FEES “Passes” vs. “Procedures”
The concept that if an SLP can “pass" the endoscope through the nose into the pharynx, then they can do the FEES assessment procedure. This is far from clinical reality and not fully appreciated by SLPs wishing to learn the procedure.
“Passes” imply practicing endoscope insertion into the nasal passage and into the pharynx and coming out.
“Procedures” are more technical including endoscope insertion and manipulation while administering a standard FEES protocol.
Passing the endoscope through the nasal passage is a tricky, and sometimes uncomfortable, skill and accounts for <10% of the FEES procedure. The FEES procedure encompasses, not only inserting the endoscope into the nose successfully and comfortably, but also manipulating the endoscope after each of 20+ swallow trials to capture the best representation of the swallow event so you can talk about it later in your report and/or plan effective treatment. Learning from an ENT does not teach FEES.
Once in the pharynx, the FEES procedure involves administering a predetermined protocol of multiple trials of different consistencies in varied amounts and from different presentations (spoon, cup, straw). Capturing the best video representation of the individual swallowing events is paramount to being able to score, analyze, and interpret the findings (>90% of FEES). Simply learning to “pass” the scope through the nose does none of that.
Dr. Susan Langmore, the mother of FEES, recommends 25 “passes” but really she means 25 procedures under supervision to gain competency in performing the FEES procedure. FEES is a skilled, professional, medical procedure and requires good training from seasoned FEES SLPs. In our course, you will complete supervised 15 procedures, not passes, on normal volunteers. The other 10 should be on real patients with potential swallowing problems under mentor supervision.
There is nothing magical about obtaining 25 supervised “passes” or “procedures.” It is a random number suggested by Dr. Langmore. To be competent and feel confident, usually many more procedures are necessary. It is unfortunate that some state provisions have made “25” a required benchmark.
FEES “passes” versus “procedures”
FEES Passes: SASS considers this training approach inadequate for proper FEES training.
Inserting the nasoendoscope into and through the nasal passage and into the pharynx
View the pharynx and larynx
Maybe ask the person to say “eee” to view vocal fold mobility
Ask the person to swallow and view. Foods may be presented.
Remove the nasoendoscope from the person’s nose
FEES Procedures: SASS-recommended FEES training regimen.
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.
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.
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.
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.”
Learn to examine the neurological integrity of vocal fold abduction and adduction as part of the pre-FEES procedure. Say “eee” “eee”
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.)
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.
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.
Wait to determine if a secondary cleansing swallow occurs and its effectiveness. View the results.
Make picture adjustments and remain in Position 1 for the next training trial presentation.
When the training trial is complete, remove the endoscope quickly but gently.
15 graduated training trials, each requiring more steps and technical skills, are completed with supervision.