Developed by Susan Langmore, PhD, CCC-SLP in 1986.

FEES (Fiberoptic Endoscopic Evaluation of Swallow) is an objective assessment of swallow function that can accurately diagnose dysphagia and guide effective treatment strategies.  FEES involves passing a scope with a small camera on the end, along the floor of the nasal cavity to the back of the throat in order to directly assess the pharynx, larynx and upper esophageal opening. The patient swallows various food and liquid consistencies providing direct and live images of the swallow mechanism. A qualified and licensed Speech Language Pathologist completes this procedure which requires no radiation exposure or barium consumption and can be performed practically anywhere. The patient is able to consume the foods they like and in their natural eating environment during the study. The SLP evaluates anatomy/physiology including sensation, presence of aspiration, and effectiveness of compensatory strategies.

*** SLPs are only about 50-60% accurate in identifying aspiration at bedside or in the dining room, supporting the need for INSTRUMENTAL swallow evaluations to make accurate recommendations. 

With a trained, experienced SLP passing the endoscope, discomfort is minimized as the endoscope is passed through the nose. Majority of patients describe having an “odd” sensation rather than a “painful” one. Once the scope passes through the nose and into place, most patients show no signs of discomfort. Studies indicate endoscope placement has no adverse effects on swallow function.

Can Topical Anesthesia be used? This depends on the patient, the patient’s comfort level and medical history. We have the option to utilize topical anesthesia if needed and ordered by the physician.

FEES

• Takes place in the comfort of the patient’s living environment, eliminating the cost/need for transportation and patient chaperon to a hospital
• Performed in the patient’s natural eating position
• Uses ‘real food’ versus barium – which may alter the consistency of food/drink, may cause an increase in swallow dwell times, makes dry regular solids difficult to view, is known to cause constipation, and can be harmful to the lungs
• Colored recordings allow for assessment of secretion management and tissue health compared to a black and white x-ray
• Continuous recording of the entire study captures penetration/aspiration after the swallow and in between swallows (including esophageal backflow), which may • Because there is no radiation, the recording of FEES can last much longer enabling assessment for: fatigue, the effectiveness of swallow strategies in depth, reflux, and testing more challenging and difficult items
• Superior view in color allows for evaluation of anatomy, unilateral weakness, vocal fold function, and supraglottic airway closure (all important components for protection and prevention of aspiration)
• It is unlikely the primary SLP will be able to accompany the patient to the hospital, making it difficult for the hospital SLP to understand the full picture (i.e. patient eccentricities, normal eating pattern, pt’s potential to learn a specific strategy, specific items causing more trouble, etc.)
• The primary SLP can be present to provide valuable input and may bill for dysphagia treatment that same day (two minds at work is better than one outside mind who is unfamiliar with the patient)
• Procedure takes approximately 15-30 minutes to complete, significantly decreasing the hours the patient is at a hospital (no “lost” therapy minutes by PT/OT; no denial of ST claims the day of)
• Quick turn-around time as we guarantee completion of procedure within 4 business days from your request
• Full report (including color photos) provided to you BEFORE we leave
• Digital recording of procedures are securely stored for future comparison of studies

MBSS

MBS or Videofluoroscopic Swallow Study is a radiologic examination of oral, pharyngeal, and esophageal phases of swallowing that uses x-ray. This test must be performed in a video-fluoroscopy suite of a hospital with a radiologist, radiology tech, and speech-language pathologist. The patient must be seated upright for the study and is given barium impregnated foods. The study is typically time limited to reduce the patient’s exposure to radiation. Recommendations for safest diet level can be made following the study.

Multiple studies have shown the safety of FEES. The evaluation is able to be repeated as needed to show progress, re-evaluate diet recommendations, and determine if interventions are working without needing to expose the patient multiple times to radiation used with Modified Barium Swallow Studies. Of the potential risks associated with endoscopy, including gagging, epistaxis, laryngospasm, and vasovagal response; a mild case of epistaxis is the most prevalent. The rate of complications associated with FEES is less than 1% overall.

The term dysphagia refers to difficulty swallowing. It is used regarding a variety of swallowing disorders. Not all swallowing problems are dysphagia — it is normal to have occasional difficulty swallowing certain foods or liquids, such as when taking large bites of food. However, ongoing difficulty swallowing could be a cause for concern.
There are three main stages to swallowing difficulties which include:

• Oral phase— when the problem is in the mouth during chewing
• Pharyngeal phase (the throat at the back of the mouth behind the uvula and extending downward), when the problem is regarding food passing through the throat
• Esophageal phase (tube connecting the throat to the stomach) — when food is unable to move down through the esophagus

Specific s/s of Dysphagia include: Odnophagia (pain when swallowing), coughing, choking, regurgitation, nasal regurgitation, sore throat, hoarseness, shortness of breath, chest pain/discomfort , difficulties forming food/liquid into a “bolus” in mouth, needing extra time to chew or move food or liquid in the mouth, difficulties pushing food/liquid to the back of the mouth, reflux or heartburn sensation, vomiting.

FEES is about 1/4 of the cost of Modified Barium Swallow Studies and that doesn’t even include the cost of transportation to and from the hospital for an MBSS. We do not charge for any travel time or mileage. And if we cannot pass the scope, the patient is not charged for the procedure.

We follow CMS guidelines of Consolidated Billing established from the Balanced Budget Act of 1997. The consolidated billing requirement “confers on the SNF the billing responsibility for the entire package of care that residents receive during a covered Part A SNF stay and physical, occupational, and speech therapy services received during a non-covered stay.” FEES is considered a “speech therapy service” and is billed under the consolidated billing guidelines.

Bedside clinical swallow exams by SLPs have proven to be under-estimating and over-estimating aspiration; therefore, the use of instrumental swallow evaluations is vital:
• Langmore, S.E. History of Fiberoptic Endoscopic Evaluation of Swallowing for Evaluation and Management of Pharyngeal Dysphagia: Changes over the Years. Dysphagia. (2017) 32: 27. doi;10.1007/s00455-016-9775-x.

• Gerrie J.J.W. Bours, Rene´e Speyer, Jessie Lemmens, Martien Limburg & Rianne de Wit. 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. Oct 2008; 477-493.
• Langmore, S.E., Skarupski, K.A., Park, P.S., Fries, B.E. Predictors of aspiration pneumonia in nursing home residents. Dysphagia. 2002; 10.1007/s00455-002-0072-1.
• Leder, S.B., Espinosa, M.S. Aspiration risk after acute stroke: comparison of clinical examination and fiberoptic endoscopic evaluation of swallowing. Dysphagia. 2002; 17:214-218.
• Smith CH, Logemann JA, Colangelo LA, Rademaker AW, Pauloski BR. Incidence and patient characteristics associated with silent aspiration in the acute care setting. Dysphagia 1999; 14:1-7.
• Smithard, D.G., O’Neill, P.A., Park, C., et al. Can bedside assessment reliably exclude aspiration following acute stroke? Age and Ageing. 1998;27i(2), 99-106.
• Murray, J, Langmore, S.E., Ginsberg, S. & Dostie, A.(1996). The significance of oropharyngeal secretions and swallowing frequency in predicting aspiration. Dysphagia, 11, 99-103.
• Langmore, S.E. & Logemann, J.A. (1991). After the clinical bedside swallowing examination: What next? AJSLP, September, 13-20.

• Bax, L., McFarlane, M. Green, E., & Miles, A. (2014). Speech-language pathologist-led fiberoptic endoscopic evaluation of swallowing: Functional outcomes for patients with stroke. Journal of Stroke and Cerebrovascular Diseases, 23, 195-200.
• Dietsch, A.M., Solomon, N.P., Steele, C.M., Pelletier, C.A. The effect of barium on perceptions of taste intensity and palatability. Dysphagia. 2013.
• Stokely, S.L., Molfenter, S.M., Steele, C.M. Effects of barium concentration on oropharyngeal swallow timing measures. Dysphagia. 2013.
• Leder, S.B., Murray, J.T. Fiberoptic endoscopic evaluation of swallowing. Physical Medicine & Rehabilitation Clinics of North America. Nov 2008;19(4):787-801.
• Kelly, A.M. Assessing penetration and aspiration: How do videofluoroscopy and fiberoptic endoscopic evaluation of swallowing compare? Laryngoscope. 2007;117, 1732-1727.
• Aviv, J.E. Prospective, randomized outcome study of endoscopy vs. modified barium swallow in patients with dysphagia. Laryngoscope. 2000; 110, 563-574.
• Crary, M.A., Baron, J. Endoscopic and Fluoroscopic Evaluations of Swallowing: Comparison of Observed and Inferred Findings. Dysphagia. 1997;12(2).
• Mu, C.H., Hsiao, T.Y., Chen, J.C., Chang, Y.C., &Lee, S.Y. Evaluation of swallowing safety with fiberoptic endoscope: Comparison with video fluoroscopic technique. Laryngoscope. 1997;107, 396-401.
• Bastian R. Video endoscopic evaluation of patients with dysphagia: an adjunct to the modified barium swallow. Otolaryngology Head & Neck Surgery; 1991. 104(3):339-50.
• Langmore, S.E., Schatz, K., & Olsen, N. Endoscopic and video fluoroscopic evaluations of swallowing and aspiration. Annals of Otology, Rhinology & Laryngology. 1991;100(8), 678-681.
• Warnecke, T. Fiberoptic Endoscopic Dysphagia Severity Scale Predicts Outcome after Acute Stroke. Cerebrovascular Diseases. 2009; 28:283-289.
• Ajemian, M.S. Routine Fiberoptic Endoscopic Evaluation of Swallowing Following Prolonged intubation: Implications for Management. Arch Surg. 2001; 136(4):434-437
• Leder, S. B., Sasaki, C. T., & Burrell, M. I. (1998). Fiberoptic Endoscopic Evaluation of Dysphagia to Identify Silent Aspiration. Dysphagia, 13(1), 19-21.
• Madden, C., Fenton, J., Hughes, J., & Timon, C. (2000). Comparison between videofluoroscopy and milk-swallow endoscopy in the assessment of swallowing function. Clinical Otolaryngology, 25(6), 504-506.
• Rao 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.

• Evidence of aspiration/penetration after the swallow, and how fatigue can impact swallow function can be appreciated to a greater level on FEES because the recording lasts longer than the MBSS.
• The direct visualization, in color, of anatomy during FEES allows for assessment of tissue/muscle function and anatomical variants, providing insight into the true etiology for the dysphagia.
• FEES has proven to be a good assessment of vocal cord function and saliva management, high risk factors associated with aspiration pneumonia.
• FEES allows the clinician to observe the transition from breathing to apnea during swallowing.
• Aspiration occurs about 25% of the time BEFORE the swallow, about 10% DURING the swallow, and about 65% AFTER the swallow.
• Takahashi, N, Kikutani, T, Tamura, F., Groher, M., & Kuboki, T. Videoendoscopic assessment of swallowing function to predict the future incidence of pneumonia of the elderly. Journal of Oral Rehabilitation. 2012; 39; 429-437.
• Butler, S.G., Maslan, J., Stuart, A., Leng, X., Wilhelm, E., Lintzenich, C.R., Williamson, J., & Kritchevsky, S.B. (2011). Factors influencing bolus dwell times in healthy older adults assessed endoscopically. Laryngoscope, Dec; 121(12): 2526-34.
• Allen, J.E., White, C.J., Leonard, R.J., Belafsky, P.C> Prevalence of penetration and aspiration on videofluoroscopy in normal individuals without dysphagia. Journal of Otolaryngology Head and Neck Surgery. Feb 2010; 142(2): 208-13.
• Warnecke, T., Ritter, M.A., Kroger, B., Oelenberg, S., Teismann, I., Heuschmann, P.U., Ringelstein, E.B., Nabavi, D.G., Dziewas, R. Fiberoptic endoscopic dysphagia severity scale predicts outcome after acute stroke. Cerebrovascular Disease. July 2009;28(3):283-9
• Langmore, S., Endoscopic Evaluation and Treatment of Swallowing Disorders. 2001; 120,125.131.Aviv, J.E. Prospective, randomized outcome study of endoscopy vs. modified barium swallow in patients with dysphagia. Laryngoscope. 2000; 100, 563-574.
• Leder, S.B. & Sasaki, C.T. (2001). Use of FEES to assess and manage patients with head and neck cancer. In Langmore, S.E., editor. Endoscopic evaluation and treatment of swallowing disorders. New York: Thieme; 201-212.
• Smith, C.H., Logemann, J.A., Colangelo, L.A., Rademaker, A.W., Pauloski, B.R. Incidence and patient characteristics associated with silent aspiration in the acute care setting. Dysphagia. 1999; 14: 1-7.
• McCulloch T.M., Langmore S.E., Palmer P.M, Jaffe D. Timing of glossopharyngeal events during swallow: a combined electromyographic and endoscopic evaluation. Dysphagia. 1998;13:123.
• McCulloch T.M., Langmore S.E., Palmer P.M. Timing of glottis closure during swallow: a combined electromyographic and endoscopic evaluation. Dysphagia. 1997;12:111.
• Murray, J., Langmore, S.E., Ginsberg, S., & Dostie, A. The significance of accumulated oropharyngeal secretions and swallowing frequency in predicting aspiration. Dysphagia 1996; 11:99-103.

• Of the potential risks associated with endoscopy, including gagging, epistaxis, laryngospasm, and vasovagal response; a mild case of epistaxis is the most prevalent.
• The rate of complications associated with FEES is less than 1% overall.
• FEES has proven to be a safe and well tolerated method of assessing swallow function when performed by a trained Speech Language Pathologist.
• Nacci A, Matteucci J, Romeo SO, Santopadre S, Cavaliere MD, Barillari MR, Berrettini S, Fattori B.; 2016. Complications with Fiberoptic Endoscopic Evaluation of Swallowing in 2,820 Examinations. ENT, Audiology and Phoniatrics Unit, Department of Neurosciences, University of Pisa, Italy. Folia Phoniatr Logop. 2016;68(1):37-45. doi: 10.1159/000446985. Epub 2016 Jul 26.
• Warnecke, T., Teismann, I., Oslenber, S., Hamacher, C., Ringelstein, E.B., Schabitz, W.R., & Dziewas, R.; 2009. The safety of fiberoptic endoscopic evaluation of swallowing in acute stroke patients. Retrieved July 18, 2009 from www.stroke.ahajournals.org.
• Aviv, J.E., Murray, T., Zschommler, A., Cohen, M., Gartner, C. Flexible endoscopic evaluation of swallowing with sensory testing: patient characteristics and analysis of safety in 1340 consecutive examinations. Annals of Otology, Rhinology & Laryngology. 2005;114:173-176.
• Cohen, M.A., Setzen, M., Perlman, P.W., Ditkoff, M., Mattucci, K.F., Guss, J. The safety of flexible endoscopic evaluation of swallowing with sensory testing in an outpatient otolaryngology setting. Laryngoscope. 2003;113:21-24.
• Aviv, J.E., Kaplan, S.T., Thompson, J.E., Spitzer, J., Diamond, B., Close, L.G. The safety of flexible endoscopic evaluation of swallowing with sensory testing: an analysis of 500 consecutive evaluations. Dysphagia. 2000;15:39-44.
• Wu, C.H., Hsiao, T.Y., Chen, J.C., Chang, Y.C., &Lee, S.Y. Evaluation of swallowing safety with fiberoptic endoscope: Comparison with video fluoroscopic technique. Laryngoscope. 1997; 107, 396-401.

• Mor, V., Intrator, O., Feng, Z., & Grabowski, D. C. (2010). The Revolving Door of Rehospitalization From Skilled Nursing Facilities. Health Affairs (Project Hope), 29(1), 57–64. doi:10.1377/hlthaff.2009.0629
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