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Unfamiliar with FEES?  Below are some frequently asked questions (FEES FAQ) about this instrumental procedure for assessing oropharyngeal swallowing functions.

FEES or Fiberoptic Endoscopic Evaluation of Swallowing is an instrumental procedure to assess the FEES Scope in the nosesafety and efficiency of, primarily, the pharyngeal stage of swallowing.  Susan Langmore, Ph.D, developed this procedure in the 1980s as an alternative, or adjunct, to the videofluoroscopic swallow study. She, along with Olson and Schatz, published the first paper describing the procedure in 1988 (see references). This was only five years after the first publication on videofluoroscopy assessment of swallowing in 1983 by Dr. Jere Logemann. For the historical development of this procedure, read Dr. Langmore’s excellent 2017 paper, History of Fiberoptic Endoscopic Evaluation of Swallowing for Evaluation and Management of Pharyngeal Dysphagia: Changes over the Years, in the journal, Dysphagia.  As this paper and others point out, FEES has gained undeniable credentials as a reliable, valid and safe procedure for assessing oropharyngeal swallowing functions. This is particularly significant for patients who cannot be transported, such as those on ventilators, in isolation, in intensive care in hospitals, and for residents in nursing care facilities.  Today, FEES is considered a “gold standard” in the assessment of swallowing functions. Dr. Langmore published an excellent earlier review paper, found at the website: http://www.nature.com. In addition, well over 100 references to FEES and its use can be found on the Pubmed website (www.ncbi.nlm.nih.gov). Below is a brief synopsis of Dr. Langmore’s discussion of safety, validity, usefulness and efficacy of the FEES procedure.

If you have further questions, please contact SASS at info@sasspllc.com.

Is FEES a valid way to measure swallowing impairment?
How accurate and how sensitive is the FEES procedure for identifying abnormal swallowing events? The longstanding “gold standard” has been the videofluoroscopy swallow study (VFSS). There are at least nine studies listed at the www.nature.com source showing that FEES has very good sensitivity (>0.88) and specificity of 0.50 or greater when compared to the videofluoroscopy study. Further these studies have shown a high level of agreement, particularly for detecting aspiration. With years of experience administering and interpreting fluoroscopy swallow studies, the SLPs at SASS report that detection of aspiration and pharyngeal stasis using the FEES examination appears to be more sensitive than is appreciated with fluoroscopy. Quantitatively, the amounts and locations of food material left in the pharynx and larynx appear to be much greater than is seen on the VFSS. A recent study by Kelly (2007) substantiated this impression. They reported that penetration and aspiration were perceived to be greater (more severe) using FEES than those seen in fluoroscopic images.

“Gold standard” may not be totally accurate for either of the instrumental swallowing assessment studies. Both assessments are not 100% accurate due to many factors including the mediums themselves, clarity of images, time between swallows, clinician perception of event activities, etc. However, as indicated above, both instrumental studies are sensitive and valid. However, when both instrumental assessments are compared to the Clinical Dysphagia (Bedside) Examination, both instruments have far better sensitivity and specificity to detecting aspiration than does the very subjective bedside assessment (Smithard,et al.,1998; Leder & Espinosa, 2002). As Langmore states, both of the instrumental assessment tools “can rightfully be called the gold standard.”

What patients can benefit from FEES?
Concern initially arose over Speech-Language Pathologists (SLP) performing the FEES procedure. These concerns included allowing a non-emergency medically trained person (SLP) to perform an invasive procedure on another person and the use of topical anesthesia by a non-medically trained person. Subsequently, these issues have now been addressed and these concerns largely satisfied, particularly when FEES is performed in protected medical settings. Langmore cites four studies of the safety of FEES and found the rate of complications was less than 1%. In a recent study (Warnecke et al.,2009), FEES was found to be a safe and well-tolerated method of assessing swallowing function when performed by a Speech-Language Pathologist and Neurologist. A review of Pubmed listed 5 studies specially addressing the safety of the procedure, and its safe use by a trained SLP.

Langmore addresses the issue of SLPs missing medical pathologies, such as cancer, and stresses it is not the purpose of the FEES procedure to identify medical pathologies. SASS clinicians have over 46 years of combined experience, and it is the policy of SASS to report, and if possible, send still-photos of the suspect lesion separately to the nursing facility resident’s primary physician. Further, follow-up endoscopic evaluation by an Otolaryngologist is always recommended.

Reliability of FEES
There are few reliability studies on the FEES procedure and is an area ripe for research. A few studies have been reported and show fluoroscopic study and the FEES procedure have very similar reliability scores.
Efficacy of FEES
Studies of efficacy, like reliability, are lacking for both the videofluoroscopic study and the FEES procedure. Only one randomized outcome study has been reported. Aviv (2000) reported no significant difference in the abilities of the two instruments to guide treatment and prevent pneumonia in 126 outpatients with dysphagia.
Where can I find more research on FEES?

Langmore, S.E., Schatz, K, & Olsen, N. (1988). Fiberoptic Endoscopic Examination of Swallowing Safety: A new procedure. Dysphagia, 2, 216-219.

Langmore, S.E. (2017). History of Fiberoptic Endoscopic Evaluation of Swallowing for evaluation and management of pharyngeal dysphagia: Changes over the years. Dysphagia, 32, 27-38.

Aviv J.E. (2000). Prospective, randomized outcome study of endoscopy vs. modified barium swallow in patients with dysphagia. Laryngoscope, 100, 563–574.

Kelly, A.M. (2007). Assessing penetration and aspiration: How do videofluoroscopy and fiberoptic endoscopic evaluation of swallowing compare? The Laryngoscope, 117, 1723-1727.

Leder, S.B & Espinosa, J.F. (2002). Aspiration risk after acute stroke: Comparison of clinical examination and fiberoptic endoscopic evaluation of swallowing. Dysphagia, 17(3), 214-218.

Smithard, D.G., O’Neill, P.A., Park, C., et al. (1998). Can bedside assessment reliably exclude aspiration following acute stroke? Age and Ageing, 27i(2), 99-106.

Warnecke, t, Teismann, I, Oslenber,S. Hamacher, C, Ringelstein, E.B., Schabitz, W.R., & Dziewas, R (2009). The safety of fiberoptic endoscopic evaluation of swallowing in acute stroke patients.Retrieved July 18, 2009 from www.stroke.ahajournals.org.

Brady, S. & Donzelli, J (2013). The modified barium swallow and the functional endoscopic evaluation of swallowing. Otolaryngology Clinics of North America, 46(6), 1009-1022.