Dysphagia FEES SASS Minute

Fall 2015 SASS Newletter


Welcome to the Fall SASS Newsletter. Read about our wonderful trip to Saudi Arabia!

Click here to see the Fall 2015 SASS Newletter.

Dysphagia Professional Issues Research

December Research Tuesday

To Eat or Not to Eat: What Information do Clinicians Use in Recommending an Oral Diet?
I LOVE the holiday season.  I love the decorations, the spirit in the air, and spending time with friends and family.  And if you are at my house, that means food – lots of food.  Our family loves to cook and eat together, and I cannot imagine a time of year when it would be more difficult to not be able to eat. Making the recommendation for oral versus nonoral feeding is pretty much the most important decision we make as swallowing therapists.  There are very few things that more dramatically change a patient’s life than taking away their PO status.  We should not take these recommendations lightly.  With great power comes great responsibility, and we should constantly be assessing why we make certain decisions.  Back in 2008, Dr. Logemann and 24 colleagues investigated this topic – they wanted to know how and why clinicians make their oral or nonoral feeding recommendations – and luckily they published this information for us to use!
Logemann, J. A. et al. (2008). What information do clinicians use in recommending oral versus nonoral feeding on oropharyngeal dysphagia patient? Dysphagia, 23. (Full Text Here)
This study was comprised of two phases.  In the initial phase, a group of 23 experienced dysphagia clinicians identified the variables they might use in making NPO vs PO decisions.  Those variables were then rated by the clinicians to determine the most important of the identified variables.  The chart below describes the 13 most influential variables identified.
chart 12142
In the second phase of the investigation, 20 modified barium swallow studies with patient histories were sent to the SLPs for analysis.  For each patient, clinicians were asked whether they would recommend an oral diet, partially oral diet, or nonoral feeding.  They were then asked what diet consistency they would recommend if they gave a partially oral feeding, whether dental status affected their decision, and if they would recommend postures or maneuvers.
The decision for a full oral feeding was made 57% of the time, whereas the decision for limited oral comprised 15% of the recommendations and nonoral 26%. A Kappa statistic was used to determine the agreement between the clinicians.  A low Kappa statistic would signify low agreement between the clinicians whereas a high Kappa statistic would signify high agreement between the clinicians.  There was a statistically substantial Kappa statistic (meaning that the agreement was above chance happening) for the full oral decision (.72) and the nonoral decision (.66).  There was little agreement amongst the clinicians on the type of oral diet recommended. A lot of data was collected – see the full text to go through it.
The Results:
The four most influential variables for the PO versus NPO decision were
  1. amount of aspiration (by far the most frequently used variable – and a very subjective variable, as well – what is ‘a lot’ of aspiration?)
  2. frequency of aspiration
  3. diagnosis
  4. history of pneumonia (best agreement amongst the clinicians)
The most frequently recommended postures/maneuvers were
  1. effortful swallow
  2. head turn
  3. chin tuck
  4. super supraglottic swallow
  5. supraglottic swallow
  6. repeat swallow
Some thoughts:
While the frequency of recommendations for full oral feeding was the same amongst clinicians, the amount of experience was found to be an important factor in determining if limited oral feeding was allowed.  Those clinicians with fewer years of clinical experience were more conservative and recommended nonoral feeding more frequently than those with more experience.  They also recommended more maneuvers than the clinicians with more years of experience.
As I have grown in my career, I have become much more liberal with my diet recommendations and learned to trust my postures/maneuvers more.  In my earlier years I was so terrified to allow a patient to leave an evaluation without a strategy (or multiple strategies) to completely eliminate all aspiration.  While this is certainly an admirable goal, I now know so many other factors determine whether a patient actually gets pneumonia (like dependence on others for feeding/oral care, pulmonary status, etc – see my July Research Tuesday post on The Most Important Aspiration Pneumonia Article Ever for more details on this!).  I have witnessed many patients who aspirate buckets who never get pneumonia, and I have seen how well certain maneuvers/postures dramatically improve the swallow.  I don’t feel the need to have the patient use a supraglottic swallow with a head turn & chin tuck – especially if a head turn will suffice.  And how do I know all this?  I have seen it.  I have completed a MBS or FEES on the patient and determined the safest swallowing situation for them by visualizing them complete the strategy or swallow the consistency.
In our practice we have spoken with many younger clinicians who rely on bedside assessments because their facility will not allow them to get an instrumental and they are too afraid to rock the boat to demand one.  We see their patients with multiple strategies and limited diets based on the best “guess” the clinician could make from the bedside.  Is that really fair to the patient – to manipulate or forbid their mealtime  based off of a guess?  Know for sure – don’t let a bean counter take away your ability to properly determine a diet.
I really appreciate Dr. Logemann and colleagues for giving us this opportunity to glance into the radiology suites of 23 skilled clinicians.  We can learn so much from our colleagues.  I hope this article gives you new insights into your own clinical decision making, and don’t forget to share this information with some newbies!
Have a very happy holiday season from the SASS family!!



Kelley Babcock, MS, CCC-SLP, BCS-S, is a voice and swallowing therapist from Nashville, Tennessee.  She works as a clinician and educator for SA Swallowing Services which provides basic, advanced and custom FEES courses for SLPs across the country.  For more information on FEES and dysphagia, check out or connect with Kelley on Twitter or LinkedIn.

Photo credit flikr for creative commons


Dysphagia FEES Research

November Research Tuesday

 The Gamble of Blue Dye Testing
First I want to start off with what this post isn’t:
-The purpose of this post is not to bash the way many therapists have been practicing for years.
-The purpose of this post is not to convince therapists that they should never use blue dye ever again.
-The purpose of this post IS to objectively evaluate the reliability data behind the Modified Evans Blue Dye Test to best determine what we are actually observing when we do a blue dye tracheostomy swallowing exam.
So what is a Modified Evans Blue Dye Test (MEBDT)?  This clinical swallowing test was developed to identify aspiration in patients with tracheostomies with the help of suctioning by the respiratory therapist.  In the original Evans Blue Dye Test, the clinician would place a few drops of dye on a patient’s tongue and the respiratory therapist would suction the patient every few hours and report back as to whether blue dye was present in suctioned secretions.  Speech pathologists modified this to add blue dye to food and drinks to further evaluate aspiration with trials of certain consistencies. The Modified Evans Blue Dye Test was formally introduced in Dysphagia Journal in 1995.
It all makes sense.  If the patient is aspirating secretions or food consistencies, the blue dye will go into the trachea/lungs and the respiratory therapist will suction it out.  If the respiratory therapist doesn’t suction any blue out, then the patient must not be aspirating.  Bingo bango, our job is done!
Unfortunately life just isn’t that simple.  Less than 5 years after the introduction of the MEBDT, clinicians performing instrumental swallow exams began reporting on patients who had no blue dye return on MEBDT but who were found to be aspirating on instrumental exam.  Bummer.  Big bummer.
As SLPs we must critically look at any test we perform to ensure that the test is
  1. Reliable enough to produce the same results under consistent conditions
  2. Sensitive enough to identify those who do have the searched for criteria
  3. Specific enough that those who do not have the searched for criteria are not identified
There have a been many different studies looking at reliability, sensitivity and specificity of the MEBDT.  Because we are depending on pretty specific circumstances to obtain our outcome – the patient must aspirate, the respiratory therapist must suction enough and in the right spots to pull out the aspirated material, the dye must be dark enough to perceive in the secretions – many have claimed that the MEBDT may not be sensitive enough to identify everyone who aspirates.  The biggest concern with MEBDT is a false negative – this would occur if the MEBDT does not show aspiration but the patient actually is aspirating. This study, from Dysphagia Journal waaaay back in 1999,  was one of the first to identify the high likelihood of false negative results with MEBDTs.
Brady SL, Hildner CD, Hutchins BF.  1999. Simultaneous video- fluoroscopic swallow study and modified Evans blue dye procedure: an evaluation of blue dye visualization in cases of known aspiration. Dysphagia 14:146–149.  Full Text Here
This investigation analyzed 20 simultaneous MBS exams and MEBDTs to determine if the MEBDT correctly identified each aspiration event that occurred. Before the MBS, the investigators dyed thin, nectar and puree consistency barium blue.  During the MBS, if aspiration was observed, the respiratory therapist would suction the patient to identify if blue dye was present in their tracheal secretions.  The respiratory therapist also suctioned the patients at the termination of the study.  Two SLPs reviewed the MBS exams and identified the quantity of aspiration for the exam as either trace or greater than trace.  The investigators then compared the results of the MBS exams and the MEBDTs.
Aspiration occurred in 8/20 of the exams, however, suctioning after the aspiration event only identified aspiration in 4/20 exams.  Of those exams that were determined to have greater than trace amounts of aspiration, tracheal suctioning identified the aspiration in 100% of patients.  Of those exams which showed only trace amounts of aspiration, tracheal suctioning identified the aspiration in 0% of patients.  There were no charts or graphs in this study, so I made my own because I am a visual learner:

mebdt chart

In this study, the Modified Evans Blue Dye Test was shown to have a false-negative error rate of 50% in cases of observed aspiration on MBS.  Donzelli and colleagues replicated this study in 2001using FEES and found the exact same 50% false-negative error rate and only a 67% identification of aspiration in patients with large amounts of aspiration.
These are grim statistics.  Ultimately what we can take from this information is that the MEBDT is not sensitive enough to identify all aspiration events, especially when only trace amounts of aspiration occur.  This means that for every two MEBDTs performed that do not identify aspiration, one of the patients likely could be aspirating.  That is a gamble – a huge gamble – and a gamble that I don’t want to take with my patients.
So what can a MEBDT be used for?  It can be used as a screening device to positively identify aspiration.  That’s it.  If a test is performed and aspiration is identified, you can be pretty darn sure that aspiration is occurring.
Failure to consistently identify aspiration isn’t the only negative to the MEBDT.  Last time I checked, aspiration wasn’t the only indicator of dysphagia.  The MEBDT doesn’t identify penetration or significant residue- both of which constitute dysphagia.  It doesn’t identify the quantity and consistencies of penetration, aspiration or residue nor does it identify the actual physiological impairments that are causing the dysphagia or give us indications on how to treat them.
So how do we identify if a patient with a tracheostomy has dysphagia?  I think you know my answer…
This is the only way to objectively identify aspiration in a patient with a trach or without one.  Both MBS and FEES have generally good reliability, sensitivity and specificity.  They both will identify on which consistencies penetration, aspiration or residue occur, and they both will provide insight on the physiological deficits causing the dysphagia.
Don’t gamble with aspiration.  Get an instrumental exam and know for sure.

Works cited:

Donzelli J, Brady S, Wesling M, Craney M. Simultaneous modified Evans blue dye procedure and video nasal endoscopic evaluation of the swallow. 2001.  Laryngoscope;111:1746 –1750.

Peruzzi WT, Logemann JA, Currie D, Moen SG. 2001. Assessment of aspiration in patients with tracheostomies: comparison of the bedside colored dye assessment with videofluoroscopic examination. Respir Care 46:243–247.

Thompson-Henry, S., & Braddock, B. 1995. The modified Evan’s blue dye procedure fails to detect aspiration in tracheostomized patient: Five case reports. Dysphagia,10, 172–174.

O’Neil-Pirozzi TM, Lisieeki DJ, Monsek J, Connors JJ, Milliner MP. 2003. Simultaneous modified barium swallow and blue dye tests: a determination of the accuracy of blue dye test aspiration findings. Dysphagia;18:32-8.


Kelley Babcock, MS, CCC-SLP, BCS-S, is a voice and swallowing therapist from Nashville, Tennessee.  She works as a clinician and educator for SA Swallowing Services which provides basic, advanced and custom FEES courses for SLPs across the country.  For more information on FEES and dysphagia, check out or connect with Kelley on Twitter or LinkedIn.

Photo credit flikr for creative commons

Dysphagia FEES Professional Issues Research

October Research Tuesday

Ode to the Bean Counter: The Price of Dysphagia
In every medical facility there is always a bean counter, and in most, more than one.  They are the people who deny your ten thousandth request for a new Hausted chair for modified barium swallow studies because the old one “works just fine,” even when it doesn’t.  They are the folks who won’t purchase prethickened liquids because dietary can mix it up from powder, even though cups of glue keep showing up on patient trays.  And they are the ones who don’t understand why you need an instrumental exam to determine a patient’s diet status – no one has ever needed one before you came along.  So we, the ever faithful army of passionate dysphagia professionals, start collecting our own special data – we document the delayed or impossible studies, present facts about our patient’s hydration status and outline how the changes we are begging for will improve the quality of care we provide.  I’m not sure about you, but this kind of research was not covered in my graduate program…
Having been the one addressing the bean counters on many of occasions, I get waaay too excited when I find an article like this – one that speaks the bean counter’s language.  Dollars and cents!  Complex statistical analyses!  Facts and figures!  Historically speech pathologists haven’t spent a lot of time researching cost/benefit analyses and the impact on our services to hospitals, but in the last few months I have seen some promising studies coming out on this very topic (here’s looking at you, London Health Sciences Center in Ontario, Canada and the University of South Carolina).  With the changing landscape of healthcare and insurance, justification of our services will become even more crucial.  This article, which comes from our ENT colleagues at Mount Sinai School of Medicine and New York Eye & Ear, is just a small snapshot of the incidence and financial impact of dysphagia, but the information it provides could be invaluable to you the next time you have to email your bean counter.  Enjoy!
Altman KW, Yu GP, Schaefer SD. 2010. Consequence of dysphagia in the hospitalized patient: impact on prognosis and hospital resources. Archives of Otolaryngology Head Neck Surgery 136(8):784-9. Full Text Here
This study looked at the National Hospital Discharge Survey (NHDS) data from 2005-2006 to identify the incidence of dysphagia and its most common comorbid medical diagnoses as well as to further quantify the length of stay, morbidity and mortality of dysphagia.
To obtain their data, the investigators searched for the dysphagia ICD-9 code (ICD-9-CM 787.2) in the first 7 diagnosis codes of each patient abstract from the 2005-2006 NHDS data (the NHDS lists the most important diagnoses first).  They then searched for dysphagia symptoms and other major accompanying disorders listed in the first 7 diagnoses.  There were 20 major diseases identified as most frequently occurring with dysphagia.  Using some very fancy software and complex statistical analysis, the authors found the mortality rates as well as the standard errors, confidence intervals and rate ratios of the disease and mortality rates among patients with and without dysphagia.
During the years 2005-2006, there were over 77 million estimated hospital admissions and 271,983 of these were associated with dysphagia (.35% of all hospital admissions).  See the chart below for further details regarding rate of dysphagia by sex, age and race.

oct data

The authors note that the most significant findings from the demographic section of the investigation were that the percent of hospitalizations increase with age and that those with dysphagia older than 75 had twice the national average of hospital admissions than the average of all other groups.
When the authors looked at major diseases and symptoms associated with dysphagia, they noted that half of the admissions had at least one comorbid diagnosis of fluid & electrolyte disorder, disease of the esophagus, ischemic stroke, or aspiration pneumonia.  Those patients who had a diagnosis of dysphagia had an increased number of diagnoses at discharge compared to those without dysphagia – 88.9% vs 57.7% with 5 or more comorbid diagnoses, respectively.
The mortality rate of patients with dysphagia undergoing rehabilitation and those with coronary atherosclerosis was significantly elevated compared to those who did not have dysphagia.
The most notable (and bean-counter important) part of the study looked at the median number of hospital days for diseases associated with dysphagia compared to those not associated with dysphagia.  They found that the median number of hospitalization days for patients without dysphagia was 2.4 days compared to 4.04 days for those with dysphagia – that’s a 40.6% increase!!!!  Hospital stay was increased by 30% or more for patients with congestive heart failure, Parkinson disease and ischemic stroke and for patients with hemorrhagic stroke, the median hospital stay increased to 10.55 days.
To summarize their findings the author noted these three important take-aways:
  1. age older than 75 years was associated with double the risk of dysphagia associated with hospitalization
  2. the presence of dysphagia was associated with a 40% increase in length of hospital stay in all age groups
  3. patients undergoing rehabilitation had a greater than 13-fold increased risk of mortality during their hospitalization when they had dysphagia.
The aim of the study was to find statistically significant associations of variables.  The authors concede that cause and effect relationships cannot be determined from this type of data, but that important conclusions can be made.
The investigators then presented more data supporting the additional costs and the likely underestimated number of patients diagnosed with dysphagia. One of the figures was an established formula that was created to determine the actual increased cost for a one-day stay with community-acquired pneumonia.  The total daily cost was found to be $2,454 which they believe is less than the actual daily cost of a patient with dysphagia/aspiration pneumonia (alternative means of nutrition/hydration, additional diagnostic testing and more care from more providers would raise the price). They extrapolate the additional number of hospitalization days per year and the estimated additional cost per year of the extra days of hospitalization to yield an economic burden of approximately $547,307,964.
Whew.  That was a lot of math, but it is important math that helps us help the bean counters understand why we are fighting so hard to help people with dysphagia.
As a speech pathologist I most often enjoy looking at the little picture – helping the individual patient get better and eat.  While that is my mission and the joy of my heart, I must remember that the bean counter’s mission is to look at the big picture – to make sure that the hospital has enough money to stay open.  The authors conclude that the best ways to save money in dysphagia care are to identify the dysphagia early, especially in those patients with high-risk comorbid conditions such as old age, stroke, neurodegenerative disease, and pneumonia, and to provide proper intervention including evaluation, treatment and diet modification.  So, armed with all of your data, documentation, and published research, let’s work with those bean counters to get patients properly (and objectively) evaluated and treated to help improve both the big and little picture.

Kelley Babcock, MS, CCC-SLP, BCS-S, is a voice and swallowing therapist from Nashville, Tennessee.  She works as a clinician and educator for SA Swallowing Services which provides basic, advanced and custom FEES courses for SLPs across the country.  For more information on FEES and dysphagia, check out or connect with Kelley on Twitter or LinkedIn.

Photo credit flikr for creative commons

Dysphagia Research

September Research Tuesday

Which Came First – the Dysphagia or the PEG?
Early in my career as a speech-language pathologist, a close family friend was diagnosed with tonsillar cancer.  The cancer was caught early and the prescribed treatment was surgical removal of the tumor as well as radiation treatment of the area.  It was a tough diagnosis for him and his family, but I, as the all-knowing swallowing therapist, was there to sweep in to offer my opinions and recommendations.  He was receiving no management from an SLP, so I provided him with prophylactic swallowing exercises and encouraged him to talk to his physician about a feeding tube to be there as a support if swallowing became too difficult for him.  His physician offered him a feeding tube, but, as the strong Southern gentleman that he was and still is, he declined.  I, frankly, was annoyed.  He didn’t listen to my opinion.  He declined something that I thought would really help him through this battle.  I was baffled.
It is amazing how much I have learned in my career from people who declined the well-researched, thoughtful, and loudly provided advice I have given them.  Though swallowing during the treatment became very difficult for him, he did manage to go through the entire treatment and recovery without using a feeding tube.  He drank a lot of milkshakes, but now, many years out from his cancer, he is regaining weight and eating most anything he wants.
Since that time I have worked in a comprehensive head and neck (H&N) cancer clinic and had the opportunity to walk through the chemo/radiation process with hundreds of patients.  I was lucky to be a part of a clinic that provided SLP services to patients throughout their treatment and that encouraged patients to remain eating as much as they could until it became unsafe to do so.  This article came out while I was working in the H&N cancer clinic and I have passed it on to many therapists who have asked me about PEG tubes during H&N treatment.  It poses an interesting question about PEG tubes during treatment: does the use of the PEG and the decreased use of swallowing muscles actually contribute to the swallowing dysfunction during H&N cancer treatment?
Langmore S, Krisciunas GP, Miloro KV, et al. Does PEG Use Cause Dysphagia in Head and Neck Cancer Patients? Dysphagia. 2012;27:251-259.  Full text here
This retrospective study from Dr. Langmore’s lab  looked at weight and diet outcome differences in patients treated with radiation for H&N cancer who used a PEG tube versus those who did not use a PEG tube.  They also looked at differences between those who maintained a full PO diet, those who had some PO intake and those who were NPO.  Outcomes were reviewed after completion of radiation treatment and at 3, 6, and 12 months post-treatment.
The article begins with a brief review of the use of feeding tubes in management of dysphagia in head and neck cancer.  There are two common approaches to PEG use in H&N cancer: prophylactic placement, where the PEG is placed prior to treatment in preparation for dysphagia to come, and therapeutic placement, where the PEG is placed after a diagnosed dysphagia or significant weight loss occurs.  The authors acknowledge the lack of evidence supporting and refuting both PEG placement options and note that the decision is facility-dependent.  A literature review looking for studies about the topic yielded very little and those studies that were found rarely looked at swallowing outcomes on instrumental exams (FEES, MBSS).  Studies looking at weight loss found variable outcomes between the prophylactic PEG, therapeutic PEG and total oral intake.  Two studies (Chen et al., 2010 & Morton et al., 2009) found that a greater number of patients given PEGs had dysphagia at 3-12 months post-treatment compared to those who were not given PEGs.  These were two of the first studies that identified PEG tube placement as potentially detrimental to swallowing.
To identify subjects for the study, the authors completed a chart review of eligible H&N cancer patients looking at their weight, diet level, and PEG status at start of radiation,  completion of radiation and 3, 6, and 12 months post-radiation.  As instrumental swallowing evaluations were not available for most patients, the two major indicators for swallowing function were percent weight loss and diet level.  Diet levels were ranked from 1-6 based on the chart below.

sept diet levels

Fifty-nine patients with different cancer types and at different disease stages were selected. Some did and some did not receive surgical and/or chemo treatment. Twenty-seven patients received prophylactic PEGs, 6 received therapeutic PEGS and 26 did not receive PEGs.
Two analyses were completed with the first comparing prophylactic PEG with no/therapeutic PEGS.   No significant differences were found in percent weight change between the two groups, but the prophylactic PEG groups had significantly worse diet outcomes than than the no/therapeutic PEG group.
The second analysis compared patients with 100% PEG, partial PEG/partial oral diet, and 100% oral diet.  No statistically significant differences in percent weight change between the groups was found, but the partial PEG/partial oral and the 100% oral group had significantly higher mean diet scores than the 100% PEG group.  See the chart below for the data on diet scores. (click on the photo to make it larger)

sept diet outcome

Both analyses showed no significant weight loss differences between the groups, but they did show that those who had some or full oral intake had improved diet levels up to one year post radiation treatment.  In the chart above, you can see that the 12 month mean diet scores for the 100% oral diet & partial PEG groups were puree/wet soft or above, whereas the PEG group were almost all still on the PEG.  That’s some pretty good data for those wanting to maintain PO intake during treatment.
The implications for patients with H&N cancer receiving radiation are twofold:
1. we “should reconsider recommending prophylactic PEG placements in patients who are likely to depend entirely on the PEG for nutrition unless it is absolutely necessary” and
2. “when a patient is given a PEG, this study suggests that they should be strongly encouraged to continue to swallow something orally on a regular basis”
While this is a small study, the implications are big.  This study encourages us to help patients maintain PO intake as long as possible before, during and after radiation.  Our role as swallowing therapists now becomes a coach through the treatment, helping patients maintain what musculature they have and prevent loss of strength & coordination.  Because of the individualized nature of H&N cancer treatment, each patient will experience different swallowing impairments which may change throughout the course of their treatment and recovery. We want our patients to be as safe as possible during meal times, so determining whether patients NEED alternative means of nutrition/hydration is still very important – this is where our instrumental evaluations of swallowing are invaluable.  Instrumental evaluations allow us to determine what foods a patient can tolerate safely and if any compensatory strategies might help a patient. I was amazed at how many patients with H&N cancer were profoundly helped by simple strategies. Some went from not eating any solids to taking soft solids with a head turn, or went from aspirating all thin liquids to taking thin liquids with a supraglottic swallow.  Working closely with patients to customize therapy and swallowing strategies will help not only prevent the PEG, but help patients maintain swallowing strength as they recover.
So when working with your H&N cancer patients, here are a few things you can do to help them through their treatment:
  1. Prepare patients for the possible dysphagia that could come, encourage swallowing & if you are able, teach prophylactic swallowing exercises (see Hutcheson et al., 2013 for more details on this)
  2. Teach patients to identify signs/symptoms of dysphagia
  3. Teach patients how to prevent pneumonia (ORAL CARE!)
  4. Evaluate patients to find out what they can eat to help them to continue eating as much as they can!

Works cited:

Chen AM, Li B, Lau DH, Farwell DG, Lu Q, Stuart K, et al. Evaluating the role of prophylactic gastrostomy tube placement prior to definitive chemoradiotherapy for head and neck cancer. Int J Radiat Oncol Biol Phys. 2010;78(4):1026–32.

Morton RP, Crowder VL, Mawdsley R, Ong E, Izzard M. Elective gastrostomy, nutritional status and quality of life in advanced head and neck cancer patients receiving chemoradiotherapy. ANZ J Surg. 2009;79(10):713–8.

Hutcheson KA; Bhayani MK; Beadle BM; Gold KA; Shinn EH; Lai SY; Lewin J.  Eat and exercise during radiotherapy or chemoradiotherapy for pharyngeal cancers: Use it or lose it.  JAMA Otolaryngology – Head and Neck Surgery. 2013;139(11):1127-1134.

Kelley Babcock, MS, CCC-SLP, BCS-S, is a voice and swallowing therapist from Nashville, Tennessee.  She works as a clinician and educator for SA Swallowing Services which provides basic, advanced and custom FEES courses for SLPs across the country.  For more information on FEES and dysphagia, check out or connect with Kelley on Twitter or LinkedIn.

Photo Credit: Unsplash

Dysphagia Research

August Research Tuesday

Is Thicker Better for Dysphagia Treatment?
We have all seen the sad, mostly full cups sitting on tables from hospitals to nursing homes to home health.   I have even had patients tell me that they would rather dehydrate themselves and die than drink it.  Honey.  I hate honey.  I don’t put it in my tea, and I find it a huge pain to cook or bake with it.  Most of all, I really hate it when patients are subjected to “drink” honey-thickened liquids.  I mean, really, as Dr. Ashford asks us all the time, what naturally occurring liquid is honey-thick?!?  Umm…honey?
I have found over the last few years many SLPs have started to shy away from it, but, in 2005 Garcia et al. (1), found that 18.5% of SLPs still used honey-thickened liquid as their most commonly prescribed liquid modification (yes, over nectar-thick). Thankfully, this month’s Research Tuesday article gives us some evidence to avoid the goop.
But first, here’s a little history. A lot of the press on honey-thickened liquids came about in 2008 when  2 large, multi-institutional studies on the compensatory strategies of thickening liquids and chin tuck were published.  The first study from Dr. Logemann’s lab (2) involved 742 patients with Parkinson Disease.  One finding (of many) was that aspiration was most successfully eliminated with honey-thickened liquid, compared to nectar-thickened liquids and chin tuck.  The second study from Dr. Robbins’ lab (3) found that of those patients who aspirated despite all three trialed interventions (nectar-thick, honey-thick, and chin tuck), honey-thickened liquids resulted in “more than a two-fold pneumonia risk after adjustment of risk factors.”
So the frustrating paradox of honey-thickened liquids presenting from these studies is that a patient is less likely to aspirate on honey-thickened liquids, but more likely to develop pneumonia from aspirating honey-thickened liquids.
Want to prevent aspiration?  Make it thick.
Want a patient to develop pneumonia?  Make it thick.
NOOOOOOOOOOOOOO.  My head can’t handle that!
The Robbins study and many other studies in the nutrition literature also note that dehydration is more common with thicker liquids than thin.  Its not that thickened liquids are less hydrating, per say, but patients refuse it more often – hence our sad, mostly full cups.  Unfortunately, we so often find that thickening liquids requires less training and oversight – they are easier for us, family and nursing to implement.  But is thicker really better for our patients?
Leder, S., Judson, B., Sliwinski, E., Madson, L. (2013). Promoting Safe Swallowing When Puree is Swallowed Without Aspiration but Thin Liquid is Aspirated: Nectar is Enough. Dysphagia 28: 58-62. (Full text here)
This prospective study from Dr. Leder’s lab at Yale sought to determine the most appropriate liquid recommendations for patients who aspirated on thin liquids but not on puree.  Each of the 84 patients who met the inclusion criteria (aspirated on thins but not puree, stable medical condition) were evaluated with FEES.  The evaluation consisted of 3 trials of puree followed by 1-3 trials of thin liquid, on which at least one aspiration event must occur, followed by 3 boluses each of nectar-thickened and honey-thickened liquid, presented in random order.  A safe swallow was defined as no aspiration on nectar, honey or puree.  Patients were then placed on diets containing both nectar-thickened and honey-thickened liquids and nursing was asked to monitor patients for signs/symptoms of aspiration during meals for 24 hours.  Diets were considered a success if the patient did not have increased cough, increased temperature, or signs/symptoms of an upper respiratory infection for the next 24 hours.
Of the 84 participants, 100% showed no signs/symptoms of aspiration on either the nectar or honey-thickened liquids on FEES or on the diets in the following 24 hours.  See the chart below.
results august
From this data the authors concluded that nectar IS enough (emphasis mine):
“All participants who swallowed pureed food without aspiration but exhibited aspiration with thin liquid ingested both nectar-like and honey-like thickened liquid consistencies with 100% success at the time of testing and 24 h after testing. Therefore, in a specific subset of dysphagic patients who swallowed puree without aspiration but aspirated thin liquid, the data indicate that there does not appear to be a need to either test with or recommend a diet containing honey-like thickened liquid, i.e., nectar is enough. Importantly, the widespread practice-based intervention of using a thickened liquid (in the present case, nectar-like consistency) to improve patient care has been supported by empirical, research-based evidence.”
I LOVE the results, but I’m not going to lie, I really wish there were long-term outcomes as well as the 24 hour results.  Oh well.  Not every research study is designed to please my curiosity, and in medicine we very rarely get long-term data like the Robbins study.
I also thought this statement tucked into the introduction was incredibly profound:
“Although clinically intuitive, compensatory diet modification using either nectar-like or honey-like thickened liquids needs to be hypothesis-driven, accepted by the patient, and shown to be beneficial prior to their implementation in patient care.”
Clinicians should set these criteria as a standard and ask themselves the following questions prior to writing any recommendations for diet modification.
Is my recommendation:
  1. Hypothesis-driven?
  2. Accepted by the patient?
  3. Shown to be beneficial prior to implementation?
If the clinician cannot answer those three things in the affirmative, then they are subjecting a patient to a diet that may not be required or beneficial.  These questions also highlight the importance of both accepting patient autonomy in decision making (see my June Research Tuesday on this topic) and having an instrumental evaluation to prove that the diet modification is actually beneficial.  At SASS we are so privileged to provide clinicians with this objective information via FEES evaluations at their facilities.  If you as a clinician do not currently have any access to instrumental evaluations for patients, consider speaking with you DON or rehab director to see if a mobile company could provide these services for you.  It will profoundly impact your practice and your patient’s quality of life.
As for the goop?  At SASS we almost never test it and almost never recommend it.  I can’t actually remember the last time I recommended honey-thickened liquids.  In my humble opinion, if the patient is not safe on nectar, then there really isn’t a safe liquid for them to ingest.  It may be easier to recommend making the liquid super thick so that the patient does not have a chance of aspirating, but we have to remember that part of our job is ensuring the patient’s quality of life – this includes proper hydration and mealtime pleasure – and drinking glue just doesn’t do that.

1. Garcia, J., Chambers, E., Molander, M. (2005) Thickened Liquids: Practice Patterns of Speech-Language Pathologists. American Journal of Speech-Language Pathology. Vol. 14.

2. Logemann JA, Gensler G, Robbins J. (2008). A randomized study of three interventions for aspiration of thin liquids in dementia or Parkinson’s disease. J Speech Lang Hear Res. 51:173–83.

3. Robbins J, Gensler G, Hind J. (2008). Comparison of 2 interventions for liquid aspiration on pneumonia incidence: a randomized trial. Ann Intern Med. 148:509–18.

4. Logemann, J.  & Robbins, J. (2007). Landmark Clinical Trial in Swallowing Results Released : Study Tests Aspiration Risk and Related Health Outcomes. The ASHA Leader.

Kelley Babcock, MS, CCC-SLP, BCS-S, is a voice and swallowing therapist from Nashville, Tennessee.  She works as a clinician and educator for SA Swallowing Services which provides basic, advanced and custom FEES courses for SLPs across the country.  For more information on FEES and dysphagia, check out or connect with Kelley on Twitter or LinkedIn.

(Photo credit: Hillary Stein for Creative Commons)

Dysphagia Research

July Research Tuesday

The Most Important Aspiration Pneumonia Article…Ever
This month I am going old school.  Waaay old school.  I’m talking 1998 old school, which in the world of research is basically primitive and never encouraged by professors or important research-reading people. Oh well.  Sometimes we need to go back to the basics – to the seminal articles which help us understand why we do what we do, and that which has been shown time and again to be truth in our practice.  My trip to the past was motivated by my selection of this 2014 article as my original Research Tuesday post.  Its a lovely article showing how NPO status and presence of a NG tube were significant predictors of aspiration pneumonia in acute stroke management, but as I read it and attempted to write about it, I kept thinking about this beauty.  I had to share.  I couldn’t resist the antique, and I love that the shiny new article I was attempting to write about was another article that supported a lot of the information from this old faithful.  Whether its news to you or old hat, I hope you enjoy it!
Langmore SE, Terpenning MS, Schork A, Chen YL, Murray JT, Lopatin D, Loesche WJ. Predictors of Aspiration Pneumonia: How Important is Dysphagia? Dysphagia. 1998;13:69–81.
This prospective outcome study, brought to us by Dr. Langmore, Dr. Terpenning and a before-he-completed-his-PhD Joseph Murray, looked at a variety of possible predictors for aspiration pneumonia.  The authors followed 189 subjects for 4 years (!!!) to determine who got aspiration pneumonia and what predictive factors the patients had in common.  The subjects were all male and had a variety of medical diagnoses (CVA, neurologic disease, COPD) and were followed in acute care, nursing homes and as outpatients.  Each participant was given a clinical swallowing evaluation, a FEES, a MBSS, three scintigraphy exams to assess esophageal clearance and reflux, a dental exam, saliva & throat samples, a thorough chart review and an interview to gather pertinent information.  The exams and interview were repeated annually unless a status change occurred, and the patients were followed until death, an occurrence of pneumonia or till they failed to return.  A panel of physicians was established to create a consensus as to when pneumonia was present.  The features used to diagnose pneumonia were “elevated white blood cell count (12,000 or above); fever (temperature >100.5 F); and new infiltrate on the chest radiograph, with the most weight given to the radiographic evidence.”   Risk factors for aspiration pneumonia were identified in the following categories: functional status, medical/health status, oral/dental status, and swallowing/feeding status.  Here are some of the most interesting results from each category:
  1. Functional status: Dependence for feeding and oral care were associated with a high level of pneumonia.
  2. Medical/Health Status: The highest incidence of pneumonia was found in nursing home patients (44%).  Patients with COPD, GI disease, and CHF experienced pneumonia at a similarly high rate as those with neurological diagnoses, and patients with both COPD & GI disease had the highest rate of pneumonia (50%).
  3. Oral/Dental Status: Number of decayed teeth, frequency of brushing teeth, and dependence for oral care were significantly associated with pneumonia.
  4. Swallowing/Feeding Status: Aspiration of food was found to have a higher association with aspiration pneumonia than aspiration of liquids.  Pharyngeal delay, premature spillage, and excess pharyngeal residue were the physiologic swallowing parameters most linked with aspiration pneumonia. Aspiration of secretions and excess secretions in the mouth were both significantly associated with pneumonia in dentate subjects, as was reduced esophageal motility.  And of the upmost importance was this quote, one that we all shake our heads at in dismay and disbelief: “In our study, tube feeding was significantly associated with aspiration pneumonia, which is consistent with the findings of others [19,28,31–34,38,40]. Because our patients were usually not taking any food or liquid by mouth, aspiration presumably occurred with secretions.”
The authors found that the best predictors of pneumonia were:
  1. dependent for feeding
  2. dependent for oral care
  3. number of decayed teeth
  4. tube feeding
  5. more than one medical diagnosis
  6. number of medications
  7. smoking status
And then they created this awesome flow chart to show how all of the factors are linked to result in aspiration pneumonia. (click on the image to make it bigger)
predictors of pneu
WOW.  Just wow.  Its almost an entire dysphagia course in one single journal article.  I reference it at least once a week, and it is on my mind during every chart review and every evaluation I complete.  At SASS, we have taken this article to heart so much that our FEES report and oral mechanism templates cover almost all of those 7 predictors (we don’t actually sit down and count decayed teeth, but we do note oral condition). SLPs will never truly be able to identify every single patient who will get aspiration pneumonia, but with a good instrumental evaluation and these factors in mind, we can provide the patient and staff some good information as to their risk.
May I take a quick moment on my soap box?…Please?… How often do we harp about oral care only to get brushed off by family or the patient or nursing staff?  A lot.  This is the article to show directors of nursing everywhere when patients aren’t getting their teeth cleaned or are getting food administered too quickly.  Those dinky green spongy things and mouthwash don’t cut it.  Patients need friction and abrasion to get plaque off teeth and they need a toothbrush to do it.  If teeth aren’t present, gums should be brushed and dentures appropriately cleaned.  Bacteria lives in those places, too.  Dr. Ashford always says the best tools to combat pneumonia are a teaspoon, a toothbrush and a thermometer – use them! SASS has created an amazing oral care presentation designed for CNA inservices that should be available soon.  If you need help in this battle, please let us know!  Phew, ok, rant over.
There are many other articles out there that elaborate on the findings of this article in single studies (such as the one I started to write about for this post), but this one is so thorough and covers so much information about the multifactorial nature of aspiration pneumonia – it should be in everyone’s “dysphagia” file.  At the end, the authors note “ a major conclusion was that dysphagia and aspiration are necessary but not sufficient conditions for development of pneumonia.”  That is such an important take-away from this study.  There is no cookbook for dysphagia evaluation and treatment.  We have to lean on our training, experience, and articles like this one to help us best treat our patients. Never stop reading and never stop learning, and, occasionally, go back and look at some of these ancient artifacts of dysphagia research…there is much to gain from it!

Kelley Babcock, MS, CCC-SLP, BCS-S, is a voice and swallowing therapist from Nashville, Tennessee.  She works as a clinician and educator for SA Swallowing Services which provides basic, advanced and custom FEES courses for SLPs across the country.  For more information on FEES and dysphagia, check out or connect with Kelley on Twitter or LinkedIn.

Dysphagia Professional Issues

June Research Tuesday

This month’s Research Tuesday is devoted to ethics in the provision of speech pathology services.  We encourage you all to check out Gray Matter Therapy’s article roundup on Thursday to gain insights in ethics from all areas of speech pathology – from neonates to geriatrics.

His Right to Aspirate
When I saw it happen, I gasped.  His arytenoids didn’t approximate, his larynx didn’t elevate, there was no tell-tale “white out” of the swallow, the liquid just splattered into his trachea, joining the eggs that were apparently still there from breakfast.  He was my first FEES exam to meet bailout criteria (silent aspiration on 2 trials thin, nectar and puree) and I knew the only option was to recommend alternative means of nutrition and hydration.  I sat down with him and his family to discuss my plan.  The only safe option was a feeding tube, I told him. He looked me straight in the eye, shook his head and said “absolutely not.”  It wasn’t an option for him.  I’m sure at the time I got really flustered.  I probably turned red.  I left the room and tattled on him to the doctor hoping she could talk him into it.  He never got a feeding tube.  He died a few weeks later, and I never heard if it was an advancement of his cancer or from pneumonia or from some other medical malady.  He died.  I was sad.  I knew I had handled the situation poorly, but I was new and arrogant and had to move on with my patient list.  If only I knew how many more times I would be put in that same situation, offering good advice based on the best resources available, to be met with an unemotional “no.”  Maybe I would have worked harder to learn how to handle those kinds of situations better, and maybe I could have made my patient’s experiences (and possibly last few weeks of life) a little better.
Kaizer, F.,  Spiridigliozzi, A.M., Hunt, M.R.  2012.  Promoting Shared Decision-Making in Rehabilitation: Development of a Framework for Situations When Patients with Dysphagia Refuse Diet Modification Recommended by the Treating Team.  Dysphagia.  27:81–87. (Full text here)
This article comes from Dysphagia Journal and documents the creation of a diet modification refusal protocol in a hospital in Quebec.  The full article can be accessed in the link above.  It is short and well worth the read.  Though this protocol may not suit your practice or your hospital, the framework behind it can be used for creating your own protocols.
The article begins with clarifications of the ethical terms of autonomy, informed consent & beneficence.  I have provided the authors’ paragraph on autonomy below.  If you do not read anything else in this blog post, read this (emphasis is mine).
“Autonomy is typically understood as an individual’s right and ability to make choices and practice self-determination [15]. Respect for autonomy also places a negative duty on others not to interfere in the exercise of an individual’s autonomy without compelling reasons for such interference. In health care, autonomy is closely linked to the doctrine and practice of informed consent. Informed consent is a process by which a competent patient, or the duly identified surrogate decision-maker for an incompetent patient, is provided with the opportunity to receive relevant information regarding a medical decision, ask questions, weigh options, and enact decisions that are consistent with their goals and values, and free from coercion. In a range of circumstances, respecting a competent patient’s informed refusal of an offered treatment is consistent with the principle of autonomy.”
The authors from the Jewish Rehabilitation Hospital (JRH) in Laval, Quebec developed an interdisciplinary dysphagia team to ensure proper management of patients with dysphagia.  During team meetings, it was determined that a protocol should be developed for patient refusal of diet recommendations, and an outline was created.  They had experienced the same rejections as I had, what a relief!  The outline is below.
protocol for refusal
I found it interesting that during the development process the group considered and then rejected the “quick fix” of having the patient or family sign a waiver when refusing a diet – something that has been attempted at hospitals in the past to help reduce liability.  I’m not saying that these waivers are right or wrong, but that they do not solve the problem.  With the waivers the focus is placed on the SLP/hospital, not on the patient.  It is easy to have the patient/family sign a form, discharge the patient from services, and never think about them again…until they come back, usually worse off than when you left them.  The truly difficult thing is to continue to maintain your unconditional positive regard for your patient and to provide excellent education and services, if permitted.  At SA Swallowing Services, this is called “care-planning.”  This includes a process like the one above, involving patient, family and staff.  Out of the care plan meeting comes a written document specifying the patient’s diet refusal and that everyone is aware and on the same page.  Also note that waivers may not actually hold up in court.
Numerous times in my career I have been asked to “talk” a patient into a particular diet or feeding tube.  These requests usually come from a concerned family member or caring doctor, but unfortunately I have had to remind these individuals that coercion and manipulation are not part of an effective clinical skill set.  Education and counseling are, but when a competent patient makes a decision to refuse treatment we offer to them, we must respect their decision.  Just because we do not like their choice does not mean that it is wrong.
At the 2014 Dysphagia Research Society Meeting, Dr. Paula Leslie presented a beautiful lecture on ethical considerations in dysphagia management.  One point she made that has really stuck with me was the concept of “eminence-based practice.”   This idea is common in medical professionals and occurs when a clinician tells the patient to ‘do it because I say so and because I know what is best for you.’  This patriarchal assumption that the clinician “knows best” is outdated and is not best practice.  We should be communicating with patients to best develop plans centered around the patient’s goals, not our own.
The concept of patient autonomy was a huge challenge for me as a new clinician, but I hope that as I have gained years of experience under my belt, I have become better at respecting my patient’s right to make their own choices.  I have found that the burn of refusal never really goes away, but my reverence for my patients has grown, as has my realization that my clinical practice is not about me.  Its about them.

Kelley Babcock, MS, CCC-SLP, BCS-S, is a voice and swallowing therapist from Nashville, Tennessee.  She works as a clinician and educator for SA Swallowing Services which provides basic, advanced and custom FEES courses for SLPs across the country.  For more information on FEES and dysphagia, check out or connect with Kelley on Twitter or LinkedIn.

(Image courtesy of Stuart Miles /

Dysphagia FEES

April Research Tuesday

SA Swallowing Services is joining Gray Matter Therapy again for this month’s Research Tuesday!  Research Tuesday was created to “increase accountability for reading research, advocate for reading research, and improving exposure to research.” Every second Tuesday of each month, speech-language pathologists from all settings across the world join together at Gray Matter Therapy to share current literature reviews so that we may all benefit from the most up-to-date research.  This month, Kelley Babcock, M.S., CCC-SLP, BCS-S delves into the use of topical anesthetics in endoscopy.


 Comfortably Numb?  Does Anesthetic Impact FEES?  
A big debate in the world of flexible endoscopic evaluation of swallowing (FEES) is use of topical anesthetic to numb the nose prior to evaluation.  I have participated in FEES exams and trainings all over the country, and there are a variety of SLP practice preferences when it comes to anesthetic use.  Some SLPs believe that the procedure is too painful to tolerate without numbing,  some ask the patient if they prefer it, some believe that the evaluation is negatively impacted by the use of anesthetic, and some SLPs are not even allowed by their state laws to use it.  The 2004 ASHA Guidelines on the Role of the Speech-Language Pathologist in the Performance and Interpretation of Endoscopic Evaluation of Swallowing state that SLPs may use topical anesthetic alone or in combination with vasoconstrictors to allow for a more comfortable procedure (1). Each state has its own guidelines on who can administer anesthetics to patients, so always check your state rules prior to administration of any anesthetic.
Most ENTs use topical lidocaine spray when performing endoscopy, but numbing is by no means required to complete the evaluation.  I personally find the spray to be horrible in flavor and not very pleasant during administration, so when I am scoped in trainings and exhibitions, I choose to go without.  Butler and colleagues presented a paper at the 2012 Dysphagia Research Society Meeting in Toronto showing negative swallowing outcomes and increased Penetration/Aspiration Scale Scores after administration of 1cc of 4% lidocaine spray (2), so when I know a patient will be seen by the ENT before my FEES, I always ask the ENT not to spray the patient. Viscous lidocaine jelly, which is part of the original Langmore FEES protocol, is quite commonly applied by SLPs during their FEES.  This article took a closer look at swallowing outcomes, ease of exam performance, and patient comfort with the use of 2% lidocaine jelly on FEEST exams.
 Kamarunas, E.E., McCullough, G.H., Guidry, T.J., Mennemeier, M.,  Schluterman, K.  (2014). Effects of Topical Nasal Anesthetic on Fiberoptic Endoscopic Examination of Swallowing with Sensory Testing (FEESST).  Dysphagia.  29:33–43.  (Original article here: Effects of Topical Anesthetic 2014)
This article, which looks at the effect of 2% lidocaine jelly on flexible endoscopic evaluation of swallow with sensory testing (FEESST) outcomes is an excellent addition to the literature on anesthetic use.  Kamarunas and colleagues completed a prospective, double-blind, controlled, randomized, crossover study on healthy, nondysphagic adults who underwent a FEESST exam with .4mL of 2% lidocaine jelly and again with a placebo lubricant.  Though they are not frequently performed in clinic settings anymore, the FEESST exam was chosen for this study as it contains the entire FEES exam as well as the sensory testing of the laryngeal adductor reflex (LAR).  The LAR is an involuntary closure of the vocal folds which occurs as a protective mechanism against aspiration (3).  It is stimulated either via a puff of air to the aryepiglottic folds, as in this study, or via touching the aryepiglottic folds with the tip of the scope.
The examination included a test of LAR as well as 3 trials each of 10mL & 20 mL of milk and 3 trials of one teaspoon of applesauce.  After the exam, each participant completed a comfort scale rating form and the examiner completed a form identifying the quality of the scope performed and the ease with which the scope was passed.
The physiologic aspects of the swallow studied were the LAR, bolus dwell time at the vallecula & pyriform sinuses, pharyngeal closure duration, pharyngeal residue scales, and penetration/aspiration scale scores.  The only physiologic aspect of the swallow which was found to have a significant difference between the sham and true anesthetic was the bolus dwell time at the vallecula and pyriform sinuses with 10mL of liquid.  The laryngeal adductor reflex was determined to be “normal” for both exams for all participants.  The presence of  lidocaine did not improve the participant’s ability to tolerate the sensory testing, nor did it improve patient comfort, ease of exam or the quality of the view.  The chart below shows the score differences between lidocaine and sham testing in patient comfort, ease of exam, and quality of view on a scale of 0-100.
april data
At SA Swallowing Services, we train clinicians to scope without any anesthetic.  We do not believe that it is required for an accurate exam, and this study shows that it does not significantly improve patient comfort, the ease of the scope or the quality of the view.  Because we train clinicians from all over the country, we do not want clinicians to leave our courses feeling dependent upon the use anesthetic to perform a good evaluation, as their state rules may not allow them to use it.  This study shows that if you have the luxury of access to 2% lidocaine jelly, your patients will not have significant swallowing impairment from its use, but they may not be any better from it either.  If you can scope both with and without anesthetic, you as the SLP can make the best judgement for each individual patient to perform the easiest and most comfortable exam. If you have further questions on endoscopy or would like to pursue basic or advanced training in performance of endoscopy, check out our CEU courses  or contact us at
1. ASHA Special Interest Division 13: Swallowing and Swallowing Disorders (Dysphagia) Committee on Endoscopic Evaluation of Swallowing Guidelines. (2004(. Role of the speech-language pathologist in the performance and interpretation of endoscopic evaluation of swallowing: guidelines. Accessed 1 April 2014.
2. Butler S, Lester S, Langmore S, Lintzenich C, Wright S. (March 2012). Effects of topical nasal anesthetic on flexible endoscopic evaluation of swallowing. 20th annual meeting of the Dysphagia Research Society Meeting, Toronto, ON, Canada.
3. Kamarunas, E.E., McCullough, G.H., Guidry, T.J., Mennemeier, M.,  Schluterman, K.  (2014). Effects of Topical Nasal Anesthetic on Fiberoptic Endoscopic Examination of Swallowing with Sensory Testing (FEESST).  Dysphagia.  29:33–43.


Kelley Babcock, MS, CCC-SLP, BCS-S, is a voice and swallowing therapist from Nashville, Tennessee.  She works as a clinician and educator for SA Swallowing Services which provides basic, advanced and custom FEES courses for SLPs across the country.  For more information on FEES and dysphagia, check out or connect with Kelley on Twitter or LinkedIn.

Dysphagia FEES

Everything You Ever Wanted to Know about FEES®

Gray Matter Therapy – a wonderful adult-based therapy blog – recently asked us to write an informational post on FEES for their dysphagia month.  Our post covered what you need to know to get started with FEES and to bring FEES to your facility.  We frequently get emails asking us questions about FEES training, cost/benefit of FEES and comparing FEES vs MBSS, so if you are thinking about FEES training, check out our post here:
Feel free to use our contact box or email us if you ever have any questions – we are always available to answer your questions!
Here’s a chart comparing FEES and MBSS from the post:
What stages of the swallow does it assess? Pharyngeal phase before & after swallow, but can make inferences about oral & esophageal phases Oral, pharyngeal, & cervical esophageal phases
Where can it be performed? Anywhere: clinic, hospital bedside, SNF, pt’s home Hospital radiology suite or mobile radiology van
What pts cannot have the exam? Pts with severe craniofacial trauma. For extremely combative pts, can test compliance by inserting a long Q-Tip at nare entrance Vent pts, severely obese pts, difficult/impossible to transport or position pts.
What are the best indications for the exam? Concern of aspiration of secretions, suspected laryngeal damage, questionable laryngeal sensation, positioning in fluoroscopy problematic, extremely severe dysphagia/concern about any amount of aspiration, fluoro not available, pt transport would put pt at risk or is too expensive, concern about radiation exposure (especially with kids) Need to assess oral stage, need to asses structural movements or submucousal anatomy not visible on FEES (CP opening, cervical osteophytes), suspected esophageal etiology, vague symptoms, no known medical problem, complaint of food “sticking” in throat
What are the limitations of the exam? Cannot see the exact moment during the swallow – a whiteout period occurs.  Therefore must make inferences about this based on what is seen immediately before & after.  Cannot view oral or esophageal stages. To reduce radiation exposure, fluoro is turned on & off throughout the exam and SLP may miss what happens when fluoro is off.  Cannot always test to fatigue due to radiation exposure.  Cannot view laryngeal surface anatomy.  Changes in food consistency secondary to addition of barium.
Bonus material Can assess velopharyngeal closure. Can be used as a biofeedback tool. Can complete an assessment of esophagus.