Learning FEES

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 with documented specialty training in FEES.

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 supports this position.  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 physical functions, or physics and biomechanics, of swallowing. It is not a medical diagnostic procedure.  It is  primarily an SLP procedure, but in some countries FEES 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 (C ) with standard audio recording capability, and (d) a video capture device with software 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) most do not have audio recording capability, and (c ) many do have very limited post-processing capabilities. Vendors promise improved changes that are only coming slowly. 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.