When it comes to instrumental swallowing assessments, FEES (Flexible Endoscopic Evaluation of Swallowing) has spent years in the shadow of its more established cousin, the Modified Barium Swallow Study (MBSS). But let’s be real—it’s time to stop treating FEES like the red-headed stepchild of the dysphagia world.
Let’s dive into what FEES really is, how it has evolved, and bust a few myths along the way.
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What is FEES?
FEES is a procedure that uses a flexible laryngoscope passed through the nasal passage to the pharynx to directly visualize swallowing and related structures. It allows clinicians to assess secretion management, bolus flow, penetration/aspiration, and residue—in real-time and without the use of barium.
A Quick History Lesson
FEES was first described in the literature in 1988 by Dr. Susan Langmore, ENT Dr. Nels Olson, and SLP Ken Schatz (Langmore et al., 1988). At first, the procedure used mirrors and single-person viewing scopes—pretty limiting. There was no way to record or replay what was seen. Fast-forward to today and we’re talking high-definition, distal chip technology, and live recording for review and education.
Development & Breakthrough
When FEES was first tested on healthy individuals, the inventors weren’t impressed. It wasn’t until they scoped patients with dysphagia that they realized the true value—seeing spillage, residue, aspiration, and structural deficits right before their eyes (Langmore, 2017).
Debunking the Myths: Let’s Get Real
Myth #1: “FEES is too painful for patients.”
Actually, not really. While the idea of a camera up the nose may cause a few squirmy reactions, most patients report only mild pressure. Proper technique (exploring both nares, using pediatric scopes) and patient education go a long way (Hiss & Postma, 2003; Aviv et al., 2000).
Topical anesthetics may help but can affect pharyngeal sensation, so they’re not always recommended (Leder et al., 1997).
Myth #2: “You can’t see aspiration with FEES.”
False! You absolutely can. FEES provides excellent views of aspiration before and after the swallow. Material entering and sitting in the laryngeal vestibule, or bubbling on the vocal cords post-swallow? You can see that (Schatz et al., 1991; Leder & Espinosa, 2002; Colodny, 2002).
Yes, there’s a “white-out” during the actual swallow—but you’re not missing the full picture.
Myth #3: “FEES is too dangerous.”
Let’s look at the data. In over 2,800 FEES exams, the incidence of adverse events was low—epistaxis (0.14%), vasovagal response (0.1%), and laryngospasm (0.07%) (Nacci et al., 2016). All resolved spontaneously. Even in pediatric populations and acute stroke patients, FEES is considered safe (Aviv et al., 2000; Link et al., 2000; Warnecke et al., 2009).
Myth #4: “MBSS is the gold standard.”
MBSS has long been the default—but that doesn’t mean it’s the only gold standard. FEES is now recognized alongside MBSS for its unique value. Studies show that FEES is more sensitive for detecting residue and penetration/aspiration, often scoring these more severely than MBSS (Pisegna & Langmore, 2016; Kelly et al., 2007).
As Langmore (2017) stated: “The gold standard should represent the truth as close as we can ascertain. FEES is more sensitive to bolus findings.”
Why Choose FEES?
- Portable: Can be done at bedside, in a chair, or practically anywhere.
- No barium required: Use real food and drink, usually tinted with food coloring.
- Secretions and anatomy: You can see secretion management, laryngeal structure function, and anatomical anomalies in detail.
- Repeatable: No radiation means it can be done frequently for follow-ups or trials.
- Clear view of penetration, aspiration, and residue: Especially helpful in identifying silent aspiration (Leder et al., 1998).
MBSS vs. FEES: Stop the Rivalry
Rather than choosing one over the other, why not both? Each test offers unique strengths and perspectives. Like CT and MRI scans used together for stroke patients, FEES and MBSS can be complementary (Brady & Donzelli, 2013; Aviv, 2000).
In practice, the results from both tests often align. In many clinical cases, recommendations based on both studies have been nearly identical—even when the clinicians didn’t know the other study was happening.
Let’s Change the Narrative
It’s time to reframe how we present FEES—not as an alternative, but as a powerful, sometimes superior tool in our dysphagia toolkit. The key is matching the right test to the patient and clinical question.
As SLPs, our role is not just to identify aspiration but to understand the full physiology of the swallow to guide meaningful treatment.
Let’s continue to educate physicians, fellow SLPs, and caregivers alike that our assessments go far beyond just choosing thickened liquids.
Let’s advocate for both tests when needed. Let’s push for best practice.
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References
Aviv, J. E., Kaplan, S. T., Thomson, J. E., Spitzer, J., Diamond, B., & Close, L. G. (2000). The safety of flexible endoscopic evaluation of swallowing with sensory testing (FEESST): An analysis of 500 consecutive evaluations. Dysphagia, 15(1), 39–44.
Aviv, J. E., et al. (2005). Flexible endoscopic evaluation of swallowing with sensory testing: Patient characteristics and safety analysis in 1,340 consecutive evaluations. Annals of Otology, Rhinology & Laryngology, 114, 173–176.
Brady, S., & Donzelli, J. (2013). The modified barium swallow and the functional endoscopic evaluation of swallowing. Otolaryngologic Clinics of North America, 46(6), 1009–1022.
Colodny, N. (2002). Interjudge and intrajudge reliabilities in fiberoptic endoscopic evaluation of swallowing (FEES) using the Penetration–Aspiration Scale: A replication study. Dysphagia, 17(4), 308–315.
Hiss, S. G., & Postma, G. N. (2003). Fiberoptic endoscopic evaluation of swallowing. The Laryngoscope, 113(8), 1386–1393.
Kelly, A. M., Drinnan, M. J., & Leslie, P. (2007). Assessing penetration and aspiration: How do videofluoroscopy and fiberoptic endoscopic evaluation of swallowing compare? The Laryngoscope, 117(10), 1723–1727.
Langmore, S. E. (2003). Evaluation of oropharyngeal dysphagia: Which diagnostic tool is superior? Current Opinion in Otolaryngology & Head and Neck Surgery, 11(6), 485–489.
Langmore, S. E. (2017). History of fiberoptic endoscopic evaluation of swallowing for evaluation and management of pharyngeal dysphagia: Changes over the years. Dysphagia, 32(1), 27–38.
Langmore, S. E., Kenneth, S. M., & Olson, N. (1988). Fiberoptic endoscopic examination of swallowing safety: A new procedure. Dysphagia, 2(4), 216–219.
Leder, S. B., Ross, D. A., Briskin, K. B., & Sasaki, C. T. (1997). A prospective, double-blind, randomized study on the use of a topical anesthetic, vasoconstrictor, and placebo during transnasal flexible fiberoptic endoscopy. Journal of Speech, Language, and Hearing Research, 40(6), 1352–1357.
Leder, S. B., Sasaki, C. T., & Burrell, M. I. (1998). Fiberoptic endoscopic evaluation of dysphagia to identify silent aspiration. Dysphagia, 13(1), 19–21.
Leder, S. B., & Espinosa, J. F. (2002). Aspiration risk after acute stroke: Comparison of clinical examination and fiberoptic endoscopic evaluation of swallowing. Dysphagia, 17(3), 214–218.
Link, D. T., Willging, J. P., Cotton, R. T., Miller, C. K., & Rudolph, C. D. (2000). Pediatric laryngopharyngeal sensory testing during flexible endoscopic evaluation of swallowing: Feasible and correlative. Annals of Otology, Rhinology & Laryngology, 109(10), 899–905.
Nacci, A., Matteucci, J., Romeo, S. O., et al. (2016). Complications with fiberoptic endoscopic evaluation of swallowing in 2,820 examinations. Folia Phoniatrica et Logopaedica, 68(1), 37–45.
Pisegna, J. M., & Langmore, S. E. (2016). Parameters of instrumental swallowing evaluations: Describing a diagnostic dilemma. Dysphagia, 31(3), 462–472.
Schatz, K., Langmore, S. E., & Olson, N. (1991). Endoscopic and videofluoroscopic evaluations of swallowing and aspiration. Annals of Otology, Rhinology & Laryngology, 100(8), 678–681.
Warnecke, T., Teismann, I., Oslenber, S., et al. (2009). The safety of fiberoptic endoscopic evaluation of swallowing in acute stroke patients. Retrieved from www.stroke.ahajournals.org
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