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Fiberoptic Endoscopic Evaluation of Swallowing (FEES)

Fiberoptic endoscopic assessment of swallowing (FEES) is a portable procedure that may be completed in outpatient clinic space or at bedside by passing an endoscope transnasally (Langmore et al., 1988). FEES may be recommended regardless of setting (e.g., hospital, skilled nursing facility). FEES is used without concerns of radiation exposure and can be used within therapeutic contexts and for diagnostic therapy to assess current progress and effectiveness of therapy. If there are clinical indications for a laryngoscopy evaluation (e.g., hoarse voice, pain on swallowing), the speech-language pathologist (SLP) may consider consulting with a physician regarding a referral to an otolaryngologist to rule out the possibility of disease in the nasal, pharyngeal, or laryngeal region.

In addition to the general indications for instrumental evaluation, the following indications are specific to FEES:

  • sensitivity to increased difficulty with swallowing over the course of a meal, secondary to fatigue
  • sensitivity to velum function for hypernasality and/or suspected nasal regurgitation
  • need for visualization of the hypopharynx/larynx for biofeedback and/or rehabilitation
  • need to assess vocal fold dynamics or laryngeal adductor reflex (LAR) related to swallow function (see below)
  • documented pharyngeal dysphagia on VFSS that can be retested with endoscopy to
    • monitor progress,
    • directly assess pharyngeal and laryngeal anatomy, and/or
    • limit radiation exposure
  • suspected or observed difficulty with swallowing saliva/oral secretions
  • inability to tolerate contrast media (e.g., barium, iohexol) due to allergy or aversion
  • concerns or safety issues associated with radiation exposure (e.g., pregnancy)
  • patients’ inability (including individuals on a ventilator) to leave the bedside because of mobility and/or postural deficits
  • difficulties with obstructed fluoroscopic viewing (e.g., patients wearing a halo, patients wearing a cervical collar)
  • limited access to radiologic equipment

In addition to the contraindications for all instrumental evaluations, the following contraindications are specific to FEES:

  • severe agitation and/or inability to cooperate with the examination
  • severe movement disorders that interfere with safe administration
  • severe bleeding disorders and/or recent severe epistaxis (nosebleed)
  • history of recent trauma to the nasal cavity or surrounding tissue and structures secondary to surgery or injury
  • bilateral obstruction of the nasal passages

Procedure

Procedures for FEES vary across setting and across clinicians. Clinicians should follow guidelines from their facility and licensing body regarding FEES procedures.

Prior to bolus delivery, the SLP may

  • educate the patient and/or caregiver regarding FEES procedure and rationale for the exam;
  • position the patient consistent with the patient’s typical eating posture (e.g., upright, reclined);
  • provide topical anesthetic if appropriate (see below for further information regarding anesthetic);
  • select the appropriate endoscope type and size;
  • insert the scope;
  • identify anatomical landmarks and any abnormalities;
  • flexible endoscopic evaluation of swallowing with sensory testing (FEESST) is administered, if indicated, to determine laryngeal adductor reflex (LAR) sensitivity and vocal fold dynamics; and
  • assess basic movement abilities of anatomical structures through specific maneuvers (e.g., perform Valsalva maneuver to evaluate vocal fold closure, ask patient to say words with no nasal phoneme stimuli to assess velopharyngeal closure).

During or following bolus delivery, the SLP may

  • identify abnormal swallow function and the subsequent effect on laryngeal penetration, residue, sensory awareness, and effectiveness of the patient’s response to laryngeal penetration and/or residue—aspiration is inferred based on patient response and/or observation of material below the vocal folds after the swallow;
  • monitor for adverse reactions to the examination and respond appropriately;
  • assess the influence of fatigue on pharyngeal swallow function over multiple trials;
  • assess initiation of swallow and timing of structural movement in response to bolus;
  • identify any residue remaining in the pharyngeal or laryngeal cavities after the swallow; and
  • introduce strategies to minimize and/or eliminate aspiration.

Typically, food is minimally colored to assist in assessing secretions and residue in the pharynx after the swallow is completed.

The SLP can test sensation in the hypopharynx and larynx directly with a modification of the FEES procedure. Flexible endoscopic evaluation of swallowing with sensory testing (FEESST) requires a two-channel scope and uses pulses of air to assess sensory perception of the larynx and to monitor the laryngeal adductor reflex (LAR). LAR is characterized by a brief closure of the true vocal folds. FEESST uses a pressure- and duration-calibrated air puff, delivered anterior to the arytenoids along the aryepiglottic folds to test the intensity level at which LAR is elicited.

SLPs do not require special certification from ASHA or any other entity to perform instrumental assessments. SLPs with appropriate training and competence in performing FEES are qualified to use this procedure independently for the purpose of assessing swallow function and related functions of structures within the aerodigestive tract. ASHA does not require the presence of a physician for an SLP to perform FEES. Physicians may also be involved in functional swallowing evaluation and/or may be present to assess the integrity of laryngeal and pharyngeal structures in order to provide a medical diagnosis. SLPs should be aware of state laws, facility policy, and third-party payer requirements related to the presence of a physician during FEES and should also be aware of any scope-of-practice requirements related to endoscopy. See ASHA’s page on States With Specific Instrumental Assessment Requirements.

Observations From FEES

Lip closure Patient’s ability to approximate top and bottom lip
Tongue control Volitional and controlled lingual movement
Bolus preparation Patient’s ability to create a well-contained bolus
Bolus transport Patient’s ability to move the bolus from the oral cavity to the pharyngeal cavity
Oral residue Remaining residue in the oral cavity following oral transport
Initiation of the pharyngeal swallow response Head of the bolus at the initiation of the pharyngeal swallow (hyoid burst) response
Soft palate elevation Upward movement of the soft palate to create velopharyngeal closure
Laryngeal elevation Extent and timeliness of upward movement of the larynx during the swallow
Anterior hyoid motion Extent and timeliness of forward movement of the hyoid
Epiglottic movement Extent and timeliness of passive epiglottic inversion to meet with the arytenoids (moving anteriorly and superiorly)
Laryngeal closure Medial movement of the larynx observed at the vocal folds; may be able to observe only from the anterior–posterior view
Pharyngeal stripping wave Contraction of the posterior pharyngeal wall from top moving downward
Pharyngeal contraction Approximation of the pharyngeal walls
Pharyngeal esophageal sphincter opening Opening of the pharyngeal esophageal sphincter to allow the bolus to move from the pharynx to the esophagus
Tongue base retraction Posterior movement of the tongue base to make contact with the posterior pharyngeal wall
Pharyngeal residue Remaining residue in the pharynx following the pharyngeal swallow
Esophageal clearance in upright position General observation of the passage of the bolus through the esophagus

Limitations of FEES

The FEES procedure includes the following limitations:

  • Inability to visualize the oral or the esophageal phase of swallowing.
  • Limited ability to visualize pharyngeal phase; however, a clinician may be able to visualize initiation of pharyngeal structural movements through
    • pharyngeal squeeze,
    • superior movement, and/or
    • epiglottis inversion.
  • “White-out”—passage of the bolus and movement of the pharyngeal structures cannot be observed during the swallow because of reflected light from pharyngeal and laryngeal tissues into the endoscope.
  • Inability, by some patients, to tolerate the procedure due to discomfort and/or medical conditions.

Precautions and Safety Considerations

The patient may, on rare occasions, experience adverse effects when undergoing FEES (Langmore, 2001). These may include but are not limited to

  • discomfort,
  • vomiting,
  • epistaxis (nosebleed),
  • mucosal perforation,
  • allergic reaction or hypersensitivity to topical anesthesia or nasal spray, and
  • laryngospasm.

Clinicians should be well trained in the signs and symptoms of adverse reactions, know their facility’s plan for response and intervention to such reactions, and be ready to take appropriate action if they occur. It is advisable to have suction equipment and personnel trained in the use of such equipment if available. Use of a cardiac monitor may be warranted for patients with significant pulmonary disease, cardiac arrhythmia, seizure disorders, or other medical conditions. Special care is taken with use of topical anesthesia in medically fragile infants and children. Clinicians are encouraged to consult with the child’s medical team prior to using anesthesia with these children.

SLPs follow universal precautions and facility procedures for infection control (e.g., adequate disinfection of equipment). Decontamination, cleaning, disinfection, and sterilization of multiple-use equipment before reuse are carried out according to facility-specific infection control policies and services and according to manufacturers’ instructions. All equipment is used and maintained in accordance with the manufacturers’ specifications. For further information on infection control, please visit ASHA’s page on Infection Control Resources for Audiologists and Speech-Language Pathologists.

Please also see ASHA’s page on Coronavirus/COVID-19 Updates as well as Guidance to SLPs Regarding Aerosol Generating Procedures.

Resources

Dysphagia Competency Verification Tool (DCVT) [PDF]

References

Langmore, S. E. (2001). Endoscopic evaluation and treatment of swallowing disorders. Thieme.

Langmore, S. E., Kenneth, S. M. A., & Olsen, N. (1988). Fiberoptic endoscopic examination of swallowing safety: A new procedure. Dysphagia, 2(4), 216–219. https://doi.org/10.1007/BF02414429

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