The value of FEES

Flexible Endoscopic Evaluation of Swallowing (FEES) may be new to you. However, FEES has been used by Speech Language Pathologists since the early 90s. FEES was actually initially created by Dr Susan Langmore back in 1988, when she decided to explore the use of endoscopy, as used by ENTs, to visualize swallowing function.

Since then, the technology has evolved tremendously and its efficacy tested numerous times, and FEES has become a Gold Standard test to evaluate pharyngeal dysphagia. While in some places, FEES is the most widely used exam to evaluate patients with dysphagia, in other areas, FEES is only performed by a limited number of clinicians and physicians, and offered in a limited number of facilities.

This is the case with South Florida, where many healthcare practitioners have limited information about FEES. I have encountered this situation as I have visited facilities and requested scripts from doctors. Considering FEES provides a convenient and accurate way to evaluate patients with dysphagia in numerous settings and across the life continuum, it is a cost effective alternative, allows for direct visualization of laryngeal and pharyngeal anatomy and physiology, and may the the only option for certain patient populations, it is well worth the effort to increase awareness and educate practitioners in our community about FEES.

So why is FEES so valuable?

The best way to explain the difference between video swallow studies (the most used alternative in this area) and FEES to many healthcare practitioners, is to use the CT scan vs MRI analogy. Like the latter tests, FEES and video swallow studies, have many things in common, but are also very distinct, at times warranting use of both of these tests to evaluate one single patient.

What does FEES offer that a video swallow does not:

-Direct view of the pharynx and larynx, allowing for assessment of symmetry, movement, cranial nerve integrity, reflux related changes, anatomical changes related to intubation (i.e. granuloma), etc.

-No need to transport the patient to the radiology suite. The patient is typically seen in their natural environment (i.e. dining room). Patients are also seen at the bedside, if in an acute or post acute care setting. Examination at physicians offices is also common.

-Allows evaluation of patients who are bed bound, wheelchair bound, or have positional constraints due to body habitus or conditions that prevent optimal position to obtain lateral or AP views for video fluoroscopic swallow studies.

-Patients are assessed while consuming real food items. This makes the evaluation more naturalistic and more likely to resemble a meal. In addition, specific food items that have been reported as “problematic” may be tested to assess effect on swallowing safety and efficiency.

-Patients are assessed for a longer period of time (average 10 min vs 3 min of videofluoroscopy), during which the scope is always on. This is beneficial to assess change over time (common in some populations), assess patients with a larger number of trials to establish a pattern of deficits, determine efficacy of compensations and diet modification with larger volumes (compared to a video swallow test, which is limited due to exposure to X-ray).

-Visual feedback is provided to assist with patient and caregiver understanding of swallowing deficits, and provide opportunities for training in strategies/maneuvers.

-FEES findings may also incidentally uncover findings that warrant further referrals, and provide insight into patients deficits and symptoms (i.e. reduced vocal fold mobility, presence of lesions, glottic stenosis, etc).

What are some of the contraindications of FEES:

Bilateral nasal passage obstruction.

Unstable facial fractures.

Severe agitation.

Refractory epistaxis.

Inability to cooperate with exam for any other reason.

How to order FEES?

FEES exams require a prescription from the patients physician, specifically stating the name of the procedure (see sample Rx below). FEES is covered by insurance (CPT code 92612).

To perform the procedure, an informed consent is also obtained. This may be signed by the patient, POA, or medical surrogate.

If you have any additional questions, please feel free to reach out to us, a speech language pathologist trained in FEES, or your local Mobile FEES endoscopist.


Isabel Ramati, M.S., CCC-SLP

Speech Language Pathologist

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