FEES “Passes” versus “Procedures”

FEES “passes” versus “procedures” are different when training. “Passes” imply endoscope insertion. “Procedures” are insertion using a standard protocol. SASS is often asked how many “passes” a trainee will receive during our basic training course. “Passes” imply practicing endoscope insertion. “Procedures” are more technical including endoscope manipulation during a standard test protocol administration.  The number of training procedures with supervision is determined by individual state licensing boards, and not organizations, such as ASHA.  ASHA states there is no set number of procedures required for competency and will vary with each person being trained.  The number “25,” often reported as required, is meaningless.

FEES “passes” versus “procedures”

FEES Passes:  SASS considers this training approach inadequate for proper FEES training.

  1. Inserting the nasoendoscope into and through the nasal passage and into the pharynx
  2. View the pharynx and larynx
  3. Maybe ask the person to say “eee” to view vocal fold mobility
  4. Ask the person to swallow and view. Foods may be presented.
  5. Remove the nasoendoscope from the person’s nose


FEES Procedures: SASS-recommended FEES training regimen.

  1. Insert the tip of the nasoendoscope into the anterior nare and identify turbinates 2 and 3 and the larger meatus into which the scope will pass easier.
  2. Advance nasoendoscope and identify the posterior pharyngeal wall. Learn to ask the patient to say “eee” to check scope orientation with velum elevation at the 6 o’clock picture position.
  3. Advance the endoscope into the pharynx to “Position 1” or high examination position. Learn to adjust the endoscope so the vocal folds are in the middle of the picture with the base of the tongue and valleculae visible at the bottom of the frame, the lateral channels are visible on both sides and the Postcricoid space is visible at the top of the picture.
  4. Learn to methodically exam the “4-corners” of the pharynx for structural abnormalities. Learn to advance and rotate the endoscope deep into the piriform sinuses on both sides and then to move into position to closely examine the vallecular spaces. Then back to “Position 1.”
  5. Learn to examine the neurological integrity of vocal fold abduction and adduction as part of the pre-FEES procedure. Say “eee” “eee”
  6. Learn to administer a predetermined presentation protocol to be used with every patient every study every time. This includes announcing the trial amount, the consistency being administered, and the trial number. (The protocol is set up for 23 to 26 trials per study.)
  7. The trial is announced, test material presented, and the patient swallows. Quickly move from the high examination position (Position 1) into close examination position, or Position 2. Position 2 requires advancing the endoscope tip over the epiglottis and into the laryngeal vestibule, viewing the vocal fold’s anterior commissure and the proximal esophageal space below the vocal folds for test material.
  8. Quickly withdraw the endoscope back into Position 1 to record all of the pharyngeal cavities and residues. The study is only as good as its pictures.
  9. Wait to determine if a secondary cleansing swallow occurs and its effectiveness. View the results.
  10. Make picture adjustments and remain in Position 1 for the next training trial presentation.
  11. When the training trial is complete, remove the endoscope quickly.
  12. 15 graduated training trials, each requiring more steps and technical skills, are presented.