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MBSS AND FEES. Why Not Both?


Whenever you read the literature, you often see MBSS vs. FEES or a similar thought comparing the two tests, attempting to find the superior, gold standard assessment.

On social media, we seem to have 2 camps.   Team MBSS and Team FEES.   You can’t be friends and in separate camps!!  (Completely joking here!!!)

Many facilities choose one test or the other.   You can either request MBSS or FEES.  They’ll have a contract for Mobile MBSS or Mobile FEES.   In the hospital, it’s either/or.

What would happen if we try to change that thought.   What if, we changed from an either/or to a both.

What If…….

What if companies had the option of both.  Maybe the ability to do both tests at one time?  Even if they are completed at different times.  Both tests give you such a varied viewpoint of the swallow while often providing the same information regarding the swallow.

The literature says……

The majority of the research tells us that we see the same pharyngeal events with FEES that we see with MBSS including decreased back of tongue control/oral containment resulting in premature posterior loss of bolus, decreased hyolaryngeal excursion, decreased epiglottic introversion, decreased laryngeal closure resulting in penetration/aspiration or vallecular residue.   We may see decreased opening of the Pharyngoesophageal Sement (PES)/Upper Esophageal Sphincter (UES)  resulting in pyriform sinus residue and maybe aspiration.  We can see residue on the posterior pharyngeal wall due to decreased pharyngeal squeeze/stripping wave.

So, in fact, with either test we can see the physiological events of the swallow that lead us into a plan of treatment.

Much of the research states that residue, aspiration, etc are all rated as more severe when using FEES.

What about the doctors

Look at physicians.   they will often order a CT scan for a stroke patient.   When this doesn’t give them all the information needed, they often then order an MRI.   The CT and MRI do give different viewpoints and provide some different information and compliment each other very well.

Anecdotal thoughts.

In my experience, not just reading the research, when a patient had a FEES (performed by me) and later had an MBSS (performed by a colleague) the findings were exactly the same leading to identical recommendations.   In fact, I did not know until after the test that the patient was going to have an MBSS and the other SLP did not know until after the test, the results from the FEES.

Changing our thinking.

So let’s work on changing our thinking to BOTH tests, not just one or the other.  Let’s educate other medical professionals that we are looking for much more than just aspiration or penetration and that we can do so much more than just change a diet.

Let’s make a change!


Aviv, J. E. (2000). Prospective, randomized outcome study of endoscopy versus modified barium swallow in patients with dysphagia. The Laryngoscope110(4), 563-574.

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

Brady, S., & Donzelli, J. (2013). The modified barium swallow and the functional endoscopic evaluation of swallowing. Otolaryngologic Clinics of North America46(6), 1009-1022.

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

Bastian, R. W. (1991). Videoendoscopic evaluation of patients with dysphagia: an adjunct to the modified barium swallow. Otolaryngology—Head and Neck Surgery104(3), 339-350.

Langmore, S. E. (2003). Evaluation of oropharyngeal dysphagia: which diagnostic tool is superior?. Current opinion in otolaryngology & head and neck surgery11(6), 485-489.

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Myths of FEES Part 3

You don’t use FEES.  Maybe you don’t believe in FEES because you’ve heard somewhere that it’s dangerous.

Myth #3……..FEES is too dangerous for my patients.

I’m pretty sure that if FEES were that dangerous, it wouldn’t still be a thing.  I mean, if we’re doing harm to patients with use of a procedure, it would either be modified to make it safer or would not be a thing at all.

Sometimes, we are so afraid of the unknown and if you have never been exposed to FEES first-hand, you may be a little weary of the procedure.

So, how safe is FEES?

There have been several studies looking at the adverse effects of FEES.   The most common adverse effects can be epistaxis (nosebleed), vasovagal response (faint) or a laryngospasm.

One study looked at 212 patients s/p CVA and other neurological events.  Of these 212, there were SIX cases of epistaxis, no change in vital signs during the procedure, no airway compromise and no laryngospasm.   (Aviv, et al 2000)

Even looking at pediatrics, FEES is a safe procedure.   In a study of 500 pediatric patients, there were only FOUR cases of epistaxis with no case of laryngospasm.   (Link et al 2000)

A review of the FEES literature in 2016 examined 2820 FEES exams finding 4 cases of epixtaxis (.14%), 3 cases of vasovagal syncopy (.1%) and 2 cases of laryngospasm (.07%) all of which spontaneously resolved.  (Nacci, et al 2016)

The risk of FEES appears to be small in the literature.  FEES has been found to be a safe procedure to determine anatomy and physiology of the swallow.


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 & Laryngology109(10), 899-905.

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.

Nacci, A., Matteucci, J., Romeo, S. O., Santopadre, S., Cavaliere, M. D., Barillari, M. R., … & Fattori, B. (2016). Complications with fiberoptic endoscopic evaluation of swallowing in 2,820 examinations. Folia Phoniatrica et Logopaedica68(1), 37-45.

Warnecke, T., Teismann, I., Oslenber, S., Hamacher, C., Ringelstein, E.B., Schabitz, W.R., &
Dziewas, R.; 2009. The safety of fiberoptic endoscopic evaluation of swallowing in acute
stroke patients. Retrieved July 18, 2009 from

Aviv, J.E., Murray, T., Zschommler, A., Cohen, M., Gartner, C. Flexible endoscopic evaluation of swallowing with sensory testing: patient characteristics and analysis of safety in 1340 consecutive examinations. Annals of Otology, Rhinology & Laryngology. 2005;114:173-176.

Cohen, M.A., Setzen, M., Perlman, P.W., Ditkoff, M., Mattucci, K.F., Guss, J. The safety of
flexible endoscopic evaluation of swallowing with sensory testing in an outpatient
otolaryngology setting. Laryngoscope. 2003;113:21-24.

Wu, C.H., Hsiao, T.Y., Chen, J.C., Chang, Y.C., &Lee, S.Y. Evaluation of swallowing safety
with fiberoptic endoscope: Comparison with video fluoroscopic technique. Laryngoscope. 1997; 107, 396-401.

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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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Myths of FEES Part 1

It seems that everywhere we go, there are myths that are associated with FEES. 

There is always that reason that “I just prefer the MBSS.”  It may be because the MBSS has been performed in your area for much longer than FEES, but there are always other reasons heard on the street.

So, here we go………

FEES Myth Number 1:

It is too painful for my patients.

It’s really not.   If you think about the way we squish and contort our patients at times to fit into the fluoro machine for modifieds, FEES can be just as painless as the MBSS.

There are ways to keep the test pain-free.

Numbing effect

Some clinicians will use a topical anesthetic.  This can be applied to the nare prior to insertion of the scope.  The downfall of using an anesthetic can be that it will eventually travel to the pharynx and may cause a numbing effect in the pharynx, thus affecting the swallow.

The grass may be greener on the other side.

It is important to explore both nares prior to insertion of the scope.   This way, you can find the path of least resistance.   Many people will have one nare that is more narrow than the other, they may have a deviated septum or there may just be some type of obstruction there.

Size does matter.

You may consider the size of your scope.   Scopes are available in various sizes and depending on the scope you use, you may be able to purchase a pediatric scope which will be more comfortable for your patient.

Anecdotal Corner

I have been doing FEES for some time now.   It seems that the biggest fear with the test is the unknown.  Most patients are nervous about the test because they’ve never had something in their nose like that.   After the test, most of these patient’s will also state that they mostly felt pressure in the nose and it was not painful.

Now, that’s not to say that there are not those overly anxious people that start screaming before you even step up to their bedside.

I’ve been scoped multiple times and I’ve even scoped myself and have walked away unharmed all times I’ve been scoped!


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 Research40(6), 1352-1357.

Hiss, S. G., & Postma, G. N. (2003). Fiberoptic endoscopic evaluation of swallowing. The Laryngoscope113(8), 1386-1393.

Fife, T. A., Butler, S. G., Langmore, S. E., Lester, S., Wright Jr, S. C., Kemp, S., … & Rees Lintzenich, C. (2015). Use of topical nasal anesthesia during flexible endoscopic evaluation of swallowing in dysphagic patients. Annals of Otology, Rhinology & Laryngology124(3), 206-211.

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.


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The History of FEES


FEES (Flexible Endoscopic Evaluation of Swallowing) is a procedure to assess the swallow.   Currently, a laryngoscope is passed transnasally (through the nose) and into the upper pharynx to observe the swallow and the swallow structures through a camera.

First FEES   Picture from:

First Description

FEES was first described in the literature in 1988.   The procedure initially involved a mirror or more invasive equipment.   This equipment was viewed by one person through an eyehole and much of the swallow was missed at that time.

Initially the exam was not recorded so the SLP completing the exam not only was the lone viewer of the exam, they also had to remember what they were seeing to develop the report.


Fortunately, over the years the equipment has changed drastically with equipment using distal chip technology and/or giving the SLP a picture in High Definition (HD).  The view of the swallow/swallowing structures is now viewed on the screen of a tablet/computer.  The study can be viewed by multiple viewers in real time and is recorded for review of the swallow.

FEES Comparison  Comparison of visualization of equipment from the article in reference 2.

Development of FEES

FEES was developed by Dr. Susan Langmore, Dr. Nels Olson (ENT) and Ken Schatz (SLP).  They had the idea of visualizing the swallow, using the same equipment as the ENT to view the structures.

Upon viewing a healthy individual using FEES, the authors were disappointed by the lack of information they saw, however when they started to assess patients with dysphagia, the authors were excited with the results.   They were able to visualize spillage into the pharynx, aspiration, residue, structural movements and secretions.

Another Gold Standard in Swallowing Assessment

FEES was once thought to be a suboptimal assessment for swallowing, however it is now considered a gold standard assessment tool along with the MBSS (Modified Barium Swallow Study).


Langmore, S. E., Kenneth, S. M., & Olsen, N. (1988). Fiberoptic endoscopic examination of swallowing safety: a new procedure. Dysphagia2(4), 216-219.

Langmore, S. E. (2017). History of fiberoptic endoscopic evaluation of swallowing for evaluation and management of pharyngeal dysphagia: changes over the years. Dysphagia32(1), 27-38.

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Mobile MBSS

Did you know?  Have you heard?

Instrumental assessments come to you!!

Now, you can schedule mobile FEES AND mobile MBSS.

This cuts down the cost of transport and the various costs of instrumental in the hospital setting.

Do you need Mobile MBSS or FEES at your facility?  Chances are, there’s one in your area.

Do you own a Mobile MBSS or FEES company?  Post a link to your website in the comments!!