What to Expect: Flexible Endoscopic Evaluation of Swallowing (FEES)
Flexible endoscopic evaluation of swallowing (FEES) is an instrumental assessment of swallowing function. A thin flexible endoscope is passed through the nose and into the throat allowing direct view of the throat, vocal folds, and airway. Food coloring is added to food and liquids to make them easier to identify during the evaluation. A speech-language pathologist (SLP) may recommend a FEES get more information about what may be contributing to any swallowing difficulty you may be experiencing and identify if food or liquid is being aspirated (going into the airway) instead of the esophagus. FEES is preferred if there is a concern of damage to the anatomy of the swallowing mechanism (e.g., paralyzed vocal fold), poor secretion (saliva) management, or when a person has a tracheostomy or is ventilator dependent. The primary purpose of the FEES is to determine what is not working with the swallowing mechanism resulting in swallowing issues and develop an appropriate treatment plan.
Miller, Claire & Kelchner, Lisa & Alarcon, Alessandro & Willging, J. (2014). Compensatory Laryngeal Function and Airway Protection in Children Following Airway Reconstruction. The Annals of otology, rhinology, and laryngology. 123.
One of the great advantages of FEES is that it is portable and can be completed in any setting including a clinic, at the bedside, or in some cases, the comfort of your own home. The SLP performing the evaluation will set up the equipment, orient you to the endoscope, and explain the procedure. Depending on state guidelines, a physician or other medical professional may be required to be on the premises when the FEES is performed. Lubrication may be added to the end of the scope to make the procedure more comfortable.
At the beginning of the evaluation, the SLP will pass the endoscope through one of your nostrils and into your throat. Sometimes blowing your nose before the evaluation can make it more comfortable. The scope will be above the larynx (voice box) and does not go below the vocal folds or into the esophagus. Sitting for a FEES exam should not be painful. In fact, a study completed in 2009 by Warnecke et al revealed that >80% of 300 participants experienced either no or minimal discomfort during a FEES exam. Having volunteered for numerous FEES courses, I have been scoped dozens of times by new endoscopists-in-training. The sensation was similar to getting salt water up your nose, but that only lasts for the few seconds it takes to get the scope through the nose. Once the vocal folds and airway are viewed, the SLP may asked you to do some non-swallowing tasks such as puffing out your cheeks or gliding from a low to a high pitch to better assess the function of structures involved in swallowing.
During the FEES, you will be presented with liquids of varying viscosity (thickness) and different food depending on your particular needs. Food may consist of applesauce, fruit cocktail, and a harder cookie such as a graham cracker or a Lorna Doone. Another advantage to FEES is there are no time limitations due to radiation exposure. A full meal can be assessed during FEES if needed. Dependent on the particular case, liquids may be regular or thickened to a nectar-like or honey-like consistency, also referred to as mildly or moderately thick. Liquids will be presented by a teaspoon then cup followed by a straw if indicated. The liquids and applesauce will be dyed with either green or blue food coloring to make them easier to see. The SLP may also have you try different compensatory strategies or postural adjustments to improve the safety or efficiency of your swallow. These may include holding your breath, tucking your chin, turning your head or leaning to one side, or doing a hard swallow. The efficacy of these strategies can only be identified through instrumental assessment. The video below from the Mayo Clinic will give you a visual of how a FEES is conducted.
After the FEES, the SLP will go over the results of the study while reviewing the video and will provide recommendations for treatment. Treatment should include exercises specific to the physiologic deficits identified from the study and may include referrals to other medical professionals as indicated, compensatory strategies, and diet recommendations. It is important to remember, the purpose of the FEES is to identify the anatomical or physiological cause of the swallowing issue and recommend treatments specific to those deficits. If you aspirate during the evaluation, the SLP should be able to tell you when (before, during, or after the swallow) and why you aspirated. If for some reason this information is not provided, do not be afraid to advocate for yourself and ask.
References:
Warnecke, Tobias & Teismann, Inga & Oelenberg, Stefan & Hamacher, Christina & Ringelstein, E. & Schäbitz, Wolf & Dziewas, Rainer. (2008). The Safety of Fiberoptic Endoscopic Evaluation of Swallowing in Acute Stroke Patients. Stroke; a journal of cerebral circulation. 40. 482-6. 10.1161/STROKEAHA.108.520775.
