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How Does Cognition Affect Swallowing

Cognition can impact many facets of life including swallowing.

Patients may be confused  enough that they don’t “recognize” food in their mouth and effectively may not know what to do with that food.

For example, when I was working in the acute care hospital, I evaluated a patient in the ICU that had sodium levels outside of normal parameters.  This person had difficulty recognizing solids in their mouth and would just sit with the solid sitting on the tongue.   This patient had increased confusion and agitation.   They were able to swallow pureeds and thin liquids.    Once their sodium levels returned to a number within normal limits, their swallowing function also returned to normal.

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Dysphagia Following Extubation Part 2

We know that intubation can impact the swallow.   How does intubation affect swallowing?

Is it a strength deficit or a sensory deficit?

This post will take a look at studies that look at the impact of intubation on sensation of the tongue and the larynx.

Continue reading Dysphagia Following Extubation Part 2

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Dysphagia Following Extubation Part 1

When it comes to patients that are intubated, there are a lot of factors to consider.

What is their current diagnosis, why are they intubated, how long were they intubated?   Was intubation traumatic?   Have they self-extubated?

There is a lot of discussion over the timing of the evaluation.   Traditionally, it has been thought that there needs to be a period of 24 hours following extubation to allow for recovery.

This series of posts will break down what the evidence tells us regarding post extubation dysphagia.

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FEES Following Extubation

The 1998 Paper

Leder, Cohn and Moller investigated the incidence of aspiration following extubation in critically ill trauma patients.

The study looked at 20 patients who required oropharyngeal intubation for at least 48 hours.   All FEES were completed around 24 hours following extubation.

Remember, aspiration is when the bolus enters the airway, below the level of the true vocal cords (as defined in this study).  Silent aspiration is when there is no accompanying behavior such as a cough or throat clear with aspiration.

During this study, 9/20 (45%) of patients were found to aspirate and 4/9 (44%) were silent aspirators.   Silent aspiration was seen in 20% of this population.   8/9 of the patients that aspirated were able to resume an oral diet within 10 days of their initial FEES.

Findings during this study:

  1.  A nasogastric tube was not associated with aspiration.
  2. Traumatic intubation was noted in 5/20 patients and 4/5 of these patients aspirated.
  3. Only the Glasgow Coma Scale rating on admission exhibited a significant difference regarding aspiration status.  (Low ratings had a higher incidence of aspiration).
  4. Trauma patients have an increased incidence of aspiration.

The authors suggest that early identification of aspiration following trauma and intubation is indicated to reduce the risk of pulmonary compromise.

There are still many questions following this study, including patients intubated for shorter than 48 hours and which variables impacted aspiration (brain injury, age, traumatic intubation, sedatives, neuromuscular blockers, respiratory status).

Some newer studies indicate:

“Patients aged >55 yrs and those with vallecular stasis on FEES examination were at significantly higher risk of postextubation aspiration. All patients with pneumonia had an associated aspiration episode.”

With prolonged orotracheal intubation, patients are at risk of aspiration following extubation.  (Barquist, Brown,  Cohn,  Lundy and Jackowski)

The  incidence of aspiration determined by FEES was 56% and 25% of  patients were silent aspirators. The patients found to aspirate were intubated for a mean duration of 8 days, 7.7 days for non-aspirators.  70% of the patients who aspirated  thin liquids while 30% aspirated  puree.  63% of the patients that aspirated showed improved swallowing and tolerated an oral diet by the time of discharge.   (Ajemian, Nirmul, Anderson, Zirlen and Kwasnik)

Instrumental assessments are critical for patients, particularly after intubation 48 hours or longer.


Leder, S. B., Cohn, S. M., & Moller, B. A. (1998). Fiberoptic endoscopic documentation of the high incidence of aspiration following extubation in critically ill trauma patients. Dysphagia13(4), 208-212.

Barquist, E., Brown, M., Cohn, S., Lundy, D., & Jackowski, J. (2001). Postextubation fiberoptic endoscopic evaluation of swallowing after prolonged endotracheal intubation: a randomized, prospective trial. Critical care medicine29(9), 1710-1713.

Ajemian, M. S., Nirmul, G. B., Anderson, M. T., Zirlen, D. M., & Kwasnik, E. M. (2001). Routine fiberoptic endoscopic evaluation of swallowing following prolonged intubation: implications for management. Archives of surgery136(4), 434-437.

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Why the Dye?

The many colors of FEES

You’ve maybe witnessed a FEES exam.   It can sometimes be quite colorful.

Often, green food coloring is used during the exam.   This helps to make the bolus “stand out” in the pharynx.   You may also see blue food coloring used or even white food coloring or naturally white foods such as milk to really make the materials visible if aspirated.

Silent aspiration

Silent aspiration has been reported in over 40% of patients referred for evaluation of swallowing in a rehabilitation hospital and as many as 77% of ventilator-dependent patients have silent aspiration.   It is imperative that we are able to “see” the aspiration.

Study using blue food coloring

In a study by Leder, Acton, Lisitano and Murray (2005), 20 adults were evaluated using FEES, 9 subjects with food that was dyed blue (2 drops of blue in 60cc of pudding and 120 cc of milk) and 11 subjects with regular non-dyed food (yellow pudding, white skim milk).

The study looked at 4 areas:

  1.  the stage transition characterized by depth of bolus flow to at least the vallecula prior to the pharyngeal swallow.
  2. evidence of bolus retention in the vallecula or pyriform sinuses after the pharyngeal swallow
  3. laryngeal penetration
  4. tracheal aspiration

Three SLPs interpreted the studies with 100% agreement in the non-dyed food and in the dyed food.

The dye was changed to green from blue after several deaths resulted from blue dye that was placed in tube feeding.

This study found that the “important variable in detecting both bolus flow to and location in the pharynx and larynx is how well a bolus reflects light (it must be brighter than the tissue it is resting on).   Therefore, the endoscopist can be assured of reliable FEES results using regular, non-dyed food trials.”

Study using green food coloring

Another study by Marvin, Gustafson and Thibeault found that the use of green food coloring improved judgement of airway invasion as compared to white foods.    


Leder, S. B., Acton, L. M., Lisitano, H. L., & Murray, J. T. (2005). Fiberoptic endoscopic evaluation of swallowing (FEES) with and without blue-dyed food. Dysphagia20(2), 157-162.

Marvin, S., Gustafson, S., & Thibeault, S. (2016). Detecting aspiration and penetration using FEES with and without food dye. Dysphagia31(4), 498-504.

Splaingard, M. L., Hutchins, B., Sulton, L. D., & Chaudhuri, G. (1988). Aspiration in rehabilitation patients: videofluoroscopy vs bedside clinical assessment. Archives of physical medicine and rehabilitation69(8), 637-640.

Elpern, E. H., Scott, M. G., Petro, L., & Ries, M. H. (1994). Pulmonary aspiration in mechanically ventilated patients with tracheostomies. Chest105(2), 563-566.

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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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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 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.