Coughing and swallowing are two seemingly natural, everyday actions that we perform almost unconsciously—we cough and swallow without even realising it. Yet they are two quite distinct reflexes. Let’s take a closer look.
Coughing is a natural and essential bodily mechanism that helps clear the airways of irritants, mucus, or foreign particles. It presents as a dry sound caused by the rapid expulsion of air from the lungs and can occur either voluntarily or involuntarily. It is often a temporary symptom, but when it persists for more than eight weeks, it is considered chronic.
Swallowing, on the other hand, is a more complex and coordinated process involving muscles and nerves regulated by the brain. It allows food and liquids to pass from the mouth to the stomach while simultaneously protecting the airways.
However, coughing can sometimes occur during swallowing. Is this something to worry about? It depends.
Dysphagia: how swallowing can trigger coughing
“Coughing during swallowing is a completely natural and physiological defence mechanism that protects the respiratory tract”, explains Professor Massimo Ralli, a lecturer in otolaryngology at UniCamillus University. “In fact, when we eat or drink, food and liquids are directed into the digestive tract thanks to the refined mechanism of swallowing, which prevents them from entering the airways—where they could cause choking or lung infections. Coughing helps expel any substance that has entered the airway by mistake”. This is a direct protective reflex and a vital mechanism for preventing suffocation and respiratory infections.
However, there are times when coughing during swallowing no longer serves a protective role.
Instead, it may take on a pathological significance—especially when episodes become intense and/or frequent. “In such cases, dysphagia may be present. What is it? It’s a swallowing disorder that can lead to serious consequences, particularly in vulnerable individuals. Conversely, the absence of coughing as a defence mechanism should also raise concern, as it deprives the airways of essential protection”, warns Ralli.
Possible causes of dysphagia
There are many causes of coughing during swallowing, often linked to various clinical conditions.
“Among the most frequent causes are those of neurological origin. For example, a stroke can compromise the muscle coordination required for proper swallowing”, explains Ralli.
Neurodegenerative diseases such as Parkinson’s disease, multiple sclerosis, and ALS can interfere with the transmission of nerve impulses, disrupting the normal swallowing process.
“Other causes may be muscular, such as myopathies or dystrophies, which weaken the muscles involved in swallowing”, says the expert, explaining how this can make it difficult for food and liquids to pass through. In many cases, dysphagia is the first symptom that initiates the diagnostic process.
There are also structural factors. “The presence of stenosis, scarring, or anatomical abnormalities can obstruct the regular passage of food, causing coughing or a sensation of choking.” Professor Ralli adds that head and neck tumours can interfere with both swallowing and breathing functions, leading to persistent coughing. This highlights the importance of a comprehensive medical evaluation.
However, aside from organic causes, there are also situational factors, which are actually among the most common. “These include gastroesophageal reflux, inflammation and allergies of the upper respiratory tract, and stress-related conditions”, explains Ralli. “In the case of reflux, acid from the stomach rises into the oesophagus and can reach the larynx, causing irritation and triggering coughing, often during or immediately after eating. Similarly, infections such as laryngitis, pharyngitis, or tonsillitis, as well as allergic reactions, can irritate the upper airways and cause coughing, especially during meals”.
Some medications also play a significant role. “ACE inhibitors, which are commonly prescribed for high blood pressure, are known to cause persistent coughing as a side effect”.
Functional or psychological causes should not be overlooked. These are particularly difficult to diagnose and often emerge after other conditions have been ruled out. “In some cases, coughing may be linked to non-organic factors such as stress, anxiety, or long-standing habits. Periods of stress or anxiety can contribute to functional coughing, which tends to worsen during meals.
In these cases, there may also be associated symptoms, such as changes in voice tone—known as psychogenic dysphonia”, adds Professor Ralli.
How can the cause of dysphagia be identified?
When symptoms of dysphagia occur, such as coughing during swallowing, it is essential to accurately identify the cause through a structured and thorough diagnostic process.
“The assessment must always begin with an ENT (ear, nose and throat) examination, to detect any anatomical or inflammatory abnormalities in the pharynx and larynx”, says Professor Ralli.
This initial evaluation is often accompanied by a fibrolaryngoscopy, an endoscopic procedure that allows the larynx to be observed directly and its function during breathing and phonation to be assessed. “To further investigate swallowing, one of the most specific tests is FEES (Fibreoptic Endoscopic Evaluation of Swallowing), which enables monitoring of the passage of food and liquids and the identification of any aspiration episodes”. In some cases, this test can be supplemented or replacedbya Videofluoroscopic Swallowing Study (VFSS)—adynamic radiological examination that analyses the movement of the food bolusin real time and highlights any muscular or mechanical dysfunctions.
If neurological dysphagia is suspected, a neurologist should perform a comprehensive assessment of both central and peripheral nervous system functions. If, on the other hand, the cough appears to be related to pharyngolaryngeal reflux, a gastroenterology consultation is advised, which may include a gastroscopy or a breath test for Helicobacter pylori, to detect any irritation caused by gastric acid. Depending on the clinical picture, additional radiological or laboratory tests may be required to rule out infections or tumour-related conditions.
Dysphagia: available treatments and therapies
Once the cause has been identified, treatment must be individually tailored. “The treatment depends on the nature of the disorder. In organic conditions, targeted or supportive therapies are used. In inflammatory or irritative cases, anti-inflammatory, anti-allergic, or anti-reflux medications may be indicated,” explains Professor Ralli. “If coughing is a side effect of medication, however, the solution is to suspend or replace the drug responsible—always under medical supervision.”
In cases of dysphagia, thickeners can be added to liquids and safer eating habits adopted, such as eating slowly, chewing thoroughly, and choosing soft foods. “The speech and language therapist plays a fundamental role in the rehabilitation process, guiding the patient through exercises aimed at improving muscle strength and coordination of swallowing movements”, adds Professor Ralli.
If there is a psychogenic component, psychological support can also be helpful in managing anxiety and reducing the hyperactivity of the cough reflex.
Therefore, the diagnosis and treatment of coughing during swallowing require a multidisciplinary approach. Collaboration between an ENT specialist, neurologist, gastroenterologist, speech therapist and, if necessary, a psychologist allows the problem to be addressed in a comprehensive and personalized way.
Can the symptoms of dysphagia be cured, or is it a chronic condition? The expert’s answer is: it depends. It depends on the accurate identification of the underlying causeand thetimeliness of intervention. “In the case of temporary conditions, such as infections, allergies, or irritation of the upper respiratory tract, coughing can be completely resolved with appropriate treatment, leading to the permanent disappearance of the symptom”, the professor emphasises.
“If the cough is due to chronic or degenerative causes, such as neurological or muscular diseases, the swallowing disorder that causes it can often persist and worsen over time as the underlying condition progresses.”
However, the expert reassures us that with adequate rehabilitation and lifestyle adjustments, it is possible to improve safety during meals and enhance patients’ quality of life. The goal in these cases is to prevent complications, such as aspiration pneumonia, which is one of the most common causes of death in these patients. For structural causes, such as malformations or surgical outcomes, appropriate treatment— often surgical—can lead to excellent functional results.
“The correct and timely identification of the underlying cause of persistent and uncontrolled coughing during swallowing is what can truly make a difference for these patients,” concludes Professor Ralli. “This allows us to initiate all the necessary steps to resolve—or at least better manage—dysphagia, preventing it from becoming chronic and leading to potentially life-threatening complications”.
Professor Ralli teaches fifth-year students in the MSc in Medicine and Dentistry, as well as in the MSc in Dentistry and Dental Prosthetics.
To enrol in one of these courses, visit our current calls for applications page.