When to consult for a FEES?

when to consult for fees

When should a Flexible endoscopic evaluation or swallowing (or fiberoptic endoscopic evaluation of swallowing) be performed?  When should I consult for a FEES?  Patients with suspected dysphagia may warrant further instrumental assessment of the swallowing mechanism to further assess swallow physiology.  Typically a clinical swallowing evaluation is performed by a speech-language pathologist prior to recommendations for a FEES.  

Clinical Swallowing Assessment

A clinical swallowing assessment is performed to determine if there are any signs or symptoms of dysphagia.  The medical chart is reviewed for any acute or chronic conditions that may increase the risk for dysphagia.  Conditions that may be associated with dysphagia include neurological disorders (stroke, multiple sclerosis, Parkinson’s Disease, ALS, dementia), pulmonary disease (COPD, pulmonary fibrosis, ARDS),  head and neck cancers, endotracheal intubation, critical illness.   During a clinical swallowing assessment, the speech language pathologist examines the oral musculature.  During a thorough assessment,  oral mechanism exam is conducted to assess the structure and function of the lips, tongue, jaw, palate, and some aspects of laryngeal function.  These correlate with cranial nerve functioning and help to determine the likelihood of dysphagia.  

The clinical swallowing assessment is an important step in determining if a patient has dysphagia.  However it is limited in determining the cause of the dypsphagia.  We cannot quanitify hyolaryngeal elevation or determine a delay from bedside swallowing assessment.  Although a patient may cough during intake of foods or liquids, we cannot determine if the patient is aspirating.  

Instrumental Assessment

Instrumental swallowing assessments include Modified Barium Swallowing Studies and Flexible Endoscopic Evaluation of Swallowing.  These studies are used to assess swallowing anatomy and physiology to determine the reason for the patient’s underlying dysphagia.  WIth FEES, there is a birdseye view of the larynx to directly view the swallowing process.  The anatomy is able to be viewed to assess any abnormality as it relates to swallowing.  

The instrumental assessment is not only to determine whether or not aspiration is present.  It’s also to determine why the person is having dysphagia so that we can effectively treat it.  

During FEES, we can determine if there is residue in the larynx, how much, where it is located.  We can also determine why the patient is having residue.  Is it due to impaired base of tongue strength? Impaired epiglottic inversion? Decreased pharyngeal squeeze?  From there we can come up with an exercise plan to target those specific deficits, if indicated.  

During FEES we can also assess for compensatory strategies.  For example if there is a delay in the swallow, we may attempt a chin tuck or 3-second bolus hold to determine if those strategies are helpful in swallowing safety.  If the patient is having issues with airway protection, we may try a superglottic swallowing maneuver.  Compensatory strategies should always be performed during an instrumental assessment.  As sometimes a strategy can increase a patient’s risk of aspiration.  

When to Refer for Instrumental

ASHA recently updated their recommendations for when to refer for an instrumental.  This information is quoted from ASHA’s website:

“Indications for an instrumental exam include the following:

  • concerns regarding the safety and efficiency of swallow function
    • contribution of dysphagia to nutritional compromise
    • contribution of dysphagia to pulmonary compromise
    • contribution of dysphagia to concerns for airway safety (e.g., choking)
  • the need to identify disordered swallowing physiology to guide management and treatment
  • the need to assist in the determination of a differential medical diagnosis related to the presence of dysphagia
  • the presence of a medical condition or diagnosis associated with a high risk of dysphagia
  • previously identified dysphagia with a suspected change in swallow function; and
  • the presence of a chronic degenerative condition with a known progression or the recovery from a condition that may require further information for the management of oropharyngeal function”

Some contraindications for instrumental swallowing assessments include medical instability.  If the resident is not medically stable or unable to remain alert for intake, it is best to hold off until the patient can participate safely.  Another contraindication would be if the patient has anatomically deviations that do not allow for the scope to pass.  


When a patient presents with signs or symptoms of oropharyngeal dysphagia, a speech-language pathologist can be helpful for rehabilitation of the swallowing process.  An instrumental assessment is key in helping to individualize the treatment program to target the appropriate muscles for therapy. 

Improving quality of life for patients with dysphagia one scope at a time.


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