.

Once the bolus is formed, it must be propelled to the back of the oral cavity. Tongue coordination is critical for this phase. Next is the actual swallow. Nearly simultaneously, several actions occur that are essential for an efficient swallow:

• The soft palate blocks off the nasal cavity by moving to the back of the throat.
  
• The larynx (voice box) rises in order to move the airway to a safer position. You can feel this by placing your fingers on your thyroid cartilage (Adam's apple) and swallowing. This movement gets the airway out of harm's way, and also serves to open the upper esophagus.
  
• Throat muscles, called the "pharyngeal constrictors," then squeeze down on the bolus, propelling it into the esophagus. In the final phase, constrictors in the esophagus move rhythmically to propel the bolus downward, into the stomach.
  

Based on the information you have given me, I can hazard a guess that your friend's granddaughter's problem was an esophageal narrowing, or stricture. The safest initial treatment of this problem is to dilate (stretch or widen) the esophagus by very carefully passing lubricated tubes through the stricture. Successively larger tubes are passed until the strictured area is wide enough to no longer cause problems. This may need to be repeated (typically at intervals of months to a year) if the stricture forms again. Needless to say, this procedure is usually done under anesthesia and should be performed by a physician who is well-trained in this method.

Your friend's problem is more perplexing. For a diagnosis, a competent physician will need to take a full history and examine him thoroughly. A good person to begin with would be his family practitioner or internist. A gastroenterologist (an internist specializing in the digestive tract) or an otolaryngologist (ear, nose and throat surgeon) may also be consulted. Your friend may also need to see a speech pathologist (a therapist who specializes not just in language difficulties, but also in swallowing problems).

To give you some idea as to the potential seriousness of his problem, here are some of the possible diagnoses that can lead to your friend's symptoms:

• Neurologic diseases, such as stroke, multiple sclerosis or amyotrophic lateral sclerosis (ALS, also known as Lou Gehrig's disease).
  
• Inflammatory conditions, such as gastroesophageal reflux disease (and, yes, inflammation due to postnasal drainage from chronic sinusitis or nasal allergies, though, as I said previously, this is unlikely).
  
• Tumors of the throat, esophagus or chest cavity.
  
• Other obstructions. For example, older people can develop "osteophytes," bony protuberances from their spinal column. If large enough, an osteophyte can press on the esophagus, causing obstruction.
  
• Impaired saliva production. In an older person, this is usually due to side effects of medications, but there are other causes as well.
  

As you can see, many of these problems are potentially quite serious. Share this information with your friend, and encourage him to discuss the problem with his doctor.