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FEEST or Famine…..

You know about FEES….

You’ve more than likely heard about FEES (Flexible Endoscopic Evaluation of Swallowing) by this time.  If not, take a look around this blog because I have been blogging about FEES all month!

But have you heard about FEEST?

Have you heard of FEEST?  Flexible Endoscopic Evaluation of Swallowing with Sensory Testing is another method to evaluate swallowing using instrumentation.

The FEEST exam is performed much like FEES with an endoscope passed transnasally to assess the swallow.   FEEST, however adds an air-pulse stimuli that is delivered to the mucosa innervated by the superior laryngeal nerve to elicit the laryngeal adductor reflex (LAR).

So what is LAR?

“The laryngeal adductor reflex (LAR) is an involuntary protective response to stimuli in the larynx. The superior laryngeal nerve (SLN) acts as the afferent limb and the recurrent laryngeal nerve (RLN) as the efferent limb of this reflex, which is modulated by the central nervous system.”

What can I see with FEEST?

FEEST, not only allows you to evaluate the pharyngeal swallow and the sensory aspect of the larynx and the mucosa innervated by the superior laryngeal nerve, you can also evaluate manifestations of GERD such as Larynopharyngeal Reflux (LPR) which can include sensation of bolus, voice changes or asthma.

What do you think?

Do you think that FEEST may be an appropriate exam for your patients?  What patients are appropriate for FEEST?


Domer, A. S., Kuhn, M. A., & Belafsky, P. C. (2013). Neurophysiology and clinical implications of the laryngeal adductor reflex. Current otorhinolaryngology reports1(3), 178-182.

Rees, C. J. (2006). Flexible endoscopic evaluation of swallowing with sensory testing. Current opinion in otolaryngology & head and neck surgery14(6), 425-430.Thompson, D. M. (2003).

Laryngopharyngeal sensory testing and assessment of airway protection in pediatric patients. The American journal of medicine115(3), 166-168.

O‘Horo, J. C., Rogus‐Pulia, N., Garcia‐Arguello, L., Robbins, J., & Safdar, N. (2015). Bedside diagnosis of dysphagia: a systematic review. Journal of hospital medicine10(4), 256-265.

Kim, T., Goodhart, K., Aviv, J. E., Sacco, R. L., Diamond, B., Kaplan, S., & Close, L. G. (1998). FEESST: a new bedside endoscopic test of the motor and sensory components of swallowing. Annals of Otology, Rhinology & Laryngology107(5), 378-387.

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. Dysphagia15(1), 39-44.

Aviv, J. E., Kim, T., Thomson, J. E., Sunshine, S., Kaplan, S., & Close, L. G. (1998). Fiberoptic endoscopic evaluation of swallowing with sensory testing (FEESST) in healthy controls. Dysphagia13(2), 87-92.

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Myths of FEES Part 2

This is going to be a big one.

This is going to maybe go against everything you’ve ever heard or known.

I mean, maybe I need a drumroll here……

FEES Myth #2 Busted………

You CAN see aspiration with FEES.

There…..i said it.

“Good agreement was found, especially for the finding of aspiration (90%).” (Regarding FEES) Schatz, Langmore, Olson 1991.  

While it is true, there is that “white-out” phase at the height of the swallow.   Although, sometimes, mine tends to look more green or black than white, you can see.

You can definitely see aspiration before the swallow.  You can see the material spill over the epiglottis and into the laryngeal vestibule.   Sometimes, when you watch close and slow down the video, you can even see the material spill into the laryngeal vestibule as the swallow occurs.

“It was concluded that the clinical examination, when compared with FEES, underestimated aspiration risk and overestimated aspiration risk in patients who did not exhibit aspiration risk.”  Leder, Espinosa 2002.

The thing with aspiration, to be considered aspiration is has to stay at the level of the vocal folds or lower in the trachea.   Now, I’ve been doing swallow studies whether it be MBSS or FEES for many years and I have very rarely seen the material just drop straight through the trachea.   There is residue that can be seen on the vocal cords or into the trachea with aspiration that is not cleared.

You can also typically see secretions or material bubble at the level of the vocal cords as the patient breaths or tries to clear the material.

“This study found that FEES was just as reliable as VFSS when using the PAS.”  Colodny 2002


Leder, S. B., Sasaki, C. T., & Burrell, M. I. (1998). Fiberoptic endoscopic evaluation of dysphagia to identify silent aspiration. Dysphagia13(1), 19-21.

Schatz, K., Langmore, S. E., & Olson, N. (1991). Endoscopic and videofluoroscopic evaluations of swallowing and aspiration. Annals of Otology, Rhinology & Laryngology100(8), 678-681.

Kelly, A. M., Drinnan, M. J., & Leslie, P. (2007). Assessing penetration and aspiration: how do videofluoroscopy and fiberoptic endoscopic evaluation of swallowing compare?. The Laryngoscope117(10), 1723-1727.

Leder, S. B., & Espinosa, J. F. (2002). Aspiration risk after acute stroke: comparison of clinical examination and fiberoptic endoscopic evaluation of swallowing. Dysphagia17(3), 214-218.

Colodny, N. (2002). Interjudge and intrajudge reliabilities in fiberoptic endoscopic evaluation of swallowing (Fees®) using the Penetration–Aspiration Scale: a replication study. Dysphagia17(4), 308-315.

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The History of the Modified Barium Swallow Study

No matter what you call it…there is a history behind the Modified Barium Swallow Study (MBSS).

Gold Standard?

The Modified Barium Swallow Study has long been called THE gold standard in dysphagia evaluation, however it does have its limitations.   The MBSS definitely continues to be A gold standard in swallowing evaluation.


Early Days

In the 1970’s, Dr. Jeri Logemann developed the MBSS or the Cookie Swallow Test.  She presented on this test at the ASHA convention in 1976.

During the Cookie Swallow Test, patients were given 2 cc of radiopaque liquid, 2 cc of paste, and 1/4 of a cookie coated with barium.  The liquid barium was given first, then paste, and last,  the cookie.   Patients were recorded with 2 swallows of each consistency.

Dr. Logemann then described liquid/food presentation as 3 swallows each of:

  • 1 ml thin liquid by spoon
  • 3 ml thin liquid by spoon
  • 5 ml liquid by syringe
  • 10 ml liquid by syringe
  • (can give larger amounts also)
  • Cup drinks
  • Saliva Swallow (no barium, just watch muscles move with swallow)
  • Pudding with barium (1/3 tsp or 1 ml of 2 parts pudding to 1 part barium)
  • Other food textures mixed with barium

Linden and Siebens,  developed a new approach to the VFSS which was based on patient specific deficits.  They used representative radiopaque foods similar to those the patient ordinarily ate.   The  study started with the food which would be safest for the patient to swallow, as determined by the SLP.  The study then progressed to increasingly difficult foods/liquids ending with those the patient was most likely to aspirate. Compensatory maneuvers (such as modifications of feeding or positioning) were tested  as a basis for developing recommendations for diet and treatment.

Standardized MBSS

Dr. Bonnie Martin Harris recently developed the Modified Barium Swallow Impairment Profile (MBSImP) which is the first standardized assessment of the MBSS.  (More on that to come!)

The Study

The MBSS consists of the patient, usually seated in a special seat, having an X-ray study, examining the oropharyngeal cavity.  The patient is given a variety of liquids and food, all mixed with barium as the barium can be viewed during the real-time video of the study.

The study is typically (should be) recorded for review of the test later.   The video can be slowed down for more accurate view of the swallowing structures.

Often, the MBSS is started and once the patient aspirates on the first consistency, the exam is discontinued.  This should not be the case as modifications can be made to:

  • amount presented
  • method of presentation
  • posture
  • position of head when swallowing
  • texture
  • temperature
  • taste

Although at one point, most SLP’s were completing the MBSS study to determine penetration/aspiration and what the best diet consistency is for the patient to safely consume, we now know better.

The MBSS is a test that allows us to view the oropharyngeal structure from the side (lateral) and from the front (A-P view) to determine the physiology of the swallow, meaning that we determine what muscles are moving and how.

Although we may test a wide variety of consistencies, thin liquid, nectar thick (mildly thick), honey thick (moderately thick) liquids, pureed, mixed consistencies, soft foods and regular foods, there is no way for us to possibly test every single consistency the person may consume.

But Why MBSS?

That is why it is important to look beyond penetration and aspiration and to look at the physiology of the swallow including what is functional and what is not.   This is what leads us to accurate diagnosis and treatment planning for patients.

More to come on the MBSS!


Logemann JA. Manual for the videofluorographic study of swallowing. 2nd ed. ProEd; Austin, TX: 1993.

Logemann JA. Evaluation and treatment of swallowing disorders. ProEd; Austin, TX: 1998.

Martin-Harris, B., Brodsky, M. B., Michel, Y., Castell, D. O., Schleicher, M., Sandidge, J., … & Blair, J. (2008). MBS measurement tool for swallow impairment—MBSImp: establishing a standard. Dysphagia23(4), 392-405.

Linden PL, Siebens AA: Dysphagia: predicting laryngeal penetration. Arch Phys Med Rehab 64:281-284, 1983.

Siebens AA, Linden PL: Dynamic imaging for swallowing reeducation. GastrointestRadio110:251-253, 1985.

Linden P: Videofluoroscopy in the rehabilitation of swallowing dysfunction. Dysphagia 3:189-191, 1989.

Palmer, J. B., Kuhlemeier, K. V., Tippett, D. C., & Lynch, C. (1993). A protocol for the videofluorographic swallowing study. Dysphagia8(3), 209-214.

Martin-Harris, B., Brodsky, M. B., Michel, Y., Castell, D. O., Schleicher, M., Sandidge, J., … & Blair, J. (2008). MBS measurement tool for swallow impairment—MBSImp: establishing a standard. Dysphagia23(4), 392-405.

Martin-Harris, B., Logemann, J. A., McMahon, S., Schleicher, M., & Sandidge, J. (2000). Clinical utility of the modified barium swallow. Dysphagia15(3), 136-141.

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What Would You Do?

I would love to share a story with you. 

Now keep in mind, I’ve been an SLP for a lot of years and feel that I do a pretty good job.   Sometimes, I may even get a little over-confident in my skills and have to examine what I’m doing.

Let’s talk about a patient I’ve had.   All identifying information will be withheld. 

This person was referred after a family member was concerned with increased choking with food and drinks.   This patient has a history of dysphagia, which had resolved. 

I get the call to go in and go in prepared for an evaluation. I did everything I would normally do in an evaluation.

I did a cranial nerve exam which all the cranial nerves seem to be intact. I had the person eat and drink while I observed. I even palpated the larynx to see what I could feel. Everything seemed to be quite normal.

I have to do vitals for home health so I went ahead and got out my pulse oximeter to see if there is any change in the person’s sats. They were able to drink some water with no change in 02 saturation.

Everything seemed to check out pretty well however the family was still very concerned, so just to cover my bases and to make sure that I hadn’t missed something I requested a modified barium swallow study.

Now imagine my surprise when I get the report for that swallow study and find out that this person’s actually aspirating multiple consistencies.

The person has timing issues with laryngeal elevation and closure and with oral containment prior to the swallow.

I mean really how can that be?

There was no change in O2 sats for me. The larynx felt like it was moving pretty well. Cranial nerves seem to be intact and functioning.

Where did I go wrong?

I didn’t. I realized my limitation without visualization. I have read my research and know that O2 sats and palpation is not always accurate.

I did right by my patient and pushed for instrumental exams.

I had push-back at first. Do you really need an instrumental? Can’t you just treat? When I told the company I need the instrumentals or I’m referring patients to another company, they started approving my requests.

Do right by your patients.

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The Interview

The Clinical Swallowing Evaluation

One of the most crucial components, at least for me, of the Clinical Swallow Evaluation (CSE), is the interview.

I haven’t found a lot of published research regarding the interview portion of the CSE, so if you’ve found any, please let me know in the comments!

There is a nice example of some interview questions in The Source for Dysphagia by Nancy Swigert.

Chart Review

I probably spend the better half of my evaluation time digging in the chart for information and then interviewing anyone I can find that can answer to questions about the patient.

The chart review gives me an idea of the patient.  You are looking for diagnoses, medications, lab values, history, etc.  (Not to fear, there will be a post on chart reviews!)

The Interview

As I said before, the interview is where I can get an abundance of information!  I typically will try to find the nurse or even the doctor after reading the chart to get more information.  What is the patient doing?  How are they eating their meals, taking their pills?  How alert is the patient?  What is the plan for the patient?

Now, unless you want the person to get all defensive on you, don’t just run into the room and start firing questions at the patient!  You don’t want them to feel ambushed.   Introduce yourself and tell them why you are there.   Maybe ask a couple of questions not swallowing related.   You can comment on who is in the room.  “Oh, you have a lot of visitors today.”  That will usually prompt some introductions as well.

I try to keep it as light as possible.   Don’t go in with the “I think you’re aspirating and you will probably get pneumonia and die” line up and ready to fire.   You have no idea what is going on with this person and they probably had no clue that a Speech Language Pathologist worked with swallowing.

We all know the famous line.   You:  “Hi, I’m Susie/Stan and I’m the Speech Language Pathologist.”  Patient/family:  “There is nothing wrong with my/their speech.   Just listen to me/them talk.”

Make that person comfortable.  Sometimes, they know that we work with swallowing.   Maybe they have had some experience or someone they love has had some experience with dysphagia and they don’t want that thick crap to drink.   Let them know you’re not the thickened liquid police and you just need to see what’s going on so that you know if you can help them with any problem they may be having related to swallowing.

What do I ask?

In a perfect world, the family is present in the room for an evaluation.   Don’t look at the family as judging you and what you’re doing.   Chances are, they have no idea what to expect from you.

If the patient is able to answer questions and the family is available, I interview them all at the same time.   I really have tried to develop a list of interview questions, but have found the interview much more effective if it is patient-driven.

I do ask about the current or most recent hospitalization.   What happened that you had to come to the hospital?  What is your current problem?  Are you having trouble with swallowing your food?   How about those pills?  How do you do when you are at home?  Do you have any trouble swallowing pills at home?

I also like to find out if there are any foods that are avoided or if there is a specific method they use to take pills.   Bonus if the nurse comes in to pass meds so that you can actually observe the patient taking their pills!!


Speaking of pills, I almost always have patients say, well, I do ok with my pills except for one.   It’s huge.  When I ask if it’s the potassium pill, the answer is almost always yes.   I would say nearly every patient I evaluate that takes a potassium pill has trouble with it.

I always ask the patient/family about neurologic diagnoses or even previous surgeries or cancer treatment.   The thing is, the chart can be great as well as the history and physical section of the chart, BUT there can be information missing or inaccurate.

Take for example, the patient I had several years ago that was in the hospital for weakness.  The chart had nothing in it about previous tonsil cancer with 37 sessions of radiation or the fact that the person had a large portion of their stomach removed due to cancer.

I really want my patient to feel like they were interrogated by the FBI.   Now, don’t shine a bright light in their face or slam the table trying to intimidate them, but you need to get down to the heart of the problem, or the lack of a problem with swallowing.

If the person is having trouble with any consistency, how long has this been happening?  Have they ever had an instrumental assessment?  Have they ever had therapy for swallowing?  If so, when, where and for how long?  It’s also nice if they or the family can remember what they did for therapy.

Has the person already had their meal today?  If so, how did they do?   Was there a consistency more difficult than the others?  What happens with that consistency, does it get stuck?  Does it make them cough?  Have them define difficulty as much as possible.

Is it Dysphagia or is it GERD?

Many times, the patient complains that the food gets stuck “right here”.  If I were a betting person, I would bet nearly every time they point to the same spot on their throat.  Which is often associated with GERD.

How do you know which is which?

Well, you don’t without instrumental assessment, but you can do something to find out the probability of GERD or reflux.   Do you use the Reflux Symptom Index?  This is a great way to have the patient answer questions related to GERD.   You can download a free copy right here.

Now what??

Remember to let the interview guide you.   You may have a million more questions based on a particular answer or comment by a patient.    The more comfortable you make the patient, the more they will likely share with you.

If they complain of difficulty with some foods, what foods are they.   Sometimes that patient may be taking pills that cause xerostomia (dry mouth) or they may have had radiation treatment causing xerostomia making it more difficult to swallow foods such as meat, bread or rice.   Maybe they need to include water with their meal.   Sometimes dipping the food in an oil, such as olive oil or adding gravy will help to eliminate the difficulty chewing or swallowing.

The interview process should answer so many questions for you and lead you into the actual hands-on part of the evaluation, maybe giving the patient some trial consistencies, recommending an instrumental assessment, the cranial nerve assessment, etc.

What do YOU ask?

Do you have a list of go-to questions or a questionnaire that you find helpful?  Post it in the comments below!  You can also go to the Internet Resources page and find some downloadable outcome measures to use in your evaluation during the interview.


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We Can’t Treat What We Don’t Know

We Can't Treat What We Don't Know

Call it what you like, a bedside swallowing evaluation, a bedside swallow, a clinical swallow evaluation. No matter what you call it it’s never the same.

At a recent ASHA convention there was a session by Leder, Coyle and McCullough which addressed the clinical swallow evaluation versus instrumental evaluation. Dr. Coyle stated that the bedside evaluation is merely a series of pass and fail screens. You can visit many facilities whether they be hospital skilled nursing acute rehab or home health and rarely will you see two SLP’s complete the clinical bedside evaluation the same.

Continue reading We Can’t Treat What We Don’t Know