Your skills are only as strong as your evidence. Brush up on your dysphagia and FEES knowledge by using the resources below!

Bible Book Books Library Reading

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. Dysphagia32(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).

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.

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.



  • Ajemian, M. S. (2001). Routine Fiberoptic Endoscopic Evaluation of Swallowing Following Prolonged Intubation. Archives of Surgery136(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 Laryngoscope112(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 Diseases23(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 Laryngoscope107(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. Dysphagia17(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. Dysphagia12(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. Dysphagia29(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 Laryngoscope117(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 & Laryngology100(8), 678–681
  • Leder, S. B., & Karas, D. E. (2000). Fiberoptic Endoscopic Evaluation of Swallowing in the Pediatric Population. The Laryngoscope110(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. Dysphagia13(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 Sciences25(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 Research3(1), 89–96.
  • Stokely, S. L., Molfenter, S. M., & Steele, C. M. (2013). Effects of Barium Concentration on Oropharyngeal Swallow Timing Measures. Dysphagia29(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 Diseases28(3), 283–289. doi: 10.1159/000228711


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.

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.


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