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 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 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.