Learning FEES and What You Need to Know

You may be considering learning FEES to enhance your clinical skills and practice. Here are some things to consider beforehand.

1. What is FEES?

Flexible Endoscopic Evaluation of Swallowing.  A predetermined and standard clinical procedure to stress the pharyngeal swallow mechanism to assess peristaltic efficiency and airway protective safety before, during, and after a swallowing event.  FEES, a highly specialized, complex, and advanced assessment procedure (<10% endoscopy; >90% FEES administration, analysis, interpretation, and report writing), requires advanced training for SLPs in the field of Swallowing and Swallowing Disorders.

2. What FEES is not?

FEES is NOT a basic or entry-level professional procedure and requires skill building and experience over time to be effectively used clinically. FEES is NOT inserting (or “passing”) the flexible endoscope into a patient’s nose and pharynx.  That procedure is called “nasoendoscopy.” It uses a small flashlight with a small camera on the end of an adjustable pole to visually examine the nasal passage, nasopharynx, oropharynx, and hypopharynx for disease and abnormalities by an otolaryngologist. However, for the SLP, the nasoendoscope provides visual observation capabilities to monitor and video record the actual administration of the FEES protocol and procedure, and the biomechanical functions of the pharynx and larynx mechanisms as they relate to swallowing.

3. Who can administer FEES?

Certified Speech-Language Pathologists in the United States, usually administer the FEES procedure.

4.  FEES is complex and advanced

Learning FEES requires training from a well-organized formal course, usually over 15 hours, covering anatomy, physiology, medical issues, equipment, infection control requirements, endoscope handling, FEES protocol and procedures, FEES analysis scoring, and FEES analyses and applications.  Hands-on, consistent, and concentrated training by an experienced and competent SLP instructor during the training course produces the best training results. On-the-job training rarely prepares the training SLP adequately.  Formal training courses should also actively teach scoring and analysis procedures with supervised practice exercises.

Beyond basic FEES instruction and beginning proficiency training, FEES competency requires additional supervised training. To ensure safety, efficiency, and completeness, all supervised procedures (not passes) must be critiqued and repeated, as needed. This may be 5 or 50 supervised procedures. Obtaining the “magical” 25 “passes” does not equate to FEES proficiency or competency. Twenty-five “passes” mean nothing by themselves!! Competency means satisfactorily demonstrating an independent proficiency, as judged by a competent supervisor, in every aspect of FEES assessment–scope handling, FEES procedure administration using a predetermined protocol, management of study and patient problems, equipment use and infection control procedures, video/audio capturing a good study, analyzing all of the results, interpreting the biomechanical components, and finally writing a concise and informative report reflecting the science of the swallowing study. No specific number of procedures defines competency.

5. FEES versus MBSS

FEES is not better than MBSS and MBSS is not better than FEES and clinical research supported.  Consider CT and MRI in Radiology.  In reality, both have individual strengths and weaknesses. However, when used together, they help make better clinical decisions. So goes FEES and MBSS.

6. Otolaryngology and FEES

FEES is not an otolaryngological procedure.  FEES assesses the functionality of swallowing and primarily is an SLP procedure, but in some countries is conducted by an Otolaryngologist or Neurologist. When FEES is administered to a patient, an Otolaryngologist’s or any other physician’s presence is NOT required; only a proper order from a referring physician.

7. Equipment

FEES equipment is NOT Otolaryngology, Pulmonology, Gastroenterology equipment, or vocal assessment equipment. These medical specialties and the SLP all use an endoscope to accomplish specific but different clinical assessment tasks.  There the similarities cease. FEES equipment, unlike ENT equipment, must have (a) a nasoendoscope (preferably digital) with a bright (LED) white light source, (b) a video capture device such as a computer with standard audio recording capability, and (c) a video capture device with archive ability, playback, frame-by-frame forward and backward advance, stop-action, and still-frame capture. Sharing equipment with ENT never works.

Good-quality studies generally come from using a good, high-quality reusable nasoendoscope. Personal experience repeatably demonstrates disposable endoscope systems (not made for FEES, by the way) (a) do not provide the same image quality as reusable endoscopes, (b) do not have audio recording capability, and (c) have very limited post-processing capabilities. Vendors promise improved changes that never come. Poor quality equipment = poor study capturing = poor study analysis = poor report = poor patient care and reduced quality of life!

8. Three Levels of FEES Assessment
Level 1: Observation of Surface Consequences

Visual observations of multiple swallowing trials are recorded using a standard FEES administration protocol and the endoscope to evaluate the anatomy and physiology of the pharynx and larynx and the “surface” consequences of a just-completed swallow event.  “Surface” consequences may include a normal efficient and safe event, loss of bolus control, cavity residue, or entry of food material into the airway. They confirm the presence of “dysphagia” or not, but provide little else about the health of the swallow mechanism.  Here, a good background in anatomy-39 pairs of muscles, 5 cranial nerves, 3 cervical spinal nerves, 7 reflexes, and 26 biomechanical functions-is mandatory. Realistically, swallowing is the most complex biomechanical function in the human body, and you are tasked with fully assessing it.

Level 2: Quantification, scoring, and Analyses

Each functional variable of a swallow event is scored using various predetermined scoring tools. Some schemes are as simple as 0 (absent) or 1 (present); others may use 5 to 8-point nominal scales. SASS scores 13 different variables per trial. Therefore, with a standard 22 administered trials and over 286 data points, certain trends and patterns of surface consequences form.  A quantified “picture” of the patient’s swallow efficiency and safety becomes evident. Analysis of these patterns provides insight into the underlying biomechanics reasons for certain consequences.  Here, workable knowledge of muscles, nerves, physiology, and basic physics provides depth to the understanding of the problems. Later, subsequent study “pictures” easily relate to this initial study “picture” for comparisons-did the patient get better or not.

Level 3: Determining Severity and Intervention Directions

Defining the underlying causes of dysphagia comes from the analysis of information from Levels 1 and 2 and application to biomechanics. Further, applying the Level 2 results to a predetermined severity scale improves the final definition and completeness of the study. Neuromotor and/or compensatory intervention options become more evident and better supported. Ironically, findings may lead to abandoning unnecessary and unsubstantiated prestudy recommendations. Finally, an informed, informative, concise, and useful clinical report results.

9. SASS FEES Adage #1:

“If you did not see it, you can talk (or write) about it.”  Good endoscope handling skills produce good video-recorded evidence.  Clinical-guess “false-positive”: Inferring a possible consequence (i.e. residue in the left pharyngeal channel) without visual evidence to support it because the scope was not in position correctly. Instrumental studies do not allow for inferences.

10. SASS FEES Adage #2:

“If you did not test it, you cannot talk (or write) about it.” Following a predetermined FEES administration protocol ensures direction, completeness, consistency in testing, and reliability. Clinical-guess “false-positive”: Inferring a possible consequence may occur with a food consistency (i.e. aspiration on thin liquid consistency) without visual evidence to support its actual occurrence because the consistency was not tested. Instrumental studies do not allow for inference.

11. Go-to Reference Source

Langmore, S. E., Scarborough, D. R., Kelchner, L. N., Swigert, N. B., Murray, J., Reece, S., Cavanagh, T., Harrigan, L. C., Scheel, R., Gosa, M. M., & Rule, D. K. (2022). Tutorial on clinical practice for use of the Fiberoptic Endoscopic Evaluation of Swallowing Procedure with Adult Populations: Part 1. American Journal of Speech-Language Pathology, 31(1), 163–187. https://doi.org/10.1044/2021_AJSLP-20-00348

Further questions or comments about learning FEES? Contact SASS at john@sasspllc.com.

Written by John R. Ashford, Ph.D. on May 6, 2023.