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:
In addition to the contraindications for all instrumental evaluations, the following contraindications are specific to FEES:
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
During or following bolus delivery, the SLP may
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.
|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|
The FEES procedure includes the following limitations:
The patient may, on rare occasions, experience adverse effects when undergoing FEES (Langmore, 2001). These may include but are not limited to
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.
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