FiberopticEndoscopicEvaluation

ofSwallowing(FEES)
Carmin Bartow,M.S.CCCSLP,BCSS
GwenProvoBell,M.A.CCCSLP
JenniferCraig,M.S.CCCSLP

Outline
Carminwillreview:ASHApositionstatementandguidelines,
trainingprotocol,contraindications,rationale,equipment,
anatomyreview,examprocedure
Gwenwillreview:pediatricperspective,howtheSLP
can partnerwithENT,candidatesforFEES, VFSSvs.FEES, SLP
roleduringFEES,jointinterpretation,useofstrategiesduring
FEES.
Jennwillreview:endoscopy,tipstoimprovecompliance,and
willreviewstudies
Longwaytogo,shorttimetogetthere
(TheBanditetal,1977)

FEES Whatisit?

Aninstrumentalassessmentwhich
involvespassingaflexibleendoscope
transnasallytoobtainasuperiorview
ofthepharynxandlarynx
Evaluatesthestructure&functionof
theupperaerodigestivetractbothat
restandatwork
Enablesvisualizationofthebaseof
tongue,nasopharynx,hypopharynx,
andlarynx
Allowsforassessmentofsecretions
andsecretionmanagement

FEESOutcomes

Identificationofnormaland
abnormalanatomyandphysiology
oftheswallow
Evaluationoftheintegrityofairway
protectionasitrelatesto
swallowingfunction
Evaluationoftheeffectivenessof
compensatorytechniques
(postures,maneuvers,bolus
modifications)inimproving
swallowingsafetyandefficiency

ASHAPositionStatement
It is the official position of the American Speech-Language Hearing Association that
fiberoptic endoscopy is an imaging procedure that may be utilized by speechlanguage pathologists to evaluate swallowing function. Fiberoptic endoscopy may
also be utilized as a therapeutic aid and biofeedback tool during the course of
swallowing treatment. The assessment and management of dysphagia falls within
the scope of practice of speech-language pathology. Speech-language pathologists
with expertise in dysphagia and specialized training in fiberoptic endoscopy are
professionals qualified to use this procedure independently for the purpose of
assessing swallowing function and related functions of structures within the upper
aerodigestive tract. The procedure is not intended to replace the fiberoptic
examination performed by the otolaryngologist to assess the integrity of the
laryngeal and pharyngeal structures. Physicians use endoscopy for functional
evaluation of swallowing and/or to assess the integrity of the laryngeal and
pharyngeal structures in order to render a medical diagnosis. Within
interdisciplinary settings, these medical diagnoses and swallowing function
assessment procedures can be accomplished through the combined efforts of
these related professionals. Care should be taken to use this examination only in
settings where medical personnel are available to ensure patient safety.

ASHAguidelinesre:FEEStraining

SpeechlanguagepathologistsperformingFEESmustundergosufficienttrainingto
demonstratetheknowledgeandskillsneededtoperformandinterpretthe
procedure.Eachspeechlanguagepathologistisethicallyresponsibleforachieving
theappropriateleveloftrainingtoprovidetheseservicescompetently.Itis
recommendedthatinstitutionsdevelopawrittenlistofcompetenciesfor
performingFEESandthatanindividual'scompetenciesbeverifiedinwritingand
maintainedonfile.Insomeinstitutions,acredentialingorprivilegingprocessmay
berequired.Insomestates,theuseofendoscopymaybespecificallyaddressedby
thespeechlanguagepathologylicensurelaw.
AccordingtoASHA'sknowledgeandskillsdocumentreferencedabove,the
followingprocesswasrecommendedinordertoacquireskillinperformingFEES:
1)observation;2)practiceunderdirectsupervision;and3)independentpractice
withindirectsupervision.

SampleFEEStrainingprotocol

1215hoursclassroomtraining
Scope10normalssupervised
Perform15FEESsupervised
Perform50FEESinordertotrainothers
Documentationoftrainingmustberecorded,signed
andkeptinyourfile

Contraindications

Severeagitationandpossibleinabilitytocooperatewiththeexamination
Historyofvasovagalepisodes(suddendropinheartrateandblood
pressurewhichleadstoreducedbloodflowtothebraincausingabrief
lossofconsciousness)
Severemovementdisorders(dyskinesia)
Severebleedingdisordersand/orrecentsevereepistaxis(nosebleed)
Historyofrecenttraumatothenasalcavityorsurroundingtissueand
structuressecondarytosurgeryorinjury
Bilateralobstructionofthenasalpassages
Historyoffrequentfainting

RationaleforFEES
LimitedavailabilityforVFSSinsettingssuchnursinghomesorsmall
hospitalsandclinics
Poorreliabilityonbedsideevaluation:40%ofaspiratorsaremissed
SomepatientsarepoorlysuitedtoVFSS:obese,medicallyfragile,unable
totransporttoradiology,bodyhabitusdoesnotpermitadequateviewof
theairway
Noradiationexposure
SeveralstudiesshowedthatFEESisequaltoorevenbetterthan
videofluoroscopyindetectingaspirationandseverityofresidues
(Langmoreetal,1991,Lederetal,1998,Kellyetal,2007)

Basicequipment

Fiberopticendoscope
Lightsource
Camera
Videorecordingsystem
Monitor

Anatomyreview

Abducted VFs

Adducted VFs

Examprocedures
Applicationoftopicalanesthetic touseornottouse?

UsevariesfromSLPtoSLP,institutiontoinstitution
Canbeadministeredsuperficiallytonasalpassages
MusthaveMDorder
Typicallyuse2%viscouslidocaine
Somepatientsmayhaveanallergicreaction

Morethan80%reportednooronlymilddiscomfortduringFEESwithoutuseoftopical
anesthesiaoravasoconstrictor,.(Warneckeetal,2009)
Nochangecomfortscores,easeofexamorqualityofviewwithorwithouttopical
nasalanesthesia.(Kamarunas,etal2013)

Examprocedures
Passthescopetransnasally

Examprocedures
Structuralandfunctionalassessment
Checkthestructuralandfunctionalintegrityofbaseoftongue,velum,
pharynxandlarynx(lookaround)
Symmetry
Appearanceofthetissues
Lesions
Pooledsecretions
studieshaveshownpooledsecretionshaveahighcorrelationwithaspiration
risk(Murrayetal,1996)

Anyfoodresidue
VPclosure
Pharyngealwallmovement(falsetto)
Laryngealadduction/abduction(phonation,inhale/sniff,forcedbreath
hold,cough)

Examprocedures
Testswallows
Completedwithmaterialsthatarevisibleinthepharynx(someSLPsaddfood
coloringtofoods/liquids)
SelectionandsequentialpresentationofmaterialsissimilartothatoftheCSE
orVFSS
Duringeachswallowaperiodofwhiteout occursatthepointofmaximal
pharyngealconstriction
Aftertheswallowstructuresarevisibleandshouldbeassessedtellingthe
patientdontswallow asthepharynxandlarynxareinspected

Foodcoloringornot?
FiberopticEndoscopicEvaluationofSwallowing(FEES)with
andwithoutBlueDyedFood,Leder,etal,Dysphagia,2005:
157 162.
FEESmaintainsbothhighintra andinterraterreliabilityindetectingthe
criticalfeaturesofpharyngealdysphagiaandaspirationusingeitherbluedyed
ornonbluedyedfoods.Theendoscopist,therefore,canbeassuredofreliable
FEESresultsusingregular,nondyedfoodtrials

OR

SalientFindings
Spillagebeforetheswallow
Residueaftertheswallow
Valleculae
Pyriform sinuses
Pharyngealwall

Laryngealpenetration
Aspiration
Patientreactiontoresidue,penetrationor
aspiration
Impactofmaneuversandcompensations