What is FEES?

Flexible Endoscopic Evaluation of Swallowing or FEES is an instrumental exam designed to assess a patient’s swallow. Using a small, flexible scope containing a light and camera, a specially skilled SLP passes the scope transnasally until the pharynx and larynx are in view. Through various tasks and as the patient consumes a variety of solids and liquids, the SLP evaluates anatomy/physiology including sensation, presence of aspiration, and effectiveness of compensatory strategies. These areas can NOT be fully assessed during a bedside swallowing exam. In addition, FEES is significantly less expensive than the cost of thickener per year: $2088-$3468 per patient, per year vs a few hundred dollars for a FEES. (O’Keeffe 2018. See Research Resources).


What are the indications for FEES?

Clinical bedside swallow exams are useful in developing a hypothesis regarding the nature of a person’s dysphagia, but they can NOT fully assess the pharyngeal phase of swallowing. An instrumental confirms or rejects that hypothesis while offering insight on pharyngeal function including timing, coordination, weakness, and sensation – the factors that lead to penetration, aspiration, and residue.

While many patients may equally benefit from either VFSS and FEES (and sometimes need both!), certain signs and symptoms present during the clinical bedside exam would indicate the need for a FEES over a VFSS.

  •  Assess secretion management, tissue integrity of the larynx, and surrounding structures
  • Assess fatigue or textures not viewable on VFSS
  • Assess for specific laryngeal and pharyngeal anatomical and sensory deficits contributing to dysphagia (e.g., paralysis, presence/absence of sensation)
  • Concurrent voice changes/dysphonia.
  • Pre- and/or post-op head and neck surgeries

Is FEES a reliable way to detect aspiration?

Multiple studies have shown FEES to be as accurate and with even better sensitivity and specificity than VFSS in detecting aspiration.  Visit our evidence based Research Resource page for specific article information.


How is aspiration diagnosed when the airway is obstructed from view during a swallow?

Instances of aspiration before and after the swallow can be viewed directly. During the swallow, a flash of white known as “white-out” related to the decreasing distance between pharyngeal tissue and the light source prevents aspiration from being viewed directly. However, evidence of aspiration during the swallow is indicated by material viewed below the true vocal cords immediately following the swallow or the brief “white out” period.


What information can FEES provide on the esophageal phase of swallow?

Presence of retro-flowing of material (from the esophagus to the pharynx) can be viewed during the FEES exam. The tissue integrity of the laryngeal structures including edema, redness, and presence of ulcerations may indicate concern for an esophageal issue. The opening of the upper esophageal sphincter (UES) may occasionally be directly viewed in instances of dysfunction or belching; however, the esophagus cannot be directly viewed. If the primary concern is esophageal dysphagia, a VFSS or GI work-up should be considered prior to the FEES exam.


Why choose FEES over VFSS?

Both exams are valid and specific assessments to assess dysphagia in a patient. However, there are certain parameters where a FEES may provide more valuable information than a VFSS.

  • Accommodate positioning restrictions including halos/braces, head of bed restrictions/spinal cord injuries, and contractures, which may otherwise limit the view capabilities in the radiology suite.
  • No radiation exposure or barium in test materials.
  • Assess patient endurance during meals without limitations on length of exam.
  • Assess patient specific food preferences, pills, and carbonated beverages.
  • Directly view the larynx and pharynx including vocal fold appearance and movement, tissue integrity including signs of reflux, and secretion management.
  • Portability to perform exam in the patient’s environment – intensive/specialty care type units/vents, medical floor, inpatient rehab, skilled nursing. No fatiguing transportation for medically fragile/cognitively impaired patients. Outpatient services also available.
  • Record entire exam (unlike VFSS where the fluoro is turned on and off during the exam). The endoscope is always “on” to view management of pharyngeal residues and secretions.
  • Significantly less expensive than the VFSS.

Is FEES painful?

With a trained, experienced SLP passing the endoscope, discomfort is minimized as the endoscope is passed through the nose. Majority of patients typically describe the sensation as “weird” or “odd” rather than one of pain. Once the scope is in place, most patients show no sign of discomfort. SuperiorView Swallow Diagnostics uses pediatric sized endoscopes for improved comfort and are smaller than the diameter of your index finger. Studies show that most patients would be willing to repeat the procedure. Studies further indicate endoscope placement has no adverse effects on swallow function.


Is there a time limit during the exam?

Unlike VFSS time limits to reduce radiation exposure, FEES is performed without radiation and is not subject to time limitations due to exposure. This allows freedom to assess positioning and swallowing endurance over the course of an entire meal, monitor for retro-flow of material post swallow/meal, and ample opportunities to trial multiple compensatory strategies for those with severe dysphagia.


Who performs FEES?

Licensed SLPs with highly specialized training in the use and interpretation of flexible endoscopy falls within the scope of practice per ASHA’s position statement. Further, the state of Ohio does not require a physician to be present during the exam nor to interpret the exam.


What are the contraindications for FEES?

Few contraindications exist for FEES. Contraindications do NOT automatically exclude a patient from FEES, but rather, are a call to thoroughly discuss all potential risks and benefits with the physician prior to ordering a FEES.

  • Facial or maxillary fractures
  • History of nasal trauma, surgery, or severe nose bleeds
  • Bilateral nasal obstruction
  • Vasovagal episodes or fainting

What populations may benefit from FEES?

While FEES is appropriate for majority of populations (see question regarding VFSS vs FEES), certain populations benefit in particular.

  • Trach and Vent patients
  • Suspected intubation/extubation trauma
  • Isolation patients
  • Contractures or difficulty maintaining positioning
  • Poor endurance/Rapidly deteriorating endurance
  • Poor command following due to brain injury or progressive neurodegenerative disease
  • Chronic wet vocal quality or cough
  • Suspected vocal fold dysfunction
  • Suspected secretion aspiration
  • Suspected laryngopharyngeal reflux (LPR)

Can you test specific foods requested by patient?

Yes! In addition to the standard food texture trials, FEES can easily accommodate specific foods/textures requested by patient, family, or SLP. Examples include, but are not limited to, fast food cheeseburgers, frozen dessert milkshakes, culturally specific homemade dishes, and communion wafers. In addition, adaptive feeding equipment may also be trialed during exam to assess effectiveness.