We all know how important instrumentals are in order to assess patients with suspected pharyngeal dysphagia, plan treatment, determine need for diet modification, and identify least restrictive diet levels for our patients.

“A non-instrumental assessment may provide sufficient information for a clinician to diagnose oral dysphagia; however, aspiration and other physiologic problems in the pharyngeal phase can be directly observed only via instrumental assessments”.

Accurate evaluation of oropharyngeal dysphagia is also important in order to:

  • Prevent complications from overly restrictive diets (i.e. dehydration, malnutrition, UTIs, depression).
  • Reduce detrimental pulmonary consequences associated with aspiration of thickened liquids.
  • Reduced cost to the facility associated with tube feedings or use of thickeners.
  • Reduce rate of hospital re-admissions.


Time and time again instrumental assessments have proven that our clinical assessments are many times mistaken. The patient that was observed to drink thickened liquids without any overt signs of aspiration at bedside may actually be silently aspirating nectar and/or honey even though they only exhibit signs of aspiration with thin liquids. A recent study by Miles et al. (2018) showed scientific evidence to support this. They concluded that “cough response to aspiration differs across volumes and viscosities”. Their findings also indicate that patients are more likely to silently aspirate thicker viscosities.

Research and anecdotal evidence have also shown that thicker viscosities may also increase pharyngeal residuals and aspiration after the swallow. Aspiration of thick liquids has also been shown to cause more pulmonary complications. So, if one of your patients is on thick liquids based on a clinical evaluation alone, there is potential for adverse effects that could be prevented.


Instrumental evaluations are be of great importance in post acute care settings. The patient who was initially evaluated during a hospital stay may show recovery from their acute illness, or may perhaps show significant improvement towards their dysphagia goals upon transfer to a SNF or shortly thereafter. In addition, as patients’ cognition and or mobility status improve, patients may be better able to compensate for lingering deficits or use compensations in a more effective way. Many times, these patients demonstrate good candidacy for diet upgrade, when they are evaluated via instrumental assessments (i.e. MBSS or FEES) during their SNF stay.

Sometimes, however, instrumentals in long term care are denied or delayed due to logistics or financial reasons. And, let’s face it, we can’t treat what we can’t see. We cannot plan treatment without an instrumental. Lack of accurate diagnostics results in delays in diet advancement, mismanagement, reduced quality of life, and sometimes, complications, such as dehydration, malnutrition, UTIs, poor po intake, electrolyte imbalance,  and pneumonia. A reliable source states that 78% of 30-day re-admissions are related to these conditions.

How can FEES help? Mobile FEES offers a convenient and cost effective solution. For a low , flat rate, FEES provides a comprehensive instrumental evaluation of swallowing, with many of the benefits of a clinical swallow exam . For instance, the patient may be evaluated in the dining room, eating lunch, while feeding themselves, and eating the food items they enjoy. For patients who require more assistance, the FEES endoscopist, together with the treating SLP, a family member, or nursing staff (some restrictions currently exist due to COVID-19) , may assist the patient during the exam.

For information about cost of FEES, please head over the the ABOUT FEES page.

What can we do as SLPS to advocate for instrumentals in LTC facilities:

  • Continue to advocate for instrumental using a combination of scientific evidence from recent research studies and anecdotal evidence.
  • Present a benefit-risk analysis to your administrator, showing evidence of increased cost to the facility, when dysphagia is not properly managed.
  • Take advantage of BHSM and Dysphagia Awareness Month to spread knowledge and awareness about dysphagia.
  • Conduct short in- services on topics related to dysphagia and prevention of aspiration related pulmonary complications, the importance of having accurate assessments, etc. Some ideas for in-services include: Oral Infection Prevention, IDDSI, Dispelling Dysphagia Myths, The Cost of Dysphagia, and Preventing Dehydration in Patients on Modified Diets. I CAN ASSIST WITH THAT 🙂
  • Document limitations and possible adverse events related to limited availability of instrumentals
  • Consider compiling cases in which prompt instrumental assessment resulted in improved patient outcomes, increased patient satisfaction, and reduced costs to the facility. Based on what we know about dysphagia management and anecdotal evidenced from many SLPs including myself, this should be easy to show.
  • Present to your administrator current trends in your facility that support the use of instrumentals to asses oropharyngeal dysphagia (i.e. % of residents re-admitted to the hospital with aspiration related complications).
  • For additional information, consider reading this article published in the ASHA Leader:


  • Providing timely instrumental assessment of dysphagia using FEES. 
  • Accurate diagnostics and identification of physiological deficits to inform your POC.
  • Thorough review of the case through chart review and clinical presentation (per your report), testing specific food items as appropriate, and collaborating with you during FEES.
  • Once the scope is out of the patient’s nose, you can start billing for therapy – no loss of therapy minutes.
  • Quick response time and easy access to consultation if you had questions about your patient’s study.
  • WE will comply with any infection control regulations imposed by your facility, so we can keep you and your patients safe. 


  • Fast turn around.
  • Comprehensive evaluation conducted by an experienced endoscopist with 15+ years of experience in the medical setting.
  • Ease of communication. Text, call, or email me directly. I will return your calls promptly. 
  • Simplified scheduling: 1. Call/Text to coordinate a date/time and 2. Send referral form and Rx. DONE!
  • SLP participates in exam. SLP can bill for treatment on the same days FEES is completed.
  • We are available via phone or email ANY TIME you have questions about your patient’s study results or would like to discuss anything related to the recommendations.
  • We are open to trying consistencies you have identified as problematic, or perhaps things the patient loves to eat, but they are not usually part of the FEES protocol.
  • We will always value your input when making recommendations or performing the assessment. You know your patient much better than us!
  • We are always willing to discuss results with families who may not be present during the exam.
  • We are huge advocates for quality of life and quality of care.


As you know, there are indications and contraindications for both FEES and MBSS.  If you feel your patient would benefit more from MBSS, that is totally at your discretion. I just want to offer FEES  to you as something to add to your SLP Toolbox. Once you get more familiar with FEES and our results, it will be easier for you to determine which test would be best for your patients and which test is more appropriate to answer your clinical questions. If you have any questions or would like help deciding which test is best in a specific situation, call/text me so we can discuss.

For benefits of FEES, please head over to the ABOUT FEES tab. You can also click on the Indications for FEES and FEES Vs MBSS tabs below for additional information.

Lastly, it should be much easier to advocate for FEES than MBSS in your facility, as it is A LOT MORE COST EFFECTIVE, and there is no need for transportation, x ray exposure, or ingestion of barium. Plus, the facility saves so much money from diet upgrades and possible placement of previously tube dependent patients on po diets (For more information on costs associated with FEES, head over to the ABOUT FEES page).


Feel free to call me/text me if you have any questions or would like to bring FEES to your facility. If you already have 1, or even 2 service contracts with other providers, no worries. Service contracts are NOT exclusive and having options will come in handy and will prove to be beneficial for your patient and the facility.  Or , you can always keep me as a back-up. 

Your patients deserve excellent care ! I am here to help . Thanks for all you do !!

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