Your skills are only as strong as your evidence. Brush up on your dysphagia and FEES knowledge by using the resources below!
Looking for a good and easy read encompassing the concepts of the resources below? Only have time to read one article? Searching for an article to start the “We need instrumentals” conversation with your facility? No problem!
Read this:
Langmore, S. E. (2017). History of Fiberoptic Endoscopic Evaluation of Swallowing for Evaluation and Management of Pharyngeal Dysphagia: Changes over the Years. Dysphagia, 32(1), 27–38. doi: 10.1007/s00455-016-9775-x
What is FEES and what can you see?
QUICK SUMMARY: FEES is an instrumental exam in assessing dysphagia using a small scope placed transnasally. FEES allows direct view of laryngeal/pharyngeal anatomy, physiology, vocal fold movement, secretion management, and penetration/aspiration – all in color. Respiration/swallowing coordination can also be observed. FEES is sensitive enough to determine timing of penetration/aspiration (before, during, after swallow).
Allen, J. E., White, C. J., Leonard, R. J., & Belafsky, P. C. (2010). Prevalence of penetration and aspiration on videofluoroscopy in normal individuals without dysphagia. Otolaryngology–Head and Neck Surgery, 142(2), 208–213. doi: 10.1016/j.otohns.2009.11.008
Aviv, J. E. (2002). Prospective, Randomized Outcome Study of Endoscopy Versus Modified Barium Swallow in Patients With Dysphagia. The Laryngoscope, 112(2), 410–412. doi: 10.1097/00005537-200202000-00039
Braun, T., Juenemann, M., Viard, M., Meyer, M., Fuest, S., Reuter, I., … Tanislav, C. (2018). What is the value of fibre-endoscopic evaluation of swallowing (FEES) in neurological patients? A cross-sectional hospital-based registry study. BMJ Open, 8(3). doi: 10.1136/bmjopen-2017-019016
Butler, S. G., Maslan, J., Stuart, A., Leng, X., Wilhelm, E., Lintzenich, C. R., … Kritchevsky, S. B. (2011). Factors influencing bolus dwell times in healthy older adults assessed endoscopically. The Laryngoscope, 121(12), 2526–2534. doi: 10.1002/lary.22372
Langmore, S. E. (2001). Endoscopic evaluation and treatment of swallowing disorders (2nd ed.). New York: Thieme
Langmore, S. E. (2006). Endoscopic evaluation of oral and pharyngeal phases of swallowing. GI Motility online. doi:10.1038/gimo28
Leder, S. B., & Murray, J. T. (2008). Fiberoptic Endoscopic Evaluation of Swallowing. Physical Medicine and Rehabilitation Clinics of North America, 19(4), 787–801. doi:10.1016/j.pmr.2008.05.003
McCulloch, T. M., Langmore, S., Palmer, P. M., & Jaffe, D. (1998). Timing of glossopharyngeal events during swallow: a combined electromyographic and endoscopic evaluation. Dysphagia, 13, 123.
McCulloch, T. M., Langmore, S. E., & Palmer, P. M. (1997). Timing of glottic closure during swallow: a combined electromyographic and endoscopic evaluation. Dysphagia, 12, 111.
Murray, J., Langmore, S. E., Ginsberg, S., & Dostie, A. (1996). The significance of accumulated oropharyngeal secretions and swallowing frequency in predicting aspiration. Dysphagia, 11(2), 99–103. doi: 10.1007/bf00417898
Pisegna, J. M., & Langmore, S. E. (2016). Parameters of Instrumental Swallowing Evaluations: Describing a Diagnostic Dilemma. Dysphagia, 31(3), 462–472. doi:10.1007/s00455-016-9700-3
Smith, C. H., Logemann, J. A., Colangelo, L. A., Rademaker, A. W., & Pauloski, B. R. (1999). Incidence and Patient Characteristics Associated with Silent Aspiration in the Acute Care Setting. Dysphagia, 14(1), 1–7. doi: 10.1007/pl00009579
Takahashi, N., Kikutani, T., Tamura, F., Groher, M., & Kuboki, T. (2012). Videoendoscopic assessment of swallowing function to predict the future incidence of pneumonia of the elderly. Journal of Oral Rehabilitation, 39(6), 429–437. doi: 10.1111/j.1365-2842.2011.02286.x
Warnecke, T., Ritter, M. A., Kröger, B., Oelenberg, S., Teismann, I., Heuschmann, P. U., … Dziewas, R. (2009). Fiberoptic Endoscopic Dysphagia Severity Scale Predicts Outcome after Acute Stroke. Cerebrovascular Diseases, 28(3), 283–289. doi: 10.1159/000228711
Need for instrumentals
QUICK SUMMARY: SLPs have been found to be both over estimating dysphagia and underestimating aspiration events during bedside clinical swallowing evaluations. SLPs don’t have x-ray vision and can NOT fully assess pharyngeal phase at bedside.
American Speech-Language-Hearing Association Adult Dysphagia Practice Portal. (n.d.). Retrieved from https://www.asha.org/PRPSpecificTopic.aspx?folderid=8589942550§ion.
Bours, G. J., Speyer, R., Lemmens, J., Limburg, M., & Wit, R. D. (2009). Bedside screening tests vs. videofluoroscopy or fibreoptic endoscopic evaluation of swallowing to detect dysphagia in patients with neurological disorders: systematic review. Journal of Advanced Nursing, 65(3), 477–493. doi: 10.1111/j.1365-2648.2008.04915.x
Langmore, S. E., & Logemann, J. A. (1991). After the Clinical Bedside Swallowing Examination. American Journal of Speech-Language Pathology, 1(1), 13–20. doi: 10.1044/1058-0360.0101.13
Langmore, S. E., Skarupski, K. A., Park, P. S., & Fries, B. E. (2002). Predictors of Aspiration Pneumonia in Nursing Home Residents. Dysphagia, 17(4), 298–307. doi: 10.1007/s00455-002-0072-5
Leder, S. B. (2015). Comparing Simultaneous Clinical Swallow Evaluations and Fiberoptic Endoscopic Evaluations of Swallowing: Findings and Consequences. Perspectives on Swallowing and Swallowing Disorders (Dysphagia), 24(1), 12. doi: 10.1044/sasd24.1.12
Leder, S. B., & Espinosa, J. F. (2002). Aspiration Risk After Acute Stroke: Comparison of Clinical Examination and Fiberoptic Endoscopic Evaluation of Swallowing. Dysphagia, 17(3), 214–218. doi: 10.1007/s00455-002-0054-7
Leder, S. B., & Warner, H. L. (2018). Comparing Simultaneous Clinical Swallow Evaluations and Fiberoptic Endoscopic Evaluations of Swallowing: Changing Practice Patterns. Perspectives of the ASHA Special Interest Groups, 3(13), 124–132. doi: 10.1044/persp3.sig13.124
Mathers–Schmidt, B. A., & Kurlinski, M. (2003). Dysphagia Evaluation Practices: Inconsistencies in Clinical Assessment and Instrumental Examination Decision-Making. Dysphagia, 18(2), 114–125. doi:10.1007/s00455-002-0094-z
Murray, J., Langmore, S. E., Ginsberg, S., & Dostie, A. (1996). The significance of accumulated oropharyngeal secretions and swallowing frequency in predicting aspiration. Dysphagia, 11(2), 99–103. doi: 10.1007/bf00417898
Smith, C. H., Logemann, J. A., Colangelo, L. A., Rademaker, A. W., & Pauloski, B. R. (1999). Incidence and Patient Characteristics Associated with Silent Aspiration in the Acute Care Setting. Dysphagia, 14(1), 1–7. doi: 10.1007/pl00009579
Smithard, D. G., Oneill, P. A., Park, C., England, R., Renwick, D. S., Wyatt, R., … Martin, D. F. (1998). Can bedside assessment reliably exclude aspiration following acute stroke? Age and Ageing, 27(2), 99–106. doi: 10.1093/ageing/27.2.99
Cost of dysphagia/Readmissions
QUICK SUMMARY: Thicken liquids cost on average $2088-$3468 per year per patient while PEG related care costs average $46,257 per year adjusted for inflation. Unplanned hospitalizations for an uncomplicated course of pneumonia begin at $14,400. Mismanagement of dysphagia can be financially costly for the facility and affect quality of life and health of the patient.
Allen, J., Greene, M., Sabido, I., Stretton, M., & Miles, A. (2019). Economic costs of dysphagia among hospitalized patients. The Laryngoscope, 00, 1–6. doi: 10.1002/lary.28194
Attrill, S., White, S., Murray, J., Hammond, S., & Doeltgen, S. (2018). Impact of oropharyngeal dysphagia on healthcare cost and length of stay in hospital: a systematic review. BMC Health Services Research, 18(594). doi: 10.1186/s12913-018-3376-3
Callahan, C. M., Buchanan, N. N., & Stump, T. E. (2001). Healthcare Costs Associated with Percutaneous Endoscopic Gastrostomy Among Older Adults in a Defined Community. Journal of the American Geriatrics Society, 49(11), 1525–1529. doi: 10.1046/j.1532-5415.2001.4911248.x
Coleman, E. A., Min, S., Chomiak, A., & Kramer, A. M. (2004). Post-Hospital Care Transitions: Patterns, Complications, and Risk Identification. Health Services Research, 37(5), 1423–1440.
Donelan-McCall, N., Eilertsen, T., Fish, R., & Kramer, A. (2006). Small Patient Population and Low Frequency Event Effects on the Stability of Snf Quality Measures. Small Patient Population and Low Frequency Event Effects on the Stability of SNF Quality Measures (5th ed., Vol. 6). Aurora, CO: Division of Health Care Policy and Research, UCDHSC
Mor, V., Intrator, O., Feng, Z., & Grabowski, D. C. (2010). The Revolving Door Of Rehospitalization From Skilled Nursing Facilities. Health Affairs, 29(1), 57–64. doi: 10.1377/hlthaff.2009.0629
O’Keeffe, S. T. (2018). Use of modified diets to prevent aspiration in oropharyngeal dysphagia: is current practice justified? BMC Geriatrics, 18(1). doi: 10.1186/s12877-018-0839-7
Patel, D. A., Krishnaswami, S., Steger, E., Conover, E., Vaezi, M. F., Ciucci, M. R., & Francis, D. O. (2017). Economic and survival burden of dysphagia among inpatients in the United States. Diseases of the Esophagus, 31(1), 1–7. doi: 10.1093/dote/dox131
Westmark, S., Melgaard, D., Rethmeier, L. O., & Ehlers, L. H. (2018). The cost of dysphagia in geriatric patients. ClinicoEconomics and Outcomes Research, 10, 321–326. doi: 10.2147/ceor.s165713
Ajemian, M. S. (2001). Routine Fiberoptic Endoscopic Evaluation of Swallowing Following Prolonged Intubation. Archives of Surgery, 136(4), 434. doi: 10.1001/archsurg.136.4.434
Aviv, J. E. (2002). Prospective, Randomized Outcome Study of Endoscopy Versus Modified Barium Swallow in Patients With Dysphagia. The Laryngoscope, 112(2), 410–412. doi: 10.1097/00005537-200202000-00039
Bax, L., Mcfarlane, M., Green, E., & Miles, A. (2014). Speech–Language Pathologist-led Fiberoptic Endoscopic Evaluation of Swallowing: Functional Outcomes for Patients after Stroke. Journal of Stroke and Cerebrovascular Diseases, 23(3). doi: 10.1016/j.jstrokecerebrovasdis.2013.09.031
Chih-Hsiu, W., Tzu-Yu, H., Jiann-Chyuan, C., Yeun-Chung, C., & Shiann-Yann, L. (1997). Evaluation of Swallowing Safety With Fiberoptic Endoscope: Comparison With Videofluoroscopic Technique. The Laryngoscope, 107(3), 396–401. doi: 10.1097/00005537-199703000-00023
Colodny, N. (2002). Interjudge and Intrajudge Reliabilities in Fiberoptic Endoscopic Evaluation of Swallowing (FEES) Using the Penetration-Aspiration Scale: A Replication Study. Dysphagia, 17(4), 308–315. doi: 10.1007/s00455-002-0073-4
Crary, M. A., & Baron, J. (1997). Endoscopic and Fluoroscopic Evaluations of Swallowing: Comparison of Observed and Inferred Findings. Dysphagia, 12(2).
Dietsch, A. M., Solomon, N. P., Steele, C. M., & Pelletier, C. A. (2013). The Effect of Barium on Perceptions of Taste Intensity and Palatability. Dysphagia, 29(1), 96–108. doi: 10.1007/s00455-013-9487-4
Kelly, A. M., Drinnan, M. J., & Leslie, P. (2007). Assessing Penetration and Aspiration: How Do Videofluoroscopy and Fiberoptic Endoscopic Evaluation of Swallowing Compare? The Laryngoscope, 117(10), 1723–1727. doi: 10.1097/mlg.0b013e318123ee6a
Langmore, S. E., Schatz, K., & Olsen, N. (1991). Endoscopic and video fluoroscopic evaluations of swallowing and aspiration. Annals of Otology, Rhinology & Laryngology, 100(8), 678–681
Leder, S. B., & Karas, D. E. (2000). Fiberoptic Endoscopic Evaluation of Swallowing in the Pediatric Population. The Laryngoscope, 110(7), 1132–1136. doi: 10.1097/00005537-200007000-00012
Leder, S. B., Sasaki, C. T., & Burrell, M. I. (1998). Fiberoptic Endoscopic Evaluation of Dysphagia to Identify Silent Aspiration. Dysphagia, 13(1), 19–21. doi: 10.1007/pl00009544
Madden, C., Fenton, J., Hughes, J., & Timon, C. (2000). Comparison between videofluoroscopy and milk-swallow endoscopy in the assessment of swallowing function. Clinical Otolaryngology and Allied Sciences, 25(6), 504–506. doi: 10.1046/j.1365-2273.2000.00385.x
Roa, N., Brady, S. L., Chaudhuri, G., Donselli, J. J., & Wesling, M. W. (2003). Gold-standard? Analysis of the videofluoroscopic and fiberoptic endoscopic swallow examinations. Journal of Applied Research, 3(1), 89–96.
Stokely, S. L., Molfenter, S. M., & Steele, C. M. (2013). Effects of Barium Concentration on Oropharyngeal Swallow Timing Measures. Dysphagia, 29(1), 78–82. doi: 10.1007/s00455-013-9485-6
Warnecke, T., Ritter, M. A., Kröger, B., Oelenberg, S., Teismann, I., Heuschmann, P. U., … Dziewas, R. (2009). Fiberoptic Endoscopic Dysphagia Severity Scale Predicts Outcome after Acute Stroke. Cerebrovascular Diseases, 28(3), 283–289. doi: 10.1159/000228711
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Safety and incidence rates of FEES
QUICK SUMMARY: FEES has a < 1% complications rate. Potential risks are mild and can include gagging, epistaxis (nosebleed), laryngospasm, and vasovagal response. Research has shown repeatedly that FEES is a safe and well tolerated procedure to assess dysphagia.
Aviv, J. E., Kaplan, S. T., Thomson, J. E., Spitzer, J., Diamond, B., & Close, L. G. (2000). The Safety of Flexible Endoscopic Evaluation of Swallowing with Sensory Testing (FEESST): An Analysis of 500 Consecutive Evaluations. Dysphagia, 15(1), 39–44. doi: 10.1007/s004559910008
Aviv, J. E., Murry, T., Cohen, M., Zschommler, A., & Gartner, C. (2005). Flexible Endoscopic Evaluation of Swallowing with Sensory Testing: Patient Characteristics and Analysis of Safety in 1,340 Consecutive Examinations. Annals of Otology, Rhinology & Laryngology, 114(3), 173–176. doi: 10.1177/000348940511400301
Chih-Hsiu, W., Tzu-Yu, H., Jiann-Chyuan, C., Yeun-Chung, C., & Shiann-Yann, L. (1997). Evaluation of Swallowing Safety With Fiberoptic Endoscope: Comparison With Videofluoroscopic Technique. The Laryngoscope, 107(3), 396–401. doi: 10.1097/00005537-199703000-00023
Cohen, M. A., Setzen, M., Perlman, P. W., Ditkoff, M., Mattucci, K. F., & Guss, J. (2003). The Safety of Flexible Endoscopic Evaluation of Swallowing With Sensory Testing in an Outpatient Otolaryngology Setting. The Laryngoscope, 113(1), 21–24. doi: 10.1097/00005537-200301000-00004
Dziewas, R., auf dem Brinke, M., Birkmann, U., Bräuer, G., Busch, K., Cerra, F., … Warnecke, T. (2019). Safety and Clinical Impact of FEES – Results of the FEES-Registry. Neurological Research and Practice, 1(16). doi: https://doi.org/10.1186/s42466-019-0021-5
Nacci, A., Matteucci, J., Romeo, S. O., Santopadre, S., Cavaliere, M. D., Barillari, M. R., … Fattori, B. (2016). Complications with Fiberoptic Endoscopic Evaluation of Swallowing in 2,820 Examinations. Folia Phoniatrica Et Logopaedica, 68(1), 37–45. doi: 10.1159/000446985
Warnecke, T., Teismann, I., Oelenberg, S., Hamacher, C., Ringelstein, E. B., Schäbitz Wolf R., & Dziewas, R. (2009). The Safety of Fiberoptic Endoscopic Evaluation of Swallowing in Acute Stroke Patients. Stroke, 40(2), 482–486. doi: 10.1161/strokeaha.108.520775
Patient comfort and anesthesia
QUICK SUMMARY: With a trained, experienced SLP passing the endoscope, discomfort is minimized. Majority of patients typically describe the sensation as “weird” or “odd,” rather than one of pain. Research has proven FEES to be a well-tolerated exam with patients agreeable to repeat the procedure. Multiple studies have shown no significant difference in swallowing performance between non-anesthetized patients and those anesthetized with lidocaine. High levels of topical anesthesia has been shown to negatively affect swallow performance.
Conlin, A. E., & McLean, L. (2008). Systematic review and meta-analysis assessing the effectiveness of local anesthetic, vasoconstrictive, and lubricating agents in flexible fibre-optic nasolaryngoscopy. Journal of Otolaryngology–Head & Neck Surgery, 37(2).
Fife, T. A., Butler, S. G., Langmore, S. E., Lester, S., Wright, S. C., Kemp, S., … Rees Lintzenich, C. (2014). Use of Topical Nasal Anesthesia During Flexible Endoscopic Evaluation of Swallowing in Dysphagic Patients. Annals of Otology, Rhinology & Laryngology, 124(3), 206–211. doi:10.1177/0003489414550153
Leder, S. B., Ross, D. A., Briskin, K. B., & Sasaki, C. T. (1997). A Prospective, Double-Blind, Randomized Study on the Use of a Topical Anesthetic, Vasoconstrictor, and Placebo During Transnasal Flexible Fiberoptic Endoscopy. Journal of Speech Language and Hearing Research, 40(6), 1352. doi:10.1044/jslhr.4006.1352
Lester, S., Langmore, S. E., Lintzenich, C. R., Wright, S. C., Grace-Martin, K., Fife, T., & Butler, S. G. (2013). The Effects of topical anesthetic on swallowing during nasoendoscopy. The Laryngoscope, 123(7), 1704–1708. doi:10.1002/lary.23899
Nankivell PC, Pothier DD. Nasal and instrument preparation prior to rigid and flexible nasendoscopy: a systematic review. J Laryngol Otol 2008;122:1024–8
O’Dea, M. B., Langmore, S. E., Krisciunas, G. P., Walsh, M., Zanchetti, L. L., Scheel, R., … Butler, S. G. (2015). Effect of Lidocaine on Swallowing During FEES in Patients With Dysphagia. Annals of Otology, Rhinology & Laryngology, 124(7), 537–544. doi:10.1177/0003489415570935
Singh, V., Brockbank, M. J., & Todd, G. B. (1997). Flexible transnasal endoscopy: is local anaesthetic necessary? The Journal of Laryngology & Otology, 111(07). doi:10.1017/s0022215100138125